New oral health coalition expected to spur changes in state

By Tara Kaprowy
Kentucky Health News

For the past 30 years, Dr. Fred Howard of Harlan has been seating patients in his blue dental chair and telling them to open up. When they do, he's seen all kinds of scenarios, from toddlers whose teeth are already rotten from sucking on bottle filled with soft drinks to 20-year-old adults with no teeth at all. On some occasions, children walk in with such a severe abscess in their mouth their eyes are swollen shut.

Though the view can be grim, Howard said he has seen some improvements in his decades of practice, but with new changes in Medicaid managed care, the overwhelming prevalence of children and teens drinking soda pop and an embedded cultural belief in some areas that "teeth are just something to get rid of," Howard concedes that making headway can feel like one step forward and two steps back.

Enter the newly re-established Kentucky Oral Health Coalition, a statewide force whose goal is to ensure Kentuckians have happy, healthy smiles.

Dozens of organizers and stakeholders met in March to discuss the coalition's aims, and a membership drive is underway to build financial momentum. The coalition will promote oral health education, statewide partnerships statewide and advocate oral-health legislation. "I think they will turn into the advocacy group for dental change," said Dr. Julie McKee, dental director for the state Department of Public Health. "They're working hard to come up with a plan. They've got their heads on straight."

One of the major issues facing the dental profession is possible expansion of the scope of practice for mid-level providers, such as dental therapists who can assess, clean teeth, replace sealants, provide fluoride as well as fill cavities and extract teeth. As nurse practitioners do in the medical field, having such providers could help address shortages in rural areas, said Dr. Jim Cecil, former state dental director and coalition steering committee chair. The concept is in practice in 54 other countries, but the only U.S. states with it are Minnesota and Alaska, mainly because of opposition form dentists.

Andrea Plummer, coalition member and senior policy analyst for Kentucky Youth Advocates, acknowledged that scope-of-practice issues "can be a very tense subject" and "there would have to be buy-in" from members of the committee, who include dentists, but discussion is ongoing. Cecil said the issue is "something we'll need to look at and take a stand on eventually."

Howard (pictured with Gov. Steve Beshear at signing of the bill that requires dental exams for students starting school) favors the expansion, but doesn't feel Kentucky's oral-health problems can be solved just by putting more boots on the ground.

"The bottom line is: We can have twice as many dentists, have more dental hygienists, but if we don't change the mindset, if we don't provide the education, I don't think we're going to solve the problem," he said.

To that end, the coalition is also investigating ways to expand school-based health and dental education, either by finding funding, collaborating with groups that are already in place or advocating legislation changes, Plummer said.

A recently enacted state law requires children to get a dental screening before entering kindergarten, but there is little else in the way of legislation that requires schools to offer services to help students with dental problems, Plummer said. "Kentucky law says that students' health does affect their learning and schools should take steps to affect their learning but it's fairly broad," she said.

An analysis by KYA last year showed school districts spend less than 1 percent of their budgets on school health services.

Examining how to get more dentists to accept Medicaid patients is another hot-button issue. Of about 2,200 dentists statewide, only about 600 are enrolled in Medicaid, Cecil said, and "They feel like they're working for free" because of the program's low reimbursements. "In many cases, they're really not meeting overhead."

The administrative burden that comes with these patients has also gotten worse since Medicaid transitioned to managed care, Cecil said. "Everything they do has to be pre-authorized," he said. "That delays approval, delays treatment, delays payment."

Under managed care, Howard said, patients now need to come in twice to get a full complement of X-rays and radiographs done, which can not only make it hard on dental practices, but for patients as well. "The more times they have to come, that gives them more opportunities to miss appointments," Howard said.

The Oral Health Coalition also sees a need for "quality, updated data," Plummer said. Getting data was one of the successes of the first coalition, formed in 1990. Run by volunteers and funded by the dental schools at the University of Kentucky and University of Louisville, it was formed after the General Assembly told the schools that they either needed to work together or one could "risk being shut down," Plummer said. The group had several successes, including working with the state to conduct an oral health survey, lobbying legislators for oral-health measures and holding an annual symposium. But after more than 15 years, "It kind of just fizzled out a little bit," Plummer said. The group went inactive in 2006 but had some assets that the new group will take over.

The group's rebirth began in 2009, when Kentucky Youth Advocates was approached by the DentaQuest Foundation, which is connected to DentaQuest, one of the largest managed-care organizations in the country that administers dental benefits. DentaQuest officials were interested in seeing the coalition resurrected and offered $80,000 to KYA so it could provide the manpower to run it, Plummer said. It was the first time the coalition had funding to back it up. The KYA talked to state stakeholders and discovered "there really did seem to be an interest in putting a coalition back together," Plummer said. Planning began in earnest and in January the steering committee drafted by-laws. In March, 70 people showed up to the first meeting.

That gathering was not just made up of dentists, oral-health advocates and experts, Howard said. Members of the media were present, along with parents, health department officials, school nurses, students and educators. That made all the difference to Howard, who said he is inspired by what changes might occur and what education can take place. "When we have people from all these different venues, we have more of an opportunity to make a difference," he said.

The coalition's next meeting will be July 25. Those interested in attending or becoming members of the coalition can contact Andrea Plummer at aplummer@kyyouth.org or 502-895-8167. Dues for individual members are $25. Government organizations pay $100, nonprofit organizations pay $250 and for-profit organizations pay $500.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Diabetes can cause gum disease and tooth decay

Though it's commonly known that diabetes can affect organ function and eyesight, an oral-health expert points out that the disease can also cause tooth decay and gum disease.

"Diabetics with uncontrolled glucose levels tend to develop more gum disease and may lose more teeth than diabetics who have good control of their glucose levels," writes Dr. John Novak, associate director of University of Kentucky's Center for Oral Health Research, in an op-ed piece for the Lexington Herald-Leader. A high carbohydrate/sugar diet can also lead to high levels of sugar in the blood, which can hamper the way the body deals with infection, he writes. Gum disease may be the result because the gums are inflamed by the increased levels of bacteria living in the mouth.

Diabetes can also cause dry mouth, which "creates the perfect environment for the growth of bacterial plaque and for fungal infections such as thrush," he writes. To avoid these problems, Novak recommends brushing teeth and gums twice a day with a fluoride toothpaste, flossing every day and using fluoride mouth wash before going to bed.

Signs of tooth decay or gum disease include tender gums that bleed easily when brushing or flossing; teeth sensitive to hot or cold temperatures; loose or broken teeth; sores, ulcers or a burning sensation in the mouth; and bad breath or a bad taste. (Read more)

Like nurse practitioners in medical field, dental profession needs mid-level providers, expert argues

With 50 million Americans living in poor or rural areas where there are no dentists to go to — and that number expected to rise by more than 5 million if the Affordable Care Act stands — states and the federal government should be training dental therapists to help solve the problem, argues Louis W. Sullivan, a physician and former secretary of the Department of Health and Human Services, in an op-ed piece in The New York Times.

"We have two years to prepare before millions of children will be entitled to access to dental care," he writes of the impending eligibility expansion under the ACA. "Access means more than having an insurance card; it means having professionals available to provide care. Public officials should foster the creation of these mid-level providers — and dentists should embrace the opportunity to broaden the profession so they can expand services to those in need."

Dental therapists provide preventive care and "routine procedures like sealants, fillings and simple extractions outside the confines of a traditional dentist's office," Sullivan writes. While they are "common worldwide," only Alaska and Minnesota allows them to practice. Legislation is pending in five other states. Generally, dentists have been opposed to such changes.

Sullivan points to Alaska as a model example for how these therapists can fill gaps in places like remote villages "only accessible by plane, snowmobile or dogsled, where high school seniors once graduated with full sets of dentures." In 2003, the state sent students to New Zealand to be trained as therapists. Now, therapists serve 35,000 Alaskans. They "travel to small clinics and schools, often carrying their equipment with them. They consult with a supervising dentist from the region but do most procedures themselves. Many were raised in the communities in which they now work, so they understand the culture," Sullivan writes.

Sullivan points out dental disease is the No. 1 chronic childhood disease in the country, responsible for more children needing treatment than asthma. In 2009, more than 830,000 visits to the emergency room were due to preventable dental problems across the nation, he points out. But dentists are in short supply and will be even harder to see if the ACA is upheld by the U.S. Supreme Court. "In a nation obsessed with high-tech medicine, people are not getting preventive care for something as simple as tooth decay," he writes. (Read more)

Effort to boost oral health in nursing homes gets tangled up with industry's attempt to insulate itself from lawsuits; both bills die

A bill to get nursing-home residents better dental services "appears to be dead after the Senate added language from another bill designed to shield the nursing-home industry from litigation," Deborah Yetter reports for The Courier-Journal.

House Bill 510 would have created a pilot project for the state's two dental schools to create "a program to provide better oral-health services to nursing home residents," Yetter writes. "But on Wednesday, the Senate Health and Welfare Committee added language from another bill that had stalled in the House that would require people who want to file malpractice lawsuits against nursing homes to first submit the complaint to a 'medical review panel'." (Read more) 

State starting free training for dentists in pediatric dentistry

One of the many problems with Kentucky's oral health is that not enough dentists are willing to accept children as patients, or lack proficiency in treating children when they are around age 1, the recommended time for a child's first dental visit.

Next week, the state Department of Public Health will start to offer free continuing education for dentists and other oral-health professionals who need or want training in pediatric dentistry, funded by a federal grant.

The Access for Babies and Children to Dentistry (ABCD) program will have one-day training sessions in Lexington on Friday, April 6, at the Embassy Suites on Newtown Pike next to the interstate, and in Somerset on Wednesday, April 11, at the Hampton Inn on US 27. Both sessions will start at 8:30 a.m. The sessions offer 8 continuing education units out of a possible 20 in the program.

For more information about the training, and to register for it, contact Meghan Towle at Meghan.Towle@ky.gov or 502-564-2154.

More young kids going under anesthesia to fix bad dental problems

Preschoolers are increasingly having to undergo extensive surgery to get fix the cavities they've gotten from lack of brushing, get root canals or have teeth extracted.

Five years ago, the Centers for Disease Control and Prevention found the number of preschoolers with cavities had increased — the first time that had happened in 40 years. "Dentists nationwide say they are seeing more preschoolers at all income levels with 6 to 10 cavities or more," reports Catherine Saint Louis for The New York Times. "The level of decay, they added, is so severe that they often recommend using general anesthesia because young children are unlikely to sit through such extensive procedures while they are awake." (Times photo by Stuart Isett)

"We have had a huge increase in kids going to the operating room," said Dr. Jonathan Shenkin, a pediatric dentist in Augusta, Me., and a spokesman for the American Dental Association. "We're treating more kids more aggressively earlier."

Causes for the increase can be linked to lots of snacking and juice or other sugary drinks before bedtime; kids drinking bottled water rather than tap water; a lack of knowledge that infants should go to the dentist by age 1 to be assessed for cavity risk.

Parents can sometimes confused dental decay with teething and don't realize there is a problem until teeth break or the pain becomes so bad the child cannot sleep. (Read more)

As with health care reform, dentistry should move from volume to value, report urges

Dentists should be paid according to the outcomes of their patients and should be monitored more closely given that there is great variability and expense when it comes to dental care, a new report argues.

"I think there is broad consensus that the current oral health system doesn't meet the needs of a significant portion of the population," said Paul Glassman, professor of dental practice at University of the Pacific Arthur A. Dugoni School of Dentistry and lead author of the report "Oral Health Quality Improvement in the Era of Accountability."

The report, funded by the W.K. Kellogg Foundation and the DentaQuest Institute, was released as the U.S. healthcare system is undergoing a transition from the "pay-for-performance" model to "value-based care." The paper argues oral health should likewise move in the same direction and make the transition from "volume to value."

The report found dentistry is the second-highest out-of-pocket health care cost after prescription medicines, and, like health care in general, its cost is increasing, reports Laird Harrison for Medscape News. Another issue is the government just pays for about 6 percent of dental care nationally, the report found, leaving people to pay for care themselves.

While expensive, the care dentists give can be inconsistent, the report found. Though Glassman said dentistry is not lacking in standards, there is limited evidence of the best practice for most dental procedures, the report found.

Another issue, the report contends, is dentists are paid according to what they produce, not by how successful they are in their outcomes. As such, dentists are resistant to change since there are few incentives to implement quality improvement programs. "If the question is 'what's the optimum system for providers,' then many feel the optimum system is what we have now," Glassman said. "If the question is 'what's the optimum system for the public,' then you will come to a different set of assumptions."

To help improve the system, the report recommends a number of proposals, including:

• The increased use of electronic health records

• Development and use of measures for oral health outcomes

• Tying incentives to the oral health of the population being served

• Relying more on allied dental professionals and non-dental professionals

It also suggests relying more heavily on telemedicine, with Glassman envisioning "hygienists and dental assistants going into schools, nursing homes, and other areas with underserved populations to deliver preventive care," Harrison reports. "Dentists, monitoring from afar with access to dental charts stored on the Internet, could gain more patients."

Steven Silverstein, director of the graduate program in dental public health at the University of California San Francisco, said the report was "outstanding" and agreed that the care dentists give can be inconsistent, saying, "If you ask 10 dentists to look at a patient you will get 10 different opinions." Part of the problem, he said, is 98 percent of dentists either practice alone or with one or two partners.

Silverstein did take issue with the fact that the report did not mention the high cost of dental education; didn't take cosmetic dentistry into account; and it did not explain how reform could lower the cost of dental care. (Read more)

Smile Kentucky! celebrates 10 years and more than 100,000 children helped

Smile Kentucky! celebrates its 10-year anniversary tomorrow, representing $1 million in free dentistry and benefiting more than 100,000 students.

"It's a wonderful program," said Arleta Watkins of Bullitt County Schools. "I've had children who've never had a dental exam before. They get that service for free."

The program serves children in Louisville and nearby counties. Since it began, more than 127,000 students in 143 schools and 11 counties have received classroom dental education, 35,000 kids have gotten free dental screenings at school and nearly 3,000 children have received free treatment.

Smile Kentucky! works with 30 elementary schools in Jefferson and surrounding counties each fall. Students receive dental education, and children in grades 3 to 6 get a free dental screening. Children without dental insurance or medical care get free treatments by going to the University of Louisville's School of Dentistry or private dental offices in February.

"Dental pain and infection is one of the leading causes of missed days at school and affects a child's ability to concentrate," said John Sauk, dean of U of L's School of Dentistry.

U of L is one of 30 agencies on the steering committee. Other founding partners include the Louisville Water Co.,  the Louisville Dental Society, Colgate, Sullivan Schein Dental, Northwest Area Health Education Center and the Bullitt County Health Department.

For more information about Smile Kentucky!, click here.

FDA wants to reduce standard for fluoride in public drinking water

Lowering the amount of fluoride in drinking water, as proposed in January by the Food and Drug Administration, will increase medical expenses and harm the poor and the poorly educated the most, a mother writes in an op-ed piece in the New York Times.

Jane E. Brody delves into the concept of fluoridation, pointing out its benefits. "In the early years, rates of tooth decay among the young dropped by 60 percent in communities that adopted fluoridation," she writes. "Every $1 invested in fluoridation saves approximately $38 in dental treatment costs."

Though fluoride was initially thought to become incorporated into developing teeth, it was later found that its benefit is topical, meaning it works on teeth already formed. "Fluoride, which is present in saliva and concentrates in dental plaque, inhibits the action of acid on tooth minerals," she writes. "It also promotes remineralization by sticking to tooth surfaces, where it attracts calcium ions present in saliva."

Still, there remains controversy about whether or not fluoride is safe, with the substance being accused of causing everything from heart disease to Alzheimer's disease. "None of these supposed risks has ever been established in scientifically valid studies," Brody writes. "The only proven risk, a condition called fluorosis, which results in white and sometimes brownish markings on the teeth from too much fluoride, rarely results from a normal intake of fluoridated water."

Since fluoride is also available in other substances, like toothpaste, the FDA proposed reducing the amount of fluoride in public drinking water to 0.7 milligrams per liter, from a range from 0.7 to 1.2 milligrams. Brody feels the move is a mistake: "Fluoridation confers the greatest benefit to those who need it most: the poor and poorly educated and those with limited access to regular dental care," she writes. "In the years ahead, removal of fluoride from drinking water will almost certainly cost taxpayers millions of dollars in increased Medicaid expenditures." (Read more)

In Kentucky, there is 100 percent fluoridation in public drinking water systems, though perhaps half a million residents get their water from wells, springs or cisterns.

Evidence grows of links between oral health and overall health

"The eyes may be the window to the soul, but the mouth provides an even better view of the body as a whole," The Wall Street Journal's Melinda Beck writes in her Health Journal column. "Some of the earliest signs of diabetes, cancer, pregnancy, immune disorders, hormone imbalances and drug issues show up in the gums, teeth and tongue—sometimes long before a patient knows anything is wrong. There's also growing evidence that oral health problems, particularly gum disease, can harm a patient's general health as well, raising the risk of diabetes, heart disease, stroke, pneumonia and pregnancy complications." (WSJ graphic; click on it for larger version)

Beck adds, "Such findings are fueling a push for dentists to play a greater role in patients' overall health. Some 20 million Americans — including 6 percent of children and 9 percent of adults — saw a dentist but not a doctor in 2008, according to a study in the American Journal of Public Health this month."

Beck urges her readers not to be fooled by shiny white teeth. "In fact, many dentists worry that people who whiten their teeth may have a false sense of complacency, since their teeth can still be harboring tooth decay and serious gum disease," she writs. "Even people who have no cavities can still have inflamed and infected gums." She quotes Mark Wolff, an associate dean at the New York University College of Dentistry: "Whiteness and the health of your teeth are totally unrelated." (Read more)

3 universites and federal agency join to improve oral health in Appalachian Kentucky

With money from the Appalachian Regional Commission and some of their own, three very different Kentucky universities will collaborate "to enhance sustainable, collaborative dental health education and care" in the state's eastern coalfield, where both are sorely lacking, they announced in a press release.

Morehead State University, the private University of Pikeville, and the University of Kentucky's College of Dentistry will design the Appalachian Rural Dental Educational Partnership Plan "to train more dentists to practice in rural areas and give them the tools necessary to set up thriving dental practices in Eastern Kentucky," the release said. The funding is $400,000 from ARC, $127,293 from UK, $82,035 from UPike and $47,873 from Morehead State.

“The majority of Eastern Kentuckians have struggled to sustain quality dental health, and one of the barriers to maintaining good dental health is poor access of quality dental care,” state Department for Local Government Commissioner Tony Wilder said. His agency handles ARC matters in Kentucky.

Said new UK President Eli Capilouto, a dentist by trade, “We know that if we can break a cycle of poor health, we can begin to break cycles of poverty. Cycles of despair can become legacies of hope. We also, increasingly, know that partnerships and greater collaboration are the best – and, perhaps, only – way to address major challenges.” He called the project a unique partnership among a federal agency, a governor and “the state’s flagship institution, Kentucky’s public institution dedicated to serving the people of Eastern Kentucky, and a critically important college with deep roots in Eastern Kentucky.” (Read more)

Appalachian Regional Commission conference in Prestonsburg Sept. 7-9 to focus on improving access to health care

Featuring the insight of 42 federal, state and local health experts, officials and community leaders, the Appalachian Regional Commission's Healthy Families: Healthy Future conference will be held Sept. 7-9 in Prestonsburg.

The keynote address will look at different ways access to quality health care can be expanded. It will be given by Marcia Brand, deputy administrator of the Health Resources and Service Administration. HRSA is the primary federal agency for improving access to health-care services for people who don't have insurance, are geographically isolated, or are medically vulnerable.

Other conference topics include childhood obesity and diabetes; substance abuse in adolescents; improving access to dental care for children; health information technology; and Appalachian perspectives on infant mortality reduction.

The conference will be at Jenny Wiley State Resort Park in Prestonsburg. To register, click here. Online registration ends Wednesday, Aug. 31.

Oral health grant for 25,000 Appalachian children should be beginning of statewide effort, Al Smith says

In an op-ed piece, veteran Kentucky journalist Al Smith praised the recent announcement that 25,000 Eastern Kentucky children in 16 counties will receive preventive dental care this school year.

The project, funded by a $1 million grant from the Appalachian Regional Commission and $250,000 in state funds, will involve painting the teeth of those children with a special varnish that prevents tooth decay. As co-founder of the Institute for Rural Journalism and Community Issues and former federal cochair of the ARC, Smith has pushed long and hard for the improvement of oral health in Kentucky.

He spoke of the grant announcement in conjunction with discussions of the continued $900 million expansion of the University of Kentucky's Chandler Medical Center. "Obviously, the bricks and mortar go to serve extremely important life saving and health purposes, but the ARC pilot treatments of children's teeth should persuade all Kentuckians that this care is essential for every county," he wrote.

The project is called Healthy Smiles and was announced by Gov. Steve Beshear last week. "Over the course of 2011-2012 school year, two protective fluoride tooth varnish treatments and educational materials for healthy dental practices will be offered to children in the first through fifth grades at selected schools," Smith summarized.

Counties that will benefit from the project are Bell, Breathitt, Clay, Elliott, Floyd, Harlan, Jackson, Knott, Knox, Lee, Magoffin, Menifee, Owsley, Perry, Russell and Wolfe.

The Institute for Rural Journalism and Community Issues told Beshear about Kentucky's serious oral health deficits when he was running for governor four years ago, Smith said in his op-ed piece. That assessment showed "that half of Kentucky's children had decay in their baby teeth; and nearly half of children ages, 2, 3, and 4 had untreated dental problems," Smith wrote.

Cavities and loss of teeth create problems in later life, Smith asserted. He referred to statements made by Dr. Steve Davis, interim commissioner of public health, who said Kentuckians looking to join the military may be turned away if they have a mouthful of oral health problems: "The Navy, particularly, takes seriously the warning that a sailor stricken by a toothache in the depths of the sea could mishandle a task on a sub and send the craft plunging to the bottom." For a Word version of Smith's op-ed, click here.

Promising tooth varnish that prevents tooth decay will be applied to 25,000 students in 16 Kentucky Appalachian counties

Using an innovative fluoride technique, about 25,000 children in 16 Appalachian Kentucky counties will receive preventive dental care at school, under a $1.25 million pilot project announced by Gov. Steve Beshear yesterday. The counties are Bell, Breathitt, Clay, Elliott, Floyd, Harlan, Jackson, Knott, Knox, Lee, Magoffin, Menifee, Owsley, Perry, Russell and Wolfe.

In the Smiling Schools program, children in first to fifth grades "will have their teeth painted with two fluoride treatments over a four- to six-month period," reports Mike Wynn of The Courier-Journal. "Fluoride prevents and reverses the early affects of tooth decay and slows the progress of existing problems."
(Photo by James Mann, The Winchester Sun: Emily Havens of Clark County gets the treatment)

The University of Kentucky Dental School will examine the children before and after the tooth varnish treatments to assess the effectiveness of the program. Results of a project that Beshear said inspired the program are promising. About 3,000 children in Clark County had their teeth painted with the varnish and decay rates in a group of sixth graders fell dramatically. By the third year of the treatment, decay rates had fallen from 50 percent to 14.5 percent, one of the lowest rates in the state, said dentist Rankin Skinner, who spearheaded the project.

In 2001, Kentucky children had tooth decay in their baby teeth almost twice as often as the national average, Beshear said Thursday. More than 46 percent of children ages 2 to 4 went untreated that year. "The impact of these dental problems is much more than just an uneven smile or a poor national image, Beshear said. "Dental problems affect overall health and development — everything from nutritional choices to speech development to performance in school." (Read more)

Rachel Parsons of The Winchester Sun reports that the impetus for the project was a December 2007 New York Times story about Kentucky's poor dental health, particularly that of children. Prompted by his son who read the story, Will Hodgkin of the Clark County Community Foundation contacted Skinner, who had learned of the varnish while completing a study in Ecuador, where dentists had noted big decreases in decay rates after using the substance on teeth. The foundation funded treatment for all preschool and elementary students in 2008-09, and the program is now run by the Clark County Health Department. (Read more)