Lack of Dental Health Care Is Growing Concern

Family physicians -- particularly those practicing in low-income urban and rural areas -- know all too well that patients experiencing dental emergencies often turn to their primary care physician or the local hospital emergency room for relief.

A report released in late July by the Center for Studying Health System Change reveals that the inability of low-income patients to access dental care is a cause for concern. The report, "Community Efforts to Expand Dental Services for Low-Income People," focuses on 12 nationally representative metropolitan communities around the country and concludes that "dental care is one of the most difficult health care services for low-income people to obtain."

The report cites a variety of factors for the lack of care, including unavailability of dental insurance, limited dental benefits available through public insurance programs and a "lack of dentists willing to serve low-income patients."

In addition, said the study authors, "the demand for services far exceeds available resources," and the "overall supply of dentists should be examined since the number of practicing dentists has not kept pace with the growing population."

Enter the Maine-Dartmouth Family Medicine Residency program, where residents learn oral and dental health skills not taught in many -- if any -- other family medicine residency programs around the country.

According to William Alto, M.D., a member of the Maine-Dartmouth faculty, "we're training our residents to put on a pair of gloves and to get in there and check the mouth -- look for cancers, look for problems -- and to deal with them."

"We really have a shortage of dentists here in Maine," said Alto. "Most of the dentists are concentrated along the coast where there's more money and more dental insurance."

Nearly five years ago, Alto made a bold move on behalf of his patients desperate for dental services. Alto secured funding for basic dental health training for three faculty members, including himself, via the local Veterans Affairs hospital.

Jim Schmidt, D.M.D., (then) chief of dental services at the Togus VA hospital, gave the three FPs hands-on experiences in tooth extractions and other oral health procedures. Eventually, that training morphed into Schmidt's current every-other-week visits to the residency program sites in Augusta and Fairfield.

"My intent when I went out there was to expose these young physicians to what they don't get in medical school and what they do see in their clinical practice," said Schmidt, the sitting president of the Maine Dental Association.

According to Schmidt, every patient seen in the dental clinic is referred by a primary care provider. In the clinic, the resident is in charge. "I'm in the room, and I'll have the resident assess the patient," said Schmidt. "Young physicians are learning how teeth are numbered, top, bottom, right, left quadrant."

After a few sessions together, residents begin recognizing periodontal disease and tooth decay, and "they start assessing white lesions in the mouth," said Schmidt. The patients get managed appropriately and referred when necessary, he added.

"When these residents leave, they have a much stronger awareness of dental pathology and oral pathology then they'd ever get without a program like this," said Schmidt.

According to Alto, the residents at Dartmouth "all get assigned to the dental clinic two or three times during their careers here." In the past three and a half years, Alto said residents at the two residency locations have seen close to 200 patients for dental extractions and referred many more to oral surgeons and dentists.

The Maine Board of Dental Examiners is on board with the residency's training program and encourages physicians to create relationships with oral surgeons or dentists. The Maine Dental Access Coalition -- an organization looking for solutions to the state's dental health crisis -- also recognizes the residency's contribution. "The coalition really supports providing wider access in a number of ways, and this is certainly one of them," said spokesperson Sarah Shed.

The enthusiasm for attaining dental health skills seems to be contagious. Medical students and family medicine residents packed a meeting room at a Kansas City, Mo. convention center earlier this month to listen to a clinical lecture on dental emergencies and procedures for family physicians.

The session, led by Harry Colt, M.D., residency director at the Maine-Dartmouth program, was offered during the AAFP's National Conference of Family Medicine Residents and Medical Students.

Colt received his dental training alongside Alto at the VA hospital in Maine. He asked his Kansas City audience for a show of hands as to who had received more than a week of oral health training in medical school or residency. Just one hand shot up.

"This is a very typical group of medical health professionals who are grossly undertrained in dental health," said Colt. "It's time to reconnect the mouth to the rest of the body," he added, quoting former U.S. Surgeon General David Satcher, M.D., Ph.D.

Colt told his audience that dental health care should be considered a part of the Future of Family Medicine report's team approach to patient care -- a model that the AAFP supports.

Basic dental and oral anatomy should be incorporated into medical training, said Colt. He encouraged those in the audience to "learn the language" dentists use to help earn their respect and cooperation in taking care of patients.

He pointed out that oral anesthetic procedures taught in dentistry "are very helpful with oral biopsies and lacerations," things FPs often see in their practices.

Colt encouraged attendees to go back to their residencies and push for basic dental health training. "Advocate for your patients. Your patients have problems that are not being met. How can you remedy that?" he asked.