But, yeah, there’s this marketplace issue. Private organized dentistry protects the marketplace for care and the power of private practitioners to provide it but that leaves a lot of people out. Stories like the battle of this dental hygienist in South Carolina, or the battle that’s going on over these midlevel providers called dental therapists in a number of states, really illustrate how fiercely that terrain is protected. Organized dentistry continues to say the current supply of dentists can meet the need, that if the system paid more for the care, more providers would locate in these poorer areas. That we Americans need to value our care more and go out and find care more aggressively. They see the fault as being with society at large. Beck: This opposition to hygienists stepping up and filling that role, does that have anything to do with the fact that hygienists are mostly women? You quoted some old-timey dentists who were like, “Ah yes, the best assistant for a dentist is a woman because she won’t be ambitious and take over our patients." And it kind of sounds like that attitude is still around in some ways. Otto: You could say that there might be a sense of that still. There’s certainly a deep sense among the powers of organized dentistry that only dentists are qualified to do the lion’s share of dentistry. Beck: Are there other plans proposed to fill the gap in dental care, if not letting the hygienists or the dental therapists do it? Is there another plan that would be more pleasing to dentists? Otto: They have their own alternative model. It's kind of a health navigator who connects people with existing dentists, a community-health-worker type of model. [The navigator] helps divert people from ERs into existing dental offices, helps people make dental appointments, educates them about maintaining oral health, and taking care of their children. But it’s guiding people to existing dentists, rather than expanding the dental workforce. Beck: And if they don’t have insurance then it’s not going to help very much? Otto: It’s not as helpful. Unless there’s a philanthropy or some kind of group that’s raising money to pay for the care. Beck: The separation between dental and medical care is pretty entrenched at this point. Do you think it can be overcome, that it should be overcome, that the two could be integrated a little more? What might that look like, do you think it would help? Otto: Something that was talked about in the medical world during the work going into the Patient Protection and Affordable Care Act was the “Triple Aim”: bending the cost curve toward prevention, expanding care more broadly and more cheaply, and [creating] a better quality of care. It’s something that needs to be discussed in the oral health world too, and I think it’s being discussed more.
Mary Otto has explored the separation of dental and health treatments in her latest book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. In the US, the distinct insurance and care given to oral health and general health can be lethal if the connections between the two are not made in time. Dentistry originally became a separate profession to general healthcare in 1840s Baltimore, and the separation has been maintained since, from education up to treatment and insurance. Otto believes that the divide is due to the marketplace and the desire to maintain professional autonomy, rather than viewing the separation as detrimental to healthcare provision. Over a million US citizens a year visit the emergency department for dental issues, costing over a billion dollars annually. The increased difficulty of gaining dental insurance because of the separation of oral and general health has led to a gap in dental care provision for many Americans. Despite the stereotype of a healthy “American smile”, dental care is still perceived as being optional, with basic care being neglected. Plans to change the situation are largely to force the system to pay more for care, with organized dentistry believing that the current supply of practitioners is enough, despite a dearth of rural care. Otto believes that to truly tackle the issue, a reform in dentistry and an integration of oral care into general health care will be necessary.