The reason Brandee Winter could take her children to the local WIC office for a dental checkup was because of an experimental project by researchers at the University of Washington and Advantage Dental Services, which provides dental services for Oregon Medicaid beneficiaries. The project is part of a randomized controlled trial across 14 rural counties in Oregon to test whether paying Advantage on a capitated basis and offering performance-based incentives to providers who offer care in the most efficient setting—not necessarily a dentist's office—can get dental care to children who ordinarily would not receive it. The trial is funded with a grant from Finding Answers, a program of the Robert Wood Johnson Foundation. The beauty of the initiative is that it's designed to use resources efficiently, according to Dr. Peter Milgrom, a professor of oral health sciences at the University of Washington and principal investigator for the project. Children are assessed for their caries risk level, and only if a child needed a sealant would he or she get it, for instance. “The kids who don't need a lot of care don't get it,” Milgrom said. With the appropriate care, expensive trips to the emergency room for dangerous, painful conditions such as tooth abscesses can be prevented, he said. “Reducing childhood caries is a key area of interest, I think, for both the medical profession and the dental profession,” said Dr. Jane Grover, director of the Council on Advocacy for Access and Prevention at the American Dental Association. “If we can save some of those disease patterns from starting, then we can reduce costs very effectively across the board.” Other efforts to increase access to dental care among underserved populations have adopted a different approach, such as integrating it with primary care. In a pediatric project at Jacobi Medical Center in New York City's borough of the Bronx, where 66% of patients are uninsured or on Medicaid, the hospital's dental residents teach primary-care providers to conduct oral exams, teach parents about diet and dental health, and apply fluoride varnish. By getting basic care during pediatric visits, children receive preventive dental care that they otherwise might not. “There's no special dental chair or equipment that's needed,” said Dr. Nadia Laniado, director of community dentistry and population health at Jacobi. “If they require more extensive work, they're referred to clinic.” In 2015, the U.S. Preventive Services Task Force gave the protocol a high rating, which means primary-care providers can now be paid to apply fluoride varnish for children up to the age of 6 as long as the Affordable Care Act remains in force. For the state's poorest children, New York's primary-care providers can bill for it through the state Medicaid program. “Even though there's a moral imperative, there's also now financial incentive as well, to incorporate this in their daily protocol,” Laniado said. At Jacobi, the logistics of the projects could hardly be simpler. Dentists, who are on the third floor of the hospital, head down to pediatrics on the first floor to train the pediatricians. They teach through practice, and after two or three rounds, primary-care providers are usually able to work on their own. If they want to learn more, they can take online educational modules through Smiles for Life, a national curriculum for oral health. Outside a hospital, it would be harder for dental residents to train primary-care providers, Laniado acknowledged. “In a hospital, just by definition, we are integrated,” she said.
The leading reason for Americans avoiding the dentist, whether insured or not, is the prohibitive cost, leading to issues of medical costs for preventable general health issues down the line. Growing research has found that treating dental issues such as gum disease can aid diabetics in controlling blood glucose levels and in lowering medical costs. Dental pain is a common cause of emergency room visits, with 2.1m visits to the ER in 2010 alone being caused by dental problems, according to the American Dental Association. The effects of poor dental care is even reflected in the working sector as well, as poor dental conditions lead around 30% of low-income citizens to be concerned that it affects their employability. There is a lack of national progress in addressing this issue and including it in general healthcare practices, rather than treating it as a specialty treatment. Separate systems hinder the healthcare system in treating patients effectively, as well as leaving many patients with skyrocketing bills. The Affordable Care Act, now under fire, does mandate that children up to 10 years old are covered for dental care, but adult health insurance through Medicare and Medicaid does not cover dental. New methods of providing dental care are being explored throughout the country on a local level, but the fundamental lack of cohesion between dental care and general health care is even down to an administrative level, as record systems are different for health and dental.