Oxford county experiences high barriers to oral health care

STATE — For decades, Maine has struggled with an oral health crisis. The issue is particularly acute in rural communities, like Oxford Hills.

Oral health stakeholders agree the barriers to adequate oral health include a dentist shortage, limited insurance coverage and a lack of awareness.

A recent study of Maine's oral health conducted by the Center for Health Workforce Studies (CHWS) at SUNY University at Albany (New York) shows 50.6 percent of adults in Maine had at least one tooth extracted in 2010, nearly 7 percent higher than the national average – an indication of the problem.

Dentist shortage

Some stakeholders say a shortage of dentists is critical – without dentists, people cannot receive care.

According to the CHWS report, Oxford County has the lowest dentist-patient ratio in the state – only 2.25 per 10,000, less than half the state average. Almost the entire county is a designated dental Health Professional Shortage Area (HPSA).

As Marc Coulombe, research associate with the Department of Health and Human Services explains, a variety of factors, including poverty, area, population distribution and dental office capacity are used to calculate HPSA.

“In a rural state, the number and distribution of the health care workforce in general, but dentists in particular, is going to be a challenge for access to care,” says Judith Feinstein, director of the Maine Oral Health Program at the Maine Center for Disease Control.

Despite the shortage, John Bastey, from the Maine Dental Association, says many dentists have openings for new patients – poor oral health isn't explained by to few dentists, he says.

Bastey uses the example of no-shows to illustrate his point. Some dentists have told him 20-30 percent of patients do not come to appointments – other patients could have filled those spots.

“Is that an access problem?” he asks. “There's a dentist ready and available.”

Maurice Convey, owner of Oxford Hills Dental in Norway, has been practicing in the area for 16 years and business is steady, but not overwhelming – Convey says he is always accepting new patients.

Sometimes, paying for the care is the problem.

Insurance woes

“We don't have a system of care that's covered adequately by either private or public insurance," says Sarah Shed, from the Maine Dental Access Coalition.

Shed says about a third of Maine's population does not have dental insurance and the cost is prohibitive to pay out-of-pocket.

But insurance only covers a fraction of the cost, Shed says.

"The dental benefits that some employees have, it goes up to $1,000," Shed explains. "Which is what it was 20 years ago ... Even if you have dental coverage through your employer, it doesn't cover very much, then you have to go right to out-of-pocket."

Medicare doesn't even cover oral health, Shed says.

"There's no dental benefit in Medicare. None," Shed says."Once you turn 65 you've got nothing, unless you can do private pay."

MaineCare patients are in a similar situation. According to Feinstein, oral care is covered for those under 21, but adults are limited to urgent care – like tooth extraction – and prior authorization is required.

Even if MaineCare covered adults, dentists still might not accept them. Reimbursement does not cover costs, says Bastey – the fee schedule should be increased.

"MaineCare pays about 40 percent of the usual customary rates," Bastey explains, "but the overhead for dentists is about 65 percent.

“If you're getting paid 40 cents, you're losing 20-25 cents before you even break even.”

Convey says that he used to accept children on MaineCare free of charge, but with recent financial constraints he can't accept new MaineCare patients at all.

Convey estimates 60 percent of his patients have dental insurance. Thirty-eight percent pay out–of–pocket.

Without access to preventative care, many patients end up in emergency rooms.

Emergency care

According to the CHWS report, in 2006, "complaints for avoidable health care conditions was the top reason why MaineCare patients or uninsured patients between the ages of 15 and 44 went to an [Emergency Department] for services.”

Emergency dental care in Maine cost around $6,590,888 in 2009, according to the study.

Dr. Rebecca Chagrasulis, the ED director at Stephens Memorial Hospital in Norway says the department receives around one patient a day for dental pain – often an infection or abscess has developed.

Despite the influx of patients, physicians are unable to offer more than prescriptions for antibiotics and pain medication, Chagrasulis explains.

"We try to tell the patient – 'we're not dentists; we can't fix your tooth,'" she says.

Convey agrees that too many oral health patients use the ED – it is expensive, inefficient and sometimes physicians misdiagnose and wrongly treat an issue.

The cost of equipping a hospital with dental health facility and keeping an on-staff dentist is prohibitive – some EDs in the state are trying to expand care by shifting emergency patients to local dental care centers but no such arrangement is currently available in Oxford Hills.

In the absence of care, patients often need to have teeth extracted.

“These people are getting teeth pulled for no reason,” Chagrasulis says. “If they had got dental care from an early age they probably wouldn't be in that situation."

Education

Poor oral care frustrates stakeholders in part because it is almost entirely preventable – but many people don't appreciate how important it is.

"They view it as less essential than it actually is," Shed says. "That's a cultural thing that we need to educate people about."

Feinstein, from MECDC, doesn't completely agree.

“I would not want to lump people together and say that people think their dental care or their oral health is not important,” says Feinstein. "Purchasing dental care competes with other needs people have."

Convey says that education is a comprehensive problem – he even sees physicians come in with “rotten mouths.”

"It's not just poor people who are uneducated and don't know how to take care of their mouths,” he says. “I have many educated patients who come in regularly and their mouths are in terrible shape."

People need to understand how lifestyle affects their health outcomes, Convey says.

"I see … kids walking home from high school with a two-liter bottle of Pepsi or Mountain Dew in their hand ... I know if I open up that kid's mouth, he's going to have a mouthful of cavities," Convey says.

“Its very frustrating ... unless you can break those dietary habits, things aren't even really going to change for the people you are able to care for."

Dentists themselves don't often have the time to offer additional education, Convey says.

"They're so focused on fixing what the problem is it's hard to take a step back and look outside the box and say 'we've got to change your behavior here because I can fix these little problems all day long and you're going to come back with the same problems.'"

All stakeholders agree that the problem is persistent – none have seen a significant change in the past few years.

Many are pinning their hopes on the new College of Dental Medicine that will open at the University of New England in 2013. Training more dentists in state will increase the chance they will practice here, stakeholders say.

But even with more dentists, a sea-change in Maine's oral health might be a long way off.