Fluoride Action Network

Many in Appalachia suffer dental woes that start early and last a lifetime

Source: The Columbus Dispatch | December 30th, 2012 | By Misti Crane
Location: United States, Ohio

MARIETTA, Ohio — Some of the adult patients at the Southeastern Ohio Dental Clinic didn’t see a dentist once during childhood. Children as young as 5 have had to have all their baby teeth pulled.

Patients in their 20s sometimes need dentures.

Often, the only thing that brings them there is pain that won’t relent and keeps them from sleeping or working.

The Marietta clinic is run by the Washington County Health Department and is a rarity in Appalachia: a dentist’s office that cares for Medicaid patients and those with no insurance who pay on a sliding scale according to income.

For most of them, that means about $30 an appointment, office manager Karita Miller said.

It is considered a shining example of good in a region that is home to many without the money and resources to take good care of their teeth.

These problems aren’t unique to one region of the state. Dental care is the top unmet health need in Ohio.The problems are amplified in Appalachia, where children have an almost 60 percent higher rate of tooth decay and about half of working-age adults don’t have dental insurance.

There are many problems, few resources and no easy fix.

Dr. Paul Casamassimo, chief of dentistry at Nationwide Children’s Hospital, said his staff sees many patients who can’t find care in Appalachia. The Marietta clinic refers children with severe problems to Columbus, and children from throughout the region end up there, often when problems cannot be ignored any longer.

“You’re talking about this hot spot of tooth decay in Ohio that is the result of many things — social deprivation, lack of fluoride, lack of access to care, just general poverty,” Casamassimo said.

“Ultimately the solution, whatever the constellation of approaches is, really is going to cost money, and I think that’s something that’s a very, very high hurdle to get over.”

Current efforts to help include school-based sealant programs in most Appalachian counties. Almost 60 percent of children in the region had at least one sealant, according to a 2009-2010 survey.

State leaders and other experts say they’d like to see more pediatricians provide basic dental education and apply sealants. (They are allowed and are reimbursed for it through Medicaid.)

Dr. Patrick Lloyd, dean of Ohio State University’s College of Dentistry, said he considers dental care in southeastern Ohio a priority for the school, which is working to recruit a higher percentage of students from the region. Currently, about 3 percent of the students come from Appalachia; Lloyd wants that to increase to 6 percent with the next freshmen class.

The key to planting more dentists in Appalachia is twofold, as he sees it. New dentists who grew up there are more likely to return. And if the state helps more dentists get rid of debt if they practice in the region, they’ll be lured there. Lloyd said he has been working with state leaders to discuss new loan-forgiveness programs. “There are some of these, but there aren’t enough.”

Dentists graduate with an average debt of $195,000, he said.

In Ohio, there is one dentist for every 1,874 people, according to the Ohio Department of Health. In Appalachia, there is one for every 3,138 people.

One of those dentists is Dr. William Gable of McConnelsville in Morgan County. And he accepts Medicaid.

Gable said the only way he sees more of his colleagues setting down roots in Appalachia is if reimbursement from Medicaid increases.

He chose his practice almost three decades ago because he thought it had a lot of potential. Then he fell for the town. “The practice brought me here, but the people kept me here.”

More than half of his patients are on Medicaid, and things can get tight for him financially, Gable said.

The state has had some success luring dentists to poorer areas with its existing loan-repayment program, but most don’t stay in Appalachia for the long term, said Barbara Carnahan, an oral-health information specialist with the Ohio Department of Health.

A task force convened by the department recommended in 2009 that the state explore higher Medicaid reimbursement for dentists practicing in the region.

Carnahan said she thinks that more portable dental clinics, which can be set up in gyms, libraries and elsewhere, could help if dentists are willing to visit the area regularly.

“We have to think nontraditionally about how to bring care to them,” Carnahan said.

The Marietta clinic, which provides all the care that can be performed without general anesthesia, is funded through a state grant.

Nearby dentists who do accept Medicaid patients limit the number, Miller said. The nearest oral surgeon who will accept them is in Lancaster, about 45 minutes away. The wait to get in is long, months usually, she said.

Miller, the office manager, and hygienist Adessa Jackson said that poverty is the primary obstacle to better dental health in the region, but there are many contributing factors.

Some patients say they can’t afford toothpaste and toothbrushes (the clinic helps by providing some free); others say they don’t understand why they should worry about their children’s baby teeth. (Healthy baby teeth help ensure a healthy adult mouth.)

And then there are the challenges of nutritional habits. Sugary drinks in toddlers’ sippy cups are common. One mom came to an appointment during which her child was having teeth removed carrying a bottle of Mountain Dew for the child to drink.Smoking also contributes to dental problems, and rates are especially high in Appalachia.

Jackson said she tries to educate as much as she can during appointments, stressing the importance of a low-sugar diet and regular oral hygiene.

“I try to educate the kid if the kid doesn’t have any backup at home, if there is no enforcement,” she said. Sometimes, she shows them scary pictures of what could happen if they don’t care for their teeth.

Mistey Deeter, a 37-year-old Medicaid patient who was having work done at the clinic this month, travels about a half hour from her home in Belpre. It’s not uncommon for patients to have to travel significant distances for care, and transportation can be an obstacle.

“It’s hard to find anybody who will take the Medicaid card,” Deeter said. “They either aren’t taking new patients or they just take them if their families are established already.

“I’d love to see this kind of place all over to help people.”