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Band-Aid Solutions to the Dental Access Crisis: Conceptually Flawed—A Response to Dr. David H. Smith

Key words: access to dental care, professionalism, volunteerism, oral health, children, disparities, bioethics

	Abstract

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Though laudable, "band-aid solutions" are inadequate to solve dental access problems. By nature, such efforts are provider-driven and not designed to match the needs of underserved populations. They do not empower patients, families, or communities or provide for ongoing care. Band-aid solutions do not ensure a workforce with the capacity or geographic distribution to meet the needs of the underserved. Neither do such solutions address systemic issues such as lack of dental insurance or the need to prioritize prevention. Such solutions do not engage other health professionals in promoting oral health. Furthermore, such solutions maintain the prevailing viewpoint that dental volunteer efforts are all that is required of the dental profession; they fail to acknowledge that a response is mandated by the social contract between dentistry and society. Finally, such an approach fails to recognize the complexity of health disparities and the broad solutions that must be advanced. In the case of children, it is possible to outline an approach to defining a basic standard of oral health care and to argue that all children should receive such care. Band-aid solutions could never ensure a population-wide distribution of care and hence are not morally defensible.

I agree that band-aid solutions are not working. Indeed, who could disagree? I also concur that an inadequate view of professionalism and social responsibility within dentistry contributes to the problem, as Nash also concluded in his detailed review of the Principles of Ethics and Code of Professional Conduct of the American Dental Association (ADA) in 1984.² Although the ADA has since revised this document, it is not clear that there is a broad consensus across the dental community on issues of professionalism. And I agree that pragmatic solutions will require public-private partnership, coupling the resources and power of government with the oral health knowledge and services of the dental field. I also believe in the role of leadership within dentistry to bring about such solutions.

However, I believe there are many more reasons why band-aid solutions do not work. I infer from Smith’s paper that he believes the problems are the inconsistency of care and unfairness to a few dental providers that result when we rely on random volunteer efforts and that, with the appropriate mobilization of governmental resources and inducement of socially responsible volunteer efforts among more dentists, dental access problems will be solved. I don’t believe this is true. The problem is that band-aid solutions to dental access problems are conceptually flawed. That is, there are qualitative as well as quantitative issues at stake.

I hasten to add that there is nothing wrong with volunteer efforts. Every volunteer act should be applauded. Volunteer efforts speak to a sense of social responsibility and community engagement that many dentists possess and act on. It is not the fault of these volunteers that their efforts are inadequate. But such efforts should be part of, but not a substitute for, larger systemic solutions.

	Conceptual Flaws in the Band-Aid Solution Approach

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Band-Aid Solutions Are Not Patient- or Population-Centered
The biggest flaw with volunteer efforts is that the arrangements for and type of care provided are practitioner-driven and not necessarily responsive to patient or population needs. Such efforts depend upon who is available to provide what kind of care, when, and where. Because of the sporadic nature of such efforts, they are unlikely to match patient and population needs. In addition, such providers cannot be counted on for the long term, as Smith points out. Here are some examples of such mismatching of effort to need.

Location.
Volunteer efforts are limited to sites and communities where dentists are willing to participate. It may be that a particular community has a community health center where dentists volunteer. But it may also be that the greatest need is in a local nursing home, prison, half-way house, or outlying community. Care is often provided in emergency rooms.³ Most communities, however, do not have a regular dentist on-call for the emergency room. Transportation and related costs may also be major barriers to access.

Timing.
In some populations, the biggest barrier to care may be timing of clinical services. For example, some underserved communities have many farm workers who need evening and weekend clinic hours in order to access care when they return from the fields.

Language services.
In communities where English is not the primary language, there may be a real need for translators and culturally sensitive office personnel who will help individuals and families through the registration and care process. Not all voluntary settings ensure such services.

Comprehensiveness of care, including adequate preventive services.
For multiple reasons, volunteer clinical services may preclude comprehensive care. There may be limited access to regular preventive services such as cleaning by dental hygienists, so that periodontal disease progresses to tooth loss. Crown and bridge work may not be financially feasible, and patients may have no choice but to have multiple extractions. There is wide variation in the scope of services provided in volunteer-staffed efforts. The overall emphasis on urgent needs deflects from the need to stress prevention at the individual (and community) level.

Continuity of care.
In some remote regions, dentists fly in to provide care on an episodic basis. While that may be appropriate in remote communities, a basic principle of good health care is continuity of care. Volunteer efforts are often episodic, so that the same patient may see a host of different providers with different approaches and levels of skill and/or experience significant gaps in service over time. It is hard to ensure adequate treatment planning and management on an ongoing basis with such arrangements.

Availability of specialty services.
Volunteer efforts will always be limited to who is willing to provide such care. It may be that one kind of dental care is needed—for example, full mouth restoration for a small child—but there are no pediatric dentists or appropriate hospital facilities in this community to provide advanced care. Patients and families may not make it to the next level of care because of distance, lack of pediatric providers or appropriate facilities, or existence of similar volunteerism at the referral site.

Office-based services may discriminate among recipients.
Since health professionals get to choose among recipients of health care in their own offices, volunteer efforts may include pro bono work for "deserving" patients. Bias and discrimination could easily come into play in the dental professional’s choice of a "deserving" patient. Or such decisions might be made by front office staff without the dentist even being aware of the choices.

Addressing needs of patients who don’t get "in the door."
Other patients do not get in the door because of the lack of oral health education or values that support utilization of such care. These patients’ needs go unaddressed in a system that relies largely on dentists providing voluntary care in nonsystematized ways. While adults may make such choices for themselves (although one wonders whether such decisions are truly informed or driven by ignorance and fear), we cannot let the issue slip by when it comes to vulnerable populations such as children. Broader-based community efforts are needed to reach such individuals and families.

Empowering individuals, families, or communities.
Such efforts should take advantage of local strengths by empowering individuals, families, and communities to create systems of cares that meet their own needs.⁴ Volunteer efforts that are largely provider-driven, that lack a strong base within the community itself, will not be able to optimize such locally driven solutions. For example, in some Hispanic communities the use of promotoras (lay health workers) to make home visits, provide health education, and connect families to services has been an important innovation.^5,6 Creative solutions can arise when community efforts include a broader constituency in addition to the dental community.

Band-Aid Solutions Do Not Address Provider Capacity/ Distribution
Workforce capacity.
Workforce capacity includes numbers, distribution, and training of dental providers. Even identifying patient or population needs does not ensure dentists will have the technical or psychosocial skills to meet those needs, although it provides a good starting point. Underserved populations include many young children, patients with special needs, and those from diverse cultural groups. Dental schools have not traditionally provided adequate training in pediatric dentistry⁷ or in the care of patients with developmental disabilities.⁸ A recent survey showed that less than 10 percent of dentists are willing to see children by age one, as recommended by the American Dental Association, the American Academy of Pediatric Dentistry, and most recently the American Academy of Pediatrics,⁹ regardless of insurance status.¹⁰ In addition, dental school education in cultural competency, communication skills, and how to work with underserved families is needed. There is little time to emphasize such skills in the traditional, packed dental curriculum. Quite clearly, the recruitment of a diverse dental workforce is another critical part of the picture that band-aid solutions alone do not address. Diverse populations may be more comfortable with providers of their own ethnicity and race; providers from racial and ethnic minorities are more likely to work with their own populations.

Workforce distribution.
This issue is acute in outlying and rural areas.¹¹ Despite all the goodwill in the world, in many situations there are just not enough dentists to provide care under current arrangements. A systematic approach to providing services to remote regions needs to be created. We must not be distracted from important issues like this.

Use of mid-level practitioners.
Similarly, we need to consider the efficient use of the oral health workforce. This, too, may be skirted with a focus on dentists’ volunteer efforts. While the use of allied health professionals to increase access to dental care is often impeded by scope of practice issues and other battles, it still makes good economic sense. Other more innovative models of care delivery may be needed for remote areas or especially hard-to-reach populations.¹² A focus on dentists’ volunteer efforts will support the status quo in this arena and preclude further needed discussion.

Engaging the non-dental workforce.
There are many physicians, nurses, nurse practitioners, physician’s assistants, and other health professionals (including but not limited to speech/language therapists, occupational/physical therapists, social workers, and pharmacists) who are in a position to promote oral health. Primary care medical providers in particular see children much more frequently and earlier than do dentists. With the limited number of dentists caring for children, this workforce should be educated to screen for and recognize dental disease and promote oral health,¹³ as well as, in some cases, provide simple preventive measures (such as fluoride varnishes). The support of these providers is also needed in joint advocacy efforts for oral health with families, insurers, and policymakers.¹⁴

Band-Aid Solutions Do Not Address Larger Health System Issues, Risk Framing Dental Efforts as Gratuitous, and Do Not Address the Complexities of Disparities
Larger health system issues must also be addressed to substantially improve access to dental care. These include, among others, the absence of dental coverage for large numbers of Americans, including many working poor, and the lack of access to medically necessary dental care in many cases (such as general anesthetic for dental restorations in developmentally disabled populations and oral and maxillofacial surgery or orthodontic care for children with craniofacial conditions).¹⁵

Relying solely on volunteerism risks framing the dental profession’s efforts as nice and commendable (which indeed they are), but not necessary—not a required part of a profession’s social contract with the public it serves. This approach creates a false sense that we are "doing some good," but only a few are doing the good, and it does not acknowledge the professional’s responsibility to the public and the profession’s responsibility for leadership in this area.²

By focusing on a provider-driven model of access, these solutions not only will fail to provide access systematically, but they deflect us from the larger, complex issues behind health disparities. Access to dental care is only one aspect of the solutions that must be advanced to eliminate health disparities. Broad interdisciplinary efforts across health, social, and other sectors will be necessary to effect such change. Patients, parents, advocates, and other stakeholders from communities of concern must be involved. Still, it is the dental profession that must bring the oral health expertise to the table and create the leadership to do so.

	Children’s Right to Dental Care

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Band-aid solutions will never guarantee access to care for all children who currently lack it and are thus not morally defensible as a substitute for more systemic approaches that could support such access. (One might make this argument for other vulnerable populations as well.) We have argued elsewhere that all major ethical approaches to justice (egalitarian, libertarian, utilitarian, and communitarian) support the prioritization of care for children.^16,17 The reasons to prioritize care for children are many and include their vulnerability and dependency on adults and the fact that they are not to blame for their oral diseases. Untreated oral problems interact with children’s health, development, and learning and can affect later opportunities. Children are at the beginning of the lifespan with a maximal chance for prevention of disease and establishment of lifelong health habits. Such care is less costly and avoids placing the burden of disease on children, their families, the health care system, and, ultimately, society. Because of the increasing diversity of the child population (37 percent are from ethnic and racial minorities now, and 50 percent will be by 2025¹⁸) and the poverty of U.S. children (a staggering 38 percent of all children live in poor or near-poor families¹⁹), a very large number of children are at high risk for oral disease. This is a burden that must be prevented; it cannot be handled in the current manner.

Children are society’s investment in a robust future, and their health care must be prioritized. Given our position in the richest society history has ever known—whatever you might say of scarce resources today—an approach that does not create systematic access to oral health care for all children is not morally defensible.

	Oral Health Care Services for Children: A Needs-Based Approach

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Regardless of the difficulties one encounters when tackling the question of "access to what?," it is possible to propose an approach to basic oral health care for children that follows conceptually from the unique needs of children and their disease patterns. This approach follows the work of Wehr and Jameson, who have discussed definitions of medical necessity for children.^20,21 Other approaches are possible, but any construction of basic services must consider the vulnerability of children and their developmental and overall health needs. I will just touch on several principles for such care and leave details to the actuarial experts. To the extent possible, such care should be based on the best scientific evidence available. In the case of pediatric dental disease, there is actually a lot of data on pathogenesis of caries and disease prevention.

Underlying principles of such care for children include the following:

Care must be provided early and emphasize prevention.
Oral health care must start early and involve parents, starting even in the prenatal or early postnatal time period when parents are receptive to health information, in order to intervene in the transmission of pathogenic bacteria. The rate of early childhood caries can double between the first and second year of life, highlighting the need for the one-year oral evaluation. Certain interventions for children with craniofacial anomalies, such as cleft lip and palate, must occur with key changes in physical development to maximize outcomes (for example, alveolar bone grafting). Dental care should include preventive treatments, including fluorides, sealants, and health counseling and, when indicated, restorative care. Timely treatment is necessary to avoid impact on the child’s development. Procedures that lack evidence of effectiveness, such as routine prophylaxis, should be re-evaluated.²²

Children with special health care needs need special attention.
Children with special health care needs (CSHCN) are defined as those "children who have or are at risk for chronic physical, developmental, behavioral, or emotional conditions, and who also require health and related services of a type or amount beyond that required by children generally."²³ About 15 percent of children have special health care needs.^23,24 These children should be provided with medically necessary care to promote development and prevent secondary complications. This might be condition-specific when high oral health needs can be anticipated, such as for children with cleft lip and palate (one of the most common birth defects). General anesthetic should be covered for children requiring extensive restorations or who are developmentally unable to undergo restorative treatment. For all CSHCN, the complex interactions of health, development, and environment lead to the need for coordinated, interdisciplinary team care.²⁵ Such team care should include the full integration of oral health professionals, as in craniofacial teams.²⁶ Collaboration with other health professionals can lead to better oral health care for CSHCN. Pharmacists, for example, can provide information on the oral consequences of chronic medications children may require.

Parents must be considered in health benefits.
The transmission of cariogenic bacteria from mothers to infants necessitates the provision of oral health care for mothers.²⁷ With such coverage, prevention of transmission and establishment of better health habits may be possible. This may have the added benefit of decreasing the risk of adverse pregnancy outcomes in mothers with periodontal disease.²⁸

Children require "wrap-around" services.
Children’s dependency and vulnerability create a positive obligation in health systems to ensure that children have access to needed care, regardless of their parents’ social and economic difficulties. This leads to the need for "wrap-around" services, such as provision of transportation, case management, and other outreach services, which are explicit in the Medicaid EPSDT benefit (which includes dental care).²⁹

Services should be provided where the children are.
In addition, effective means to reach children will engage many other community stakeholders beyond the dental and medical communities, including but not limited to Head Start/Early Head Start, WIC, day care centers, developmental preschools and schools, school nurses, social and case workers, etc. In some communities it may be that dental care would be best provided in these settings.

In summary, band-aid solutions to solving dental access problems are inadequate because of the inevitably sporadic and limited nature of such care and their failure to specifically address the needs of underserved populations. More systematic solutions that cross health professions and health sectors are needed. In the case of children, there are strong moral reasons to ensure access to care to benefit both children and lessen the burden on society. Dentistry has a critical role to play in addressing health disparities, but must partner with other public, private, and community stakeholders to ensure adequate access and a rational approach to health disparities. While a policy that includes basic medical and oral health coverage for all children will not immediately solve the many educational, workforce, and policy issues, with other reforms and broad participation by the dental profession, it could help create an adequate safety net for our most vulnerable citizens. Finally, a broader discussion of professionalism within the dental community could provide additional moral fuel for resolving dental access issues.

	Footnotes

 
Dr. Mouradian is Director, Regional Initiatives in Dental Education (RIDE) and Clinical Professor of Pediatrics, Pediatric Dentristy, Dental Public Health Sciences, and Health Services (Public Health), University of Washington School of Dentistry. Direct correspondence to her at the University of Washington School of Dentistry, Box 357136, B242 Health Sciences, Seattle, WA 98195; 206-543-4885 phone; 206-616-7470 fax; wendy{at}mouradian.net.

Dr. Mouradian’s work was supported by funding from the U.S. Health Resources and Services Administration, Maternal and Child Health Bureau (training grant #1 T17 MC 00020-01) and by the Comprehensive Center for Oral Health Research through its grant from the National Institute of Dental and Craniofacial Research (#P60 DE13061).

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