Allan J. Formicola

Improving the Oral Health of Prisoners to Improve Overall Health and Well-Being

General health and oral health are linked. The surgeon general’s report on the state of the nation’s oral health indicates that you can’t have one without the other. The same report notes that while the oral health of the nation improved significantly over the 20th century, there are major disparities in oral health among subpopulations.1 The formal call for papers for this issue of the Journal yielded no papers on oral health in the prison system. A review of the literature in PubMed turned up very few published articles on the oral health of prisoners or systems to provide prisoners with oral health care; of the 12 peer-reviewed articles found, 5 were published outside the United States, 4 were published in 1977 or earlier, and only 1 discussed juvenile offenders in detention. To better understand the status of oral health in our nation’s prisons, we read what literature we could find and spoke to several dentists who work in the prison system.

The Dental Profession in Transition

During the 20th century, dentistry has evolved as a profession, one offering a full range of services, from effective prevention to complex oral and maxillofacial surgery and from basic restorative care to full rehabilitation of severely compromised dentitions. Our understanding of the underlying pathology that accounts for oral diseases and our knowledge about the interaction between oral diseases and diseases and disorders of different organ systems has been significantly enhanced through basic, translational, and clinical research. The dentist is well respected by the public,1 and the 2000 Surgeon Generals report2 on the oral health of the nation stated that the oral health of the nation over the past century has greatly improved. On the other hand, the same report indicated a silent epidemic of oral disease was impacting low-income individuals as well as racial/ethnic minorities. These groups have limited access to dental services. Reports of children dying because of neglected oral disease have heightened public and professional, as well as legislative and governmental awareness of this problem.3 Some have called this time period (i.e., the 20th century into the beginning of the 21st century) the best of times and the worst of times for dentistry. Presently, the profession is able to offer a high level of care to approximately 75% of the public through the private practice system. By contrast, at least 25% of the public—or 75 million Americans—have either limited or no access to oral health care. Furthermore the profession must seriously discuss its future as it pertains to the new health care environment. According to many, dentists—with an undergraduate degree, four years of dental school, and with additional postdoctoral training—are overeducated for much of what they routinely do (more than 60% of recent graduates opt for one or more additional years of postdoctoral training).4 The dental profession needs to address the issue of scope of practice, which will allow the profession to both define itself in the context of primary health care while also providing services to a greater proportion of the public. A November 2010 US Government Accountability Office (GAO) report5 to Congress showed that there were still 4377 dental Health Professional Shortage Areas (HPAs) and a limited involvement of dentists treating Medicaid and Childrens Health Insurance Program (CHIP) children, with 25 of 39 states reporting fewer than half of the dentists treating any children in those programs. Some limited progress has been made over the past four or five years to increase the number of dentists and hygienists providing dental services in health centers (from 1912 to 2577 practitioners) through federal grant programs, but these centers only provide care to 3.4 million patients. Although we applaud the effort to increase the dental workforce in health centers that dedicate themselves to the underserved, finding ways to provide access to the millions who cannot receive treatment will require fundamental shifts in how the profession at large approaches the problem. Since 1981, Columbia University College of Dental Medicine has addressed various issues in dentistry from the broad perspective of society. In November 2010, the 15th Dunning Symposium—named in memory of James Dunning, a 1930 graduate of the dental school and a founder of the field of public health dentistry—hosted discussions on the practice of dentistry for the 21st century. The invited speakers considered the health care reform, the access-to-care challenge, as well as a vision for dental education and future practice. We believe that a careful reading of the six articles in this issue (representing the Symposium topics) will point to new ways in which dentistry can play a stronger role in the primary care health system and can improve access to care for those left behind. In our view, an important message garnered from these articles is a call for the profession to “scope up,” that is, to become a stronger part of the primary care workforce by screening for chronic disease in their patients. Many of these diseases affect the presentation of oral disease or a patients ability to tolerate dental treatment. Dental schools can prepare their graduates to integrate into the primary care workforce through offering a wider range of courses, emphasizing interprofessional education, and allowing dental students opportunities to focus on public health and other electives during their training. For a dentist to be able to concentrate on the more complex dental patients and the more complicated and medically compromised patients, some of the basic procedures can be delegated or “scoped down” to midlevel providers. These delegated tasks would occur under the dentists supervision and as part of a team approach to the provision of dental services. Dentistry can be expected to extend care to the underserved by using midlevel providers without disturbing the current private practice system that serves the majority of the public, but this implementation will take a new commitment by the profession to come together and utilize a new type of provider to help reach the 25% of the public that cannot obtain care. The GAO report points out that the use of mid-level dental providers is not widespread in the United States, and other countries have used them to improve childrens access to dental services.5(p28) The dental therapists currently working in remote villages under the Alaska Tribal Health Consortiums plan have been shown to practice safely and to provide quality care within their defined scope of practice. We understand that improving the oral health of the underserved or uninsured in all 50 states and the District of Columbia is a complex problem that must carefully take into account cultural beliefs and economic factors, including the distribution of dentists. However, we cannot hide behind those reasons for inaction, but, instead, must seize this time of health reform in the United States to improve the oral health delivery system. Lest we forget the human element surrounding the desire of the poor for oral health care, we turn to Uninsured in America.6 In this book, the authors report that the underinsured populations number one request is for dental insurance. Uninsured people suffer because of a lack of access to dental care; the appearance of their rotten teeth prevented them from getting jobs, eating a proper diet, and thereby controlling obesity and managing diabetes. Responding to this need is a task for us all.

Lamster and Formicola Respond

Giddon et al. suggest that as midlevel dental providers (MLPs) are introduced, confusion can occur regarding who is a dentist and who is an MLP. They suggest that a name change is in order and that “oral physician” be used to differentiate doctoral-trained providers (dentists) from others who do not receive this level of education. The authors reference our recent editorial,1 which introduced reports from the 2010 Dunning Symposium, a meeting held every few years at the Columbia University College of Dental Medicine with a focus on the role of dentistry in society. In fact, an article by Lamster and Eaves,2 also from this symposium, included a discussion of the arguments for and against the name change from “dentist” to “oral physician” and reviewed the case made by others regarding a name change. This subject was specifically included because it relates to the topic being discussed—expansion of health services in the dental office. In the United States, MLPs are a new class of dental providers that have been proposed to address access to oral health care concerns. They will provide a limited range of basic but nonreversible procedures. MLPs receive considerably less training than dentists and would provide services in areas and locations where dental care services are not readily available. These providers would work under the indirect supervision of a dentist. In the United States, MLPs have been introduced on a very limited basis.3,4 Although Lamster and Eaves2 do not draw any conclusions regarding the desirability of using the term “oral physicians,” let us address the argument made by Giddon et al. First, the introduction of MLPs in the United States has encountered considerable resistance, and widespread introduction is not imminent. Second, the name change question would likely complicate the more substantive issue raised,2 which is the desirability of expanding the scope of dental practice to include primary health care activities. Third, as midlevel providers have been introduced in medicine with appropriate identification, patients have not been confused by the role filled by midlevel providers (e.g., physician assistants and midwives) versus the role filled by physicians. Giddon et al. feel passionately about the importance of this name change.5 Perhaps a more prudent approach would be to implement changes in clinical care and determine how these changes impact the health of patients and the mix of services provided by dentists. If benefits to patients’ health are realized and interaction between dentists and other health care providers increases, perhaps a name change would be indicated. Then the debate could be reexamined with a focus on the substantive issue of improving health, not on avoiding confusion.