24 February 2010

Ignore your teeth and they'll go away

DentalCariesOne of the least-favorite complaints for an ER doc is the patient with dental pain. It's one of those low-level annoyances. The typical dental pain visit takes about three minutes and no mental effort -- it's usually not a challenging interaction. It is just about risk-free and reimburses nothing. But it's frustrating because usually there's nothing an ER doc can do for the toothache but write a script for antibiotics and narcotics. Some practitioners like the dental blocks, though I usually don't bother because they're such a temporary band-aid. And many of the patients complaining of dental pain are repeat visitors for the same problem, so there's a tendency to write them off as drug-seekers, which some but not all of them truly are.

The problem is that the dental pathology we see is real, and awful. I'm not talking about the scumbags with their meth-mouth, though that's bad enough. I see a lot of regular folks, middle to lower-class, and look into their mouths and see maybe a dozen intact teeth, with the other 20 teeth either in a state of advanced decay or, more commonly, just broken off at the gum line. No wonder it hurts! There's often signs of a brewing periodontal abscess, but even without an infection it still makes me wince to see. And I check the records and see that this patient has been in the ER ten times for dental pain. So I ask, "Have you thought about seeing a dentist?"

The response never varies: "I've called all around and nobody will take me because I've got no dental insurance/they don't take the DSHS insurance."

And I believe them. Bear in mind I'm not just talking about the completely indigent, but also the working poor who may have health insurance but do not have dental coverage and cannot afford the all-cash cost of dental care.

There are free clinics, and the traveling dental van, but they are totally overwhelmed by the demand, and in many cases they cannot perform the very difficult extractions and other procedures required by the severe dental disease they are faced with. And they tend to give priority to children and women, which leaves the poor males without any access to care. The best I can do is give them a referral to the University dental school, which is 30 miles away and not really accessible by public transportation.

That, my friends, is the definition of futility.

Harold Pollack over at TNR's The Treatment has a highly link-worthy piece about this problem, and how it represents a huge gap in the health care reform debate.
[M]illions of Americans do not receive needed dental care. Crummy teeth have long provided a painful and stigmatizing symptom of extreme poverty. Medicaid often provides meager coverage and pays dentists very little. (Dental care is a continual problem for many low-income Medicare recipients.) The Washington-area death of 12-year-old Deamonte Driver from an untreated tooth abscess brought public attention to the most dire potential consequences of untreated dental concerns. ... Basic dental care is not particularly costly. Unfortunately, it is generally restricted to its own silo, separate from the rest of American medical care. Some dental leaders such as Burton Edelstein and Allen Finkelstein have argued for a stronger focus on prevention, and a greater integration of medical and dental concerns. They face difficult challenges in dental care financing, existing public policies, and the mores of the dental profession itself.
Part of this is linked to the collapse of Medicaid programs nationwide. But the "separate silo" point is particularly incisive. Why is dental care not generally considered part of health care? Why are dental policies typically a separate insurance policy from health care insurance policies? When states mandate health care insurance plans to cover basic health services and preventative care services, why is dental care not considered part of this? If mental health parity is to be included in health care reform, it is a missed opportunity for health care reformers not to have included dental health parity in the reforms as well.

By the way, I'm not criticizing the dental profession here. Most of the local community dentists do offer some charity care and some discounted care. The reality is that as private businesses, they can't afford to give away all their time for free, and the demand far, far exceeds the capacity of the dental community's ability/willingness to provide charity care. Counting on charity to fill the gap is clearly not a realistic solution to the problem.

This has been -- and remains -- a major blind spot for the health care policy wonks, and looks to remain so even if the health care bill moves forward. More's the pity.


  1. Another local good resource for cheap dental care are the community and technical college dental programs. Many take DSHS coupons, even, and they *LOVE* people who haven't had a cleaning in four or five years or more.

    I thought they only did minor stuff like cleanings, but turns out they do complex stuff including extractions and prosthodontics. Fillings are $75-100 cash, a cleaning is $50, and the work is excellent. I pay about $300 ($75/visit x 4 visits), for a deep-root scaling and planing, compared to the last time I went to a private practice and paid close to $1400. If I had dental coverage, they'd bill them as well.

    It's a good deal; the downside is longer time in chair for some services, and once in awhile, you'll get someone who is just awkward and pokes around in sensitive spots. I use Lake Washington Technical College and see an academic endodontist for a freaky problem, and they're consistently impressed with the quality and thoroughness of the work. Overall, it's a great option. Maybe you could lean on social work to come up with a better referral list?

  2. Annual dental care costs far less than a monthly cellphone. And yet every poor person I see has a cellphone.

    Priorities priorities.

    Watch an MTV special called "My parents are poor" or something like that, and marvel that a family of 4 with two pregnant 16 year old twins all carry cellphones while they fight for the charger in the double wide.

    It boggles the mind.

  3. Sure, it's cheap if you've consistently had two cleanings a year and decent oral hygiene.

    Fixing a mouth of doom like in the picture is a multi-thousand dollar process and even my luxo-phone only runs me $1500/yr in monthly increments. Hearing an estimate of 6K to stabilize the worst problems is enough to make anyone blanch. Hell, I couldn't swing $6K in cash right now, and I'm in a pretty swell financial position compared to 95+% of the world's population.

    Dental rates are also vastly outpacing both inflation and wage growth - they're on about a 7.5% annual increase path, for about the last ten years, so they're effectively doubling every ten years. It's one segment of healthcare that is largely immune from managed care pressures - DMOs are rare birds, and very few patients have plans that prohibit balance billing, so the sky is *really* the limit.

    I agree that a large amount of dental pathology is made worse by lifestyle factors; smoking, sugary soda, lack of oral hygiene, well water (or bottled water without fluoride), drugs, and choosing to spend the money on something other than dental care, but if you haven't had to pay cash for dental care recently, you'd be shocked as to how expensive stuff is in the private market. In the Seattle area, a simple anterior root canal by a private general dentist starts at $1000, cash on the barrelhead. Figure $1500 for a molar or if you have it done by an endodontist. Gone are the days of the $100 root canal.

  4. A secondary effect from bad teeth is poor nutrition. People are unlikely to eat an Apple without teeth to bite, and people will be unable to grind their food up with molars to-swallow-to digest properly.
    I`m in Canada and our dental coverage is free for those on welfare.

  5. >>Sure, it's cheap if you've consistently had two cleanings a year and decent oral hygiene.<<

    And any family that has a cellphone, cable TV and/or an XBox that has neglected two cleanings a year and doesn't floss and brush daily are fools. They deserve whatever they get in the way of bad teeth.

  6. Even getting their teeth checked out once a year, instead of the recommended twice, could save people unbelievable amounts of pain and discomfort, let alone $$.

    But if your parents didn't bring you to the dentist as a kid, and didn't teach you any oral hygiene (which maybe they were in dentures by 35, so what would they know about O.H.?) then by the time you might possibly be able to afford once- or twice-yearly visits, you are so far behind in the cavities dept. that those visits won't accomplish anything.

    If people were better educated about their teeth, then better/more dental insurance wouldn't be necessary.

  7. To the Anon with the cell phone problem:

    Um. I usually don't leave comments. But the 'you have a cell phone, you aren't poor' thing is getting to me.

    I am on food stamps and medicaid. I have a baby and a boyfriend (the father of said baby and my only sexual partner ever -because every time I say boyfriend people just assume he a boyfriend-of-the week). We'd be married already, but both our families want a big party and we just can't afford one right now. Funny how I feel like I have to qualify all of this after seeing your comment.

    Anyway, we both have cell phones, and here's both of our monthly bills. Mine: $0. Boyfriends: $0. Our families bought and pay for them. They cost us nothing, we didn't even have to pay for the phones themselves. They were gifts. Should I give them up so you can feel better when you see me?

    God I am so tired of feeling like I have to justify myself. Too bad classism isn't as much of a stigma as racism.

  8. In Washington most of the Family Med. residences have incorporated some training in oral health emphasizing screening and preventive care for kids. Free training is also available for practicing primary care physicians who are willing to incorporate oral health into their well child checks. I can't solve everybody's problems but it is a good start. Take a look at
    the Washington Dental Services Foundation's project.

    I know that I haven't had dental care as an adult. I'm fortunate to have good teeth and some self awareness. I'm also close enough to take advantage of the UW School of Dentistry if I have a need.

    Promoting Oral Health: The Family Physician's Role

    Delivering Preventive Oral Health Services In Pediatric Primary Care: A Case Study

  9. Anonymous, if you think dental care is cheaper than a cell phone perhaps you ought to go check out the various "go phone" type carriers around. You are getting ripped off by your carrier. My last T-mobile go phone cost me literally 70 cents a month. That, dear friend, is less than a tube of toothpaste. Maybe you could take the money you save and donate it to the poor.

    Poor people need to keep in touch with their families and loved ones just like the middle class do.

    What would make you think poor people don't need to talk to friends and family just like you do.

    I have bad gums and if I wasn't comfortably middle class with medical insurance from my job I'd be toothless by now. To keep teeth in my head I have to have quarterly cleanings by my hygienist. Its not cheap. When I see these people with their rotten teeth I think there but for the grace of god go I, not fuck them, they should have made better decisions, picked their parents better, been luckier in the lottery of life or whatever.

  10. Anybody complaining about poor people with cellphones is stuck in the nineties. For many of us, cell phones are no longer a luxury; they are now a requirement. Is the bus stuck in traffic? You are expected to call work and let them know. And your boss had better be able to reach you on the weekends.

    Anon@2:13, don't you think it's possible that there might be something about these poor folks that you don't know? Have you been in their shoes? Howabout walking a mile or two in them before you condescend to judge?

    Nobody deserves bad teeth.

  11. Many community colleges have dental hygiene programs which offer free cleanings done by students under supervision of their instructors. It's another option for those who can't afford a regular dentist.

  12. "Nobody deserves bad teeth"

    Deserve? It is not rocket science.
    If you have bad parents, never taught the daily discipline to brush-floss, you have bad teeth.

    Myself I drank cokeacola too much- without food and didn't know how bad it was for my teeth/ was addicted to the sugar-mix.

    I lost a molar.

    Only since I lost a molar do I now take my oral health seriously.

    You don't know what you have until its gone.