Dentistry as canary?

The United States faces a hidden health care epidemic of near-crisis proportion. But this epidemic has not received the attention it needs or deserves. The crisis is in oral health. Yet, several key professional issues related to this crisis extend well beyond oral health disease and treatment--how the nation's health care system and health care professionals respond to this epidemic speaks volumes about the typical responses to a long list of anticipated health care crises we may witness over the next two decades as our population ages.

First for the crisis ... the Surgeon General's report (1) on oral health care illuminated the problem. Despite advances in dental science and practice that have resulted in great improvements in our nation's ability to provide oral health care, dental disease of all varieties has reached epidemic proportions. More significantly, however, disease is becoming localized with greater intensity among populations that have limited access to care because of inability to pay, age, cultural dissonance, and/or physical isolation. (2) These problems manifest in many different ways, but they also coalesce in unique ways, resulting in oral health problems for the elderly, new immigrants, children, the poor, the uninsured and for individuals whose health-seeking behaviors are culturally distinct from mainstream, Caucasian, middle-class norms. As these problems become more evident, their divergence from the existing system of oral health care delivery also becomes more obvious.

This perspective is not offered to impugn the dental delivery system. For where professionals have directed special attention, efforts have been enormously effective. However, the general lack of response raises serious questions about where our system of care is currently focused, and where it will be focused as Americans become older, more culturally diverse, with incomes more disparate, and with insurance less likely to cover oral health services.

What needs to be done? First, the dentistry profession must ask itself whether it wants to be the leadership profession for the nation's oral health concerns, or the leadership profession for bungalow solo private practices in the nation's suburbs. If it is the latter, then the profession can continue on its current pathway, and resign itself to serve less of the overall oral health care needs for the nation. If it wants to pursue the former, the pathway is less clear but far more important. The profession must turn its enormous energy and talent to creating new ways of organizing and delivering oral health care. This pathway is reminiscent of the crusade for fluoridated water supplies: even this effective public health measure is still inadequately deployed, but could serve as a model of redesigning oral health efforts. An essential next step must be targeting populations--old, young, culturally diverse, poor--that need but do not receive adequate care. It will be vain to try to fit this set of needs into the suburban bungalow practice model. Instead, dentistry must take the lead in applying or inventing relevant strategies that reach into schools, nursing homes, disadvantaged neighborhoods and primary care medical practices to organize, deliver and finance oral health care services.

This will take a great deal of vision and courage by each profession involved--also for practitioners, regulators, public health leaders, insurers, and educators. It will also require that these leadership communities work together, not against one another, to create a new pathway for the nation's oral health and for professions that have accepted responsibility for this care.

If dentistry chooses the status quo, it will likely continue its recent advances, but will find that its success has waning relevance to the country's oral health needs. Soon, many dental professionals' nightmares that oral health care will be provided outside the dental professional model will become a waking reality. The time for the profession to choose is now.

In coal mines of old, canaries were an important indicator of when and how to respond to changing conditions. Dentistry will face these health care challenges sooner than other segments of the system; but, as we consider increasing costs of all care, the tattered safety net, the plight of the uninsured, the demise of effective primary care and growing concerns about patient safety, all parts of the health care system will need to respond to similar leadership challenges.

References

(1.) United States Department of Health and Human Services. Oral health in America: A report of the Surgeon General. Rockville, MD: U.S. Dept. of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. 2000.

(2.) Mertz E, O'Neil E. (2002). The growing challenge for providing oral health care services to all Americans. Health Affairs 21 (5), 65-77.

Edward O'Neil, M.P.A., Ph.D., is Professor of Family and Community Medicine and Dental Public Health at the University of California, San Francisco. He also serves as the Director of the Center for the Health Professions, a research, advocacy and training institute created to assist health care professionals, health professions schools, care delivery organizations and public policymakers to respond to the challenges of educating and managing a health care workforce capable of improving the health and weft being of people and their communities. For more information about the Center for the Health Professions please visit www.futurehealth.ucsf.edu.