Doctors Take On Dental Duties to Reach Low-Income and Uninsured Patients

DENVER — On a recent Monday, pediatrician Patricia Braun and her team saw about 100 children at a community health clinic. They administer flu shots and treat illnesses like ear infections. But Braun also did something that most primary care doctors didn't do. She peered into her mouth looking for cavities or applied fluoride varnish to her teeth.

“We see more oral disease than the average population,” Braun said of the patients she treats at the Bernard F. Gibson Eastside Family Health Center, a division of Denver Health, Colorado’s largest safety-net hospital. One segment, serves low-income, uninsured and underinsured residents.

Braun is part of a trend across the U.S. to incorporate oral health into medical exams for children, pregnant women and others who can't afford or have easy access to a dentist. Supported by federal and private funding, these programs have expanded over the past decade, but they face socioeconomic barriers, labor shortages, and the challenge of responding to the needs of new immigrants.

Braun and her colleagues used a five-year, $6 million federal grant to help train 250 primary care providers in Colorado, Montana, Wyoming and Arizona. Similar programs are ending in Illinois, Michigan, Virginia and New York, funded by the federal Health Resources and Services Administration's Bureau of Maternal and Infant Health. In addition to evaluation, education and preventive care, primary care providers refer patients to on-site or off-site dentists or work with embedded dental hygienists as part of their practice.

“Federally qualified medical centers have a long history of collocating dental services within their systems,” Braun said. “We're taking the next step and the care is not just co-located, meaning we're upstairs and the dentistry is downstairs, but we're integrated so that it becomes part of the same visit for the patient.”

Tara Callaghan, director of operations for the Montana Primary Care Association, said having doctors, nurses and physician assistants at community health centers to assess oral health, make referrals and administer fluoride would be a critical benefit for many who don’t have access to dental care. crucial for children.

“Providing these services during doctor visits can increase the frequency of fluoride applications and improve parents' knowledge of caring for their children's teeth,” Callahan said. But barriers remain.

Callahan said recruiting dental professionals is difficult because of Montana's vast size and sparse population. She added that 50 of the state's 56 counties are designated dental shortage areas, and some don't have a single dentist who accepts Medicaid. Montana ranks near the bottom for residents with access to fluoridated water, which prevents cavities and strengthens teeth.

Pediatric dental specialists are especially scarce in rural areas, she said, and families sometimes have to drive hours to neighboring counties to seek care.

Having a dental hygienist work alongside a doctor is one way to reach patients through a single visit.

Valerie Cuzella, a registered dental hygienist, works closely with Braun and others at Denver Health, which serves nearly half of the city’s children and operates at five Children's clinics are staffed by health nurses.

Regulations vary from state to state as to what services a hygienist can provide without dental supervision. In Colorado, Kuzera was able to independently perform X-rays and use silver diamine fluoride, a tool that hardens teeth and slows cavities. She does it all from the comfort of her corner office.

Braun and Kuzera worked closely, often completing each other's sentences. They text each other throughout the day, and during brief breaks Kuzera can rush into the exam room to check for gum disease or demonstrate good toothbrushing habits. Braun himself takes similar opportunities to assess oral health during exams, both focused on educating parents.

Medical and dental care have traditionally been siled. “Schools are getting better at interprofessional collaboration and education, but by and large, we train separately and practice separately,” said Katy Battani, a registered dental hygienist and assistant professor at Georgetown University. Battani said.

Battani is working to bridge that gap, helping community health centers in nine states, including California, Texas and Maryland, integrate dental care into prenatal care for pregnant women. Pregnancy creates opportunities to improve oral health, Batani said, because some women receive Medicaid dental coverage and see a health care provider at least once a month.

In Denver, housing instability, language barriers, lack of transportation and the “astronomical” cost of dental treatment without insurance prevent many children, immigrant communities and seniors from accessing dental care, said Sung Cho, a dentist who oversees Denver's dental program. Community health center serving the Denver metro area.

STRIDE attempts to overcome these barriers by providing interpretation services and a sliding-scale wage scale to the uninsured. Among them was Celinda Ochoa, 35, of Wheat Ridge, who was waiting at STRIDE Community Health Center for her 15-year-old son, Alexander, to have his teeth cleaned. During a past physical, he was flagged as needing dental care, and he and his three siblings now see the dentist and hygienist regularly at STRIDE.

One of Ochoa's children has Medicaid dental coverage, but her other three children are uninsured and would otherwise not be able to afford dental care, Ochoa said. STRIDE offers inspections, X-rays and cleanings for $60 to the uninsured.

Last year, Zhao saw an influx of immigrants and refugees who had never seen a dentist before and needed extensive care. Ryn Moravec, director of development at STRIDE, said the number of medical screenings STRIDE conducts for refugees will increase from 1,300 in 2022 to 1,700 in 2023. She estimated the program would attract 800 to 1,000 new immigrants by 2024.

Cho said even as demand continues to grow, the “relaxation” of Medicaid, which is reexamining eligibility for the government program that provides health insurance to low-income and disabled people after the pandemic, has created financial uncertainty. He said he's concerned about the upfront cost of new employees and the expense of replacing aging dental equipment.

At STRIDE's Wheat Ridge clinic, two hygienists move between dental and pediatrics as part of the medical-dental integration. However, Cao said he needs more hygienists at other locations to meet demand. The demand bottleneck caused by the pandemic is only now slowly being cleared, especially because so few dentists accept Medicaid. If they do accept it, they typically limit the number of patients they accept on Medicaid, Moravec said. Ideally, Moravec said, STRIDE could employ two hygienists and three dental assistants.

In 2022, Colorado enacted a law allowing dental therapists (mid-level providers who practice preventive and restorative care) to practice to alleviate workforce shortages. But there are no schools in Colorado to train or certify them.

Before age 3, children will be scheduled to visit the pediatrician 12 times, an indicator of integrated medical and dental utilization, especially for high-risk children. As part of Braun's program in the Rockies, providers have used more than 17,000 fluoride varnishes and increased the proportion of children 3 and younger receiving preventive oral care to 78%, up from 33% in the previous 2 1/2 years.

Callahan of the Montana Primary Care Association has seen it firsthand at community health centers in Montana. “This is to take advantage of the fact that children are going to see a medical provider more frequently and before they go to a dental provider — if they have a dental provider.”

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