Reaction to “Oral Epidemiological Trends in Maryland”

Abstract

The paper by Vargas et al. describes trends in oral health in Maryland over the past 10 years, illustrating Maryland's considerable progress in improving oral health for children covered by Medicaid 1. Some of the factors identified that impact children's oral health included the following: Strong dental and dental hygiene workforce. Death of 12-year-old Deamonte Driver because of a dentally related infection. Strong water fluoridation program statewide. Doubling of the percentage of Medicaid enrolled children under 21 years of age. Physician's participation in providing oral health preventive service. Increase in school-based sealant program resulting in a doubling of the percentage of Maryland children with sealants. The net result of these factors, as well as others, has been positive for the oral health of Maryland's children. In addition, over the past 10 years, Maryland has also seen modest reductions in edentulism and age-adjusted oral cancer incidence and mortality. While this is all good news, the findings of Vargas et al. also illustrate the oral health chasm that still exists in Maryland and, indeed, throughout the nation 1. The “chasm” issues include the apparent continuing disparities in oral health, which are largely related to geography, income, socioeconomic-ethnic status, and oral health literacy. While the caries experience in children declined over a 10-year period, there still remains a gap of 25-30 percent untreated caries, which is close to the national average. From this author's perspective, the benchmark comparison of Health People 2020's objective of 25.9 percent of 6- to 9-year-olds with untreated caries is appropriate but, simply stated, the benchmark itself is too low, given the resources in the nation and the amount of money spent on health care. The paper demonstrated Maryland's commitment to preventive care and their willingness to use the eight benchmarks created by the Pew Center for the States. However, the data reveal that the percentage of children with a preventive visit and who received dental treatment in 2009 still ranks below the national average. The lack of a statewide sealant program is a further illustration of the gap in prevention that continues. So, although Maryland has achieved success in reducing caries in children, it has probably reached a steady state until prevention becomes more widespread and the diagnostic coding and reimbursement system rewards the oral health workforce for preventive services and for rewarding improvements in health outcomes rather than paying for procedures. The unsettled state of the US economy and the resultant reductions in funding for Medicaid across many states suggests an increase in oral and systemic chronic disease problems in the future. A recent report in the New York Times demonstrated that more places are “defluoridating” water supplies to save money 2! How can that be helpful? Vargas et al. also point out that the poverty index has been increasing, thus putting more individuals with declining incomes into the Medicaid-eligible category. Indeed, at the national level, recent studies on The Pine Ridge Reservation in South Dakota demonstrated that 90 percent of adults and children had active decay and about half were missing teeth 3. Batliner points out that in the Pine Ridge community oral diseases are rampant and access to care is a “cruel joke”2, 4. The call by Batliner and others is to rethink the make up of the oral health workforce to include a midlevel provider (dental therapist) 2-6. There is considerable discussion of this issue as the most appropriate comprehensive means to address the oral health-care access problem. This author's reaction to the data of Vargas et al. is to compliment Maryland on its proactive status as it moves forward with health-care reform and health exchange to include dental. At the same time, there remains disappointment in how far Maryland and the nation needs to go to truly improve access to quality oral health care and to reduce the burden of disease. The data show that Maryland can be recognized as a leader at a pivotal time in the nation's commitment to the elimination of disparities, which improve access to care and for demonstrating the power of a committed coalition aimed at improving the oral and systemic health of its citizens. The author declares no conflict of interest.