Poor Economy Negatively Impacts Dental Health

[sushantpatel_doc]

When the economy was declining in recent years, people chose to skip dental visits instead of cutting other costs. That trend may be changing, however.

But the problems have worsened for the patients who now have some dental issues that need to be taken care of and cost will be significantly more than it would have been before. Being proactive about one’s dental health would have saved a lot of money.

There were more than a third of Americans who chose not to visit a dentist during 2008, according a Kaiser tracking survey. It was one of the top ways people tried to limit spending on health care in 2008.

There were some dentists forced to lay off staff, cut office hours or both.

But the trend is going in the other direction now. Dental profit margins were up 15 percent in 2010, after dropping from 17 percent to 13 percent from 2007 to 2008. This information comes from a study done by Sageworks, a company that analyzes financial trends.

This doesn’t mean the number of patients has increased. Instead of coming in for proactive treatment, there are now more people with major dental problems that come with major costs.

Another problem is that among the roughly 172 millions Americans under 65, there are about 45 million without dental insurance. And the coverage doesn’t necessarily cover some of the more involved procedures. That’s why some dentists have to work with the patient to create a long-term treatment plan to maximize the dental coverage.

        

[Anonymous]

Awareness regarding dental health is not a prime concern unless it becomes painful.

        

[Anonymous]

A SURVEY CONDUCTED IN AMERICA REGARDING COSTS IN DENTAL CARE
Objective: Dental disease is concentrated among those with low socioeconomic status. Dental care is not publicly funded, and many Canadians must therefore make difficult financial choices when accessing dental care. Families who live in poverty have difficulty meeting even their most basic household needs, so dental treatment may not be affordable. The objective of this study was to understand how the cost of dental treatment affects the monthly budgets of families with low incomes.

Materials and Methods: A chart review was conducted for a sample of 213 new patients examined at the Dalhousie University dental clinic over a 1-year period. Costs for proposed treatment plans were averaged. The patients’ ability to pay for proposed treatment was examined in the context of various income scenarios.

Results: Two hundred and one patients were included in the final analysis. Dental treatment costs per patient averaged approximately $1600 for the year, with 42% of the planned treatment completed within the first year. The estimated monthly cost of completed treatment was $55. When the cost of a healthy diet was included in the monthly budget, it was determined that families in Nova Scotia with parents working for minimum wage and those receiving income assistance would experience a 100% shortfall for dental expenses.

Conclusions: Low-income families in Nova Scotia were unable to afford both a nutritious diet and dental care. This is disturbing, given the links between a healthy diet and both overall health and dental health. An understanding of the significance of income shortfalls for those with low incomes, especially as they affect even basic nutritional needs, will help dental professionals to appreciate the seriousness of this issue and the difficulties that many Canadians face when trying to access basic dental care.

Introduction

It is well established that dental disease is concentrated among those with low socioeconomic status.1,2 Even in Canada, which ranks among the most developed countries, those who bear the greatest burden of morbidity have the most difficulty affording dental care.3 In most jurisdictions, those who do not have access to private dental insurance and do not qualify for government assistance programs are required to pay for dental care out of their own pockets.4 This is a difficult situation for many Canadians, especially the “working poor” and those receiving government assistance.4

According to the National Council on Welfare, 11% of Canadians live in poverty.5 Families who live in poverty are known to have difficulty meeting even their most basic household needs.6 Among the most troubling reality is “food insecurity,” a situation characterized by a lack of sufficient resources to meet the requirements for a healthy diet.7 Of particular relevance to dentistry is the impact that dental disease and the costs of dental treatment may have on the household budgets of low-income families and, by extension, their food security. Research has demonstrated that dental disease is linked to food insecurity when food purchases must be compromised to pay for dental care.8 In the face of these difficult choices about how income is to be spent, it is not difficult to understand why many Canadians are unable to place a high priority on dental care.

The purpose of this study was to better understand the economic implications of the real costs of dental treatment as they relate to budgeting for low-income families. University dental clinics provide ideal sites for such research. A large proportion of patients who attend such clinics have very low incomes and seek care in this setting to take advantage of fees that are typically lower than those in private practice.9 Using various income scenarios, we set out to examine dental treatment costs in relation to other household expenses, particularly food costs.
Materials and Methods

In this study undertaken at Dalhousie University, Halifax, Nova Scotia, the average treatment costs for new patients attending the dental teaching clinic were calculated. Ethics approval was obtained from the Dalhousie University Health Sciences Human Research Ethics Board. Retrospective data were collected from the clinic’s computerized patient database (axiUm, Exan Enterprise Inc., Las Vegas, NV). From the list of patients who had received a treatment plan during the academic year 2006–2007, every fifth patient chart was selected to generate a sample of 213 patients. Edentulous patients and children under the age of 16 were excluded using specific identifier codes. The sample represented 14.8% of the 1439 new patients seen that year. Twelve patients had total fees that were greater than 2 standard deviations above the mean, and these outliers were removed, for a final sample size of 201. Income data were not available for the patients in the sample.

The costs of planned and completed treatments were determined for each patient for the 1-year period after approval of the treatment plan. Treatments analyzed included diagnostic and preventive procedures, periodontics, restorative procedures, removable prosthodontics, minor surgery, interceptive orthodontics and endodontics. Prosthodontic procedures related to fixed and implant-retained prostheses were excluded from the analysis because of the complexity of these treatments and the lengthy time frames for their completion. Fees at the dental clinic were based on approximately 50% of the fees in the 2006 fee guide of the Nova Scotia Dental Association (for general dentists). Therefore, an estimation of the costs of similar treatments in private practice can be determined by doubling the fees reported here. Projected household costs for families with various incomes were obtained from food-costing data for 2004/056 and included the cost of the National Nutritious Food Basket (NNFB) for a family of 4. To understand the financial burden of treatment needs for families living at or below the median income range, the average cost of treatment was examined in the context of 5 income scenarios for a family of 4 with 2 children: income assistance without benefits for dental services; income assistance with Nova Scotia Department of Community Services employment support and income assistance dental benefits; employment with minimum wage, with 1 parent working full-time and the other working part-time; employment with average call centre wage, with 1 parent working full-time and the other working part-time; and median income for Nova Scotia families. No adjustments were made to account for the 1-year difference between the income and food-costing data (2004/05) and the dental costs in the fee guide (2006), as the increase in dental fees from 2005 to 2006 was negligible (less than 3%).

        

[Anonymous]

This Research in Action highlights dental care research sponsored by the Agency for Healthcare Research and Quality (AHRQ). Studies look at the impact of factors such as reimbursement, race, income, and age on access to and use of care.

Research suggests that educating families about how to enroll in and access the Medicaid system, streamlining Medicaid administrative procedures, and adjusting provider reimbursement could facilitate broader access to dental care. Studies show that specific treatments such as dental sealants for children may have a positive impact on both health outcomes and costs. The quality of dental care can be further improved by developing and using performance measures for specific treatments. Finally, the production of evidence reports evaluating research on various aspects of care helps to advance evidence-based dental practice and thereby improve the quality of care.

The Surgeon General’s recent report states that oral health is essential to the general health and well-being of all Americans.1 Although oral health extends beyond dental health, the report clearly stresses the importance of the two leading types of dental disease:

* Tooth decay (dental caries).
* Periodontal disease.

Dental care can be either preventive or restorative. Preventive care, such as tooth cleaning and dental sealants, is aimed at avoiding dental problems. Restorative care repairs problems such as those caused by tooth decay and periodontal disease.
Making a Difference

Poor children receive fewer preventive health care visits than those with higher incomes.

Dental sealants can reduce the number of cavities and decrease the cost of care in the Medicaid program.

Minority elderly receive less dental care because of financial barriers to care.

Unexplained variations in dentists’ clinical decisions are widespread.

Relative cost-effectiveness of dental crowns and their alternatives has not been established.

Use of performance measures by dental plans could improve quality of care.

Evidence-based practice is advanced by evidence reports evaluating various interventions.
Oral Health Improves Overall but Gaps Exist

Over the past several decades, oral health in the United States has improved.a Among most age groups, the average number of teeth per person affected by dental caries has decreased. Also, the average number of teeth per person that show no signs of infection, as well as the proportion of the population that is caries free, has increased. In addition, a lower proportion of U.S. adults have lost all their natural teeth (a process associated with both tooth decay and periodontal disease) now than was the case two decades ago. This improvement is most pronounced at older ages.

Despite the overall improvement in oral health status, gaps in the provision of care remain. Over the 20-year period 1977-96, the gap in the use of services between low-income people (those with incomes under 200 percent of the Federal poverty level) and higher income people (those with incomes over 400 percent of the Federal poverty level) increased.2 The number of preventive visits is below recommended levels, and access to dental care remains problematic for minorities, the elderly, children on Medicaid, and other low-income children. For example:

* More than one third (36.8 percent) of poor children ages 2 to 9 have one or more untreated decayed primary teeth, compared to 17.3 percent of nonpoor children.
* Uninsured children are half as likely as insured children to receive dental care.3
* Untreated dental decay afflicts one-fourth of children entering kindergarten in the United States.
* Low-income and minority children have more dental cavities than other children.
* Poor Mexican-American children ages 2 to 9 have the highest proportion of untreated decayed teeth (70.5 percent), followed by poor non-Hispanic black children (67.4 percent).
* Poor Mexican-American and non-Hispanic black children see the dentist less often than other children.
* Less than one of every five poor children enrolled in Medicaid receives preventive dental services in a given year, even though Medicaid provides dental coverage for enrolled children.

In addition to the considerable access problems faced by poor and Medicaid-eligible children, poor elderly people and minorities have their own problems with access.

* In the 50-69 age group, non-Hispanic blacks (31.2 percent) are more likely than Mexican Americans (28.2 percent) or non-Hispanic whites (16.9 percent) to have at least one tooth site with periodontal disease.
* In the age category 70 years and over, the percentages rise to 47.1 percent, 32.0 percent, and 24.1 percent for the three groups.

With more elderly people having discretionary income and retaining their natural teeth, demand for dental services among the elderly has grown. But this demand can be substantially influenced by financial barriers and other health concerns. Studies show that the elderly typically underuse needed dental services.

The underuse of cost-effective preventive services such as dental sealants, plastic coating applied to protect the chewing surface of teeth, also illustrates that dental care in the United States has room for improvement.

        

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