Delivery of Care

Moving beyond a state of decay

A new national report places Rhode Island seventh in the dental care of its older residents, but Dr. Sam Zwetchkenbaum, dental director at the R.I. Department of Health, says there is plenty of room for improvement, including the idea of making dental benefits a part of Medicare

Photo by Richard Asinof

Dr. Sam Zwetchkenbaum, the dental director at the R.I. Department of Health.

By Richard Asinof
Posted 5/21/18
As the number of Rhode Islanders over 65 continues to grow as a demographic trend, there is a need to look at how oral care for them is being provided. Despite Rhode Island’s recent “good” ranking, the solution may be to bring dental health care under Medicare as a benefit.
How can the rates for Medicaid reimbursements for adults be increased? Is there a way to provide direct correlation between dental disease prevention for those with chronic disease such as diabetes and lowered medical costs, as a function of health insurance rates? How many pharmacists in Rhode Island list oral health effects with medication? What are the racial breakdowns of disparities in dental care in Rhode Island for older adults?
As part of my public speaking training, the topic I often posed to participants to answer was this: why is it important to brush your teeth? It appeared to be a simple question, which resulted in guffaws from many participants. But what participants discovered, it required them to talk about their own beliefs of self-image, and how that motivated their work or made them fearful to smile, or proud to be smiling. Our teeth and our gums are very much a litmus test for how we feel about ourselves.

PROVIDENCE – The recent 2018 report by Oral Health America, entitled “A State of Decay: Are Older Americans Coming of Age without Oral Health Care?” ranked Rhode Island seventh in the nation, with a “good” score of 87 percent.

By comparison, Minnesota was the best at 100 percent, Mississippi was the worst at 0 percent, Connecticut was fourth at 94 percent, Vermont was 10th at 74 percent, and Massachusetts was 24th at 51 percent.

The rankings were based on a number of factors, including a look at the 2016 Behavioral Risk Factor Surveillance System data for 153,500 adults aged 65 and older; severe tooth loss, dental visits, adult Medicaid benefits, whether or not there was a state oral health plan, and the results of a basic screening survey.

There is both good news and not so good news to be found in the rankings, according to Dr. Sam Zwetchkenbaum, the dental director for the R.I. Department of Health’s Oral Health program as well as dental director for the state’s Medicaid program.

Zwetchkenbaum shared a number of data points about the survey and what it revealed about the state of dental health for older Rhode Islanders during a recent interview with ConvergenceRI

On the positive side, the percentage of severe tooth loss has decreased in Rhode Island during the last two decades.

“We’ve gone from 25 percent of people over 65 being edentulous, which means missing all your teeth, in 1999, to just 12 percent in 2016,” Zwetchkenbaum said. “People are retaining their teeth, which is wonderful.”

Another positive takeaway: almost 75 percent of those Rhode Islanders over 65 had a dental visit in the last year.

On the not so positive side, Zwetchkenbaum continued, for people over 65, the use of dental health services is highly dependent on wealth, according to the data. “People who had money continue to go to the dentist.”

In terms of dental health literacy, Zwetchkenbaum offered a cautionary note: nationally, some 52 percent of people on Medicare think they have a dental benefit – “which means they haven’t gone to the dentist and asked about Medicare dental benefits.”

Zwetchkenbaum agreed with one of the conclusions in “A State of Decay” report by Oral Health America: to integrate comprehensive dental coverage in Medicare.

“We need to look at the fact that the mouth is part of the body,” he said. “I think there would be a lot of benefit to considering oral health as a Medicare benefit.”

There is a large swath of people who are over 65, who are not on Medicaid, that do not have access to dental insurance, Zwetchkenbaum said.

It would be tough, politically, to push through such a change, he continued. “But, to me, it makes sense.”

Here is the ConvergenceRI interview with Dr. Sam Zwetchkenbaum, dental director at the R.I. Department of Health, talking about a wide range of issues about dental health care in Rhode Island.

ConvergenceRI: What are the takeaways from the new report, “A State of Decay,” by Oral Health America?
ZWETCHKENBAUM:
Rhode Island ranked number seven in Oral Health America’s recent report, “The State of Decay.” Our ranking was [labeled] “good.”

In some ways, we should be happy with that ranking. But, in some ways, it may not be the full story about oral health in Rhode Island.

The focus of the report was on older adults, looking at six components.

One was what percentage of residents 65 and older have severe tooth loss, based on the behavioral risk factor surveillance survey data; 32 percent of Rhode Islanders over 65 have severe tooth loss. That is not great; but compared to other states it’s good.

About 75 percent of those over 65 years of age had a dental visit in the last year.

We do have Medicaid coverage for adult dental care, which, once again, compared to some other states, is good.

And, 84 percent of our public water supplies are served with community water fluoridation, a big benefit to prevent tooth decay.

We do have a state oral health care plan, and we have done a basic survey screening older adults to get a sense of how bad is [the incidence] of dental disease.

Those are the things, because of what we do, that got us that “good” rating.

Does that tell the whole picture? No.

First of all, things could be better. We’d like to see more people over 65 having an annual dental visit.

I think that will involve increasing oral health literacy among older adults, and increasing understanding among physicians and non-dental health colleagues about the importance of oral health.

ConvergenceRI: Do you know the number of people who go to the hospital emergency room every year with dental health problems?
ZWETCHKENBAUM:
[looking it up on his computer] Hospital discharge data showed that 2.6 percent of ED encounters, about 6,500 Rhode Islanders a year, were for non-traumatic dental purposes.

The highest age group [being seen for non-traumatic dental purposes] is the 21-34 age group, which is actually the lowest utilizers of preventive dental services.

Among teenagers who have Medicaid coverage, the percent for dental cleanings a year at age 12 is at 59 percent, but it drops to 48 percent for 16 year olds.

A lot of this is about educating young people about the importance of preventive dental services.

Medicaid coverage for children through RIteSmiles does actually pay well. I’ll admit that adult services under Medicaid pay poorly.

ConvergenceRI: What do you think is the solution to improve dental health care for Rhode Islanders over 65?
ZWETCHKENBAUM:
Oral Health America is looking at the idea of Medicare covering dental services. They are saying that when people stop working after turning 65 and lose dental benefits, the use of dental services is highly wealth dependent; people who have the money continue to go to the dentist.

So, at age 65, when many people lose dental benefits, they now have greater needs; their mouth is often dry, due to medications, they may have arthritis, which impairs their ability to take good care of their teeth. And, they may have cognitive changes.

Just at the point when people’s dental needs are increasing, they no longer have coverage.

I think including dental health care as part of Medicare is a great idea, actually. Why not treat the mouth as part of the body? Why shouldn’t Medicare?

ConvergenceRI: As people age, turning 65 and older, there are a lot of chronic diseases that bloom, flower and peak, including heart disease and diabetes, among others. Is there any data that looks at the percentage of those with chronic disease and dental disease?
ZWETCHKENBAUM:
The sicker someone is, the more chronic disease they have, the less likely they are to get dental services. That is a shame.

The data shows actually in the case of diabetes, that if people are receiving preventive services to help manage their gum disease they are going to have better outcomes with their diabetes.

Glycemic control is worse if periodontal disease is poorly managed. There is an opportunity to cut our overall medical costs if we properly manage dental disease.

There is a sort of bi-directional thing going on: if we have better medical/dental integration, if there was dental coverage under Medicare, then it would be easier for a physician to say, hey, I just prescribed this medication that is going to reduce your saliva flow, now go to the dentist, you have coverage.

Again, if people don’t have dental coverage, or if Medicaid reimbursement is so poor and people cannot find dentists to accept their dental insurance, then they are not going to go [to the dentist].

ConvergenceRI: Most every year, in Rhode Island, there is what is known as the Mission of Mercy, where free dental care is provided, where people line up…
ZWETCHKENBAUM:
This is a program that occurs all over the country. The most recent Journal of the American Dental Association published its May cover story detailing Mission of Mercy patient characteristics and dental-related emergency department use.

[“Patients line up for hours in advance and often exceed clinic capacity, underscoring the substantial unmet need for oral health care,” the article reported.]

ConvergenceRI: The Mission of Mercy programs appear to be responding to the symptoms of the lack of access to affordable dental care. While integrating dental care as part of Medicare will require federal legislation, what can the state do to facilitate greater access to dental care?
ZWETCHKENBAUM:
We do have state oral health plan, for 2017-2021, which was developed by the state oral health commission. We came up with goals to improve access, remove barriers. We do have a pretty good set of safety net clinics at federally qualified health centers.

But it is hard for them to meet the demand as the number of private practitioners who accept Medicaid goes down. Ideally, if we have more private practitioners accepting Medicaid, then there would be greater access. That would require improved reimbursement rates.

ConvergenceRI: Going forward, who are the advocates for such changes?
ZWETCHKENBAUM:
I would say the oral health commission, from a Medicaid standpoint. We do want to look at strategies to incorporate more medical/dental integration. Somehow, if we can work together to improve rates, that will ultimately result in improving access to care – and in reducing medical expenses.

If you improve preventive services, especially for older adults, then you have less costly dental disease in the long run.

ConvergenceRI: Is it difficult to recruit young dentists to open up new practices in Rhode Island?
ZWETCHKENBAUM:
The story I tell is that I went up to Woonsocket, and Thundermist has a beautiful dental clinic up there, and they have some some wonderful dentists, and they all commute down every day from Boston.

On the way back, I stopped at Woonsocket High School, and I asked: When was the last time that somebody came and talked about dental careers? They said: Nobody ever has.

Because we don’t have a dental school in Rhode Island, we need to talk to our young people about how wonderful a dental career is. We need to have dentists who look like Rhode Islanders, a more diverse dental workforce for the future. If they grew up in Rhode Island, they probably will have a greater likelihood of wanting to come back here.

If you look at the number of first-year dental students across the country, and the ADA does this, they ask: where did you grow up? A very small percentage actually grew up in Rhode Island.

So, if we can increase interest among high school students in dental careers, the hope is they will come back, that is often why people move back to Rhode Island, because they have family here.

But, you’re right. We have to have good reimbursement rates, so that they can repay their dental loans. Dental school is very expensive, and a lot come out of school with significant loans. And, if they are not being reimbursed well…

ConvergenceRI: Isn’t another part of the expense of being a dentist is maintaining the equipment needed for an office?
ZWETCHKENBAUM:
Dentistry has gotten very expensive. It’s very different than when my grandfather was a dentist.

One grandfather was a dentist in Washington, D.C., and his only help was my grandmother, she ran the front desk. He maybe saw five or six patients a day, things were pretty slow.

Dental offices are very elaborate today. You have to have a full staff. You have to go through an elaborate infection control. I think costs to run a dental practice are very high.

ConvergenceRI: Where are the nearest dental schools?
ZWETCHKENBAUM:
There are three in Boston, and one just west of Hartford, Conn.

Harvard, Tufts and BU all have dental schools. The newest dental school in the region is in Portland, Maine.

Because we don’t have a dental school in Rhode Island, we have to really look at how we are encouraging high school students. We had a program this past year for pre-dental students at our colleges, URI, PC and Brown, to introduce them more to dental professions.

ConvergenceRI: Is there an opportunity? Would it be a good thing to have a dental school in Rhode Island? We’ve seen a number of new physician assistant programs. We’ve expanded the nursing programs.
ZWETCHKENBAUM:
I would say, let’s see first, how University of New England does in Portland, Maine. It is very expensive to run a dental school, because you have to have a certain number of faculty, so I don’t know. It’s something to think about.

ConvergenceRI: Where do we need to go from here? Beyond improving access and improving reimbursements?
ZWETCHKENBAUM:
Again, I think we do need to look at the fact that the mouth is part of the body. I think there would be a lot of benefit to considering oral health as a Medicare benefit.

The focus on prevention is really important. I think physicians, when they prescribe medications that dry people’s mouths that may cause them to have increased dental disease, should inform [patients] about the oral side effects, just like any other side effect.

I’ve spoken with Brown about talking to their medical school class about oral health issues.

Wouldn’t it be great, in collaboration with CVS and other drug stores, if whenever a pharmacist dispenses a medication, you tell the patient about all the side effects, including the oral side effects?

ConvergenceRI: Is there an opportunity, given the recent study by the Blue Cross Blue Shield Association that found a high rate of major depression diagnoses in the state, and with it, an increased emphasis on screening for depression at the primary care level, to piggyback the integration of dental health with behavioral health? Because if your teeth hurt, you’re going to be depressed, I would think.
ZWETCHKENBAUM:
Oh, yeah. People who have behavioral health issues are often taking mediation that can impact their teeth.

People for instance, with schizophrenia, a lot of those medications, impact their saliva flow, so they tend to have more dental disease.

Plus, they are probably not going to the dentist that frequently.

I think it is very important that we encourage other medical colleagues to include oral health as part of their examination.

I gave a presentation to RIC nursing students yesterday. We talked a lot about pregnant women, if you are seeing a pregnant woman, to ask her or instruct her to go to the dentist.

Or when seeing older adults, we need to teach our geriatricians, too.

ConvergenceRI: What haven’t I asked you that you would like to talk about?
ZWETCHKENBAUM:
We’ve talked about workforce, we’ve talked about improving oral health literacy for older adults, and the need for better medical/dental integration, and the need to increase oral health literacy among older adults.

As far as older adults in long-term care, I think we need to increase providers’ willingness and capability to provide care in alternative settings.

We do have new members of our workforce that have been permitted by statute, called the public health dental hygienist, who will be able to go into nursing homes and provide preventive services without the patient having to be seen by a dentist.

The new law was enacted in 2016, and the first group of graduates will be graduating this spring. CCRI is providing the courses for them.

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