Although federal, insurance, and community programs have made strides in providing better access to quality oral healthcare for a wider range of people, the reality is that significant disparities exist among different populations.
A May 2015 Centers for Disease Control and Prevention (CDC) data brief highlights the differences. More than one in four adults ages 20 to 64 have untreated dental cavities. Within this same age group, the differences by ethnicity are striking: 42 percent of African American adults and 36 percent of Hispanic adults have untreated disease compared with 22 percent of Caucasians.
Another CDC study found that among those ages two to eight, instances of untreated tooth decay in primary teeth are twice as high for Hispanic and African American children than they are for Caucasian children. Preventive treatments such as sealants are more prevalent among Caucasian children (44 percent) compared with African American and Asian children (31 percent each) and Hispanic children (40 percent).
Low-cost or no-cost dental care is often available at many dental schools, which offer services provided by students and supervised by faculty members as part of their dental education. While this service helps address some of the financial barriers that keep some underserved populations from accessing dental care, other obstacles exist that limit their ability to seek treatment, including transportation, education and awareness, and an inability to take time off from work.
University of Minnesota School of Dentistry
A total of 16 community clinics make up the outreach program at the University of Minnesota School of Dentistry in Minneapolis to provide dental care to underserved populations. One of the clinics is mobile; five are Indian Health Service (IHS)/tribal sites located in northern Minnesota, North Dakota, and Montana; and the other 10 are located in rural and urban areas.
[Above: UMN’s mobile dental clinic]
“Our mobile dental unit is a custom-designed bus with three dental chairs, and we provide primary dental care such as exams, X-rays, cleanings, fillings and extractions,” explains Paul Schulz, DDS, an associate clinical specialist and the director of the Mobile Dental Program. “Patients have no insurance or Medicaid.”
The mobile clinic rotates among 15 sites — identified by the school’s sponsoring partner, UCare, a nonprofit health plan — spending one week at each location and traveling 48 weeks each year, says Schulz. In addition to providing dental services, the mobile clinic has a conference room space for consultations and teaching, he adds.
Although the school has had multiple clinics for more than 15 years, it was not until the community outreach effort was formalized as a division of the school that Schulz was able to keep the clinics fully staffed. “Between nine and 12 weeks of time working in an outreach clinic is required of all students in the last year of their education, with the exact time commitment determined by their specific course of study,” says Schulz, adding that the graduation requirement applies to all dental, dental therapy, and dental hygienist students.
To ensure that dental students working at all locations throughout the three states receive the same level of training as they do at the main campus, local dentists at each location are appointed as adjunct faculty. They must attend annual two-day seminars that explain how to teach and train dental students as they perform their rotations and that clarify expectations for students, adjunct faculty members, and the school.
The long-term value of outreach programs is the ability of communities to attract dentists to their area after graduation, Schulz says. “Before we began offering formal externships, the IHS clinics often had open positions for dentists that they could never fill. In just a few years, the clinics no longer have openings because they hire students who volunteered there,” he says. “Students don’t think about working in areas where they’ve never been, and the outreach requirement gives them the opportunity to be exposed to life in rural or tribal settings they never considered before.”
At Hiwassee College in Madisonville, Tenn., after two years of planning, the dental program began operating a mobile dental clinic in early 2017. Funded by a grant from BlueCross BlueShield of Tennessee, the state-of-the-art clinic expands the geographic region in which students are able to provide hygiene services, as well as community education, says Randa Colbert, interim director of the dental hygiene program and an instructor at the college.
“We go to a rural medical clinic, and we have a relationship with a school system,” Colbert says. Free services include cleaning, fluoride treatments, sealants, and radiographs, which are all performed in the mobile unit by students, who also provide education about smoking cessation, nutrition, and other factors that affect oral health. A local Rotary Club covers the cost of supplies for trips to local schools.
“The biggest challenge we’ve faced is the demand for services, so we had to focus our school program on fourth graders,” explains Colbert. “We chose this group for several reasons. Children this age still have some primary teeth but also have permanent teeth, which provides a good learning opportunity for our dental hygiene students. We also have a chance to teach children about good oral hygiene to minimize dental problems as they get older.”
Additionally, fourth graders are an easy choice, says Colbert, because “they are mature enough to sit still for treatment and can understand its importance.”
A community dental health class is part of the curriculum at Hiwassee and requires 12 hours worked at a medical clinic in a remote area — one that provides health services for free. While this requirement fills the staffing needs for the college’s mobile unit on the days it visits a rural clinic, Colbert relies on volunteers when it goes to elementary schools to provide treatment or to health fairs and other events to conduct screenings.
“I ask for volunteers, but my students point out that sometimes they are ‘voluntolds’ when I have spots to fill,” Colbert says. “We want to make sure students understand our responsibility as health professionals to provide care to underserved populations.”
University of Southern California School of Dentistry
In the late 1960s, the Herman Ostrow School of Dentistry at the University of Southern California (USC) in Los Angeles set up dental clinics in schools and community centers in southern and central California to provide dental services to migrant workers. Dental and dental hygiene students provided services for seven days to ensure patients received thorough and complete treatments — from cleanings and initial assessments to restorative treatments.
Over the years, the dental clinics transformed and became mobile — trailers with a total of 15 chairs. They continue to visit rural areas but have also expanded to include urban neighborhoods that are underserved, says Santosh Sundaresan, DDS, director of the USC Mobile Dental Clinic.
The importance of addressing children’s oral health led the school to form a partnership with the Los Angeles Unified School District to provide dental care to students in second through fifth grades. In addition to hygienists providing preventive care, such as cleanings, sealants, and education, dental students go to the schools to complete treatments. “We are at each school every 18 months and stay for several weeks to be able to screen, diagnose, and treat,” explains Sundaresan, adding that having both a dental hygiene and dental program enables USC to serve 5,000 students each year.
The mobile clinics — which are part of a comprehensive community outreach program to serve the local homeless population — are designed to help address several barriers to care for underserved communities. “We come to them so parents don’t have to take time off work to take their children to the dentist. We don’t charge for services, and we stay long enough to complete necessary treatments,” says Sundaresan, adding that such programs are funded by grants, donations, and university support.
Students are required to work in the free clinics as part of the dental program, and many report that this experience is critical to their education. “Ninety-two percent of students identify community engagement as one of the most important components of the student experience on surveys,” says Sundaresan. “In fact, many of [our alumni] who are now in private practice return to volunteer in the clinics.”
He believes that community outreach is a win-win. “We can provide quality care to populations that need it most, and it is the best education for students, giving them real-time experience with a wide range of patients,” Sundaresan says. “There is no textbook or lecture that can make them understand why they want to be a dentist, but working in these clinics shows them what they can contribute. It is a practical and satisfying experience for faculty and students — and patients.”●
Sheryl S. Jackson is a contributing writer for INSIGHT Into Diversity.