By Michael T. Childress and Michal Smith-Mello (*)
From Foresight, No. 50
published 2007
The oral health of our citizens is important for several reasons. First, it is important as a quality-of-life issue; healthy teeth and gums can translate into a better appearance, higher self-esteem, and more self-confidence, which are key to a better quality of life. Second, missing and decayed teeth or diseased gums can make it difficult to find employment and perform well on the job, adversely affecting the pocketbooks of individuals and families as well as the state’s capacity to realize economic development and increase prosperity. Third, and perhaps most important, missing teeth, inflamed gums, and cavities often make it difficult to eat a balanced diet, and increasingly research links poor oral health to illness, chronic disease, and even early mortality. Though the proverbial chicken-or-the-egg question has yet to be definitively answered, the connection is clear: poor oral health routinely coexists with heart disease, cancer, diabetes, and other illnesses. Behavioral factors such as smoking and poor diets have clearly established causal links to poor oral health. While real public health gains have been made in oral health here, Kentucky’s overall status can best be termed as below average.
Nationally, Kentucky had the nation’s highest percentage of edentate persons, those who have lost all their natural teeth due to tooth decay or gum disease,(1) among working-age adults (age 18 to 64)(2) in 2004; the second highest percentage among older adults (age 65 and older); and, as shown in Table 1, the second highest percentage among adults aged 18 and older.(3) Kentucky ranks 8th for adults who have lost at least one permanent tooth due to tooth decay or gum disease and 14th for adults who have lost 6 or more teeth.(4) On the brighter side, the percentage of Kentucky adults who have visited a dentist or dental clinic within the past 12 months, about 70 percent, is at the national average.(5)
Table 1: Comparison of Oral Health Indicators, Kentucky and the U.S., 2004
While dental health has improved markedly here as water fluoridation, the nation’s second highest rate,(6) has helped reduce cavities and extractions, the findings of a 2001 state survey of children suggest that a high percentage of even very young children in Kentucky may be in pain every day, a circumstance that could affect overall health as well as the capacity to learn. Among other things, the survey found disturbingly high levels of cavities among two- to four-year-olds (47 percent), and visible, untreated tooth decay among 29 percent of third and sixth graders.(7) As research unfolds, we may find that these conditions are precursors to serious illness and disease.
A growing body of research confirms an association between poor oral health and a number of poor health outcomes. From preterm births(8) to recent evidence from Harvard researchers of a dramatically higher incidence of deadly pancreatic cancer among men with periodontal (gum) disease,(9) the associations between poor oral health and disease or chronic illness are extensive and well documented. In one large-scale study, markers of inflammation in the mouth were linked to coronary heart disease in both men and women.(10) Associations have also been found between periodontal disease and the incidence of heart disease and stroke,(11) and tooth loss has been linked to heart disease.(12) Nevertheless, the American Heart Association cautions as would most researchers that “no substantial evidence” yet shows that oral bacteria causes heart disease or causes or worsens cardiovascular events. As AHA President Augustus O. Grant observes, people who are poor, under- or uninsured, or simply have poor health habits also tend to have poor dental health.(13) Whether poor oral health causes or contributes to poor health outcomes, the web of associations appears strong in Kentucky where poor oral health coexists with high rates of chronic disease. In 2000, the American Heart Association ranked the mortality rate for cardiovascular disease (CVD) in Kentucky among the worst in the nation at 48th; 73 of Kentucky counties had CVD mortality rates higher than the national average at the time.(14) More recently, a 2005 survey conducted for the Centers for Disease Control and Prevention found that Kentucky ranked behind only West Virginia in the prevalence of heart disease, the percentage of the population who are either heart attack survivors or have angina (chest pain)/coronary heart disease.(15)
Not coincidentally, the state also led the nation in smoking rates at 29 percent of the population in 2004.(16) Smoking, observes Dr. James Cecil, who leads Kentucky’s Oral Health Program for the Department of Public Health, prevents healing in the mouth, increasing the likelihood of periodontal disease and any disease it may cause or exacerbate. Further, diabetes and poor oral health often coexist because diabetes also retards the healing process. Because obesity is linked to diabetes, the sixth leading cause of death in the United States, the relatively high portion of Kentuckians who report being overweight (62.5 percent) and obese (24.4 percent) may be indicative of high rates of poor oral health and, possibly, other diseases and illnesses.(17)
While dental care exacts high out-of-pocket costs at all income levels, that share is clearly more burdensome for lower-income families and households. National data show that the uninsured in Kentucky and the state’s disproportionately poor older population likely face significant economic disadvantage in their ability to afford dental care. In 2004, the uninsured shouldered 72.3 percent of the cost of dental care compared with 39.9 percent for those with any private coverage, and 24.6 percent for those with public coverage only. Older individuals, specifically those aged 45 to 64 and 65 and older, also had higher cost burdens, 47 percent and 68 percent, respectively, compared with an average of 39.9 percent for all individuals under age 65. Among Medicare recipients, those with no supplemental coverage paid 92.3 percent of dental costs out of pocket, compared with 63.3 percent for those with some private coverage, and 33.6 percent for those with public coverage. Likewise, those who report fair or poor health status assume higher cost burdens.(18) Consequently, Kentucky’s relative poverty, particularly the disproportionate poverty of its older citizens, and its generally poor health status are likely strong contributors to the state’s poor oral health profile.
In effect, higher out-of-pocket costs for health care discourage people of all ages from seeking care due to the cost.(19) Lagging incomes may discourage Kentuckians more than many. A 2005 survey for the Kentucky Health Insurance Study found that 30 percent of working-age Kentuckians (18 to 64) had a dental problem in the past year but did not see a dentist because of the cost. Further, 20 percent of respondents reported that either their spouse or their children had not gotten dental care when they needed it due to the cost. Though about 56 percent of Kentuckians reported having some type of dental insurance in 2005, about 20 percent of the insured reported not seeking care for a dental problem due to cost.(20) Thus, lower incomes, high cost burdens for care, and a large population of people with no dental insurance likely discourage many from seeking dental care they need.
While national rankings form a discouraging picture, indicators of oral health among Kentucky adults generally improved between 1996 and 2004.(21) We examine two factors from the CDC’s 2004 Behavioral Risk Factor Surveillance System Survey, whether one is at risk for permanent tooth extraction(22) and whether one has visited a dentist or dental clinic in the last 12 months, and find an across-the-board improvement for virtually all social, economic, and demographic groups (see Table 2). Among the total population, the percentage at risk for permanent tooth extraction decreased from 63 to 50 percent while the percentage who visited a dentist in the prior year increased from 62 to 70 percent.
Table 2: Indicators of Oral Health, Kentucky, 1996 and 2004
We project Kentucky’s percentages for being at risk for permanent tooth extraction and annual dental visits to 2015 using a statistical model derived from CDC Behavioral Risk Factor Surveillance System (BRFSS) data. Using logistic regression, we estimate the underlying relationships between oral health and socioeconomic factors, like age, education, income, race, and gender.(23) If current trends continue without significant changes in individual behavior, medical technology, or the insurance and cost environment, then the percentage of Kentucky’s adult population at risk for permanent tooth extraction could decline to 28 percent by 2015 (see Figure 1) while the percentage making an annual dental visit could increase to 78 percent (Figure 2).
While our analysis indicates that Kentucky’s oral health picture should brighten, it is not without caveats. First, the use of dental services could decline if the dental insurance market changes in ways similar to the health insurance market, with patients assuming even higher out-of-pocket costs. Recent trends (1996-2003) in health insurance show that greater cost burdens are being shifted to families and individuals. In 1996, about 15.8 percent of the population had total cost burdens, including premiums, coinsurance, and copayments, that exceeded 10 percent of family income while another 5.5 percent had burdens exceeding 20 percent of income; by 2003, these populations rose to 19.2 percent and 7.3 percent, respectively.(24) The adverse effects of higher out-of-pocket costs were disproportionately felt by the poor, people with serious illness, citizens aged 55 to 64 years, and those with nongroup health insurance which typically exacts higher coinsurance costs.(25)
Cost disparities are less evident with dental care which typically commands high out-of-pocket costs at all income levels. Nationally, persons who had a dental expenditure in 2004 paid 48 percent of the cost out of pocket compared to 43 percent paid by private insurance and 4.7 by public insurance (4.2 percent, Medicaid; 0.5 Medicare).(26) In 2003, these out-of-pocket costs were two and a half times the rate paid for overall health expenditures.(27) On average nationally, only vision care and prescription drugs command higher out-of-pocket shares of the cost, with people at all spending levels shouldering relatively high shares of the average cost of dental care.(28) However, those in the top 5 to 10 percent of total dental care spending, which reflects use as well as need, paid 52 percent of the cost on average compared with 39 percent for those in the bottom 80 percent.(29) While projections by the U.S. Department of Health and Human Services show no appreciable change from 1996 to 2008 in the percentage of out-of-pocket expenses for dental services (see Figure 3),(30) any one of a number of trends or shifts could change this trajectory.
Second, just as insurance cost burdens may shift, the cost of dental care could change, which would in turn affect the number of dental visits. Per capita dental expenditures are expected to increase along their current trajectory at least until 2008 (see Figure 4),(31) a growth rate that is outpacing income gains. From 1996 to 2003, per capita dental expenditures increased 44 percent while per capita personal income increased 30 percent.(32)
Figure 4: U.S. Per Capital Dental Expenditures, 1996 to 2003, Projected 2004 to 2008
Third, the trend line of improving dental health may also be affected by the supply of dentists in some regions of the state. Nationally, the American Dental Association has projected a 12 percent decline in the dentist-to-population ratio from 2001 to 2015.(33) Statewide in 2006, Kentucky had around 5.6 dentists per 10,000 population(34) compared to 5.4 nationally,(35) but the vast majority of Kentucky’s counties have fewer than 4 dentists per 10,000 people (see map).(36) Moreover, based on our analysis of data from the Kentucky Board of Dentistry, dentists in these “underserved” areas tend to be, on average, slightly older. The average age of dentists in counties with a below-average number of dentists is 50.1 years, compared to the statewide average of 47.9 years. Consequently, should there be a future shortage of dentists due to an aging workforce, it will likely be felt initially in those areas that can least afford it.
Map: Number of Licensed Dentists, Kentucky, 2006
Whether newly minted dentists choose to remain in Kentucky to practice and how they practice dentistry are other matters. According to Dr. Cecil, who administers the state’s Oral Health Program, out of 130 graduates of Kentucky’s dental schools last year, just 30 stayed in Kentucky. The makeup of future dental practices, which have become increasingly focused on high-profit cosmetic dentistry, will also affect the availability of general dental care.
Fourth, since Medicare only provides dental care if it is related to a covered (nondental) medical condition, access to dental care could diminish as the population gets older. The Kentucky State Data Center projects that Kentucky’s population age 65 and older will increase from 12.4 percent in 2005 to 14.4 percent by 2015 (and eventually to just over 20 percent by 2030).(37)
Fifth, given the linkages between smoking, obesity, diabetes, and oral health, any improvements in the overall health of our population will likely affect oral health in a positive way. Unfortunately, the smoking, obesity, and diabetes trends are not moving in a favorable direction (see Figure 5).(38) As Dr. Cecil notes, “It is difficult to control blood sugar levels in the presence of oral infections (periodontal diseases and periapical diseases) and the obverse has been shown as well that oral infections are not amenable to treatment in the uncontrolled diabetic.”(39) Nonetheless, the future course of these trends could change as governments, businesses, and individuals increasingly recognize the cost implications of poor health outcomes.
Figure 5: Percentage of Adult Population Diagnosed with Diabetes, Kentucky and the U.S., 1998-2005
While the state’s Oral Health Program has adopted a multipronged approach that successfully reaches thousands of people throughout the state, much more will be needed to achieve real gains in oral health. The goal of improving oral health is clearly intertwined with the state’s leading health goals: reducing smoking and obesity rates. Indeed, a public health campaign that sensitizes providers from the dental and medical professions to the interrelated nature of infection and disease of the mouth and body could heighten detection and improve treatment.
At the same time, Dr. Cecil emphasizes the need for a comprehensive dental health safety net to provide services to those who cannot otherwise afford them. At present, the state major safety net programs—the universities of Kentucky (UK) and Louisville dental schools, the UK Rural Health Center in Hazard, St. Clare Medical Center in Morehead, and Trover Clinic in Madisonville—are far flung. Some Federally Qualified Health Centers (FQHCs) have dental capability, but most do not. Dr. Cecil envisions enhancing the capacity of both community health centers and FQHCs and ensuring uniform local health department dental services.
The dearth of Kentucky’s practicing dentists who participate in the Medicaid program also makes dental care difficult to access for the poor who qualify for coverage. Reimbursement rates that still lag the going market in spite of a recent increase are believed to be the reason why fewer than a fourth of the state’s dentists participate in the program.(40) Moreover, while Kentucky’s income-eligible population, even single adults, can access basic emergency services through the Medicaid program, awareness of the option may be low. Effective outreach programs could alleviate suffering, increase productivity, and prevent more tooth loss. But the Medicaid program’s effectiveness ultimately rests with the accessibility of services, which will require the participation of more dentists, and, most agree, new investment in the program.
Creative incentives that will help ensure the replenishment of a comprehensive and accessible oral health care workforce will likely be needed if gaps in care are to be avoided. From loan forgiveness in exchange for practice in an underserved area or for a public health clinic, to the training and use of paraprofessionals to identify and treat basic dental problems, new thinking will be needed to substantially improve Kentucky’s oral health. Moreover, given the social and economic consequences of missing teeth, creative thinking around the issue of making dentures more affordable will be needed to help many Kentuckians become healthier, more productive members of society. While it may require significant public investment, improved oral health may reduce public costs over the long run as significant social, economic, and health benefits are likely to be realized.
* Michael T. Childress is Executive Director and Michal Smith-Mello is Senior Policy Anaylst at the Kentucky Long-Term Policy Research Center. Return to text.
1 The BRFSS survey question is: How many of your permanent teeth have been removed because of tooth decay or gum disease? Do not include teeth lost for other reasons, such as injury or orthodontics. [Include teeth lost due to “infection.”]. Return to text.
2 Centers for Disease Control and Prevention (CDC), Behavioral Risk Factor Surveillance System Survey Data, 2004, 5 Feb. 2007 http://apps.nccd.cdc.gov/brfss/list.asp?cat=OH&yr=2004&qkey=6606&state=UB. Return to text.
3 Kentucky Long-Term Policy Research Center (KLTPRC) calculations from 2004 Behavioral Risk Factor Surveillance System (BRFSS) data. Return to text.
4 KLTPRC, BRFSS. Return to text.
5 The BRFSS survey question is: How long has it been since you last visited a dentist or a dental clinic for any reason? The 70 percent represents those who answered “Within the past year (< 12 months ago).” Return to text.
6 Jim Cecil, “Kentucky is Number 1 in ‘Toothlessness,’” Kentucky Epidemiologic Notes and Reports, May 2004. Return to text.
7 Cecil, “An Overview of Selected Kentucky Oral Health Issues,” Kentucky Department for Public Health, Oral Health Program, 26 Jan. 2004. Return to text.
8 Robert L. Goldenberg, J.C. Hauth, and W.W. Andrews, “Intrauterine Infection and Preterm Delivery,” New England Journal of Medicine 342 (2000): 1500-7. Return to text.
9 Dominique S. Michaud, Kaumudi Joshipura, Edward Giovannucci, Charles S. Fuchs, “A Prospective Study of Periodontal Disease and Pancreatic Cancer in U.S. Male Health Professionals,” Journal of the National Cancer Institute 99 (2007): 1-5. Return to text.
10 Jennifer K. Pai et al., “Inflammatory Markers and the Risk of Coronary Heart Disease in Men and Women,” The New England Journal of Medicine 351.25 (2004): 3599-2610. Return to text.
11 See, for example, T. Wu et al., “Periodontal Disease and Risk of Cerebrovascular Disease: the First National Health and Nutrition Examination Survey and Its Follow-up Study,” Archives of Internal Medicine 160.18 (2000): 2749-55. Return to text.
12 See, for example, H.C. Hung et al., “The Association between Tooth Loss and Coronary Heart Disease in Men and Women,” Journal of Public Health Dentistry 64.4 (2004): 209-15. Return to text.
13 American Heart Association, “Poor Oral Health Associated with Coronary Heart Disease,” Journal Report, 17 Feb. 2004, 29 Nov. 2006 http://www.americanheart.org/presenter.jhtml?identifier=3019173. Return to text.
14 National Center for Health Statistics, CDC, “Fast Stats A to Z,” 6 Oct. 2006, 29 Nov. 2006 http://www.cdc.gov/nchs/fastats/map_page.htm. Return to text.
15 CDC, “Prevalence of Heart Disease—United States, 2005,” Morbidity and Mortality Weekly Report U.S. Department of Health and Human Services 16 Feb. 2007, 19 Feb. 2007 www.cdc.gov/mmwr/preview/mmwrhtml/mm5606a2.htm. Return to text.
16 CDC, “State-Specific Prevalence of Cigarette Smoking and Quitting Among Adults—United States, 2004,” Morbidity and Mortality Weekly Report U.S. Department of Health and Human Services 11 Nov. 2005, 19 Feb. 2007 www.cdc.gov.mmwr/prview/mmwrhtml/mm5444a3.htm. Return to text.
17 Kentucky Department for Public Health, Kentucky Behavioral Risk Factor Surveillance System, 2002 Report (Frankfort: Cabinet for Health and Family Services, Aug. 2004). Return to text.
18 Medical Expenditure Panel Survey (MEPS), “Dental Services—Median and Mean Expenses per Person with Expense and Distribution of Expenses by Source of Payment: United States, 2004, General Dental Visits Only,” Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2007, 15 Feb. 2007 www.meps.ahrq.gov. Return to text.
19 Jessica S. Banthin and Didem M. Bernard, “Changes in Financial Burdens for Health Care: National Estimates for the Population Younger than 65 Years, 1996 to 2003,” Journal of the American Medical Association (JAMA) 296.22 (2006): 2712-2718. Return to text.
20 These survey results are from the Kentucky Health Insurance Research Project, a joint effort between the Center, the University of Kentucky Center for Rural Health, and the University of Louisville. The data presented here are from a 2005 telephone survey conducted by the University of Kentucky Survey Research Center between May 27 and September 12. Households were selected using random-digit dialing, which gives each telephone line in Kentucky an equal probability of being called. A total of 2,068 surveys were completed for a response rate of 38.3%. The margin of error is approximately ± 2.16% at the 95% confidence level. Return to text.
21 There is a well-documented national trend of improving oral health over the last few decades. Refer to Stephen A. Eklund, et al., “Trends in Dental Care Among Insured Americans: 1980 to 1995,” The Journal of the American Dental Association 128 (1997): 171-8. Return to text.
22 An individual is considered “at risk” if at least one permanent tooth has been removed because of decay or disease (RMVTEETH=1 or 2 or 3, where 1 equals “1 to 5;” 2 equals “6 or more, but not all;” and 3 equals “all”). Return to text.
23 Refer to the technical appendix for information about the models www.kltprc.net/foresight/no50techinfo.pdf. Return to text.
24 Banthin and Bernard. Return to text.
25 Banthin and Bernard. Return to text.
26 MEPS, “Dental Services … 2004.” Return to text.
27 John P. Sommers, “Dental Expenditures in the 10 Largest States, 2003,” Statistical Brief # 112, Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality, Jan. 2006. Return to text.
28 Kaiser Family Foundation, “Distribution of Out-of-Pocket Spending for Health Care Services, Snapshots: Health Care Costs May 2006, 15 Nov. 2006 www.kff.org/insurance/snapshots/chcm050206oth.cfm. Return to text.
29 Kaiser. Return to text.
30 MEPS, “Dental Services … 2004.” Return to text.
31 MEPS, “Dental Services … 2004.” Return to text.
32 KLTPRC analysis of MEPS and Census data. Return to text.
33 Tryfon Beazoglou et al., “The dental work force in Wisconsin: Ten-year projections,” The Journal of the American Dental Association 133 (2002): 1097-1104 http://jada.ada.org/cgi/content/full/133/8/1097. Return to text.
34 We derived this ratio from data on practicing dentists who are licensed in Kentucky. The data is collected by the Kentucky Board of Dentistry. Lisa A. Turner, Kentucky Board of Dentistry, e-mail, 25 Jan. 2007. Return to text.
35 Karen Fox, “Forum looks at increasing diversity in dental profession,” ADA News, 26 May 2006, 12 Feb. 2007 http://www.ada.org/prof/ resources/pubs/adanews/adanewsarticle.asp?articleid=1928. Return to text.
36 Of Kentucky’s 120 counties, 78 have fewer than 4 dentists per 10,000 population. According to the American Dental Association Health Policy Resource Center, the states with the highest dentist-to-population ratios have about 7.4 dentists per 10,000 population, while those with the lowest ratios have 3.5 to 4.0 per 10,000 population. We use these ratios to illustrate the distribution of dentists in Kentucky as a point of comparison (i.e., 0 to 4, 4.1 to the state average of 5.64, 5.65 to 7.4, and 7.5 and above). See Fox, “Forum looks at increasing diversity in dental profession,” ADA News. The Kentucky data from the Kentucky Board of Dentistry indicate the dentist’s zip code, which could be either their residence or their practice location (i.e., office). Return to text.
37 Kentucky State Data Center, 23 Feb. 2007 http://kscd.louisville.edu/kpr/pro/hmk2004_detailedtables_toc.xls. Return to text.
38 We estimated future obesity and smoking rates in previously published work. See Michael T. Childress, “Future Obesity and Smoking Rates,” March 2006 http://www.kltprc.net/policynotes/pn0020_obesity_smoking.pdf. Return to text.
39 Dr. James Cecil, Kentucky Cabinet for Health and Family Services, e-mail to the authors, 21 Feb. 2007. Return to text.
40 Telephone interview with Dr. James Cecil, Nov. 2006. Return to text.