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Report highlights difficulties accessing dental care in ND

Dr. Chris Eriksson and Tanya Adams, clinic manager and dental assistant, apply sealant to the tooth of Sagal Duale, 13, of Grand Forks. Eriksson is a dentist who commutes from Fargo to the Valley Community Health Center Dental Clinic every week. Lori Weber Menke / Forum News Service

GRAND FORKS – Poor dental care not only can hurt your smile, it can threaten your physical health and prevent you from getting a job.

Kids who endure the pain of untreated dental problems may have difficulty paying attention and learning in the classroom or studying at home.

“Infection in the mouth can lead to infections in other parts of the body,” said Dr. Shawnda Schroeder, who led a group at the UND Center for Rural Health to prepare a report on the status of North Dakota’s oral health, which found that 12 counties in the state don’t even have a dentist.

The report, presented to a legislative interim committee this fall, indicates there’s a need to strengthen prevention programs and improve access to dental care throughout North Dakota, especially among “special populations,” including children, the aging population, Medicaid patients, low-income, homeless, new Americans, Native Americans, people with physical or mental disabilities and rural residents.

“There’s a tremendously critical shortage of access to dental care in North Dakota,” said state Sen. Judy Lee, R-West Fargo, who chairs the Health Services Interim Committee. “The reservations are in terrible shape.”

State legislators turned to the Center for Rural Health to conduct the assessment because it could “provide unbiased information on the availability of services and providers in North Dakota,” Lee said.

“Oral health is part of the holistic spectrum (of health),” Schroeder said. “It should be considered just as important as other aspects of primary care – our vision, our hearing, our sight.”

If a patient’s condition has worsened to the point that rotted teeth have to be extracted, “it changes what they can eat,” she said. “It influences their nutrition.”

While the report did not directly address lifestyle problems that result from lack of proper dental care, Schroeder heard the concerns of people in the dental community and others who described the risks, she said.

“It may seem like it’s not so important if you’re missing your front teeth, but it limits your job opportunities and limits self-worth and self-esteem,” she said.

“Kids can’t learn if their teeth hurt,” Lee said.

Input from many sources

The report, prepared in response to legislation passed in 2013, was presented to members of the Health Services Interim Committee in October. Work on the report started last spring and involved convening a group of stakeholders – which functioned like a focus group – and gathering data from numerous sources, Schroeder said.

Input was collected from dental care providers, advocacy groups, state governmental departments, public health units, insurance providers, research experts and public schools.

The stakeholders assessed the capacity of the current oral health workforce and unmet need for oral health care in North Dakota.

The report was supported with funding from The Pew Charitable Trusts, an organization that earlier had requested that the Center for Rural Health study this issue, Schroeder said.

The Pew organization has reported that 75,000 North Dakotans live in “dental shortage areas,” and 66.4 percent of children on Medicaid in this state did not receive dental care in 2011.

Pew has also found that nationwide more than 90 percent of dentists own or work in private settings, but many don’t accept Medicaid patients because of low reimbursement or administrative hurdles, said Nate Myszka, senior associate with Pew’s Children’s Dental Campaign.

The organization is examining how mid-level providers, called “dental therapists,” are helping private dental practices serve low-income patients in states such as Minnesota and Alaska, he said.

In North Dakota, the relatively more-limited access to dental care in rural areas is “a pressing point,” Schroeder said. And the elderly, in particular, face “a lot of barriers.”

Twelve counties in the state have no dentist, nine have one dentist and nine have two dentists.

“So in places where you have two or fewer dentists, if it’s not an issue of travel, it’s an issue of wait time,” Schroeder said.

For those North Dakotans with special needs, “some procedures may require sedation or special attention when receiving services, (which means) people have to travel to places like Bismarck or Fargo,” she said. “That’s a significant barrier.”

The dentist-to-population ratio in North Dakota is about 61 per 100,000 – below the national figure of 76 per 100,000.

The number of active licensed dentists in North Dakota has slowly increased from 2007 (when there were 327 dentists) to 2013 (when there were 380 dentists). However, 36 percent of those currently practicing plan to retire in the next 13 years, the report states.

“Although the Medicaid reimbursement is higher for dentists than almost any other health professional, it doesn’t cover their costs,” Lee said.

Recommendations

In the Center for Rural Health report, recommendations of the stakeholder group included strengthening existing prevention programs, expanding Medicare and Medicaid to provide incentives for dentists to accept more patients and improving coverage for enrollees. It also called for improving access to care by addressing the uneven distribution of the current dental workforce and expanding the scope of practice of current providers as needed.

Since “North Dakota has no dental school and no relationships with other schools to allow dental students to take rotations in the state, how do you bring students back to North Dakota to practice dentistry?” Schroeder said.

In recent years in North Dakota, there’s been “an increasing interest” in using mid-level dental care providers – in much the same way that physician assistants and nurse practitioners have extended medical services – to improve access to dental care services among underserved populations, Lee said.

The experience of using dental therapists in Minnesota “has been positive,” she said. “Dentists (there) are providing more coverage for patients.”

By using mid-level providers to take on some of the more routine aspects of dental care, “it frees up the dentist to do the higher level stuff, which I think would be professionally fulfilling.”

“The bottom line is I’d rather that someone is looking at the mouth than nobody is looking at the mouth.”

Lee said members of the Health Services Interim Committee did not take any action this fall to create a bill concerning oral health for the upcoming legislative session, but did pass a resolution to continue to study the matter, including the possibility of expanding the role of the dental hygienist.

The state’s dental hygienist organization “actually supports the mid-level idea,” Lee said. “The state and national dental associations do not.”

“We want to throw everything on the table and figure out what’s best for North Dakota,” she said. “We’ve got to do something to bring dental care to more North Dakotans.”

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