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MyView: Access: Only one part of the solution

October 16, 2017

By Mark Koday, D.D.S.

Photo of Dr. Koday
Mark Koday, D.D.S.
I’ve been the chief dental officer of The Yakima Valley Farm Workers Clinic, a large community health center, for the past 31 years. I’ve had the great fortune to be at the dental department’s helm as it grew from a six operatory, two clinic program to more than 120 operatories, 11 clinic system spanning eastern Washington and Oregon. My organization’s mission is to serve the poor and address their oral health needs. From the very beginning, I understood that the needs of the communities we serve are overwhelming. I kept thinking; if I just had one more dentist, I could solve their problems.

While we serve multiple counties, Yakima County is where we have the majority of our dental clinics and the best oral health data. I was told (and believed) that access was the answer and my job was to increase access as much as I could, which we did. In the Yakima Valley, my health center grew to seven clinics and 65 operatories, including two pediatric dental clinics. We developed an advanced education in general dentistry residency and partnered with Lutheran Medical Center out of New York University to initiate a pediatric dental residency in order to bring in even more high trained dentists to address the needs of our patients.

We worked with our dentists who had previous private practice experience to develop incentive programs to enhance our productivity and achieve higher practice efficiency. We lowered our broken appointment rate to under 13 percent, which further supported greater clinical productivity. We partnered with the University of Washington during the early 1990s as they did research on fluoride varnish. We expanded our sealant placement and upgraded the prevention protocols within our program. The goal and my mission was to do everything possible to improve oral health for the underserved.

Over the years, Yakima County private and public dentists have achieved phenomenal success in providing care to Medicaid-eligible children. Washington State developed the ABCD program, abcd-dental.org, which pays enhanced rates for the 0-5-year-old Medicaid-eligible population.  This program has had tremendously positive effects in increasing access over the years. Working together, 68 percent of Medicaid-eligible individuals now have access to dental care. This is the highest in the state and one of the highest access rates in the country, rivaling even commercial insurance
access. Access for these children is still open in both sectors, so parents seeking a dentist can find one. I can proudly say that, in many ways, we have solved the access issue for Medicaid-eligible children in our county.

The state of Washington conducts a Smile Survey every five years. It involves a statewide oral health screening of three groups of children: low-income preschoolers enrolled in the Head Start/Early Childhood Education and Assistance Program; kindergarteners; and third-graders. The survey produces statewide and county data, so I am able to follow the data and trends in Yakima County for the past 20 years. The dentists practicing in Yakima County, whether in the private sector or in community health settings, are an incredibly hard-working group. The Smile Survey shows the untreated caries have decreased from 25 percent in 2005 to 8 percent in 2015 for the 3-5-year-old Medicaid-eligible children. The Yakima County dentists have done an incredible job of accessing this vulnerable population and treating their existing disease.

Even though the dentists have achieved tremendous access and have worked hard to reduce the amount of untreated decay to only 8 percent, the actual number of newly decayed teeth is on the rise. The caries experience for 3-5-year-olds has gone from 45 percent in 2005 to 49 percent in 2015. The sad fact is that Yakima children’s teeth are decaying faster than the dentists can restore them. Medicaid spends millions of dollars in Yakima County alone to address children’s dental needs. In the past five years, an average of $8.8 million has been spent annually just to treat the dental needs of the 0-5-year-old Yakima County Medicaid-eligible children.

In my opinion, the cost is unsustainable. Bottom line, we are spending millions each year to restore an endless number of carious teeth caused by a chronic disease that is preventable. I don’t know a better definition of a failed system.

As I come to the close of my career, I realize that the oral health care delivery system for low-income children must change. While we clearly help countless individuals, we have failed to have any real effect on the oral health of our low-income populations. This failure is one that both our profession and our government are responsible for. This failure arises from our narrow focus on access as the only solution to the oral health issues of the poor and the lack of aggressive community-based prevention efforts.

What can turn this failure around? The time has come to reach out beyond the walls of the dental clinic to deliver preventive care and utilize case management, which has brought greater success to our medical colleagues when treating chronic diseases. There is good evidence that hygienists embedded in primary care medical teams performing secondary prevention procedures like utilizing silver diamine fluoride and placing glass ionomers in the 0-5-year-old population will lower caries rates.

Medical offices are ideal since they access a far greater number of children in this age group than are seen in dental and they are already familiar with the medical model of treating chronic disease. Hygienists can already perform this education and preventive procedures under general supervision in many states so this will not likely require changes in the dental practice acts of those states. As our profession demands, we should have proof that something works, so develop pilot projects that can produce the data needed.  Such a well-designed process will further integrate medical and oral health and bring more patients into our offices.

Dental caries is probably the only chronic disease where case management has not been used to combat it. It is time that the dental profession brings this critical care piece forward to fight the caries crisis. Case management is needed to bring back the children on a risk based schedule and refer those that require restorative care into the dental clinics.

I’m a big fan of dentists utilizing dental assistants and/or hygienists trained as Community Dental Health Coordinators to do the case management. I’ve seen the CDHC curriculum and have talked to this new member of the dental team. I realize the value of that training, especially with regard to motivational interviewing and other case management skills.

The dental profession has been beat up over the years on the access issue. It’s time we turned the argument around to enable states to concentrate on solutions that give us better tools to fight our chronic diseases instead of continuing to repeat those that offer dubious access.

Dr. Koday is the chief dental officer for the Yakima Valley Farm Workers Clinic in Yakima, Washington, and the director of the Northwest Dental Residency.