Periodontal therapists Suzanne Newkirk and Lynne Slim discuss dental access to care in Georgia. Looking at the lush greenery of the Georgia mountains or the enticing beaches and barrier islands along the Georgia coast, tourists wouldn't describe Georgia as a desert, but the thousands of Georgians who lack dental insurance or funds for basic preventive dental care know otherwise. A lack of access to care renders lush Georgia into a barren place for patients.
The U.S. Department of Health and Human Services (HHS) defines a dental desert as a dental Health Professional Shortage Area (HPSA), which are defined as areas with a population-to-provider ratio of at least 5,000 to one, or 4,000 to one if there are unusually high needs in the community. As of February 2023, nearly 70 million Americans were living in dental deserts. Approximately 70 million Americans live in areas without enough dental providers. In 2022, the U.S. average patient-to-dentist ratio was 1,538:1. In some places in the Southern U.S., that ratio jumps to 20,000:1 or even zero. This situation has created an access-to-care crisis in America, leaving people without dental care due to a shortage of dentists, especially in rural areas and marginalized urban communities. In addition, many dentists don't accept Medicaid, making it difficult for low-income individuals to access dental care even if a provider is available. According to HHS, it would take nearly 15,000 additional dental practitioners to meet the current needs of these Americans.
According to a 2022 report at Byte.com reviewed by Dr. Jay Khorsandi, DDS on county-by-county data across the United States, rural counties in the South have the worst access to dental care. The top five worst counties for access to dental care are in:
· Georgia
· Texas
· Virginia
· Mississippi
· Tennessee
Georgia is the largest and fastest growing state in the south of the US. With just one dental school in Augusta, and only 4.4 dentists per 10,000 people, the state ranks 49th among states for dentists per capita. This means that too many people in Georgia don't have access to dental care. Many uninsured and low-income Georgians seek care at Grady Memorial Hospital's Emergency Department, averaging between 70 and 105 dental emergencies per week and costing taxpayers millions of dollars. Sadly, dental care provided in an emergency room is prohibitively expensive, inefficient, and can do very little to help a patient with an emergency toothache, root canal or extraction. The result is usually a pain prescription and hospital fee for hundreds of dollars that leads to a patient requiring a dentist visit anyway for problems that were preventable in the first place through routine dental care.
Dental caries remains the single most common, chronic disease of childhood. When left untreated, dental caries (commonly referred to as "cavities") results in pain, infection, distraction from learning, and missed school days, and may inhibit general growth and development because of the associated nutritional liabilities. Severe abscesses, caused by untreated decay, frequently send many low-income Georgians to an emergency room. Periodontal disease is primarily a disease of adulthood, typically established during adolescence and continuing throughout life. It is the single most common cause of adult tooth loss.
Some dental infections can travel from decayed teeth to the brain and, if untreated, can result in death. In 2007, 12-year-old Deamonte Driver died from an infected tooth. By the time Deamonte's aching tooth received attention, the bacteria from the abscess had spread to his brain, and after two operations and more than six weeks of hospital care, Deamonte died. In August 2011, 24-year-old Kyle Willis also died from a tooth abscess because he couldn't afford to pay the $27 cost of antibiotics. Willis, who was an unemployed and uninsured single father, sought emergency room treatment when his face began to swell and his head started to ache. He was given prescriptions for both antibiotics and pain medication, but because he couldn't afford the cost of the antibiotics, he paid $3 for the pain medication. The infection spread, causing his brain to swell. He died, leaving behind his six-year-old daughter. Both these cases made national headlines and served as a poster child representation of the problem that affects thousands of Americans and people globally.
Lack of access to dental care has become a national crisis. In February 2012, Senator Bernie Sanders, chairman of the Senate Subcommittee on Primary Health and Aging, held a congressional hearing to address the dental crisis in America. In his report, Senator Sanders cited potential solutions to increase dental access by expanding the number of oral health providers to treat low-income individuals and other populations that face barriers to care. To date, 35 states allow dental hygienists to provide care directly to patients; 15 permit state Medicaid department direct reimbursement to dental hygiene providers. Forty-four states allow general supervision, meaning dental hygienists provide care without dentists' direct supervision. Throughout the nation, state policymakers, consumer advocates, and oral health coalitions are pioneering innovations to extend the reach of oral health care delivery to the underserved. Because oral diseases are mostly preventable, many states are expanding dental hygiene practice acts to allow hygienists to provide services in nontraditional dental settings, such as clinics, nursing homes, hospitals, and facilities that treat people with developmental disabilities – except for Georgia.
Georgia's past public health director, Dr. Rony Francois, said that Georgia's current rules governing hygienists are among the most stringent in the nation.' According to the 2011 U.S. Census Bureau, Georgia ranks as the sixth-highest state for poverty in the U.S. About 20% of Georgians do not have health insurance, making Georgia one of the leaders in states with the most uninsured residents. In April 2011, an Institute of Medicine (IOM) report called on the U.S. government to explore an expanded role for nondentists and new ways of providing dentistry in order to address the dental crisis.
In July 2012, dental providers, researchers, legislative leaders, and health professionals gathered at a regional oral health conference in Atlanta, sponsored by Morehouse School of Medicine, to focus on Georgia's dental deficits and explore opportunities to improve access to oral health care. Dr. David Satcher, former U.S. Surgeon General, and Dr. Louis W. Sullivan, former U.S. Secretary of Health and Human Services, spoke at the conference and expressed support for dental therapists to provide care for those in underserved communities.
Unfortunately, proposals to license midlevel dental providers have stirred controversy across the United States since the inception of the Alaska Dental Health Aide Therapist (DHAT), founded in 2005 to reduce the oral health inequities affecting many Native American children. In 2009, Minnesota approved legislation for the first U.S. dental therapy program, and in 2011, the first class of dental therapists graduated from the University of Minnesota School of Dentistry. Although Minnesota is currently the only state to license dental therapists, 20 states are actively exploring this innovative approach to expanding oral health care. But the American Dental Association (ADA) and their state dental associations vehemently oppose the creation of midlevel dental providers as a solution to care, denying there is a shortage of dentists and stating, "The situation is entirely a matter of geographic misdistribution," and consistently maintaining that dental therapists are not adequately trained to perform irreversible procedures.
However, a reports on 26 nations' and territories' experiences with midlevel dental providers found that they provide good quality, cost-effective care, and according to the January 2013 issue of the Journal of the American Dental Association, dental therapists were found to treat caries as effectively as dentists. In election years, special interest lobbyists get a chance to be major political players; in 2012, the ADA and its 157,000 members doled out millions in federal and state contributions, making it a heavy hitter on the Washington political scene. Donation dollar accomplishments include effectively opposing federal funding for "Alternative Dental Health Care Provider Demonstration Projects," meaning dental therapists. Because dentists are major campaign contributors in local and state elections, they usually win the legislative battles, but the general public loses out in the long run.
In December 2022, the federal Advisory Committee on Training in Primary Care Medicine and Dentistry issued a comprehensive government review of dental therapy. The report concluded that dental therapy improves access to dental care, decreases oral health inequities, and creates a more representative workforce, and therefore recommends further federal funding to train and deploy more dental therapists across the U.S.
As of 2023, there are 5,212 practicing dentists in Georgia, compared to 7000 licensed dental hygienists. Georgia currently has 16+ dental hygiene programs actively enrolling students as compared to only one dental school. Dental hygienists graduate only to find limited job availability. The dental hygiene job market and their ability to provide care to patients is shrinking when it could be growing. Georgia's restrictive practice acts make it illegal for dental hygienists to provide dental hygiene services to the public without the direct supervision of a dentist, thus making dental care for low-income adults even more cumbersome and cost-prohibitive.
Throughout the nation, many states are expanding practice acts for dental hygienists, putting licensed oral health-care professionals to work and increasing access to care for low-income individuals while improving oral health. In 2009, Massachusetts adopted the Public Health Dental Hygienist Program, which began operating in 2011 as a demonstration project through a grant from the University of Massachusetts Medical School. The hygienists, who are authorized to be "directly reimbursed for services administered in a public health setting," began working in schools, nursing homes, Head Start programs, and residences of the homebound, providing preventive dental care to both children and adults and also acting as an important bridge for continuing care by referring patients to dentists for ongoing services. During its first full year, the program served approximately 2,700 Massachusetts residents. In 2012, the number of people who received care topped 6,900 – an increase of 155%.
A combined, consistent effort is urgently needed in Georgia to improve oral health care. If policymakers in Georgia were to adopt legislation similar to that of Massachusetts, Georgia's licensed dental hygienists could increase access to care for low-income patients and help lower the cost of preventable emergency dental visits, thus saving the state's taxpayers millions of dollars while expanding employment for an existing workforce of licensed professionals. Although the Georgia Dental Association asserts there is no lack of dentists in the state and continues to restrict hygienists' ability to assist thousands of low-income individuals, eventually consumer advocates and oral health coalitions will pressure Georgia's policymakers to make changes for the good of the public. Until then, the dental forecast for Georgia is expected to stay hot and dry.
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