Topics in Health: Lessons From The Field
Debbie Crites had a secret.
When Crites visited the dental clinic in Fort Gay, West Virginia in the winter of 2007, her X-rays showed that two teeth were missing since the last time she visited. Her dentist, Dr. Dan Brody, was puzzled. What happened to the two teeth? he asked her. Did they fall out?
Crites grinned, and then launched into a story about how her teeth had ached with pain the previous fall and how she couldn't afford to have them extracted. So she had taken matters into her own hands, she told the dentist. She mentioned a night at a bar. A pair of wire pliers. Moonshine.
After evaluating the teeth that were left in her mouth, it didn't take long for the dentist to declare the necessary treatment. A "full-mouth evacuation" was in order. The last of Crites' teeth - all 11 of them - would have to come out.
I had heard similar stories of self-dentistry from patients at rural dental clinics before, but Crites had X-rays to support her claim. (Later, she took me to her basement apartment under a local bar to show me the tools she used to yank out her teeth after a night of drinking at a bar named "The Wildcat II.")
In the several months after I met Crites, I talked with numerous other West Virginians who faced similar fates, people suffering with painful toothaches, gaping cavities, gum infections and cracked molars. Some had up to 15 teeth removed during one sitting.
Their tales became the heart of my series of stories published in the Charleston Gazette in the spring of 2007. By most measures, I reported, West Virginia had the worst oral health in the nation.
Early on in my research, I realized that oral health was one of the nation's most undercovered health issues. Sure, I found a large number of newspaper stories about "Give Kids a Smile Day" or "Mission of Mercy" programs in which dentists offer free services to hordes of low-income people unable to afford to routine dental care. The programs deserve praise. The dentists and hygienists deserve kudos.
But the national story of poor dental health and its implications - former U.S. Surgeon General David Satcher called it a "silent epidemic" in 2000 - isn't getting the attention it deserved. The issue, for most public officials, is out of sight, out of mind.
It's not just about teeth
Studies have shown that poor oral health isn't a problem confined to the mouth. Decay and infections in teeth have been linked to other health problems: heart disease, diabetes, pneumonia, stroke, and premature and underweight babies.
I started my research with the U.S. Centers for Disease Control's National Oral Health Surveillance System Web site and examined a host of dental health indicators for every state:
- percentage of people 65 and older with no teeth
- adults who lost six or more teeth
- adult dental visits
- fluoridation statistics
- percentage of people who had their teeth cleaned
Much of the same dental survey data is broken down by metropolitan statistical areas (SMSAs), allowing you to compare cities within your own state. Also, a call to your state's Behavioral Risk Factor Surveillance System office - which collects the data for the CDC - should turn up figures for every county within your state.
What makes the state-by-state data even more valuable is that you can analyze it by race, gender, age category, education and income level. Look for disparities. How does the oral health of low-income residents compare to that of people who make more than $50,000 a year? Are younger adults more likely to go to the dentist than the elderly? How do African Americans, Latinos and whites compare?
Getting statistics on children's oral health in your state and community can be a little trickier. One place to start: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) data. EPSDT is a Medicaid program for children that focuses on prevention and early diagnosis and treatment.
The state-by-state EPSDT numbers show how many Medicaid-covered children receive medical and dental exams each year. You can use the data to figure out the percentage of Medicaid children in your state who received a dental exam in a given year.
In West Virginia, only about one of every three kids covered by Medicaid visits a dentist, even though the health insurance program for the poor covers most dental procedures. After interviewing Medicaid families, I learned some of the reasons: lack of transportation, a dwindling number of dentists willing to accept new Medicaid patients, and lower expectations for dental health.
Medicaid claims data - the fees dentists submit to Medicaid for reimbursement for dental services they provide to patients - are another source of information on children's dental health. Of course, getting your state Medicaid office to release the data can be -- pardon the pun -- like pulling teeth
Our state Medicaid office refused to release its claims database, but I was able to obtain the same information - dental claims, minus patients' names -- from the West Virginia Health Care Authority, a regulatory agency that monitors health care costs and collects data from other state offices, such as the Medicaid agency. I used the figures to show that West Virginia dentists were billing the state more for pulling children's teeth than for cleaning them. Prevention was taking a back seat to drilling and filling teeth - and taking them out.
To save time, you might check to see whether your state can provide aggregate dental claims data by procedure. Some states - not West Virginia - compile the information in monthly, quarterly or annual reports.
Finding real people with dental problems
Armed with data, it's now time to make an appointment with a dentist.
The best place to start: free clinics and community health centers that serve low-income patients and those without insurance. Many have dental programs. The people who work there are on the front lines in the battle against dental disease and decay. Talk to the dentists, hygienists and dental assistants.
The clinics also frequently sign on third- and fourth-year dental school students for semester-long practicums. Spend the day with them. Watch their reactions. They're seeing everything from a fresh perspective. They're seeing things they never saw in dental school.
To find clinics, contact your nearest dentistry school - there's at least one in most states - and talk to professors and administrators. They'll know which dental centers, and, perhaps, private dentists' offices will be most likely to allow a reporter to hang around.
While working on my oral health series, I spent day after day talking with patients at dental clinics and dentist offices. If you have the dentists on your side, and they make the introduction, most patients will talk to you. During my project, few people declined to be interviewed. In some cases, a reporter's presence serves as a distraction and helps ease anxiety.
Of course, patients who are in obvious pain might not want to talk, or won't be able to. But I found most people were willing to speak about their dental history -- before the drill started whirring and the dentist picked up a pair of forceps. Their stories will provide a narrative that goes beyond the numbers you collect.
From a policy standpoint, you might want to check to see what dental services Medicaid covers in your state. In West Virginia, Medicaid will only pay for tooth extractions for adults ages 19 and older. It won't pay for teeth cleanings, fillings, crowns, dentures or any other dental procedures. A majority of states have similar restrictions. And some state Medicaid programs won't pay for any dental services whatsoever. Dental services are usually the first thing to go during a budget crunch.
Medicaid does pay for dental services for children in all states because of a federal mandate.
After you publish your first story on oral health, be prepared for phone calls and e-mails from readers desperate to find a dentist. Try to help them. See if they'll talk to you about their struggles to get their teeth fixed or acquire a new set of dentures. Refer them to dental clinics and offices you found through contacts you made during your reporting.
There are many more people like Debbie Crites out there. It's our job to tell their stories and to bring dental health issues to the forefront so that people recognize the problem and work to improve access.
You never know. Your stories may help put a smile back on someone's face.
Eric Eyre is the health reporter for the Charleston (W.Va.) Gazette.
Photo credit: Ashlee Martin via Flickr