SARAH: This is at the core of care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families, and communities.
I'm Sarah Hexem Hubbard, Executive Director of the Pennsylvania Action Coalition, and the National Nurse-Led Care Consortium.
As part of our special access to care series, we're going to rural Pennsylvania. We'll learn how some health systems are working there to expand access to dental care, and improve oral health and underserved areas, particularly for kids.
At last count, the majority of Pennsylvania counties didn't have any pediatric dentist registered with Medicaid, and 22 counties didn't have any pediatric specialists at all accepting public or private insurance. And some general dentists don't take very young children as patients.
This shortage of pediatric dental care underscores the need for preventive care, which had been at a premium especially in rural areas long before the pandemic exacerbated it.
A statewide coalition has documented successes across its multi-pronged efforts in recent years, including recruiting providers running mobile clinics, launching sealant programs and dozens of schools, and training primary care providers and preventive dental care.
With COVID-19 compounding the shortage of dentists, those solutions have taken on more significance. But it might not be enough to head off the crisis, some say lies ahead without wider adoption and other changes in how dental care is delivered.
We'll hear from advocates working on the issue statewide, as well as nurses and dentists delivering care in Pennsylvania's Coal Region.
Our producer Emily Previti went there recently to talk to providers about how they're navigating obstacles from transportation to water supply and food insecurity, to cultural norms and broadband availability.
TAMMY: My name is Tammy Lobach. I'm a family nurse practitioner. I have been practicing for the last six years graduated from DeSales University. And I'm currently in Bloomsburg University's doctorate program. I actually was a nurse's aide way back in probably the 2000s, knew that I want to be in the healthcare field, wanted to care for people. And just pursued through the nursing field: becoming a nurse's aide, I became a registered nurse. I did an associate degree, bachelor degree. Moved forward, got my masters, and just slowly climbed the ladder.
I was working in a rural health setting, definitely was a need in the area that I was working in. A lot of children having dental issues, and nowhere to go. Most practices, from a dental standpoint, don't really take Medicaid, or state insurances. And there was always a problem with getting these kids into the proper resources that they needed.
EMILY: At the time, Tammy was based in the Nesquehoning Federal Rural Health Clinic within St. Luke's Miners Health Network. The borough of around 3,300 people is in Carbon County. In carbon, zero pediatric dentists are registered with Medicaid. And there are more Medicaid recipients per general dentist that accepts it in all but six other counties, each of them rural. The high rate of Medicaid reliance at odds with provider availability wasn't the only issue with accessing care that Tammy observed.
TAMMY: A lot of patients need to sign up on the internet while they don't have internet access, if they do live in rural internet access and broadband is very poor reception. So, there's always something – there’s always a hurdle to cross. Pennsylvania has ranked one of the lowest states to receive chlorinated water. Monroe, Carbon, and Schuylkill only have three water systems that have fluorinated water, and 146 of them do not.
Most people are under the misconception about when their child needs to go see a dentist and that was another thing that I found when I was calling to see who accepts what insurance I did go that again and ask the dentist office at what age is the dentist comfortable seeing the child and I was shocked to actually hear back that they were comfortable seeing the child at the age of seven, which is entirely too late. And there's few pediatric dentists in the area. Most are family practice and that was their comfortability – with seven.
A few years ago, MORE Care came in, introduced the program that they wanted to integrate oral health care into a rural medicine.
EMILY: When Tammy says more care, she's referring to the Medical Oral Expanded Care Initiative, launched in 2015 by the DentaQuest Partnership for Oral Health Advancement to train nurses and other primary care providers in preventative dental care in rural Pennsylvania, South Carolina, Colorado, and Oregon.
Dental Hygienist Kelly Braun oversaw the program in Pa. through its conclusion in 2019. Now, she's the dental delivery systems coordinator for the State's Office of Rural Health and is overseeing similar training for primary care providers, along with other initiatives to improve dental health.
KELLY: We asked medical providers to complete an oral health risk assessment for the pediatric population. We generally use the American Academy of Pediatrics oral health risk assessment, which goes through a series of questions, both for the caregiver and then also about the child's oral health. And that helps the provider to determine how at risk a child is for developing dental cavities or dental caries. After the risk assessment, especially if the child is high risk, we do recommend that fluoride varnish be applied. And fluoride varnish is essentially a sticky fluoride paint. And it comes in a little generally a little well, or a little packet where you can kind of apply it to your glove and it gets painted on with what looks like a little tiny paintbrush, typically teeth need to be as dry as possible. So, the patient can either be down kind of on the exam table so that their head is flat on the exam table. Or it can be applied using what we call a knee-to-knee exam where the providers its knee to knee with the caregiver, and the child is able to sort of be laid back into the provider’s lap. So, the provider has a really good view of the child's teeth and is able to dry them off and then paint the fluoride varnish on. As the provider is taking a look at the teeth and right before they apply that fluoride varnish, we do ask as part of their exam that they take a look at the teeth on the way to the tonsils.
EMILY: Over the course of the program – and since then – more than a dozen sites across three health systems have trained providers according to the MORE Care model.
TAMMY: We had to do modules we had testing at the end, we had trained on the oral health risk assessment tool. A dental hygienist did come in talk about fluoride application, things to look forward an oral exam. And we implemented the program. I guess the biggest goal was identifying the children at risk, educating the family or parent or guardian that they were with on proper oral health care, and then getting them into a dentist. Sounds easy, but it definitely was a work in progress.
As far as the dental offices in the surrounding area, I must have maybe a dozen offices that are within a 10-mile radius from our office, but not one of them accepts state insurances. These people need to travel to bigger cities in order to get the dental care that they need. Because of COVID and dentist offices being closed, they're probably slowly getting back into seeing their regular patients who needed assistance all of 2020, playing catch up, and now having a hard time getting new patients in.
EMILY: Tammy actually grew up just 10 miles or so from Nesquehoning, in Tamaqua, Schuylkill County. Tamaqua’s home to another St. Luke's Rural Health Clinic involved in MORE Care. Like others in the pilot program, providers at the Hometown clinic found referral follow-through challenging to say the least – despite the dentist office just around the corner.
Given that and the community's need for dental care documented by successive health needs assessments, the clinic set up an on-site dental office and brought on part-time specialists.
Jessica Brennan was among the first of those hires.
JESSICA: My name is Jessica Brennan and I'm a public health dental hygiene practitioner at the St. Luke's Rural Health Center in Tamaqua, Pennsylvania. I always liked going to the dentist when I was a child. So, I actually had some issues. I had trauma to my face. When I was probably around 10, I was ice skating and I fell I tripped my two front teeth off. So, I went to the dentist a lot. And I loved it. I had root canals. I don't know, I just always love going to the dentist. Which may sound odd to some people, but I just fell in love with dentistry then. And that's kind of how I decided to go into the dental field. And then in 2019, I came aboard St. Luke's and I started working here as a PHDHP, a public health dental hygiene practitioner. We like to say PHDHP because it's a mouthful to say constantly.
I was here for preventive care, but most of our patients are beyond preventative at this point. So, to make those referrals, that's when I'm like, ‘Wow, there really is no one here to help these patients that need the care.’ There's only a handful in the area and most of them or not taking new patients. It's been challenging. So, in July of 2020, we did have a dentist come aboard. And then Dr. Ben started in December of 2020.
SOUMAYA: My name is Soumaya Bendjilali. I usually get called Dr. Ben because it's easier for the patients here. I'm a dentist at the rural health clinic. I graduated from Temple Dental School. I've been working here since December of 2020. But before that, I was a resident here at St. Luke's Dental. I grew up around the area, I went to Lehigh University and Saucon Valley School before that. So, yeah, I'm familiar with the area. And the reason I got into the subject to become a dentist, in general, was because I always loved art. And I loved the medical side of everything. And I felt like it joined both things together. Just being able to reconstruct a smile for somebody, that's life-changing for the patient. It's a way for me to help the patient and also it does take a lot of art perspective into it. So, there's different colors of teeth, different shapes of teeth. Each filling is different. It really does take an artistic ability: fine motor skills, you know, being able to distinguish between the different shades of teeth, the smile line.
EMILY: When I met with Jess and Soumaya, we started out with an overview of dental equipment.
JESSICA: This machine over here is an external suction unit. So, as you can see, it's like a cup here. We just bring it over the patient, we turn it on, it just is a HEPA filter. It sucks the aerosols in, helps clean the air. So, this is another safety measure that we added in post-COVID.
EMILY: I learned a lot about dental equipment, much of it beyond the scope of this podcast, in part because their 11 am appointment didn't show up. They told me the clinic's no-show rate is relatively high and attribute that to multiple factors, including transportation issues and inability to take off work. Not to mention that people don't always take dental care as seriously as they probably should.
SOUMAYA: Sometimes we have the full day everybody shows up even the patients that we've saved booked any emergency that sometimes we do get emergency patients, they're not patients for the clinic, per se, but maybe they have a tooth pain or something and we want to see them. So, we try to fit them into the schedule right away. And sometimes the full schedule shows up the ones that are scheduled and the emergency patients. So we have a full day. It's very busy. Other days, we have a couple patients show up couple don't show up. Many patients here say like, you know, I was never taught that. I should brush daily.
EMILY: Teledentistry does have its limits.
SOUMAYA: We like a full set of X-rays every five years. But about every year we take four bite wings – bite wings are just kind of side views of the teeth – so we can kind of see what's happening between the teeth. A lot of cavities start in between the teeth. We can't see them clinically. So, we see them on the X-rays. A lot of cavities have been diagnosed clinically. Most we cannot. We have to see them on the X-ray.
Fluoridated water helps solidify teeth, kind of like a vitamin for teeth. I like to say that it helps them actually be anti-cavity. So, they resist cavities more than teeth without fluoridated water. So, it already puts them at a disadvantage. The fact that they don't have a dentist that takes they insurance, they don't have a pediatric dentist here. They're already disadvantaged from the beginning, with not having strong teeth.
EMILY: With millions of Pennsylvanians using well water and the vast majority of public water systems opting out of fluoridation, the state's percentage of residents with access to fluoridated water is lower than all but 10 other states. That ranking ultimately spurred the creation of the Pennsylvania Coalition for Oral Health. Helen Hawkey is executive director.
HELEN: What we realized was there was actually a much bigger need than just water fluoridation. We continue to grow stakeholders, we gather people from the community, we get dental providers and medical providers, community advocates, insurance agencies. We try to really get as many people at the table as possible that are passionate about oral health.
It's not just, ‘Did I brush my teeth today?’ It's also, ‘What does my diet consist of? What do I regularly drink? Where do I do my grocery shopping?’
When we see families that have access to healthy foods and are getting to buy fresh fruits and vegetables, they're going to have a much better time. I'm keeping their mouth healthy and eating the right nutritional things. If you're relying on the local dollar store to get the bulk of your groceries, we see a bigger issue with that.
When you go to seek dental care, where are you going for that dental care? Is there a dentist in your community? For a lot of our rural populations, they run into trouble trying to find a dental office that, yes, is located within a reasonable driving distance, is maybe willing to accept their insurance. Maybe you have a family and someone has a disability and, you know, you need to find a provider that's willing to see that person with a disability as well. Or see extremely young children. Oftentimes, dentists seem to set a minimum age threshold for families to come in. And that can be a pretty big barrier when we're trying to encourage families to start seeking dental care at age one.
Pennsylvania is actually in the middle of year three of a four-year HRSA oral health grant. And one of the projects that we're working on with that is introducing dental services into rural health clinics. So, we've been successful in years one and two, we were able to add services at three rural health clinics across the state. We do have one more year left of that HRSA grant. And so, we will be offering in the fall another request for proposal to add on at least one more rural health clinic and the grants are to buy equipment.
EMILY: In the meantime, the state legislative budget and finance committee is researching dentistry and teledentistry over the summer and is expected to issue a report this fall. Also, the number of primary providers delivering preventative dental care continues to rise.
HELEN: Our state really made a push to get pediatricians to start asking oral health questions and making good referrals to their patients. So that they were getting to dental care at an early age and also offering fluoride varnish as a preventive service. Oftentimes, for especially kids in the zero to three range, Mom and Dad are taking them into the pediatric provider quite a bit. You know, sometimes every two months, you've got a visit there. So, there's a lot of potential for a touch-around oral health. We've had a few hundred different pediatricians’ offices across the state that have taken up that practice of making good oral care referrals and doing fluoride varnishes. It's become really almost the norm, which has been great. It's being reimbursed by insurances; patients are expecting it.
Another really successful project has been through the Pennsylvania Head Start Association. They have really focused on oral health as a priority for the kids and the Head Start group serve the zero to five population. So, we've had a number of them that are now hiring dental staff.
And then we've even seen an uptick in – even prior to COVID – we’ve seen an uptick in the use of teledentistry.
EMILY: Statistics from the Kaiser Family Foundation show that compared to other states, Pennsylvania has been doing better than most add meeting dental needs, but also needs a relatively high number of providers to close the gap. Those numbers came out a year ago, that was well into the pandemic. But the next iteration could show more clearly how COVID’s affected dentistry – on top of the stories circulating about wait times of six months or even a year to get into the dentist.
HELEN: In terms of long-term what we're going to see come from COVID, I think that the people who are already struggling are going to struggle 10 times worse. And I think it's going to take more than a few years to really see a rebound. We’re expecting to see a steady decline in the number of dentists available until the year 2035. It's just going to be a complete mess in terms of being able to match up people with care. It's just – it’s not going to work. So, I think our system, it's going to break under that pressure.
We've got to come up with some kind of new system that's going to fix this problem or at least alleviate this problem. We always come back to prevention. An ounce of prevention is worth a pound of cure. Dental disease is extremely costly to fix. It takes a long time, and you need a high level of a specialist to treat it. So, if we can maybe not necessarily reduce the amount of disease that we have, but the level that the disease gets to, we can then think of more creative ways to start serving people. Maybe outside of brick-and-mortar dental office. You know, we've seen different approaches where we start to think of, you know, maybe you get your regular preventive care somewhere outside of a dental office, and when you need restorative care or you have a higher level of disease, that's when you would visit the dentist as the provider who can treat that disease for you. Using teledentistry, with someone how’s able to through video conferencing able to do a screening and exam for 12 patients in an hour, they can never do that life, in person, in a chair. So, we're going to need to spread our providers out, spread those services out to people make sure that we're trying to meet them where they are, and save that time of them heading into the dental office. I don't think it's going to be easy. I don't think we're going to have an easy time of trying to fix this problem. But I do think we have to work together, you know, and where we can see the biggest bang for our buck is within those pregnancy to age five. That's really the place where I think we can make the biggest difference.
SARAH: Funding for our special access to care series comes from the Center to Champion Nursing in America, which is a joint initiative of the Robert Wood Johnson Foundation, AARP, and AARP Foundation.
At the Core of Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.