Doctors take on dental duties to reach low-income and uninsured patients

DENVER — Pediatrician Patricia Braun and her team saw about 100 children at a community health clinic last Monday. They administered flu shots and treatments for illnesses like ear infections. But Braun also did something most primary care doctors don’t do. She scanned the inside of their mouths for cavities or applied fluoride varnish to their teeth.

“We’re seeing more oral disease than the general population. There’s a greater need,” Braun said of the patients she treats at the Bernard F. Gipson Eastside Family Health Center, part of the Denver HealthColorado’s largest safety-net hospital, serving low-income, uninsured and underinsured residents.

Braun is part of a trend across the United States to integrate oral health into medical exams for children, pregnant women and others who don’t have the financial means or can’t easily access to dentists. With federal and private funding, these programs have grown over the past 10 years, but they face socioeconomic barriers, labor shortages and the challenge of meeting the needs of new immigrants .

With a $6 million federal grant over five years, Braun and his colleagues helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming and Arizona. Similar projects are completing in Illinois, Michigan, Virginia and New York, funded by the Office of Maternal and Child Health of the federal Health Resources and Services Administration. Beyond assessment, education and preventive care, primary care providers refer patients to on-site or off-site dentists, or work with integrated dental hygienists as part of their practice.

“Federally Qualified Health Centers have a long history of co-locating dental services within their system,” Braun said. “We’re moving to the next stage where care is not just lumped together, meaning, let’s say, we’re upstairs and dental care is downstairs, but we’re integrated so that they do part of the same visit for the patient.

Having doctors, nurses and physician assistants who assess oral health, make referrals and apply fluoride at community health centers is essential for the many children who lack access to dental care, Tara said Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five urban Indian organizations.

“Providing these services during doctor visits increases the frequency of fluoride application,” Callaghan said, and “improves parents’ knowledge about caring for their child’s teeth.” But obstacles remain.

Due to Montana’s large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Fifty of the state’s 56 counties are designated dental shortage areas and some counties don’t have a single dentist who takes Medicaid, she added. Montana ranks among the last residents with access to fluoridated water, which can prevent cavities and strengthen teeth.

Pediatric dental specialists, in particular, are scarce in rural areas, with families sometimes driving hours to neighboring counties for treatment, she said.

Integrating dental hygienists with doctors is a way to reach patients in a single medical visit.

Valerie Cuzella, a registered dental hygienist, works closely with Braun and others at Denver Health, which serves nearly half of the city’s children and has embedded hygienists in five of its clinics that see children.

State regulations vary as to what services hygienists can provide without the supervision of a dentist. In Colorado, Cuzella can, among other things, independently perform X-rays and apply silver diamine fluoride, a tool for hardening teeth and slowing decay. She does all this in a comfortable office area.

Braun and Cuzella work so closely that they often finish each other’s sentences. Throughout the day, they text each other, taking advantage of brief lulls when Cuzella can visit an exam room to check for gum disease or demonstrate good brushing habits. Braun herself uses similar opportunities to assess oral health during her exams, and both focus on parent education.

Medical and dental care have traditionally been compartmentalized. “Schools are getting better at interprofessional collaboration and education, but overall we train separately, we practice separately,” said Katy Battani, a registered dental hygienist and assistant professor at Georgetown University.

Battani is trying to bridge the gap by helping community health centers in nine states, including California, Texas and Maryland, integrate dental care into pregnant women’s prenatal visits. Pregnancy creates opportunities to improve oral health because some women have dental coverage through Medicaid and see providers at least once a month, Battani said.

In Denver, housing instability, language barriers, lack of transportation and the “astronomical cost” of dental care without insurance make dental care inaccessible to many children, the migrant community and residents. the elderlysaid Sung Cho, a dentist who oversees the dental program at STRIDE Community Health Center, serving the Denver metro area.

STRIDE attempts to overcome these barriers by offering interpreting services and a sliding pay scale for those without insurance. That includes people like Celinda Ochoa, 35, of Wheat Ridge, who waited at the STRIDE Community Health Center while her 15-year-old son, Alexander, had his teeth cleaned. He was flagged for dental work during a previous medical exam and now he and his three siblings regularly see a dentist and hygienist at STRIDE.

One of Ochoa’s children has Medicaid dental coverage, but her other three are uninsured and wouldn’t be able to do so otherwise. afford dental care, Ochoa said. STRIDE offers an exam, x-rays and cleaning for $60 for the uninsured.

Over the past year, Cho has seen an influx of migrants and refugees who had never seen a dentist before and needed extensive care. Health screenings for refugees at STRIDE increased from 1,700 in 2023 to 1,300 in 2022, said Ryn Moravec, STRIDE’s development director. She estimates the program welcomed between 800 and 1,000 new immigrants in 2024.

Even with growing needs, Cho said the Medicaid “unwinding” — the ongoing process to reexamine post-pandemic eligibility for the government program that provides health coverage to low-income and disabled people — has created financial uncertainty . He said he was concerned about facing the upfront costs of new staff and replacing aging dental equipment.

At STRIDE’s Wheat Ridge clinic, two hygienists float between dental and pediatric care as part of medical-dental integration. Still, Cho said he needs more hygienists at other sites to meet demand. The pandemic has created bottlenecks that are only slowly being resolved, in part because few dentists take Medicaid. If they accept it, they often limit the number of Medicaid patients they accept, Moravec said. Ideally, STRIDE could hire two hygienists and three dental assistants, Moravec said.

In 2022, Colorado enacted a law aimed at alleviating workforce shortages by allowing dental therapists – mid-level providers who provide preventive and restorative care – to practice. But Colorado has no schools to train or accredit them.

Before age 3, children must see a pediatrician for 12 well visits, a measure that medical and dental integration capitalizes on, especially for at-risk children. Under the Braun program in the Rocky Mountain region, providers applied more than 17,000 fluoride varnishes and increased the percentage of children ages 3 and younger who received preventative oral health care to 78 percent, up from 33% in the first two and a half years.

Callaghan of the Montana Primary Care Association is seeing this firsthand in community health centers across Montana. “It’s about taking advantage of the fact that children are seeing their doctor for a well-child visit much more often and before seeing their dental provider, if they have one.”

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the primary operating programs of KFF – the independent source for health research, polling and policy journalism.