Rx for Rural Health | Lack of insurance, poverty, drug abuse lead to dental problems
Mar. 29—CUMBERLAND — While rates of emergency department visits for dental conditions are lowering in Maryland among people younger than age 65, numbers are on the rise for senior citizens.
Dr. Diane Romaine recently cited that data from the Maryland Health Services Cost Review Commission, and several other statistics that show an inequity of dental care for folks of a certain age.
Nationally, “70% of people age 65 and older … have no dental benefit,” she said.
Romaine, who offers comprehensive dental care at practices in Frostburg and Bedford, Pennsylvania, is a dean’s faculty educator for the University of Maryland School of Dentistry and an adjunct faculty at the West Virginia University School of Dentistry.
Her practice provides a clinical externship site for University of Maryland fourth-year dental students.
The effort is coordinated by Area Health Education Center West in Cumberland to attract health professionals to underserved rural areas throughout Appalachia.
Romaine is a past president of the Maryland State Dental Association and current president of the Maryland State Dental Association Foundation, where she chaired the Maryland Dental Emergency Department Workgroup that developed a resource guide to reduce patients that seek dental treatment in hospital emergency departments.
“One of the big measuring devices of (dental care) need is traffic to emergency rooms with people with dental issues,” she said. “You have situations of people now going to urgent cares where it’s really hard to count totally.”
In 2014, Romaine coauthored an American Dental Association Health Policy Institute research brief that indicated diverting emergency department dental visits could save Maryland’s Medicaid program $4 million per year.
“Between the years of 2013 and 2016, 15 Maryland adults died entering Maryland emergency departments for a dental-related issue,” she said.
Romaine currently works with stakeholders in Maryland to develop a more robust adult dental Medicaid program and has served on the Emergency Department Workgroup for the American Association of State and Territorial Dental Directors and the Eldercare Workgroup for the American Dental Association.
Veterans among those without dental coverage
“Cost of care is the number one reason for not going to the dentist,” Romaine said.
Maryland is one of few states that has no dental benefit for adults on Medicaid.
“The (ADA) is definitely in support of a Medicaid dental benefit in all states for adults, which Maryland wouldn’t even comply with,” she said.
The state in June 2019 began an $800 per year dental benefit for “dual eligible” people ages 21-65 that have Medicaid and Medicare.
“They’re mostly disabled people,” Romaine, who was involved in the state’s political action, said. “For the state of Maryland, this is kind of like a project to study and get data on and see … if it can translate into an adult dental Medicaid benefit.”
COVID-19 has slowed the process, however.
Many veterans also lack dental insurance.
“It’s really not right that you can be a veteran and not have a basic dental benefit,” Romaine said. “I see that all the time, or there are a lot of barriers of complexity. … That is definitely revealing itself as a big issue.”
Benefits for children, pregnant women
Maryland has a robust children’s dental Medicaid benefit.
“Those children have some of the highest rates of going to the dentist,” Romaine said.
The benefit also covers pregnant women but only until they gave birth.
That’s probably about to change.
Gov. Larry Hogan’s administration is expected to approve a 60-day postpartum dental Medicaid benefit that could start this spring.
“Delegate Mike McKay locally was really part of the push for that,” Romaine said.
In 2010, Romaine initiated the Western Maryland Mission of Mercy free adult dental clinic that has hosted large events at the Allegany County Fairgrounds and developed into a program across the state that has delivered roughly $23 million in free dental services.
Although COVID-19 halted the clinics, plans are underway to rebuild the program.
“This is something that is now being reworked to find a safe way to do it,” Romaine said.
Younger patients needing full-mouth extractions
For many rural Americans, poverty, drug abuse and/or poor nutrition can lead to tooth decay.
Dr. Roslyn Kellum, a dentist and registered nurse, is dental director of a separate Mission of Mercy organization, which serves Maryland and Pennsylvania.
The independent, nonprofit and faith-based community organization provides free health and dental care, and prescription medications to uninsured and underinsured people.
“We care for our patients. We want to help them,” she said. “We want to get them comfortable and healthy … with dignity, love and respect.”
Founded in 1991 and launched in 1994, the group does not receive government funding, which means patients that utilize its services don’t need proof of poverty or residency.
The organization receives financial donations, including via its website at amissionofmercy.org, that help fund a mobile unit that’s equipped with three dental chairs and operated by medical professionals including volunteer dentists.
While the group also provides services for folks in Arizona and Texas, Kellum’s team visits communities in various parts of Pennsylvania and Maryland, including Knoxville in Washington and Frederick counties, each month.
People that go without dental care can be at risk for health problems including diabetes, cardiac and respiratory issues, she said.
“Your mouth is the gateway to a lot of working systems in your body,” Kellum said.
Her team provides blood pressure screenings and refers patients with high readings to the organization’s medical professionals for further medical tests.
“It’s saved (some patients) from heart attacks and strokes,” Kellum said. “We’re going to begin soon doing glucose screenings to see if we can detect anyone who may be at risk for diabetes.”
In her more than 30-year career, she’s seeing an all-time high number of patients in their 20s, 30s and 40s that require full-mouth teeth extractions due to abuse of substances including opioids and alcohol.
“Prior to the pandemic it was bad, but since we’ve been in the pandemic, people are stressing out, they’re using more and it’s affecting their teeth,” Kellum said and added that substance-abuse patients neglect their oral health and hygiene sometimes for months at a time. “My older patients have more teeth in their mouths than the younger patients.”
People that suffer from substance addiction tend to crave and eat foods high in sugar and carbohydrates “that attack the teeth in a destructive way,” she said and added that in general, poor diet and nutrition can lead to dental problems.
Rural access to healthy food lacking
Rural communities often lack access to grocery stores that sell healthy food, said Geri Henchy, director of nutrition policy at Food Research & Action Center.
The Washington, D.C.-based organization is the leading national nonprofit that works to eradicate poverty-related hunger and undernutrition in the U.S.
“Most commonly what (rural people) can get to might be something like the little food part of the gas station stores,” she said and added that those shops often have high prices and limited selection of healthy food.
“People have to go a long way if they want to get to a full-service (grocery) store,” Henchy said. “That means they have to make (food) choices of what they can bring back and make last for longer.”
Although many rural areas include farms, most locally grown food is shipped away to grocery stores.
“That complicates issues for rural communities,” Henchy said. “Food could be produced right in your community but you don’t get access to it because it has to go out.”
People, including senior citizens, in rural areas that don’t have enough money to buy healthy food often turn to federal, and public school, programs for help, she said.
“So there’s higher rates of participation on (the Supplemental Nutrition Assistance Program) in rural areas,” Henchy said. “SNAP is an important resource.”
The federal Special Supplemental Nutrition Program for Women, Infants, and Children, also known as WIC, has an interface with the health care program, she said.
“Everyone who is on Medicaid is automatically eligible for WIC,” Henchy said.
WIC offers a fruit and vegetable voucher, the amount of which the recent American Rescue Plan Act of 2021 roughly tripled, that can be used at farmers markets, she said.
Programs are also underway to provide food for some folks that lack access to grocery stores.
According to the United States Department of Agriculture, most states including Maryland, Pennsylvania and Ohio participated in a SNAP online food purchasing and delivery two-year pilot program launched in April 2019.
Programs including SNAP and WIC benefit food systems as well as local economies, Henchy said.
“If you think about how much money is coming through in SNAP and WIC to a grocery store in a rural region, it’s a lot of money,” she said. “That’s why we think it’s key to supporting the health of rural families.”