The Pennsylvania Dental Care Crisis

An examination of dental care access as a social issue

Though oral health is a critical part of overall health, dental care is rarely prioritized in adult Medicaid plans. According to the U.S. Department of Health and Human Services, coverage is optional for states, and some that do provide it only cover emergencies (“Does Medicaid Cover Dental Care?”). However, routine preventative care is crucial for the maintenance of tooth and gum health, and can prevent those very emergencies. One study found that more preventative services resulted in less expenditure on more extensive restorative and periodontal procedures for low-income or chronically ill individuals later on (Pourat, et al).

Pennsylvania’s Medicaid program provided comprehensive dental coverage for enrolled adults prior to 2011. However, the state’s budget cuts removed the program and left recipients with a plan that only covers one set of dentures per lifetime, routine exams, cleanings and fillings (Pennsylvania Department of Public Welfare).

More extensive procedures like root canals and crowns are only covered by the insurance if the patient qualifies for a benefit limit exception (BLE). To receive a BLE, the provider must submit an application form to the Department of Human Services indicating whether the patient meets certain criteria for an exception. The criteria are extreme and limited. In order to qualify, the patient’s life must be at risk due to the dental issue, the exception must be the most cost effective solution, or the exception would need to be granted to comply with a federal law. Pregnant patients or those with certain chronic illnesses may also qualify (DHS/Office of Medical Assistance Programs).

So in this scenario, a state government agency is determining whether an oral procedure prescribed by a medical professional should be made affordable to a patient on a low-income insurance plan. Due to costs, that decision is often no, because an extraction is a cheaper option for a diseased tooth than other procedures. 

A person’s life should not have to be in immediate danger for the most appropriate treatment to be deserved and affordable. Instead, a treatment plan should ask, what does the patient need now? How much pain are they in? What is their oral history? How would a missing tooth impact their life? What is the recovery time? The bureaucratic indifference of the BLE application process does not take into account the whole patient, whose life can be permanently altered, for better or worse, by what happens to their teeth. 

The United States’ negative liberty ethos, which values individual autonomy, including bodily autonomy, is reflected in constitutional healthcare decisions that do not allow medical procedures against one’s will (Ruger, et al). Although the patient may willingly agree to have their tooth extracted, if that is their only option, if their insurance plan is government-provided and that plan determines which procedure they can afford, and without that extraction they are at risk for life-disrupting pain and health risks, is it actually their choice? 

Procedure costs are not the only factor driving the dental crisis. There is also a shortage of dentists, dental hygienists and dental assistants in Pennsylvania, as well as a shortage of dental practices that accept Medicaid. Practices are not required to participate in the program - they may choose to do so and the coverage payments come from the individual state (“Policy Basics: Introduction to Medicaid”). According to the Pennsylvania Coalition of Oral Health, the state has suffered a 10% decrease in dental providers since 2015, with the most extreme drops occurring during the COVID-19 pandemic. The number of dental offices that accept Medicaid has also decreased 13.5% while Medicaid recipients continue to increase (Pennsylvania Coalition for Oral Health). The 5 S’s - staff, stuff, space, systems and social supports, are critical in addition to affordability and patient-centered care. Even if these procedures were free, and appropriate treatments were prioritized rather than costs, people would still be going without care if they don’t have a dentist in their area or their local dentist is overburdened due to staff shortages.

Western Pennsylvania had an interesting response to the shortage. The local Central Penn College added a new Expanded Function Dental Assistant program and accelerated courses to educate and train professionals and get them into overwhelmed offices more quickly (York). Still, the state will need immediate remedies in other locations as well. 

In Pennsylvania, Expanded Function Dental Assistants can perform some procedures that only dentists can in other states, which can stretch treatment capacity in offices. Some states are also experimenting with allowing a different type of practitioner, a dental therapist, to perform routine treatments. This is similar to a nurse practitioner or physician assistant who can examine and treat a patient instead of a doctor for routine or generalized care. This could increase the number of available providers at an existing practice, hopefully increasing participation in preventative dental care, and maybe even allow new dental offices to open in areas that are underserved with few or no providers. The concept is controversial, but one study found that it could increase care access and that countries that utilize dental therapists have better oral health outcomes (Yang, et al). 

Dr. Ruth Lewis, a resident physician at Temple University Hospital in Philadelphia, said that she frequently sees patients who visit the emergency department for dental pain, cracked teeth and infections that are a result of prolonged delays of care. In those moments, the patients are desperate for relief and medical attention. “It’s really frustrating because I can’t really do much to help them,” she said. “I honestly hope it’s an abscess because then I can treat it and at least make them feel better. It’s something I can do. Or if it’s truly a surgical emergency, I could ask for oral surgery to pull a tooth. But usually they really need a dentist.” That lack of which, of course, being what brought them into her care in the first place. 

Of the immediate health impacts related to dental and gum health, she said there is risk of severe infections in the face and neck. “They are almost always dental in origin,” she said. “They can be life-threatening. It’s a worst-case scenario but it happens. And if you’re predisposed, the bacteria in your bloodstream can lead to endocarditis,” a life-threatening inflammation of the heart valve and chamber linings. She has had patients need to be admitted for intravenous antibiotics or other treatment. 

A steady pattern that Dr. Lewis sees in her patients is that their dental struggles are often accompanied by the comorbidities of housing insecurity, food insecurity, drug use, mental illness, or the inability to afford care. It is well-documented that marginalized populations suffer more from poor oral health (Northridge, et al) and that there is social stigma against missing teeth or teeth that do not conform to society’s standards (Moeller, et al). Patients often apologize to her for their appearance and express reluctance to share what is going on with their teeth due to embarrassment. “I don’t care what anyone’s teeth look like!” Dr. Lewis said. “I just really want them to feel better.”

The state of teeth and gums can also point to chronic health issues. Issues like gum inflammation and tooth erosion can be linked to HIV, diabetes and cancers (Pratt). Dentists are also trained to identify and report child abuse (Singh). Routine, accessible exams and attention to the mouth do not only benefit teeth, but could potentially identify serious illness or abuse. 

While the 2011 Medicaid cut is what initially stripped its members of much of their dental care, the current dental crisis in Pennsylvania is the result of compounding events and problems. It is made up of crises within crises that are social in nature. Bureaucratic systems are prioritizing costs over appropriate care. Providers aren’t incentivized enough by Medicaid reimbursements to participate sustainably in the program. The provider shortage is partially due to COVID-19 burnout that so many healthcare workers and administrators are suffering. And something that this project has not even explored is how diet impacts oral health, while a population’s diet is often determined by social factors.

It is extremely complex and so many people are holding the pieces together - the advocacy groups speaking out and pushing for Medicaid expansion, the patients sharing their vulnerable stories with journalists, the dentists doing the jobs of multiple people at understaffed practices, practitioners like Dr. Lewis triaging and treating vulnerable patients until they can get care, the graduating dental assistant students entering the field, and so many others. The solutions are as varied as the problems. A compelling piece to focus on for a broad solution is the fact that dental care is optional for states to provide under Medicaid (“Policy Basics: Introduction to Medicaid”), as if oral health is optional. Even when states do decide to provide it, it is often minimal. If state plans were required to fully cover both preventative and more extensive dental treatment, those who currently have access to treatment would at least be able to continue it and make longer-term comprehensive care plans, rather than piece together their oral health needs with limited visits, extractions or emergency room visits. This may also allow people to pursue more preventative care generally. It does not account for provider shortages and the many things that come between patients and oral health, but it would signify a standard that dental health is overall health by being required in the same plan. This would be logical considering how critical oral health is to the entire body and one’s well-being, physically and socially. 

Sources 

Center on Budget and Policy Priorities, Apr. 2020, www.cbpp.org/research/health/introduction-to-medicaid.DHS/Office of Medical Assistance Programs. “Pennsylvania Benefit Limit Exception Form.” dhs.pa.gov, www.dhs.pa.gov/docs/Documents/MA%20Response%20Forms/Dental%20Benefit%20Limit%20Exception%20Request%20Form.pdf. Accessed 3 May 2023.“Does Medicaid Cover Dental Care?” HHS.gov, 8 Dec. 2022, www.hhs.gov/answers/medicare-and-medicaid/does-medicaid-cover-dental-care.

Lewis, Ruth. Interview. 4 May 2023. By Interviewer Kiera Murray. Telephone Interview.

Moeller, Jamie, et al. “Assessing the Relationship Between Dental Appearance and the Potential for Discrimination in Ontario, Canada.” SSM-Population Health, vol. 1, Elsevier BV, Dec. 2015, pp. 26–31. https://doi.org/10.1016/j.ssmph.2015.11.001.Northridge, Mary E., et al. “Disparities in Access to Oral Health Care.” Annual Review of Public Health, vol. 41, no. 1, Annual Reviews, Apr. 2020, pp. 513–35. https://doi.org/10.1146/annurev-publhealth-040119-094318.

Pennsylvania Coalition for Oral Health. Access to Oral Health Workforce Report Part II, 2022. https://paoralhealth.org/wpcontent/uploads/2023/01/PCOH-23-Workforce_full-report.pdfPennsylvania Department of Public Welfare. “MA Dental Benefits Changes 2011.” padental.org, 26 Sept. 2011, www.padental.org/Images/OnlineDocs/Advocacy/MA_DentalBenefitsChanges2011.pdf. Accessed 3 May 2023.

“Policy Basics: Introduction to Medicaid.” Center on Budget and Policy Priorities, Apr. 2020, www.cbpp.org/research/health/introduction-to-medicaid.

Pourat, Nadereh, et al. “Evidence of Effectiveness of Preventive Dental Care in Reducing Dental Treatment Use and Related Expenditures.” Journal of Public Health Dentistry, vol. 78, no. 3, Wiley-Blackwell, June 2018, pp. 203–13. https://doi.org/10.1111/jphd.12262.

Pratt, Elizabeth. “Dental Exams Can Detect Signs of Disease Elsewhere in the Body.” Healthline, 13 Sept. 2017, www.healthline.com/health-news/dental-exams-can-detect-disease-elsewhere#Signs-of-disease-elsewhere.

Ruger, Jennifer Prah, et al. “The Elusive Right to Health Care Under U.S. Law.” The New England Journal of Medicine, vol. 372, no. 26, Massachusetts Medical Society, June 2015, pp. 2558–63. https://doi.org/10.1056/nejmhle1412262.

Singh, Vishwendra. “Child Abuse and the Role of a Dentist in Its Identification, Prevention and Protection: A Literature Review.” PubMed Central (PMC), 1 June 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7386370.

Yang, Yang, et al. “Dental Therapists: A Solution to a Shortage of Dentists in Underserved Communities?” Public Health Reports, vol. 132, no. 3, SAGE Publishing, Mar. 2017, pp. 285–88. https://doi.org/10.1177/0033354917698114.

York, Samantha. “New Program to Address the Dental Care Crisis Causing Long Wait Times for Patients.” WHP, 26 Dec. 2022, local21news.com/news/facing-the-future/new-program-to-address-the-dental-care-crisis-causing-long-wait-times-for-patients.