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Posted on April 22, 2013 at 5:57 AM

Nanette R. Elster, JD MPH

When we think about primary care, we think about health promotion, disease prevention, treatment of acute illness and management of chronic disease, as well as an initial point of contact into the health care system for many. We also think about physicians, nurses, and physician assistants, but we rarely consider dentists and the integral role they can and should play in primary care. Access to such services is particularly important for our aging population–many of whom suffer from chronic conditions such as diabetes, hypertension and cardiovascular disease.

The lack of focus on oral health as a component of primary health care for senior citizens has become more pronounced with the Affordable Care Act’s (ACA) failure to include dental services as an essential health benefit for adults, concomitant with a scaling back of Medicare and Medicaid coverage for oral health services. According to the Centers for Medicare and Medicaid Services (CMS), fewer than 50% of states provide for comprehensive dental services for adults under Medicaid, and under Medicare, primary dental care services are not covered at all. Those 65 and older comprise more than 13% of the total US population which will likely grow to about 20% by 2030 according to US Census data. With senior citizens comprising a growing part of the population, meeting the oral health care needs of this segment of the population would seem to not only be a public health imperative but a matter of social justice as well.

Just this week, I encountered a 75-year-old woman with diabetes and hypertension wholly dependent on Social Security. She had not visited a dentist in decades due to the high cost until a broken 40-year-old bridge necessitated an emergency visit. No questions asked, the dentist repaired the bridge, performed a long overdue debridement procedure to remove years of plaque build-up, and developed a treatment plan to address the patient’s many dental issues. Recognizing that the patient is on a fixed income, the dentist provided a range of treatment options and discussed the risks and benefits of choosing one course of action over another. All in all, this was a stellar example of respecting the patient’s autonomy. My gripe, however, is with the system – a system that does not recognize that oral health is not optional, but essential to a person’s overall physical health. The ideal “treatment plan” presented would cost this patient in excess of $15,000. Informed or not, this woman cannot pay more than her annual income earned through Social Security (a mere $12,000), and despite having both Medicare and a supplemental plan, none of the treatments recommended are covered.

Oral health is not about veneers and teeth whitening; it is about primary health care. According to the American Dental Association (ADA), periodontitis may be associated with a number of health conditions including heart disease, diabetes and possibly even strokes ( The Alliance for Aging Research estimates that about ¼ of those 65 and over has periodontal disease. This may in part be due to the fact that seniors cannot afford dental care, putting them at risk of a range of other health conditions and/or exacerbation of existing health problems. A goal of Healthy People 2020 is to reduce the proportion of adults between 45-74 with moderate to severe periodontitis. Setting goals without the means to achieve them, however, is merely idealistic and not very practical. When we have a growing aging population with known health risks, it would seem to be an important social obligation to allocate the resources necessary to reach the goals that we as a nation have set – a matter of social justice. Hubert Humphrey may have said it best when he said: “the moral test of Government is how that Government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.”



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