August 15, 2012 — Dental health across the U.S. has improved steadily in recent years, and most Virginians receive more frequent preventive care than the national average. But some segments of Virginia's population have clearly been left behind in access to dental care, according to a study by two University of Virginia economists.
 
Significant disparities exist in Virginians' dental health across race, income and regions of the state, Terance Rephann of U.Va.'s Weldon Cooper Center for Public Service and Tanya Wanchek of the School of Medicine write in the current issue of The Virginia News Letter published by the Cooper Center.
 
The greatest barrier to dental care is financial, the authors found. Low-income residents without insurance or with low-cost public care are least likely to visit a dentist. African-Americans in Virginia are less likely than other groups to have visited a dentist or dental clinic in the past year. And Virginians in the highly urbanized northern and eastern regions of the state are more likely to have received dental care than residents of the more rural western and southern regions.

Other findings:
 
• With about 62 dentists per 100,000 residents in 2010, Virginia is slightly below the national average. But the Northern Virginia, Richmond and Hampton Roads areas have higher concentrations of dentists than less urbanized portions of the state. Four rural counties with relatively high percentages of African-Americans have no dentists at all: Charles City County, King and Queen County, Surry County, and Sussex County.
• The federal government designates 84 areas of Virginia, including 45 counties and cities, as dental Health Professional Shortage Areas, where the population has an insufficient number of dentists to serve its needs. Approximately 15.6 percent of the state's population lives in those areas, mostly in Virginia's western and southern regions.
• For uninsured patients, hospital emergency rooms are the only regularly available recourse for painful oral infections and trauma – though the services offered are generally restricted to prescribing antibiotics and painkillers and a referral to a dentist for care.
• Virginia offers very limited dental services to low-income adults for two reasons. First, the state Medicaid eligibility rules for adults are fairly stringent, excluding some who would be covered in other states. Second, Medicaid-eligible adults are generally offered only emergency services.
• Virginia has the sixth-highest rate of fluoridation of public water systems in the nation, a major factor in preventing tooth decay. In 2010, more than 95 percent of the population on public water supply systems received fluoridated water, compared to about 74 percent nationwide.
 
Alternative Providers 

Evidence suggests that improvements in oral health in underserved populations could be achieved by expanding the services offered by dental professionals other than dentists, Rephann and Wanchek write. Expanding the functions that dental hygienists can perform and relaxing the requirements for supervision by dentists would increase the quantity of services delivered to underserved residents and would lower the price of receiving basic care.
 
"In particular, allowing hygienists to offer fluoride varnish and routine cleaning without supervision by a dentist has the potential to generate significant health improvements at low cost," they write. "The resulting increase in visits by those previously not receiving care has a very important side benefit. The hygienist providing the service would be in a position to identify patients in need of additional care and to refer the patient to a dentist for treatment of the condition."
 
A Practical Roadmap to Better Policy Effectiveness
 
Virginia has made some notable progress in improving care, and in some public policy areas, such as low-income children's access and utilization, the state compares very favorably with best practices, the authors write. However, the state draws only an average "C" rating from oral health monitoring organizations.

"If Virginia measures its success by continued progress toward improving oral health for all its citizens, regardless of race, income, or where they live, new and more creative policy initiatives will be needed in the near future," the authors write.
 
In addition to funding programs to educate the public and increase awareness of oral health issues, Virginia's policy efforts have focused on four areas: funding and improved management of public dental insurance, implementing programs for at-risk children, sponsoring programs to address medically underserved areas and increasing public water supply fluoridation.

"In the future, proponents will need to demonstrate not only how additional spending and new programs can improve oral health, but how such programs or modifications to dental care delivery can be used to save taxpayer money," Rephann and Wanchek write. "New models for providing dental care to needy and underserved populations should be strongly considered."