Monday, October 16, 2006
By Stephen Smith, Globe Staff
In one-fifth of Massachusetts cities and towns, there is not a single dentist to soothe toothaches or fill cavities, and the absence of dental care is especially acute on the western edge of the state, according to a landmark report scheduled to be released this week.
For the first time, researchers have charted the distribution of general-practice dentists as well as dental specialists in the Bay State, finding, for example, that more than half of the state's communities do not have a periodontist to treat gum disease or an endodontist who can perform a root canal.
The report from the Oral Health Collaborative of Massachusetts, a consortium of dental educators, medical associations, and health advocates, concludes that the poor and the rural disproportionately bear the burden of the dental care imbalance identified in the study.
The consequences can be found in the mouths of patients forced to wait too long to seek treatment -- delays that can result in the unnecessary loss of teeth, and perhaps trigger other medical woes. An expanding body of medical evidence has demonstrated that the bacteria responsible for tooth disease are also implicated in heart ailments and the delivery of underweight babies.
"We still have a long way to go to have an oral-health system that is going to genuinely meet the needs of everyone in the state, particularly the vulnerable," said John McDonough, executive director of Health Care for All, an advocacy group that has gone to federal court in the past to press for better care for indigent dental patients. "There are large segments of the state where you just have a tough time finding access to the services you need."
Maps included in the report graphically tell the story of dentist distribution. Across Greater Boston, with few exceptions, dental care is plentiful: In most communities, there is at least one dentist for every 1,500 patients, a figure considered more than adequate.
But in a belt of cities in central Massachusetts and another in the west, dentists are far scarcer. There are also scattered communities in Southeastern Massachusetts and on Cape Cod and Martha's Vineyard that lack dental services.
"In some communities, people will have to travel over 20 miles to go to the dentist," said Dr. Ana Karina Mascaren has, director of dental public health at the Boston University School of Dental Medicine.
But Dr. Alan S. Gold, president of the Massachusetts Dental Society, a professional organization, said that people living in more rural areas are simply accustomed to traveling. He has practiced in Pittsfield for more than two decades, moving there from New York City, and said his neighbors think nothing of driving 30 to 40 minutes, whether it is for school or dental services.
"We may have a very different perception out here of what relative distance is," Gold said.
The reasons behind the lack of dentists in 69 Massachusetts communities are complex, said the deans of the other two dental schools in the state, at Harvard and Tufts universities.
"High tuitions and resulting indebtedness are factors that drive people to practice in areas where payment is good," said Dr. Bruce Donoff, dean of the Harvard School of Dental Medicine. Many dentists "stay away from the rural areas, where the economic conditions may not be as good."
With recent dental school graduates shouldering debts that can easily top $150,000, they gravitate toward more affluent neighborhoods, where patients may be as interested in high-ticket cosmetic dentistry as in disease treatment, said Dr. Lonnie Norris, dean of the Tufts University School of Dental Medicine.
"There's so much emphasis on whiteners and straighteners and glamour, and on that end, dentists are doing extremely well," Norris said. "Then you have this gap -- on the lower end, you have people who don't have the income to have access to care or don't have the insurance."
Long-standing access problems for the poor were exacerbated in 2002 when the state's MassHealth Medicaid program stopped covering the dental costs of indigent adults; those services were restored as part of the sweeping healthcare reform adopted last year.
To address the imbalance of dentists, several recent private and public efforts aim to give students a break on tuition or help them repay loans if they agree to practice in community health centers.
Delta Dental of Massachusetts, for example, is phasing in a program to provide scholarships to eight students at a time.
To better understand whether the maldistribution of dentists is having an impact, the Oral Health Collaborative is embarking on research to evaluate the dental health of kindergarten and third- and sixth-grade students across the state, said Dr. Michael Monopoli, director of dental public health policy for the parent of Delta Dental.
Michelle Heard grew up in several towns on the Cape, and her experience as a child illustrates the ramifications of not having enough dentists, especially ones who will accept Medicaid. Her experience now as an adult demonstrates what is being done to address the problem.
Her family received MassHealth, and when she was 10, she had a hard time getting the braces she needed.
Now, she is at BU, in a program designed to prepare recent college graduates to enter dental school. Heard, 22, is hoping to receive a scholarship that would cover the cost of her master's degree program, in return for promising to work in a community that lacks dentists.
"From my experience as a child, I saw the amount of people who were not helped, who waited until the point that they had to have a tooth extracted rather than just have it filled," Heard said. "And I'm more of a rural girl anyway. I don't think I'm made for the city."
Stephen Smith can be reached at email@example.com.