Saddened and Inspired:
I was saddened by the deaths of five people in the past few months.
Dr. David Ast (1903-2007) lived a long and full life. He was the first recipient of the John W. Knutson Distinguished Service Award in Dental Public Health in 1982, an award of APHA’s (then) Dental Health Section. I was fortunate to have been present at that meeting in Montreal. Dr. Ast was an inspiration to many of us at the time and should remain so well after his passing, even among those who have not previously been aware of his illustrious career. I encourage you to read the comments made by and about him in these links (David Ast) (New York Times).
Dr. Edward D. Maggiore, DDS, MA, DrPH (1934–2007) was a member of APHA for more than 40 years. A faculty member at USC and UCLA and previous director of the Venice Dental Clinic, Ed was a longtime volunteer with community health programs. His obituary appeared in the JPHD.
Dr. Umo Isong was a UCSF faculty member and colleague whose life was cut short by complications from sickle cell anemia. A diplomate of the American Board of Dental Public Health, Dr. Isong received her BDS degree from the University of Lagos (1984, Nigeria), an MPH degree from the University of Alabama at Birmingham (1988) and a PhD from the University of North Carolina (1995). She is missed by all who she touched with her dedication to improving the public’s health, in spite of her own health problems – an inspiration to us all.
Then there were the two young boys whose deaths have caused all of us to re-energize our efforts to reduce the burden of dental diseases and improve the oral health of all. The recent deaths of children in Maryland and Mississippi from lack of dental care illustrate the importance of the dental safety net for vulnerable populations. Deamonte Driver (Washington Post 2/28/07), a 12-year-old Maryland boy, succumbed to an infection that started in his tooth and spread to his brain, and 6-year-old Alexander Callendar died in Mississippi March 1, 2007 of the complications of tooth decay.
For so long we have been describing dental caries as the commonest chronic disease of childhood in order to draw attention to the need for preventive and treatment services. But no one should have to die because of dental disease. These boys’ deaths have renewed attention to the barriers to oral health care among those who live in or near Washington.
There ought to be a law:
In response to the deaths of these boys, a hearing was held in Congress on March 27, 2007, led by Congressman John Dingell, chairman, Committee on Energy and Commerce, entitled “Insuring Bright Futures: Improving Access To Dental Care And Providing A Healthy Start For Children”. http://energycommerce.house.gov/Press_110/110st29.shtml Out of that hearing came HR 1781 designed to provide disadvantaged children with access to primary dental care services. (H.R.1781: text) As of June 7, 2007 the bill had 65 cosponsors. This was a companion bill to what Senator Bingaman, D-N.M., had been working on with the dental community for several years.
On May 3, 2007, The Washington Post ("Maryland Child’s Death Explores Dearth of Dental Care") reported on a separate hearing in the House Oversight and Government Reform Committee, Subcommittee on Domestic Policy (Oversight Adequacy of the Pediatric Dental Program for Medicaid Eligible Children) that looked extensively at the role of the Centers for Medicare and Medicaid Services in guaranteeing children on Medicaid access to dental care. (THE STORY OF DEAMONTE DRIVER) (Washington Post, May 3, 2007) Rep. Kucinich, D-Ohio, and an official from United Healthcare made claims and counterclaims on the availability or lack of dentists on the list for Deamonte Driver’s family’s dental plan in the county. Rep. Kucinich and Rep. Cummings summed up the findings of the hearing in a letter to CMS Director Dennis Smith, who has yet to respond Baltimore Sun, June 19, 2007.
Other bills have been introduced in Congress in response to the deaths of these boys. The ADA is supporting HR 2472, “Essential Oral Health Care Act of 2007” introduced on May 24, 2007. The bill is designed “To amend titles V and XIX of the Social Security Act to improve essential oral health care for lower-income individuals under the Maternal and Child Health Program and the Medicaid Program and to amend the Internal Revenue Code of 1986 to provide a tax credit to dentists for dental services provided to low-income individuals.” (H.R.2472: text) As of June 10, 2007 this bill had three cosponsors.
The ADA is also supporting HR 2371, “Deamonte’s Law - The Children's Dental Health Improvement Act,” introduced on May 17, 2007, that is designed “To amend the Public Health Service Act to expand and improve the provision of pediatric dental services to medically underserved populations, and for other purposes.” (H.R.2371: text) As of June 10, 2007 this bill had 13 cosponsors.
On the Senate side, S 739 was earlier introduced on March 1, 2007, known as the Children's Dental Health Improvement Act of 2007; a bill to provide disadvantaged children with access to dental services. (S.739: text) As of June 10, 2007 this bill had 10 cosponsors.
I called upon Bob Isman, past chair of the Oral Health Section, and expert on dental access issues to guide me in determining which of these bills should receive further support from APHA. Bob advises that it might be worth trying to get APHA to support reauthorization of the Dental Health Improvement Act. The American Dental Education Association (ADEA) has good information on federal legislation related to dental issues. Please visit the ADEA Web site for what's going on with this and other federal legislation. Bob provided me with some analysis on these recent federal bills related to improving children's access to dental care. In turn, Bob had sought guidance from Meg Booth, MPH, director of governmental affairs for the Washington, D.C.-based Children's Dental Health Project.
HR 2371 ("Deamonte's Law") is about dental expansions of FQHCs and expanding pediatric dental work force.
HR 2472 ("The Essential Oral Health Care Act of 2007") looks to be a testing ground for the Community Dental Health Coordinator proposed by the ADA; 2) provides grants for volunteer dental projects using portable/mobile dental equipment; 3) increases FMAP (Federal Medical Assistance Percentages) by 25 percentage points, up to 90 percent, for states providing assurance that children have access to oral health care services "to the same extent as such services are available to the pediatric population of the state;" 4) provides a tax credit for donated dental services. Recommendations for amendments to HR 2472 were made in a letter from Burt Edelstein of the Children’s Dental Health Project to Rep. Wynn. CDHP commended Wynn for his attention to children’s oral health and suggested a variety of ways that the principles in the bill could be further broaden to provide greater opportunities to address recognized problems confronting children’s oral health.
While great and prolonged attention has been paid to responding to the needless deaths of these boys, I fear that, without persistence, this will become yesterday’s news and the legislative efforts at improving the safety net infrastructure through congressional action will die prematurely in committee.
We must push for required dental coverage for children in SCHIP (currently an option) across the country as a major step in patching our so-called health care system.
I wondered whether there have been any studies that have determined the proportion of deaths caused by dental diseases. While not a commonly identified cause of death in developed countries, where few preventive and treatment services exist, dental caries is the cause of more deaths than I would have thought. It was reported as recently as 2005, in a region of Northern India, that dental caries infections were the cause of 1.9 percent of deaths from all causes among a random sample of deaths of those aged 25-64 years. (Singh RB, Singh V, Kulshrestha SK, Singh S, Gupta P, Kumar R, Krishna A, Srivastav SS, Gupta SB, Pella D, Cornelissen G. Social class and all-cause mortality in an urban population of North India. Acta Cardiol. 2005 Dec;60(6):611-7).
Philanthropy
Foundations also have a role in supporting the infrastructure for access to preventive and treatment services. The Robert Wood Johnson Foundation, through the Dental Pipeline Program, has pledged an additional $4 million to a $19 million program it created in 2001 to address the lack of dental care in underserved areas. This program has drawn added support from The California Endowment (additional $6.3 million) and $1 million from the W.K. Kellogg Foundation.
Role of APHA
Our Oral Health Section needs to monitor dental access issues at the national level, working together with APHA staff and experts in other organizations. We also need to collaborate with the other Sections and SPIGS. An interesting recent report from the United Kingdom caught my eye. Researchers in Leeds found that a dental health education program of home visits with mothers of young infants to prevent early childhood caries and starting at 8 months of age, gave better benefit-costs and costs effectiveness ratios than other preventive programs. Perhaps we can collaborate with folks in Public Health Nursing and other Sections to make the outreach to families in need to help them manage the often-complex system of accessing dental care as well as providing practical advice on prevention. Through linkage with other health care professionals we could provide a better system than currently exists.
The lives and deaths of others, some of whom we have had the privilege to know or meet and some whom we have only read about, can inspire us to do what we can to reduce the burden of disease and make the lives of others better in some way than would otherwise have been the case.
Submitted June 19, 2007
Howard Pollick, BDS, MPH
Chair, Oral Health Section, APHA