Pandemic Threatens to Deepen Disparities in Dental Health

ENSCONCED IN A once-hard but rapidly gentrifying corner of northeast Washington, D.C., Dimples Dental Suite has a clientele that, in normal times, largely reflects the diversity of a changing urban neighborhood. In Dr. Takeisha Presson's waiting room, white patients with office jobs on nearby Capitol Hill often rub elbows with working-class African Americans, the municipal clerks and bus drivers who keep the city functioning. Presson, a young, ebullient Black woman with dreadlocked hair and a radiant smile, also cares for uninsured patients or people whose treatments are subsidized by the government – typically, low-income African Americans.

But when the coronavirus pandemic swept in and shut down dental work across the country except for emergency care, Presson suddenly found herself treating patients who were almost exclusively Black and poor – people in pain who couldn't afford a dentist but badly needed treatment. And the office phone kept ringing. "I had an abundance of people calling my practice because they heard I was open," says Presson, a lifelong Washington resident who grew up in public housing. Low-income people like her former neighbors in the Langston Terrace development, she says, "were the ones with all the emergencies. It wasn't the people that were white."

Presson's experience points to how a contagion that's hit African Americans and Latinos particularly hard is magnifying racial disparities in oral and dental health, sometimes called the stepchild of the American health system. Black Americans, for example, are more likely than whites to have untreated tooth decay, while older Black adults are more likely to see cost as a barrier to getting maintenance and care.

Over the past half-century, oral health in America is "a public health success story," according to the federal government's Healthy People 2020 initiative. The improvement is due largely to "effective prevention and treatment efforts," according to the initiative's website, which notes community water fluoridation and school-based sealant programs have proved particularly potent in preventing tooth decay. Yet "people who have the least access to preventive services and dental treatment have greater rates of oral diseases," the site states, and oral health access is linked to "factors such as education level, income, race, and ethnicity."

Efforts to reach those people appear to have yielded mixed results, according to a 2019 Centers for Disease Control and Prevention report. It found a decline in recent years in the prevalence of untreated tooth decay in the primary teeth of Black and Mexican American children, and the same for the permanent teeth of adolescents and teens. But there was a lack of similar progress for adults, and disparities remained. Experts now worry about the impact of the COVID-19 crisis and its corollaries.

Centers for Disease Control and Prevention safety guidelines for resuming non-emergency procedures, for example, call for weighing "the risk to the patient of deferring care" and the wearing of expensive personal protective equipment. Dentists working in low-income neighborhoods – who don't make as much money treating poorer patients, and who operate on thin financial margins even in good times – likely will struggle to comply, and some may go out of business.

Meanwhile, experts say, some patients in African American and Latino communities already coping with high coronavirus infection rates are anxious about undergoing close-up dental work in the middle of a pandemic. And the delayed opening of school systems in the fall means at-risk children won't get screenings or preventive treatments from in-school clinics.

Dr. James Crall, chair of the Division of Public Health and Community Dentistry at the University of California-Los Angeles School of Dentistry, says the ongoing pandemic threatens to worsen a public health issue that's often treated as an afterthought.

"There were already some underlying trends that I think COVID-19 is going to exacerbate," Crall says. That includes government policies that incentivize fixing teeth rather than creating an accessible system that emphasizes prevention over repair.

"Filling teeth does not stop disease," he says. "We're not going to drill our way out of this." Indeed, dental care isn't mentioned as often in the conversations around racial disparities in health care. Back in 2000, then-U.S. Surgeon General David Satcher published a landmark report on oral health in America; two decades later, Surgeon General Jerome Adams is slated to publish a second, though officials did not respond to requests for comment on its timeline.

Satcher's comprehensive analysis noted that in comparison with whites, greater shares of very young Black children and Black 15-year-olds had tooth decay compared with whites; a higher percentage of Blacks over 18 were missing teeth, though they were less likely to have lost all their teeth; and Blacks experienced higher levels of the gum disease gingivitis.

"In addition "the percentage of people of all ages who had untreated (tooth decay) was substantially higher for blacks than for whites – about twice as many." Issues clearly have lingered in ensuing years. According to a 2016 report by Dr. Vivek Murthy, President Barack Obama's surgeon general, some 25% of preschool-aged poor children had untreated tooth decay in 2009-2010 "compared with about one in 10 children living above the federal poverty level."

As of 2012, he wrote, "more than 29% of non-Hispanic black adults aged 65 years and older had complete tooth loss compared with fewer than 19% of the overall U.S. population of the same age." Data from the American Dental Association underscores the problem: Only 1 in 4 adults who visit a federally subsidized medical clinic – facilities that often see patients who are low-income and people of color – also have had a dental visit within a 12-month time frame.

"Clearly, we've documented disparities in oral health of both children and adults, tied to a lot of factors, including race and ethnicity," Crall says. And while pandemic-related office shutdowns have threatened any progress at a ground-floor level, he says, the crisis also could create a trickle-down effect through Medicaid cuts that will make the problem worse.

"When states get into tough financial times like they are now and are going to be for a while, they drop adult dental benefits" to balance the books, Crall says.

Then, he says, "dentists are no longer able to receive any payment for those other than what people might be able to pay out of their pocket. And for a lot of populations, that's a big barrier. So then care shifts to emergency rooms, which is the last thing we need in a time of COVID."

Dr. Debony Hughes, a dentist and director of the Office of Oral Health in the Maryland Department of Health, says low government reimbursement rates for poor patients were an issue for practitioners even before the pandemic. Now, with extra precautions needed to avoid a coronavirus infection, the financial operating margins for providers have gotten even smaller.

"I'm not in practice anymore, but I think about how practices stay viable with the costs that are incurred for infection control," she says. "You can't see as many patients as you did before. You shouldn't do aerosol procedures," even though many dental procedures involve spraying water or blowing air on a tooth.

"So how are you going to meet the demands of your patients, and at the same time – let's be real – make any money?" Hughes says. "You're supposed to see the same amount of patients with the fees that aren't being paid."

The financial pressure, she says, means dentists that treat poor patients are likely to shut down, "and so now we're looking at access issues" for patients who may have no other options.

That's an uncomfortable reality Presson, the dentist in Washington, had to face. After weeks of treating patients who couldn't afford to pay her and getting reimbursements from the government that didn't cover her expenses – including PPE that cost $47 a set, with a fresh set donned for each patient – Presson stopped taking emergency calls from new patients. After a few weeks, she closed her practice to everyone but patients she'd previously treated.

"I was operating in the red," to the point she had to furlough staff, Presson says. Turning away needy patients, she says "hurt me to my core. It's sad."