In Denver, Pediatrician Patricia Braun and her team treated around 100 children at a community health clinic. In addition to providing flu shots and treating illnesses like ear infections, Braun also conducted oral health assessments, checking for cavities and applying fluoride varnish to their teeth.
"We're seeing more oral disease than the general population. There is a bigger need," Braun explained, referring to the patients she sees at Bernard F. Gipson Eastside Family Health Center, a part of Denver Health, the largest safety-net hospital in Colorado catering to low-income, uninsured, and underinsured residents.
This practice of integrating oral health into medical checkups for children, pregnant women, and others who lack access to dental care is becoming more common across the United States. Thanks to federal and private funding, these programs have grown over the past decade. However, they still face challenges such as socioeconomic barriers, workforce shortages, and meeting the needs of new immigrants.
Revolutionizing Oral Health Care in Underserved Communities
A recent initiative funded by a five-year, $6 million federal grant has made significant strides in improving oral health care access in underserved regions across the United States. Led by a team of dedicated professionals, 250 primary care providers in Colorado, Montana, Wyoming, and Arizona have received specialized training in oral health.
Similar projects in Illinois, Michigan, Virginia, and New York, supported by the federal Health Resources and Services Administration's Maternal and Child Health Bureau, are also nearing completion. These projects focus on enhancing assessment, education, and preventive care services. Additionally, primary care providers are now equipped to refer patients to on- or off-site dentists or collaborate with embedded dental hygienists within their practices.
"Federally qualified health centers have a long-standing commitment to integrating dental services within their systems," explained one of the project leaders. "Our goal is to take this integration a step further, ensuring that oral health care is seamlessly incorporated into the patient's overall visit experience."
Recognizing the critical need for oral health services, particularly among children with limited access to dental care, professionals like Tara Callaghan, from the Montana Primary Care Association, emphasize the importance of having medical personnel trained to address oral health concerns. By offering assessments, referrals, and fluoride applications during medical visits at community health centers, the frequency of preventive treatments can be increased.
Callaghan highlighted the positive impact of integrating oral health services into medical care, noting that it not only benefits the children receiving care but also enhances parental awareness of proper dental hygiene practices. However, challenges persist in certain regions.
For instance, in Montana, the vast geographic expanse and sparse population make recruiting dental professionals a daunting task. With the majority of counties designated as dental shortage areas and limited Medicaid-accepting dentists, access to essential oral health services remains a significant issue. Furthermore, the state ranks low in the availability of fluoridated water, a key element in preventing cavities and promoting dental health.
Despite these obstacles, initiatives like this federal grant-funded project are paving the way for a more comprehensive and integrated approach to oral health care delivery, particularly in underserved communities.
Pediatric dental specialists are a rarity in rural areas, often requiring families to travel long distances to neighboring counties for care.
One innovative solution to reach patients in a more efficient manner is by embedding dental hygienists within medical practices, allowing for dental care to be provided during a single medical visit.
Valerie Cuzella, a registered dental hygienist, collaborates closely with professionals at Denver Health, a facility that caters to almost half of the city's children. Denver Health has integrated hygienists into five of its clinics that specifically cater to children.
Regulations regarding the services that dental hygienists can offer without direct supervision from a dentist vary by state. In Colorado, for example, Cuzella is authorized to independently conduct X-rays and administer silver diamine fluoride, a substance that helps strengthen teeth and prevent decay. She carries out these procedures in a comfortable office space.
Braun and Cuzella have developed a strong working relationship, often finishing each other's sentences. They communicate throughout the day via text messages, utilizing brief breaks to conduct quick oral health checks or demonstrate proper brushing techniques to patients. Braun also takes advantage of these moments to assess oral health during her examinations, with a shared focus on educating parents.
Traditionally, medical and dental care have operated in separate spheres. Katy Battani, a registered dental hygienist and assistant professor at Georgetown University, notes that while schools are making progress in promoting interprofessional collaboration and education, there is still a significant divide in how these professions are trained and practiced.
Battani is working on bridging the gap by assisting community health centers in nine states — such as California, Texas, and Maryland — in incorporating dental care into prenatal visits for pregnant women. The period of pregnancy presents opportunities to enhance oral health as some women become eligible for dental coverage through Medicaid and visit providers at least once a month, according to Battani.
In Denver, challenges like housing instability, language barriers, lack of transportation, and the high cost of dental care without insurance make it difficult for many children, the migrant community, and seniors to access dental services, as stated by Sung Cho, a dentist overseeing the dental program at STRIDE Community Health Center, which serves the Denver metro area.
STRIDE aims to overcome these obstacles by providing interpretation services and a sliding pay scale for those without insurance. This includes individuals like Celinda Ochoa, 35, from Wheat Ridge, who visited STRIDE Community Health Center while her 15-year-old son, Alexander, received dental care. Following a past medical checkup, he was referred for dental care, and now he and his three siblings regularly visit a dentist and hygienist at STRIDE.
One of Ochoa's children has Medicaid dental coverage, but the other three are uninsured and would not be able to afford dental care otherwise, Ochoa mentioned. For the uninsured, STRIDE offers an examination, X-rays, and cleaning for $60.
Over the past year, an increasing number of migrants and refugees have arrived in Cho seeking dental care for the first time, requiring extensive treatment. The number of medical exams conducted for refugees at STRIDE rose to 1,700 in 2023 from 1,300 in 2022, according to Ryn Moravec, the director of development at STRIDE. Moravec estimates that the program has served between 800 to 1,000 new immigrants in 2024.
Despite the increasing demand for services, Cho expressed concerns about the financial uncertainty caused by the Medicaid "unwinding" process, which involves reassessing post-pandemic eligibility for the government program that offers health coverage to individuals with low incomes and disabilities. He highlighted worries about covering the upfront costs of hiring new staff and replacing outdated dental equipment.
At STRIDE's Wheat Ridge clinic, two hygienists work across dental and pediatrics departments as part of the integrated medical-dental approach. However, Cho emphasized the need for additional hygienists at other locations to meet the growing demand. The backlog of needs created by the pandemic is slowly being addressed, especially due to the limited number of dentists accepting Medicaid patients. Moravec mentioned that if feasible, STRIDE aims to recruit two hygienists and three dental assistants.
In 2022, Colorado passed a law to address workforce shortages by permitting the practice of dental therapists—midlevel providers offering preventive and restorative care. Nevertheless, Colorado currently lacks educational institutions to train or certify dental therapists.
Children are typically scheduled to see a pediatrician for 12 well visits before the age of 3, a measure that highlights the benefits of medical and dental integration, especially for vulnerable children. Through Braun's initiative in the Rocky Mountain region, over 17,000 fluoride varnishes have been administered, leading to a significant increase in the percentage of children under 3 receiving preventive oral health care. This percentage rose from 33% to 78% within the program's first 2½ years.
According to Callaghan from the Montana Primary Care Association, community health centers in Montana are actively implementing these strategies. The focus is on utilizing the frequent well-child visits to medical providers, which often precede visits to dental providers, especially for children without regular access to dental care.
KFF Health News is a national newsroom dedicated to producing comprehensive journalism on health issues. It is a key program at KFF, an independent organization focusing on health policy research, polling, and journalism.
