NEW LEXINGTON, Ohio — JULY 13: Dentist, Dr. Darcy Cook in an examination room, July 13, 2023, at the Hopewell Health Center New Lexington Clinic in New Lexington, Ohio. (Photo by Graham Stokes for Ohio Capital Journal)
Dr. Darcy Cook will never forget a particular patient whose teeth she was trying to save.
The patient was a recovering drug addict who kept missing appointments — only making her dental issues worse.
But the patient wasn’t oversleeping or intentionally missing appointments. Instead, she was homeless with a pay as you go phone and only had one person in her life who had a vehicle.
If she ran out of minutes on her phone or her friend didn’t show up, she couldn’t make it to the dentist.
“My heart broke for her,” said Cook, a dentist at Hopewell Health Center in New Lexington. “You never know what someone is dealing with. I really learned from that experience.”
Many Ohioans face barriers when it comes to accessing dental care — transportation issues, insurance limitations, the cost, anxiety around going to the dentist and a lack of understanding of proper dental care.
Ohio also has a shortage of dentists and a shortage of dentists who take Medicaid — making it tough to find providers.
And not receiving proper dental care can lead to a slew of health issues ranging from gum disease to cardiovascular disease to Alzheimer’s disease.
“It is a critical but often overlooked part of overall health,” said Marla Morse, executive director at Oral Health Ohio.
A shortage of dentists
Ohio has 7,580 dentists in 2023, and Harrison and Monroe counties each only have two dentists, according to County Health Rankings.
But Ohio is short 627 dentists, said Dr. Frank Beck, the dean of Northeast Ohio Medical University’s new dental school.
“We have a shortage of dentists, hygienists and dental assistants,” said Susan Lawson, the director of Oral Health Services at the Ohio Association of Community Health Centers. “So much so that a lot of our health centers are looking into training their own dental assistants because there’s just not enough out there.”
There are 58 federally qualified health centers in Ohio that span almost 500 sites in 76 counties. Of those 58 centers, 43 have dental centers, Lawson said.
“We have a major access problem here in Ohio,” she said. “So our health centers are there as a safety net.”
Ohio has 172 dental health professional shortage areas (HPSAs), which disproportionately represent the state’s Appalachian counties, Beck said. HPSA designations are used to identify areas that have a shortage of health professionals.
Of Ohio’s 32 Appalachian counties, 10 have less than 10 dentists, according to County Health Rankings. Five additional counties (not in Appalachian) also have less than 10 dentists.
Ohio also has 170 safety net dental care programs that provide clinical dental services and are usually operated by local health departments and hospitals.
Dental Medicaid Reimbursements
Despite getting nixed from the state’s two-year operating budgeting, dental Medicaid reimbursements will increase for the first time since 2000 — meaning more dental providers will be able to see Medicaid patients.
Gov. Mike DeWine recently line-itemed vetoed the reimbursements and said putting rates in statute restricts the Ohio Department of Medicaid, the Ohio Department of Developmental Disabilities and the Ohio Department of Aging “to appropriately manage the policies and costs of the Medicaid program in a way that benefits Ohio consumers and complies with federal regulations,” he said in his veto message.
However, he instructed the departments to implement the proposed legislative rate — meaning dental Medicaid reimbursements will increase $103.74 million this fiscal year and $207.58 million in fiscal year 2025, said Ohio Dental Association Executive Director David Owsiany.
“It will allow Ohio’s most vulnerable citizens to have access to dental care without long wait lines and without having long distances to travel because there will be more providers in the community that can take medicaid patients,” he said.
Dentists have been getting reimbursed for less than 40 cents on the dollar, forcing some providers to stop taking Medicaid patients altogether.
“We were in crisis mode,” Owsiany said. “Clinics were closing. Dentists were having to limit the number of Medicaid patients that they take.”
Dr. Hal Jeter, a dentist who has his own practice in Lawrence County, echoed Owsiany’s sentiment.
“Providers are not able to participate fully in the Medicaid system because it has become so much of a financial burden from a business model survival standpoint that although our hearts are wanting to help, we have to make the choice between how much we can help and how we can survive as a business entity,” he said.
ODA is working with ODM to crunch the numbers for the new rates — which is scheduled to take effect Jan. 1, Owsiany said.
Obstacles to care
Ohioans face many challenges to accessing dental care.
Transportation might be the biggest one since not everyone has a vehicle or access to reliable transportation.
“Travel is challenging for underserved patients,” Owsiany said.
FQHCs offer transportation to their patients as a way to help bridge that gap, said Kelly Carey, the state government director for public affairs at Ohio Association of Community Health Centers.
Insurance is a big barrier. Not everyone has dental insurance and even those who do may have to pay a significant amount of out-of-pocket money. It can also be tough to find providers who take a certain kind of dental insurance — forcing people to sometimes drive across county lines to access care.
“Most of the people in Appalachia are on a fixed income,” Cook said. “They only have a certain amount of money. And if they have more severe health complications, dental tends to take the back-burner.”
Lack of understanding proper dental care is also a barrier.
“Most people don’t realize that you’re supposed to go on a regular basis,” Cook said. “The most important thing you can do is just brush the ones you want to keep.”
The opioid epidemic is another challenge. Cook said she will have patients come in every week who are either in the middle of a drug addiction or have just completed their initial stage of getting clean.
“Unfortunately, drug addiction accelerates oral health issues,” she said. “By the time they get to me, it might be too late to save teeth, but that’s always our goal.
Dental care affects overall healthcare
Dental care affects more than just your mouth.
“Dental health impacts a person’s ability to learn, to get employment, to have social relationships, and it also complicates many chronic diseases,” Morse said.
Having poor oral hygiene can lead to gum disease which is correlated with diabetes, heart disease, pregnancy complications and some cancers. Poor dental health is also linked to Alzheimer’s disease.
Having bad teeth means having a hard time chewing.
“If you don’t have good teeth, you’re not going to be able to eat healthy foods,” Cook said.
Poor dental health can also negatively affect a person’s mental health.
“A lot of people that I see won’t smile,” Cook said. “They don’t leave the house because they’re ashamed of their poor oral health.”
Jeter and Cook both said they will often get patients who haven’t seen a dentist in years who are experiencing pain from dental issues.
“If you’re seen on a regular basis, you’re going to keep the teeth and prevent the pain,” Cook said. “And then you’re going to be able to be much healthier throughout the rest of your life — mentally and physically.”
Providers usually have a wait list to see a dentist and some FQHC dental centers have a waitlist of about six weeks for a cleaning, Lawson said.
Cook is passionate about helping children understand what good oral hygiene looks like. She remembers shadowing an oral surgeon who had a 14-year-old patient who had to get all her teeth removed and needed dentures.
“She didn’t own a toothbrush,” Cook said. “And she drank Mountain Dew all day, every day like it was going out of style. And unfortunately, none of her teeth were save-able.”
Ohio Dentist Loan Repayment Program
Ohio currently has two dental schools at Ohio State and Case Western Reserve University, with a third in the works at NEOMED that is projected to start in 2025.
The average dental school graduate owes $293,900 in student loan debt and the average private school dental graduate owes $354,900, according to Education Data Initiative.
The Ohio Dentist Loan Repayment Program and the Ohio Dental Hygienist Loan Repayment Program through the Ohio Department of Health attempts to entice dentists to stay in Ohio and work in underserved areas in selected dental HPSAs.
Dentists and dental hygienists must commit at least two years to the program and they may receive $25,000 per year toward their loan repayment. The program maxes out at four years and those who continue with the program for years three and four may receive up to $35,000 per year toward their loans.
At least 29 dentists have completed the program since it launched in 2003 and about two-thirds of them still work in the same or similar areas in Ohio, according to ODA. More than 165,000 patients have been served by ODLRP dentists while under contract.
“Not only are you getting the benefit of the dentists practicing in the underserved community for four years, but sometimes they build roots in those communities and they stay,” Owsiany said.
Hopewell Health Center
Cook, who is originally from Perry County, said it was important to her to come back home after graduating from Ohio State University’s College of Dentistry to help improve access to care.
“My main concern was more of reaching them through education and helping them understand how important oral health really is to your overall health,” the 42-year-old said.
She works at Hopewell Health Center in New Lexington in Perry County, nestled in the rolling Appalachian hills.
Hopewell Health Center offers comprehensive behavioral health care, dental health care, and primary health care. They have 22 locations in nine counties in Southeast Ohio.
Having empathy and opening a line of communication helps Cook build trust with her patients. She works hard to help understand her patients’ barriers to care and provide resources as best she can.
“A lot of times, I’m able to walk right down the hall and get behavioral health involved in a dental appointment,” she said.
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