Written By Ambika Nair

Introduction

You probably begin every morning and end every day with one common practice: brushing your teeth. Maybe you feel lazy one night and promise yourself that you will brush extra in the morning. Or maybe you floss your teeth right before your 6-month dental appointment, because we all know the last thing you want is your dentist calling you out for not having good hygiene.

Either way, oral care can seem like a drag for many individuals, and dental appointments may feel like an unnecessary tag-along to everyday life. In fact, a study by the Health Policy Institute (HPI) found that only fifty percent of American adults actually follow through with their six-month dental check-up appointments. Out of the roughly fifty percent that do not, 21.3% have not been to the dentist in years. While these statistics highlight a permeating sentiment to put oral health lower on the priorities list, this is far from the reality of the importance of oral health. In fact, these statistics highlight a much deeper issue at hand: an issue of inadequate access.

The impacts of inadequate access to oral healthcare can be seen most strikingly in low-income households in the US. A variety of factors influence this access, including nutrition, communal water fluoridation, access to public transport, and current political legislation. These factors along with several other contributors remind us of the multivariable barriers and seemingly never-ending layers behind receiving adequate oral healthcare.

Here in the US, over forty-percent of low income adults suffer from oral disease and tooth decay. In fact, tooth decay, also known as oral caries, is the most common global disease     and the most prevalent pediatric disease in the US. Dental caries can lead to issues including unhealthy eating and sleeping patterns, can also lead to in-patient hospitalizations, and in rare cases, death. In 2018, it was found that the lowest income communities in the US had the highest rate of dental Emergency Department visits. The immense pain and debilitating effects of oral disease can disproportionately affect low-income individuals in comparison to other income groups when time taken off of work is needed to recover.

 Additionally, we tend to forget that our oral cavity is the so-called ‘gateway’ to the rest of our bodies, and any disease in the oral cavity can lead to serious health issues in the rest of the body. Studies have found correlations between gum disease and a variety of other issues including diabetes, heart disease, and dementia. Diabetes in particular has shown to have a bidirectional causational relationship with oral health diseases. For this reason, preventative oral care is a crucial step to reducing the permeable impacts of oral disease into other body systems, and its availability to all populations in the US is crucial in improving overall health.

Nutritional Impact of Oral Care in Low Income Communities

So why is a lack of oral preventative care so incredibly prevalent in low-income communities? There are multiple factors to take into account. For one, nutritional intake is strongly associated with  the health of the oral cavity. Minerals, such as calcium and phosphorus,help to strengthen the tooth enamel, and can be acquired through a diet rich in cheese, milk, yogurt, fortified tofu, meat, poultry, and eggs. Additionally, foods high in water content, such as in fruits and vegetables, help to mitigate sugar levels in the oral cavity and clean the teeth. Moreover, many fruits and vegetables also contain vitamins A and C, which play a significant role in strengthening tooth enamel.

Despite the evident role that nutrition plays in maintaining oral health, many low-income communities lack the economic privilege to incorporate such an idealistic diet. This is attributed to the fact that when money is scarce in a household, its distribution runs thin between priorities including rent, water and electricity. Consequently, the proportion of budget allocated towards food is most practically allocated to cheaper food items. Unfortunately, nutritious food does not come cheap in this day and age, and the current statistics on food price inflammation is simply jarring. From February 2021 to February 2022, the average national food inflammation rose by 7.9 percent. Much of this increase is in part the lingering consequences of supply-chain shortages and high consumer demands from the COVID-19 pandemic. With the onset of the pandemic, families found themselves stocking up on groceries, preparing meals at home, and cutting-out restaurant dining. This along with many food-supply plants laying off workers resulted in a highly skewed relationship between supply and demand. With high inflammation rates, many families living below the poverty line find themselves making the tough decision of quantity over quality of food for the same price. A pack of Hawaiian Punch juice boxes is a much more feasible purchase to feed a family, in comparison to a single Naked Juice bottle which is much higher in nutritious value.

The repercussions of the food market not only bar low-income communities from receiving proper nutrition, but also prevent individuals from the ability to attain proper oral hygiene. While a pack of Hawaiian Punch is a feasibly ideal purchase to make, its high counts of added sugars is one of the main demons of developing oral caries. The two major destructive bacteria in the oral cavity – S. sobrinus and S. mutans – feed on sugar deposits in the mouth and release acids that eat away at tooth enamel, cavities and gum disease. Bacterial demineralization due to processed foods and sugary drinks that are high in added sugars consequently affects food-insecure, low-income households that have to make difficult decisions between health and expenses. A 2009 study conducted by the Goldman School of Dental Medicine at Boston University found that between children in the highest tertile of healthy eating index (HEI) and children in the lowest tertile, there was a forty-four percent less chance of those in the highest tertile to develop early childhood dental caries (ECC). Those in the lowest tertile were disproportionately from low-income households Fast-forward ten years later, the statistics are more or less similar. In a 2019 study conducted by the Marquette University School of Dentistry, it was seen that preschool children with food insecurity had significantly higher levels of dental caries than food-secure populations. Both of these studies also examine the racial disparities associated with food insecure households, and found there to be a higher correlation of caries among Hispanic and black communities. This finding highlights yet another population affected by food insecurity and oral health: low-income ethnic households.

In discussing food insecurity in low-income populations, we cannot forget to address the crucial aspect of race in this equation. According to the CDC, African-american and Mexican-american adults have roughly twice the amount of untreated oral caries as white americans. Similarly in pediatric populations, roughly thirty-three percent and twenty-eight percent of african american and mexican-american children, respectively, have had caries in their milk teeth in comparison to only eighteen percent of white american children. This statistical correlation is even more so expressed in low-income communities. A study conducted by the NIH concluded there was a high disparity in oral health care of 66.3% to 40.2% in black and white Americans living in poverty and with food insecurity respectively.             

The Importance of Water Fluoridation

Another important nutritional aspect to reducing dental caries is the implementation of fluoridated water in predominantly high-income communities across the US. Fluoride is known as the ultimate fighter of cavities and tooth decay by strengthening tooth enamel through remineralization, a process that reverses the damage of bacterial acid release. For more than seventy-five years now, the implementation of fluoridated drinking water in communities has proven to greatly reduce the risk of developing oral diseases. In fact, studies have shown that children living in communities without fluoridated water are three times more likely to be hospitalized for oral health disease.

The CDC coins fluoride as the most ‘beneficial global health solution’, and yet “approximately 115 million Americans have drinking water that is not fluoridated,” as John W. Stamm, Distinguished Professor at the UNC Chapel Hill Adams School of Dentistry, mentioned back in 2019.

The US Public Health Service recommends “0.7 milligrams of fluoride per liter of drinking water”, and yet there has been no steps to enforce a regulated level of water fluoridation throughout all counties in the US. Even more so, the communities lacking fluoridated water are predominantly low-income communities,which are disproportionately affected by this disparity. A 2019 study conducted by the School of Dentistry at UNC Chapel Hill was the first study to research the association between the effects of water fluoridation and dental caries in low-income populations. Based on their findings, children living in low-income communities are less likely to live in counties with fluoridated water in comparison to other income groups.

The recency of this study highlights how under-fluoridated water in low-income communities is not an area of healthcare that is properly realized. It is imperative that steps are taken in order to ensure that the oral healthcare of the entirety of the US population is brought to light.

Additionally, this study brings to light the potentially drastic economical benefits of improved communal water fluoridation. In 2013, it was estimated that the US government spent around twenty-seven billion dollars on childhood oral disease treatments alone. Regulation of water fluoridation is estimated to be one quick preventative solution for both the government and individuals paying out-of-pocket to save summative costs of at least 2.5 billion dollars annually that gets poured into treating pediatric dental caries in communities with a population over one-thousand. No different with adult oral care, the costs of treatments for tooth restorations, extraction, follow-up appointments, and time taken off of work time due to oral disease can save total annual costs of 6.5 billion dollars with the simple implementation of water fluoridation.

In March of 2023, the multiplicity of State College of Borough in Central Pennsylvania voted to end fluoridation of water. This vote has raised high concern among oral healthcare professionals for the soon-to-be increased prevalence of increased dental caries and oral diseases. The Centre Volunteers in Medicine is a healthcare group in the multiplicity that provides essential medical and dental services to individuals living with an income of below 250% of the federal poverty line, with no healthcare insurance.

Executive Director of the organization, Cheryl White highlights how “fluoride in water is the only type of dental prevention these individuals have, this is critical to help strengthen teeth and prevent decay.”

Similarly, more and more headlines of communities not only refusing to implement water fluoridation, but also all together ceasing their supplies of fluoridation have begun to make recent news. Since the creation of the anti-fluoridation Fluoride Action Network (FAN) in 2010, more than two-hundred communities of predominantly anti-fluoride activists in the US have successfully voted against the implementation of water fluoridation. Much of this sentiment has arisen from recent, inaccurate beliefs between water fluoridation and numerous health risks, strangely enough, including dental decay itself. However, like Cheryl White has indicated from her own organization, actions of anti-fluoride activists have had the most detrimental effects on those living in low-income who cannot afford anything as simple as consuming communally fluoridated water.

Geographical & Transportational Accessibility

For many people, a trip to the dentist means hopping in your car or the bus, or maybe even just walking around the block to make it to the dentist office. Unfortunately, this convenience is not the case for many living in rural low-income communities. This is yet another barrier that low-income families face in receiving preventative dental care, this time albeit, a geographical and transportational barrier. Currently forty-three percent of Americans living in rural areas do not have geographical access to dental care The majority of this forty-three percent includes low-income families, sixteen percent of which rely on Medicaid. On top of this, many individuals relying on Medicaid will likely encounter dental offices that do not accept Medicaid as an insurance in rural areas.

Government Regulations and Recommendations

Low -Income Adult Care Disparities

Currently, under the Affordable Care Act (ACA), dental care is not considered to be an “essential health benefit” for adults, and therefore the necessity of creating dental insurance plans is up to the state and the individual private groups to decide – either to integrate it in a single plan or make it a stand alone dental plan with two premiums. However, many individuals living below the poverty line may not have a job which allows them to apply for ACA dental benefits, and would have to look to federal assistance programs such as Medicaid.

Individuals living in low-income communities and suffering from dental caries also suffer from the stigma and judgment of having an untreated oral cavity. Not only does this impact self esteem and mental health, but it also makes the search for finding jobs much more difficult. Without secure work, individuals are not able to secure a plan through the ACA that would even provide a glimpse of dental care. At that point, Medicaid, or the federal assistance program for healthcare, is the only option.

Similarly to ACA, the inclusion of dental care benefits in adult Medicaid depends on the individual state legislature. There are no minimum requirements for dental coverage in adults under Medicaid, and more than half of the states in the US do not contain comprehensive dental care. In the majority of states, Medicaid dental benefits are limited for “emergencies.”However, the truth of the matter is that dental care, like any other form of healthcare, requires a level of preventative care – including 6-month check-ups, x-rays, and cleaning. Even by doing so, the government would save significant expenses of oral health decay treatments covered by Medicaid.

At the moment, governmental actions to improve federal assistance for dental care looks somewhat bleak. It is especially difficult to realize goals when the reality is that there is a shortage of private-practicing dentists who are willing to work in the public sector in federal aid programs. In August 2022,The Biden Administration did hint at expanding necessary Medicare programs to include dental care, but there has been no recent improvement to Medicaid and ACA dental benefits.

Programs that have benefitted Children:

Coverage for children, however, does have slightly more promising regulations on both a governmental and private insurance level. Of the ten essential health benefits of the ACA, “pediatric services,”which include oral and vision care, are integrated. This means that children are, in theory, ensured oral healthcare in a single private healthcare insurance plan without the need for a supplementary dental care insurance plan . This includes 6-month check-ups and preventative care as opposed to what is offered in adult emergency oral care. Insured preventative care is extremely important because it gives individuals a greater chance of preventing highly debilitating and expensive treatments for oral disease down the line. Especially from a pediatric point of view, ensuring that children have the ability to obtain preventative care also provides them with the opportunity to develop essential hygiene practices early on in life to prevent diseases for themselves in the future.

In reality, however, in most states there is no penalty for a private insurance plan to not include pediatric dental care in their pediatric services as long as they offer stand-alone pediatric dental services. Recently, some states, such as Washington and California, have made it mandatory for pediatric dental care to be integrated into essential pediatric services within one insurance plan. Additionally, under Medicaid benefits, the Children’s Health Insurance Program (CHIP) includes Early and Periodic Screening, Diagnostic and Treatment services (EPSDT) benefits. This essentially means that, up until the age of 21, children have the benefits of receiving periodic dental preventive care including relief of pain, tooth restoration, and dental health maintenance.

Fluoride Sealant Programs:

Another initiative for improving pediatric oral healthcare has been the implementation of school sealant programs. These programs use trained dental professionals who work at elementary and middle-school settings to provide fissure sealing services to children as a way to improve oral health and prevent cavities. Sealant programs are said to reduce the likelihood of cavities by eighty percent for a two year period. While the implementation is not enforced, it is heavily recommended and currently funded by the CDC to reach about twenty states in the US.

Despite the immense benefit that sealant programs bring to prevent pediatric oral cavities, there is still a disparity between children of low and higher income households. A report by the CDC concluded that low-income children were twenty percent less likely to receive sealants than high income children. Former director of the CDC, Tom Frieden highlights how “dental sealants can be an effective and inexpensive way to prevent cavities, yet only 1 in 3 low-income children currently receive them.” According to the CDC, school sealant programs provided to 6.5 million children living in low in-come communities could potentially save both out-of-pocket payers and the government a total of three hundred-thousand dollars annually in the cost of dental treatments.

Even with this disparity in low-income pediatric dental care plans, much of the overall governmental dental actions have been geared towards improving pediatric dental health, sweeping adult dental care completely under the rug.

Conclusions

The layers of inadequate dental care access in underserved areas of the US can seem never-ending and incredibly overwhelming. From inadequate nutrition and communal water fluoridation to differences in governmental legislature between adult health and childcare, uncovering the multi-variable factors to this issue seems no different from rolling out a ball of yarn with infinite string.

Back in 2000, the United States Surgeon General, David Satcher, highlighted how, “there are profound and consequential disparities in oral health”, and yet today, twenty-three years later, that sentiment remains.

 Other than the limited factors discussed here, we cannot forget to address a multitude of other factors, including much more elaborate causes and consequences to ethnic disparities in receiving preventive oral healthcare and the exacerbated disparities in oral healthcare in a post-COVID world. These factors along with lack of dental hygiene education, and the impacts of dental care on mental health and self-confidence are areas of oral health that are yet to be explored further in literature, and are critical to improving the state of low-income dental care in this country.

Edited by Jenna Stutzman & Mohamed Diagne