ACU Column 15.3 (August 2004)

Many families must choose to set aside oral health concerns until pain or limited function forces them to seek care. As America's poor struggle to find affordable oral health care, the limited numbers of clinicians who provide it also face many challenges. The complexities of this problem include a shortage of health professionals who are committed to providing services to the underserved (in particular, to underinsured and uninsured individuals and families). Moreover, having dental insurance does not ensure access to care. Many private sector dentists do not accept Medicaid because of historically low reimbursement rates and cumbersome administrative requirements. The result is a tremendous burden of oral disease on America's poor, increased by health disparities between majority and minority racial and ethnic groups, resulting in compromised overall health for whole communities.

The following narratives describe the journeys of two community-based dentists, one rural and one urban, who between them have devoted over 30 years to working in some of America's poor and underserved communities. They have designed, implemented, evaluated and sustained oral health programs in their communities and, consequently, have made inroads to eliminating oral health disparities. Although their stories are quite different, both report that success in part grew out of collaborative partnerships. Both agree that the practice of transdisciplinary health care is among the most rewarding facets of their daily work.

Scott Wolpin, DMD, a founding member of ACU, is the Dental Director of the Choptank Community Health Center on the Eastern Shore of Maryland, a rural area where the median household income is well below the national average. The Eastern Shore of Maryland suffers from a disproportionately high incidence of children's dental disease compared with national averages (whereas the U.S. average for untreated dental decay in five year olds is 29%, on the Eastern Shore it is 82%). Here, Dr. Wolpin tells about his work at Choptank.

There are many gaps in the provision of oral health services to America's medically underserved. As a frontline clinician in a rural community health center, I have days when I silently cry inside from empathy for my patients and from my own exhaustion and I have other days when the smiles of relief and gratitude from patients young and old make the work deeply meaningful.

A typical day in a community-based clinic can be harried and unpredictable, but it is very likely to be filled with unannounced visits from people suffering with toothaches or swellings who were referred from an emergency room the night before. On such a day, I will most likely have to perform difficult procedures that, in most private practices, would be referred to dental specialists. These severe problems are usually found in the mouths of uninsured patients. A common scene finds me assessing the oral trauma of an uncooperative child who was injured in a car accident while not strapped in to a car seat, as the entire family tries to squeeze into my small treatment room. The fact that family resources are stretched very thin means that this family's first visit to me is more sudden and difficult than it would be for a family with a regular source of care for oral health who could leave the other children at home with a babysitter.

Working with an underserved community can be emotionally exhausting. Trying to communicate postoperative instructions, explanations of needed procedures or the severity of a disease is very frustrating when it is clear the family does not understand what I am saying. It is discouraging when I see my patients put buying cigarettes before oral health care. I also worry about what to do when there is nowhere to refer patients with complicated health care needs. These are just some of the daily stresses of providing community-based oral health care.

Running a community-based clinic requires flexibility and willingness to break the rules...