Oral Health Across Worcester’s Communities

Morgan Groover, Connor Hickey Ashwin Panda, Jay Patel Aditya Vangala, Michael Wang

Diversity, one of Worcester’s greatest strengths, also poses its greatest healthcare challenge. Below we explore six key populations, each with unique oral healthcare needs. We present their current state of oral health, while commenting on hurdles and next steps. Lastly, we offer conclusions and suggest more integrated care in the healthcare system.

Black Communities

African American (AA) children have higher rates of tooth decay and loss than white non-Hispanic counterparts. Similar disparities exist among access to preventive services, such as sealants. These disparities persist into adulthood. AA adults have the highest rates of tooth decay and are 13% less likely to keep all of their teeth over the course of their lives.

A 2019 systematic literature review identifies familial and structural factors that have contributed to this inequality. AAs were more likely to utilize treatments which allow for greater autonomy (brushing teeth vs. fluoride treatments). Moreover, a 2016 cross-sectional study indicated nearly half of all AA parents were unaware their children qualified for Medicaid (Como et al., 2019). Racial disparities in oral health are deeply rooted in society and will require a multifactorial solution.

Latinx Communities

The Latinx community constitutes the majority of the Massachusetts immigrant population. Although MassHealth includes dental coverage, large disparities in dental healthcare still exist amongst populations of color. Nearly 1 in 5 Latinos do not visit the dentist. Hispanic youth receive less dental care and suffer from tooth decay at greater rates than the general population. Access to care is affected by insurance, transportation, culture, and socioeconomics. Language plays an important role too. Many people are naturally “afraid” of the dentist; compound that with not speaking the same language as everybody in the office.

Although there is awareness about oral health in Latinx communities, there is a disconnect. We need more dental providers who are familiar with Latinx culture. By removing the language and cultural barrier, patients will feel more comfortable. Less than 10% of dentists in the US are Hispanic/Latinx (H/L) while 17% of the population is H/L. While solving this health disparity is complicated, increased diversity of providers would be an important step forward.

Homeless Population

There are glaring disparities in the oral health of people experiencing homelessness. A national survey reported that 60.4% of adults experiencing poverty have periodontal disease (Eke et al., 2018). Another study revealed tooth loss and oral pain are very prevalent in older homeless adults; half of participants were missing half their teeth, had not seen a dentist in over five years, and had oral pain which affected eating and sleeping (Freitas et al., 2018). Society is failing the oral healthcare needs of our unhoused neighbors.

People experiencing homelessness encounter many barriers to maintaining good oral hygiene, including lack of space and tools to brush and floss regularly. Moreover, oral hygiene falls lower on a list of priorities; most are concerned with finding shelter and food. Most homeless individuals have little control over their food origin, resulting in sugary food and drinks. Alcohol and substance use are more common, affecting oral health.

Poor oral health impacts more than just the mouth. Lack of confidence over one’s smile and concern over facial appearance can be stigmatizing, isolating, and depressing. This often hinders opportunities for education, employment, and social relationships. We must ask: does poor oral health perpetuate homelessness?

People with Disabilities

A study of people with developmental and intellectual disabilities (DID) (e.g., autism and Down syndrome) found that 80% had periodontitis and 88% had caries. Other issues include tooth malalignment and tooth fractures due to falls. People with DID are at greater risk for tooth decay from challenges to follow proper hygiene practices. They also face other obstacles to good oral health: behavioral issues, communication problems, difficulty getting to dental practices, and use of dental chairs. Common impairments like neuromuscular problems can also complicate procedures.

Fortunately, Worcester does have a dental clinic for treating people with DID (a collaboration between Tufts Dental and Seven Hills). However, our community needs more capacity and better cooperation between dental and medical services for this population.

Veterans

There are ~44,000 veterans (7% of the population) living in Worcester County. Sadly, few veterans get their dental care through the Veterans Administration (VA). To qualify for VA dental care, veterans must be former prisoners of war or incurred an oral injury while on active duty. These criteria apply to only ~7% of veterans. Compounding this, there are only four VA centers in Massachusetts proving dental care; the closest is in Bedford.

During active service, veterans experience greater rates of tobacco use, carcinogen exposure, and post-traumatic stress disorder, all contributing to increased oral disease risk. So why don’t we offer more dental care to our veterans? Simple measures such as regular dental visits could prevent a huge amount of oral disease burden. There are few people more deserving of our country’s financial support than our veterans.

The Uninsured and Underinsured

Over 6,000 residents in Worcester remain uninsured, per Blue Cross Blue Shield. MassHealth has prevented those numbers from climbing by insuring ~90,000 of Worcester’s residents. Lack of insurance leads to worse oral and systemic health outcomes, ranging from caries to diabetes. MassHealth offers a wide range of preventative and treatment benefits, including cleanings, exams, extractions, dentures, and more.

But there is more to be done. Crowns and root canals can save a tooth, which can preserve a smile, self-confidence, and even job prospects. Unfortunately, coverage for these procedures is limited in MassHealth’s current dental benefits. In 2017, the American Dental Association reported a majority of MassHealth members used the emergency department instead of dental offices for dental issues, totaling $2.5 million in avoidable costs.

Currently, MassHealth is promoting their Accountable Care Organization merging oral and medical care. This integration is vital to oral health equity. The end goal is to improve accessibility, convenience, and standardize quality.

Conclusion

With respect to Worcester’s Black and Latinx communities, its homeless population, people with disabilities, veterans, and community members with MassHealth, it is apparent that, despite all being integral parts of our community, they do not have similar oral health outcomes to our white privately insured citizens. We need better integration of medical and dental care, increased access to care, and a diverse workforce to achieve oral and overall health equity for everyone in our Worcester community.

Works Cited

Como DH, Stein Duker LI, Polido JC, Cermak SA. The Persistence of Oral Health Disparities for African American Children: A Scoping Review. Int J Environ Res Public Health. 2019;16(5):710.

Eke, P. I., Thornton-Evans, G. O., Wei, L., Borgnakke, W. S., Dye, B. A., & Genco, R. J. (2018). Periodontitis in US Adults. The Journal of the American Dental Association, 149(7).

Freitas, D. J., Kaplan, L. M., Tieu, L., Ponath, C., Guzman, D., & Kushel, M. (2018). Oral health and access to dental care among older homeless adults: Results from the HOPE HOME study. Journal of Public Health Dentistry, 79(1), 3-9.

All authors are UMMS class of 2023 who recently did their UMMS Population Health Clerkship on the Topic of Oral Health in Worcester. Morgan Groover morgan.groover@umassmed.edu Connor Hickey connor.hickey@umassmed.edu Ashwin Panda ashwin.panda@umassmed.edu Jay Patel jay.patel@umassmed.edu Aditya Vangala aditya.vangala@umassmed.edu Michael Wang michael.wang@umassmed.edu