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S. HRG. 113–811 

DENTAL CRISIS IN AMERICA: 

THE NEED TO ADDRESS COST 

HEARING 

BEFORE THE

SUBCOMMITTEE ON PRIMARY HEALTH AND AGING 

OF THE

COMMITTEE ON HEALTH, EDUCATION, 

LABOR, AND PENSIONS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

ON

EXAMINING THE DENTAL CRISIS IN AMERICA, FOCUSING ON THE 

NEED TO ADDRESS COST 

SEPTEMBER 12, 2013 

Printed for the use of the Committee on Health, Education, Labor, and Pensions 

( 

Available via the World Wide Web: http://www.gpo.gov/fdsys/ 

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS 

TOM HARKIN, Iowa, Chairman 

BARBARA A. MIKULSKI, Maryland 

PATTY MURRAY, Washington 

BERNARD SANDERS (I), Vermont 

ROBERT P. CASEY, JR., Pennsylvania 

KAY R. HAGAN, North Carolina 

AL FRANKEN, Minnesota 

MICHAEL F. BENNET, Colorado 

SHELDON WHITEHOUSE, Rhode Island 

TAMMY BALDWIN, Wisconsin 

CHRISTOPHER S. MURPHY, Connecticut 

ELIZABETH WARREN, Massachusetts 

LAMAR ALEXANDER, Tennessee 

MICHAEL B. ENZI, Wyoming 

RICHARD BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

RAND PAUL, Kentucky 

ORRIN G. HATCH, Utah 

PAT ROBERTS, Kansas 

LISA MURKOWSKI, Alaska 

MARK KIRK, Illinois 

TIM SCOTT, South Carolina 

PAMELA SMITH, Staff Director 

LAUREN MCFERRAN, Deputy Staff Director and Chief Counsel 

DAVID P. CLEARY, Republican Staff Director 

SUBCOMMITTEE ON PRIMARY HEALTH AND AGING

BERNARD SANDERS, (I) Vermont, Chairman 

BARBARA A. MIKULSKI, Maryland 

KAY R. HAGAN, North Carolina 

SHELDON WHITEHOUSE, Rhode Island 

TAMMY BALDWIN, Wisconsin 

CHRISTOPHER S. MURPHY, Connecticut 

ELIZABETH WARREN, Massachusetts 

TOM HARKIN, Iowa (ex officio) 

RICHARD BURR, North Carolina 

PAT ROBERTS, Kansas 

LISA MURKOWSKI, Alaska 

MICHAEL B. ENZI, Wyoming 

MARK KIRK, Illinois 

LAMAR ALEXANDER, Tennessee (ex officio) 

SOPHIE KASIMOW, Staff Director 

RILEY SWINEHART, Republican Staff Director 

(II) 

CONTENTS 

STATEMENTS 

THURSDAY, SEPTEMBER 12, 2013 

Page 

COMMITTEE MEMBERS

Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health and 

Aging, Committee on Health, Education, Labor, and Pensions, opening 

statement .............................................................................................................. 1 

Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin .................. 4 

Franken, Hon. Al, a U.S. Senator from the State of Minnesota .......................... 39 

WITNESSES

Catalanotto, Frank A., DMD, Professor and Chair, Department of Community 

Dentistry and Behavioral Science, University of Florida College of Dentistry, and Vice Chair of the Board of Directors, Oral Health America, 

Gainesville, FL ..................................................................................................... 6 

Prepared statement .......................................................................................... 8 

Nycz, Greg, Executive Director, Family Health Center of Marshfield, Inc., 

Marshfield, WI ...................................................................................................... 15 

Prepared statement .......................................................................................... 16 

Stallings, Cathi, MSW, Social Worker, Falls Church, VA .................................... 31 

Prepared statement .......................................................................................... 32 

Hughes, Debony R., D.D.S., Program Chief, Dental Health Program and 

Deamonte Driver Dental Project, Prince George’s County Health Department, Cheverly, MD ............................................................................................. 33 

Prepared statement .......................................................................................... 35 

(III) 

(1) 

DENTAL CRISIS IN AMERICA: THE NEED TO 

ADDRESS COSTS 

THURSDAY, SEPTEMBER 12, 2013 

U.S. SENATE, 

SUBCOMMITTEE ON PRIMARY HEALTH AND AGING, 

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS, 

Washington, DC. 

The subcommittee met, pursuant to notice, at 10 a.m., in room 

SD–430, Dirksen Senate Office Building, Hon. Bernard Sanders, 

chairman of the subcommittee, presiding. 

Present: Senators Sanders, Franken, and Baldwin. 

OPENING STATEMENT OF SENATOR SANDERS

Senator SANDERS. The hearing of the U.S. Senate Subcommittee 

on Primary Health and Aging is going to begin. I want to take this 

opportunity to thank all of the panelists who are with us today, 

and I want to thank CSPAN for putting this issue across the country. I also want to thank my colleagues, who I expect will be coming in and out for this hearing. 

In the last couple of years, we have had a lot of discussion in our 

country about a dysfunctional healthcare system in which some 50 

million people have no health insurance. We have a crisis in primary care, and despite poor outcomes, we spend almost twice as 

much per person on healthcare as do the people of many other 

countries. 

Unfortunately, in the midst of the discussion about healthcare in 

general, we have forgotten and paid very little attention to an element of healthcare that is enormously important to all Americans, 

and that is dental care and the fact that we have a major crisis 

in dental care. And I’m glad that CSPAN is here. I’m glad that everybody is here, because this is an issue that needs a whole lot of 

discussion. It has been kind of pushed under the rug, and it’s time 

that we brought it out into the sunlight. 

Last year, I held a hearing on dental care, where we learned that 

in the United States, we have a major crisis in terms of oral 

health. Simply put, we learned that people who need dental care 

the most are the least likely to get it, and that is low- and middleincome Americans, racial or ethnic minorities, pregnant women, 

seniors, individuals with special needs, and those who live in rural 

communities. 

For example, low-income kids are twice as likely as their higher 

income peers to develop cavities, and lower income adults are more 

2 

than twice as likely as middle and higher income adults to have 

had all of their teeth removed. And what we know is, all over this 

country, there are kids who are home today, not going to school because they have serious toothaches. We know that this is a major 

problem that we are neglecting. 

What we also found is that in America today, millions and millions of people live in towns and cities where it is difficult to access 

dental care. Even if they might have some insurance, they can’t 

find a dentist who will treat them. 

We learned that about 17 million low-income children received no 

dental care in 2009. We learned that—and this is a mind-blowing 

statistic—one-fourth of adults in the United States ages 65 or older 

have lost all of their teeth. What about that? 

We learned that low-income adults are almost twice as likely as 

higher income adults to have gone without a dental checkup in the 

previous year. We learned that bad dental health impacts overall 

health and increases the risk for diabetes, heart disease, and poor 

birth outcomes. We learned that there were over 830,000 visits to 

emergency rooms across the country for preventable dental conditions in 2009, a 16 percent increase over 2006. 

In other words, when people are in agony, their only alternative 

is to go into an emergency room, which, by the way, is very expensive. The people in the emergency room are not trained to deal 

with the dental problems. They deal with pain relief. And that’s 

how we are spending money on dental care. 

We learned that almost 60 percent of kids age 5 to 17 have cavities, making tooth decay five times more common than asthma 

among children of this age. We learned that nearly 9,500 new dental providers are needed to meet the country’s current oral health 

needs. However, there are more dentists retiring each year than 

there are dental school graduates to replace them. 

The dental crisis not only has high economic and financial costs 

to individuals in our country, but it comes with high social costs 

as well. Over $100 billion is spent every year on dental services in 

the United States. Over a third of these expenditures are paid outof-pocket. Dental out-of-pocket spending is second to spending on 

prescription drugs. 

In addition to the billions that are spent, billions are lost in 

missed school days and lost economic opportunity and productivity 

due to dental pain. Tragically, sometimes people become extremely 

ill because of oral infections, and, on occasion, people die because 

they don’t get the dental care they need. 

So let me be very clear. We are paying for this dental crisis now 

in an inefficient, ineffective, and unjust dental system where we 

spend money on those who come to our hospital emergency rooms 

suffering in pain. And yet we refuse to provide for people to get the 

care they need before it’s too late. I believe that making sure that 

people can get to the dentist when they need to will prevent not 

only a lot of suffering, but at the end of the day, saves our country 

money as well. 

Interestingly enough, last year, I asked the people of Vermont 

and people all over the country to send me their stories about dental access problems. We were just blown away by the kind of response that we got. We had 1,200 responses. I think people are 

3 

never asked to talk about it. What we heard was people who are 

in pain, who can’t find a dentist, who worry about their kids. It 

was really quite something. 

I think we have a real problem that needs to be discussed. When 

we talk, by the way, about the concept of insurance, we usually 

mean that insurance covers the need. But I think most people understand that dental insurance often pays for a relatively small 

percentage of one’s needs. The average benefit cap is just about 

$1,500 a year, and, as everybody knows, dental care is extremely 

expensive. 

I hope today our panel will help us to understand why dental 

care is so very expensive. If you have some serious dental problems, $1,500 is not going to do it. Despite these limits, people with 

dental insurance are far more likely to see a dentist than those 

who have no coverage at all. More than one out of every four Americans does not have any dental insurance. 

Traditional Medicare—and I see this every day. I don’t know, 

Senator Baldwin, if you run into this as well. But seniors often 

come up to us and say, ‘‘Why is Medicare not covering dental services?’’ And it certainly does not. 

I am chairman of the Senate Committee on Veterans Affairs, and 

I can tell you that right now—and this is an issue we’re working 

on—the VA does not cover dental care, except for service-connected 

problems, for our veterans. And States can choose whether their 

Medicaid programs provide coverage for dental care for lower income adults. Some do a good job. Many do not, which means that 

low-income Americans with Medicaid in nearly half of the States 

have no dental benefits or can receive services only in the case of 

a dental emergency. 

To my mind, it is unacceptable, but in our country, millions of 

people cannot get the care they need to live healthy lives. Dental 

problems, although entirely preventable, can lead to extreme pain. 

Another issue is the stigma of missing teeth. If I’m looking for 

a job, and I don’t have my front teeth, what do you think my potential employer is going to say? He would say, ‘‘Actually, you’re not 

the guy we want right here.’’ So when you have no teeth in your 

mouth, it’s like a P on your forehead, saying, ‘‘This is a poor person. This is a person we don’t want in our workplace.’’ That’s an 

issue that we have to address as well. 

The lack of access to dental care and the high cost of dental care 

are national problems. But as is often the case, the problems are 

far more acute for lower income Americans. For many people with 

Medicaid, for example, it is almost impossible to find a dentist who 

will see them. 

Medicaid is inadequate, but even if you do have Medicaid, it is, 

in many cases, impossible to find a dentist who will serve you. 

Only 20 percent of dentists accept Medicaid, and only a small percentage of dentists dedicate a significant portion of their practice 

for the underserved. 

When I ask about the high cost of dental care, I am often reminded that most dentists work in small private practices where 

the overhead is high, and dental school is extremely expensive. 

That is another very important issue that I hope we can touch 

4 

upon, the outrageously expensive cost of dental school, people graduating with hundreds of thousands of dollars in debt. 

But in a report released today, just today, the Government Accountability Office, the GAO, found wide variations in fees charged 

by dentists. For eight of 24 common procedures the GAO examined, 

those charging at the high end charge more than double what those 

with average fees charge their patients. That’s a whole other issue, 

why the cost of dental care is so expensive and the discrepancy in 

prices that we see all over the country. 

There is some good news out there, and we’re going to hear some 

good news today. The good news is that we are making progress 

in expanding the number of locations where lower income people 

and working people can get access to dental care. FQHCs, Federally Qualified Health Centers, provide dental services to more than 

4 million Americans across the country, regardless of their ability 

to pay. 

Under the Affordable Care Act, I and others worked very, very hard to expand FQHCs to the tune of some $12 billion or $13 billion and to put money into the National Health Service Corps so 

that we can help dentists get their student debts paid by the government so they can work in underserved areas. 

More than 90 percent of those that receive care at FQHCs have 

incomes that are 200 percent or below the Federal poverty line. I 

know in Vermont, we are having some success. We have about 

25,000 people getting their dental care now through FQHCs. 

We have established school clinics, and they are working really 

well in at least two locations where there’s a beautiful dental clinic 

right in the school. Kids are coming in. In some cases, adults are 

coming in. That’s a concept that I like very much, and maybe we 

can talk about that. 

Later this month, I intend to reintroduce the Comprehensive 

Dental Reform Act. This bill addresses the dental crisis in America 

by expanding coverage to people with Medicare, Medicaid, veterans 

health benefits, and the Affordable Care Act to significantly increase the number of people with insurance, expanding the number 

of places where people can seek care, enhancing the workforce, and 

improving education to respond to the needs of the underserved. 

While this bill will, in fact, cost money—it is an expensive bill— 

it is worth repeating that we’re already paying huge sums for dental care through emergency room visits, hospital stays, and lost 

wages and productivity. The bottom line is we have a crisis in this 

country in terms of dental care. We are wasting huge amounts of 

money, and it is time to make sure that every American gets the 

dental care he or she needs and to make sure that we especially 

take care of our kids. 

Senator Baldwin, I understand that you’re going to have to be 

leaving us soon and you wanted to make an introduction of one of 

our panelists. 

STATEMENT OF SENATOR BALDWIN

Senator BALDWIN. If I could make an opening statement and 

then—— 

Senator SANDERS. Sure. 

Senator BALDWIN. I can stay for a little while. 

5 

Senator SANDERS. Great. Great to have you. 

Senator BALDWIN. So we can do it in the regular order you 

planned, Mr. Chairman. 

I want to thank you, Mr. Chairman, for holding this very, very 

important hearing. 

I appreciate the chairman’s longstanding commitment to extending quality affordable dental care to all Americans. Far too many 

Americans do not have access to dental care. One of my constituents recently wrote to me and said that American dental care is 

unfortunately stratified into two buckets, the haves and the have 

nots. For those who currently lack access, the have nots, we must 

promote policy to expand coverage, including investing in Federally 

Qualified Health Centers. 

I’m pleased to have Mr. Greg Nycz here from the Family Health 

Center of Marshfield, WI. Mr. Nycz’s center has been instrumental 

in expanding dental care to vulnerable populations in rural areas 

and tribal areas in the State of Wisconsin. He will shortly be offering some keen insight on the benefits of the health center model. 

For the haves, those Americans who currently have access to 

dental care, that care has grown significantly more expensive over 

recent years, putting a lot of stress on middle-class families’ budgets. We have to do all that we can to address these increasing 

costs, because they ultimately threaten public health and economic 

security. 

But major opportunities exist at this moment. As we move forward with reforms to our underlying healthcare system, reforms 

that focus on delivering healthcare of higher quality at a lower 

cost, dental care must be an integral part of those changes and 

those reforms. 

First, ensuring access to dental care must be a major component 

of investing in preventative services so that we can save costs later 

by helping people avoid developing chronic diseases. Second, dental 

care should become more integrated into healthcare models. We 

need to tear down those artificial barriers that exist between dental and medical. They are artificial barriers. By delivering more integrated care, we will decrease cost and improve the quality of 

care. 

I look forward, Mr. Chairman, to the testimony of today’s panel. 

I can remain a little longer and would love the opportunity to introduce my constituent when that moment arrives. 

Senator SANDERS. Thank you very much, Senator Baldwin, for 

your hard work on this issue. 

Let me now take the opportunity to introduce our panelists. Our 

first witness is Dr. Frank Catalanotto. 

Dr. Catalanotto is a dentist and a professor and chair of the Department of Community Dentistry and Behavioral Science at the 

University of Florida College of Dentistry in Gainesville. He is also 

vice chair of the board of directors of Oral Health America. 

Senator Baldwin, do you want to introduce Mr. Nycz? 

Senator BALDWIN. Thank you, Mr. Chairman. It is my great 

pleasure to introduce Mr. Greg Nycz. Mr. Nycz is the director of 

the Family Health Center of Marshfield, WI, which is a Federally 

Qualified Health Center. Mr. Nycz has been involved with the 

6 

planning and operation of the Family Health Center for over 40 

years. 

The Family Health Center of Marshfield is one of the largest 

FQHC dental practices in the Nation and the largest provider of 

dental services to Medicaid patients in the State of Wisconsin. I 

have always admired the work that the Family Health Center has 

done to increase access to care in my home State. 

Mr. Nycz, I will look forward to your testimony today. 

As you noted, Mr. Chairman, unfortunately, I’m going to have to 

leave midway through the testimony. 

But thank you so much for being here. 

Senator SANDERS. Thank you. 

Our next panelist will be Cathi Stallings. Ms. Stallings is a social 

worker from Falls Church, VA, who has seen firsthand both personally, as I understand it, and professionally, the need to increase 

access to affordable dental care. She received her master’s in social 

work from Virginia Commonwealth University. 

We thank you for being with us. 

Our final witness is Dr. Debony Hughes. Dr. Hughes has worked 

at the Prince George’s County Health Department for 17 years and 

has served as the Program Chief of Dental Health there since 2007. 

In this role, she oversees the Deamonte Driver Dental Project. She 

also serves on the Maryland Dental Action Coalition Board. She 

began her public health career as a dentist in Bristol, VT. But she 

left us. 

[Laughter.] 

Again, I want to thank all of you for being here. What we are 

trying to do and what this hearing is about is to focus attention 

on a crisis which does not get the discussion that it needs. It’s 

going to be a long, hard fight, but that’s what we’re trying to do. 

Dr. Catalanotto, thank you for being here. Please make your 

presentation. 

STATEMENT OF FRANK A. CATALANOTTO, DMD, PROFESSOR 

AND CHAIR, DEPARTMENT OF COMMUNITY DENTISTRY AND 

BEHAVIORAL SCIENCE, UNIVERSITY OF FLORIDA COLLEGE 

OF DENTISTRY, AND VICE CHAIR OF THE BOARD OF DIRECTORS, ORAL HEALTH AMERICA, GAINESVILLE, FL 

Mr. CATALANOTTO. Mr. Chairman, members of the subcommittee, 

thank you very much for the opportunity to talk about access to 

oral healthcare. My name is Frank Catalanotto, and I’ve spent almost 40 years in dental education but for the last 20 years have 

been advocating for a better way to deliver oral healthcare. 

There are several indicators about this access problem that I’d 

like to mention. First, dental care utilization has declined about 10 

percent in the last decade among low-income people, primarily for 

cost. 

Second, we have made some good progress in the last decade to 

improve access to care for children. But we still have approximately 60 percent of Medicaid enrolled children who are not receiving proven, cost-effective, and preventive dental services. And, 

third, as the Senator said, hospital emergency room visits for dental problems have increased 16 percent to over 830,000 visits in 

2009, a very significant wasted cost. 

7 

What are the effects of this lack of access to care? Two examples: 

First, children who miss school because of dental problems do less 

well in school than other children. Education is the way out of poverty, but children in pain cannot learn. 

Second, a recent study from 2000 to 2008 showed that 61,000 patients across the country were hospitalized for a preventable dental 

infection. And Deamonte Driver was not an isolated example. 

Sixty-six deaths were reported in this study at an estimated cost 

of $840 million. This is not a personal tragedy only. This is an economic loss. 

Let me mention dental schools. Dental schools are an important 

part of the dental safety net, with faculty and students that actually do provide care outside of the dental school in communitybased settings accessible to the underserved. But dental education 

is very lengthy and expensive. That makes dentists a very expensive part of the healthcare team. 

The 165,000-plus dentists in the United States provide high 

quality dental care to those patients who can afford their services. 

Unfortunately, many of these dentists do not participate in the 

Medicaid program. There are many reasons for this, including low 

reimbursement rates. But no matter the reason, this significantly 

reduces access for many patients. 

Dentists provide significant pro bono care. However, I would remind you that while philanthropic care is wonderful, philanthropy 

is not a healthcare system and does little for long-term oral health 

care. 

Another concern I have and others have is that there are restrictive State dental practice acts that do very little to actually protect 

the health of the public and can specifically impede improving access to oral healthcare. I’ll give two specific examples in a minute. 

What are some of the potential solutions to this access problem? 

I will only focus on workforce, although there are many others. A 

new dental workforce model, at least new to the United States, is 

the dental therapist. 

These therapists are members of the oral healthcare team who 

provide preventive and limited restorative care to their patients. 

They have been employed in over 50 countries for over 90 years. 

They come from the ethnically and economically diverse communities they go back to serve. 

They are inexpensive to educate. They are cost-effective to hire. 

They are safe practitioners, no matter what else you may hear. 

They are currently employed in Alaska and Minnesota. There are 

at least 15 other States working to include them, but they are 

being blocked by restrictive dental practice acts at the State level 

and by the American Dental Association at the national level. 

Second, a more cost-effective location for delivering dental care is 

in a large group practice setting that employs multiple dentists and 

thus has lower overhead than the traditional dentist-owned single 

dental practices, thus reducing cost. One example you’ll hear about 

in a minute. But another example is the not-for-profit Sarrell Dental Centers of Alabama that provide excellent comprehensive care. 

In the past 8 years, they have grown from 15 sites to nearly 

500,000, using a combination of a culture of caring, evidence-based 

8 

practice, innovative business practices, marketing, and community 

outreach. 

Let me leave you with this last sentence, what Sarrell has done. 

They have reduced cost to the Medicaid program from an average 

annual cost in 2005 of $328 to $125 in 2012. This is a remarkable 

business model that takes care of patients. 

We need more of these around the country. We can’t, because 

there are some States that have a restrictive dental practice act 

that will not allow a business like Sarrell to be owned by a nondentist. This is ludicrous when the major hospitals in this country 

are run by MBAs. 

In closing, I’d like to point out that Congress is lobbied by many 

members of the dental industry, including dental academics. But 

who lobbies for the patient for increased access to care, for oral 

health services that prevent pain and suffering, for increased ability to learn and work, and for lower cost? I would suggest that we 

need you in your leadership roles in Congress to fight for those patients. 

Thank you very much, Senator. 

[The prepared statement of Mr. Catalanotto follows:] 

PREPARED STATEMENT OF FRANK A. CATALANOTTO, DMD 

Mr. Chairman, members of the subcommittee, thank you very much for the opportunity to speak with you this morning about access to oral health care in the United 

States. My name is Dr. Frank Catalanotto. I am a children’s dentist who has spent 

almost 40 years in dental education and for the last 20 years, advocating for a better way to deliver oral health care. I am currently the Chair of the Department of 

Community Dentistry at the University of Florida College of Dentistry. I am here 

this morning to ask your assistance in improving access to oral health care in the 

United States. 

1. CHALLENGES FACING THE UNITED STATES RELATED TO ORAL HEALTH CARE

There are several indicators I can share with you that clearly illustrate 

the lack of access to oral health care in this country. First, Dental Care Utilization has declined among low-income adults over the past decade (ADA Health Policy Resource Center); over 35 percent of low-income seniors have not seen a dentist 

in over 4 years, primarily because of costs. Second, while we have made significant 

progress in improving access to care for children, there are about 48 percent of Medicaid enrolled children who are not receiving preventive dental services and about 

77 percent of these children are not receiving restorative services. Third, according 

to a study released by the PEW Children’s Dental Campaign in 2012, the number 

of Americans who have gone to hospital emergency rooms for dental pain and infections has increased 16 percent from 2006 to 2009; this included over 830,000 such 

dental visits. Hospital dental emergency rooms are very expensive—in Florida in 

2010, there were over 115,000 such visits costing over $88 million, and they are very 

inefficient since for most visits, the physicians prescribe antibiotics and pain medication and suggest the patient see a dentist the next day, something these patients 

cannot afford. 

What are the effects of this lack of access to oral health care?—A number 

of recent scientific reports, some by United Concordia Insurance, have shown that 

preventive dental care can reduce overall medical care costs for patients with diabetes and heart disease. Imagine if these benefits could be extended to the entire population and how that might help reduce overall health care costs in the United 

States. Second, several studies have now shown that children who missed school because of dental problems did less well in school than children who missed school 

for other reasons. Education is a way out of poverty, thus, to me; there is a clear 

economic advantage to having improved access to dental care. Third, a recently published study showed that over a 9-year period from 2000–8, a total of 61,439 patients were hospitalized because of a dental infection. More important, a total of 66 

patients died during these hospitalizations, all for lack of access to quality preventive dental care. This is a personal tragedy, not just an economic loss. 

9 

2. THE ROLE OF DENTAL EDUCATION IN ADDRESSING LACK OF ACCESS

Dental schools educate a highly competent workforce and conduct research to address the oral health needs of our county. Congress has recognized the importance of dental schools and funds HRSA to provide grants to support 

modernizing and reshaping dental education to meet the changing needs of the oral 

health workforce with a particular focus on health care disparities. Our team actually has several of these grants at the University of Florida and for that I am grateful. For example, dental schools across the country are working hard to recruit a 

dentist workforce that better mirrors the racial and economic diversity of our country. Dental schools are an important part of the dental safety net, providing much 

care in community-based settings such as federally Qualified Health Centers. But 

I would also add that dental education is very expensive, making dentists a very 

expensive part of the oral health care team. 

3. THE ROLE OF THE PRACTICING DENTIST AND THE AMERICAN DENTAL ASSOCIATION

The 100,000 plus dentists in the United States provide high quality dental 

care to a large number of patients. Unfortunately, many of these same dentists 

do not participate in the Medicaid program; for example, in Florida, only about 12 

percent of dentists see Medicaid patients. There are many reasons for this including 

low reimbursement rates and the very high overhead of dental practice making it 

somewhat cost-inefficient, but, no matter the reason, this significantly reduces access for many patients. 

In addition, these dentists provide significant pro-bono care either in their offices 

or through such events as Missions of Mercy in which large numbers of dentist convene in a large facility or even tents and patients line up sometimes a day in advance to obtain some limited care. However, I would submit to you that while 

philanthropic care is wonderful, philanthropy is not a health care system 

and does little for long-term oral health. Another concern is restrictive dental 

practice acts that do little to help protect the health of the public and can really 

impede improving access to oral health care. I will give two specific examples at the 

end of my remarks. 

4. WHAT ARE SOME POTENTIAL SOLUTIONS TO THIS ACCESS PROBLEM?

I categorize these potential solutions into three groups including in the accompanying Power Points including dental insurance, patient education and workforce. 

Because of the limited time, I will only focus my comments on workforce: Bottom 

Line—we need an oral health workforce that is less expensive than dentists to deliver routine dental services so that dentists can focus on more complex procedures 

and we need workforce locations that are more efficient and cost-effective than private dental practices with their high overhead. 

First, a comment about ‘‘The Comprehensive Dental Reform Act of 2013.’’ This 

legislation extends dental insurance to millions of Americans. A number of other 

components will really help improve the oral health workforce in ways I will now 

address in my closing comments. But thanks for this legislation. 

A new dental workforce model—new to the United States—is the dental therapist. 

These therapists are members of the oral health care team who can provide preventive limited restorative dental care to patients under the supervision of a dentist. 

They have been employed in over 50 countries around the world for over 90 years. 

They are usually recruited from the ethically and economically diverse communities 

they return back to serve. They are inexpensive to educate and cost-effective to hire. 

They are safe practitioners, no matter what else you may hear. They are currently 

employed in the United States in Alaska and Minnesota. There are at least 15 other 

States who are working to include dental therapists in the workforce but these efforts are being blocked by organized dentistry and the restrictive dental practice 

acts I mentioned earlier. 

Second, a more cost-effective location for delivering dental practices is a large 

practice setting that employs several dentists and other oral health care providers 

and thus has a lower overhead than the traditional dentist-owned single dentist 

practices. The recent Senate Report on Corporate Dentistry has illustrated some 

concerns about the profit-driven, equity-backed corporate model but there are excellent not-for-profit models such as the Sarrell Dental Centers of Alabama that provide excellent comprehensive preventive oriented care to low-income patients. In the 

past 8 years, Sarrell has grown to 15 sites providing care to nearly 500,000 Medicaid recipients. Uses a combination of a ‘‘Culture of Caring’’, evidence-based dental 

practices, innovative business approaches, marketing and community outreach. 

Most importantly, they have demonstrated a decline in the average MedVerDate Nov 24 2008 16:39 Jul 29, 2016 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6621 S:\DOCS\20708.TXT DENISE
10 

icaid reimbursement from $328 in 2005 to $125 in 2012. This is a truly 

unique model of dental practice. Unfortunately, many State dental practice acts 

across the country prevent dental practices from being owned and managed by nondentists, something done across the country by medical groups and hospitals. We 

could use congressional help in expanding the Sarrell and similar models across the 

country. 

In closing, I would like to point out Congress is lobbied by many members of the 

dental industry including dentists, dental schools, dental industry, and insurance 

companies. But who lobbies for the patient for increased access to preventive and 

therapeutic oral health services that can prevent pain and suffering, increase ability 

to learn and work, and eventually help lower health care costs. I would suggest that 

we need you as elected Members of Congress to help these patients. THANK YOU! 

UNIVERSITY OF FLORIDA COLLEGE OF DENTISTRY

‘‘DENTAL CRISIS IN AMERICA: THE NEED TO ADDRESS COST’’ 

FRANK A. CATALANOTTO, DMD—WHO AM I?

• Educated as a pediatric dentist, 39-year career in dental education, past president of the American Dental Education Association, former dean at University of 

Florida, now chair of Department of Community Dentistry and Behavioral Science 

(Public Health). • Committed to improving access to oral health for all by education oral health 

services research, and advocacy. • Vice chair, board of directors, Oral Health America. • Chair, Leadership Council, Oral Health Florida. • Viewpoint expressed this morning is my own and does not necessarily reflect 

the views of the University of Florida, Oral Health America or Oral Health Florida. 

WHAT CAN I COVER IN 5 MINUTES?

• Challenges to U.S. oral health care system. • Role of Dental Education: 

• educating workforce, and • safety net provider. 

• Role of the practicing dentist and the American Dental Association—Philanthropic Care, Regulation and Restrictive Dental Practice Acts. • Consolidation in the dental industry. Role of: 

• corporate/for profit models of dental practice; and • large scale not-for-profit models (e.g., Sarrell). 

• Potential solutions: 

• insurance, • new workforce models, and • large, cost-effective not-for-profit dental practices. 

CHALLENGES: INDICATORS OF LACK OF ACCESS TO ORAL HEALTH CARE

• Adults not seeking dental care. • Children doing better but still a serious lack of access and utilization. • Hospital Emergency Room for dental care is increasing; but hospital ERs do not 

solve the problem. ‘‘Pay me now or pay me later.’’ 

WHO ARE THESE PEOPLE WITH DISPARITIES OF ACCESS AND ORAL HEALTH?

The Culture of Poverty 

‘‘Many of us have no real understanding of what poverty is. We may be broke 

most of the time, in debt, unsure of how we’ll pay the phone bill. But those particular definitions can apply to middle class. Poverty is something else. Missed 

meals, a reliance on government aide, homes without power or telephone services— 

these are the earmarks of the culture of poverty.’’ 

• Those in POVERTY, patients on Medicaid, CHIP. • Racial and Ethnic minorities. • Traditionally, children, the elderly, rural, single mothers. • The uninsured, including the working poor. • Any who do not understand the importance of optimal oral health. • Increasingly in this recession, lower middle-class and middle-class families. 

WORKING FAMILIES 

11 

Dental Care Utilization Declined Among Low-Income Adults and Increased Among 

Low-Income Children in Most States From 2000–2010 

(ADA Health Policy Resource Center) 

Children Adults 

2000 2010 % Change 2000 2010 % Change 

U.S. overall ......................................... 27% 41% 53% 54% 48% -10% 

*Note both still below 50 percent. 

ADULT DENTAL CARE

• The decrease in adults seeking dental care cuts across economic groups with reductions in upper income, middle income and 6 percent lower income groups. REASON—COSTS. • Recent HARRIS—Oral Health America Poll. Almost half of older adults with incomes of $35,000 or less have not been to the dentist in 2 years and 35 percent of 

all lower income older adults have not sought dental care in the last 4 years. REASON—COSTS 

Table 4: Children Age 1–20 Enrolled in EPSDT for at Least 90 Continuous Days Who Received a 

Preventive Dental Service, or a Dental Treatment Service in Fiscal Year 2011 

REGION 

Total children receiving a preventive dental service Percent Children 

receiving a preventive dental 

service 

Total children receiving a dental 

treatment service 

Percent Children 

receiving a dental treatment 

service 

U.S. Overall ................................................................... 13,550,097 42.2 7,466,214 23.3 

Source: Fiscal Year 2011, CMS–416 Reports. 

A COSTLY DENTAL DESTINATION—HOSPITAL CARE MEANS STATES PAY DEARLY

PEW CHILDRENS DENTAL CAMPAIGN–ISSUE BRIEF 2012

• Preventable dental conditions accounted for 830,590 visits to ERs nationwide 

in 2009. 

• a 16 percent increase from 2006. 

• Emergency rooms are the first and last resort because their families struggle 

to find a dentist who either practices in their area or accepts Medicaid patients. 

PAY ME NOW OR PAY ME LATER

• Hospital ER visits do not provide ‘‘treatment’’ of the underlying dental problem, 

only relief of symptoms of pain and infection. 

• Hospital ER visits cost money to Medicaid and insurance but for the uninsured, 

the hospitals usually absorb those costs. In other words, you/we are already paying 

for dental care for these patients. 

• Makes more sense to pay up front for increased access and preventive and restorative dentistry. 

• We need insurance and oral health professionals who are willing to work in underserved communities to provide these services to patients who cannot afford traditional dental services. 

EFFECTS OF LACK OF ACCESS TO ORAL HEALTH CARE

• Oral Health and overall body health. 

• Effects on School Learning in children. 

• Morbidity and Mortality. 

ORAL HEALTH AND OVERALL BODY HEALTH

• New recently published reports showing lower annual health care (MEDICAL) costs for patients with chronic disease processes such as diabetes and heart 

disease if these patients have been treated successfully for periodontal disease and continued to maintain their periodontal health. The savings noted were 

significant. 

• Visit the UCH Wellness Oral Health Study on United Concordia Web site to 

learn more. 

12 

1 Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Am J Public Health. 2011 

Oct;101(10):1900–6. doi: 10.2105/AJPH.2010.200915. Epub 2011 Feb 17. PMID: 21330579 

[PubMed—indexed for MEDLINE]. 2 J Endod. 2013 Sep;39(9):1104–10. doi: 10.1016/j.joen.2013.04.042. Epub 2013 Jul 11. 

3 (*Published; **in preparation by my team.) 

Impact of poor oral health on children’s school attendance and performance 1

• Children who missed school days because of dental problems did less well in 

school than children who missed school for other reasons. 

OUTCOMES OF HOSPITALIZATIONS ATTRIBUTED TO PERIAPICAL ABSCESS

FROM 2000 TO 2008: A LONGITUDINAL TREND ANALYSIS 2

During the 9-year study period (2000–8), a total of 61,439 hospitalizations were 

primarily attributed to dental/tooth infections in the United States. A total of 66 

patients died in hospitals. 

This is not only a ‘‘cost issue,’’ this is a life and death issue! 

ROLE OF DENTAL EDUCATION

• Academic Dental Institutions include dental schools and allied dental education 

programs. 

• Educate and train a highly competent workforce and conduct research to address oral health needs of the country. 

• Congress via HRSA has been very supportive of need for grants to support modernizing and reshaping dental education to meet changing needs of the oral health 

workforce with a particular focus on health care disparities. 

• Academic Dental Institutions are a very important part of the safety net for underserved patients. 

• Using our admissions policies to recruit a workforce that represents the diversity of the United States. 

• University of Florida Statewide Network for Community Oral Health 

sends students out to work in community settings such as Federally Qualified Community Health Centers. 

• HOWEVER, educating dentists is a very expensive component of the dental 

workforce. 

ROLE OF THE PRACTICING DENTIST AND THE AMERICAN DENTAL ASSOCIATION

• The 100,000-plus dentists in the United States provide high quality care to a 

large number of patients. 

• These dentists provide significant pro-bono care to the underserved in their 

practices, in philanthropic clinics, and in national events such as Give Kids a Smile 

days and Missions of Mercy (MOM) events. 

DENTISTS AND MEDICAID PATIENTS 3

• Low Reimbursement* (but increasing rates does not always work). 

• Administrative hassles* (this is real). 

• Medicaid patients do not keep appointments* (but they can!). 

• Do not want to mix Medicaid and other patients in waiting/reception room.* 

• Sense of Social Justice.* 

• Social Stigma of being a Medicaid provider.** 

13 

4Doyle, Roger, License to Work, Scientific American, 296:2, February, 2007. 5Kleiner, Morris and Kudrle, Robert, Does Regulation Affect Economic Outcomes? The 

Case of Dentistry, Journal of Law and Economics, 43:2, 547–82, October 2000. 6Freund, Deborah and Shulman, Jay, Regulation of the Professions: Results from Dentistry, Advances in Health Care Economics and Health Services Research, 5:161–80, 1984. 

PHILANTHROPY—MISSIONS OF MERCY

While philanthropic care is wonderful, I would submit to you that philanthropic care is not a health care system and does little for long-term oral health. 

THERE IS A BODY OF LITERATURE ON RESTRICTIVE PRACTICES IN DENTAL LICENSING 456

• Purpose of regulation (State dental practice acts) is to safeguard the health of 

the public and promote competition. • Substantial literature says this does not occur. • In fact, the more restrictive the dental practice act, the higher the income of 

the practitioners and no demonstrable effect on the health of the public. • Many State dental practice acts forbid a non dentist from owning a dental practice as will be discussed with a not-for-profit model in a few minutes. • Such restrictive regulation negatively impacts access for the underserved. 

POTENTIAL SOLUTIONS

• Insurance for oral health services 

• Patients with insurance are healthier than patients without insurance. 

• Educate patients and change their behavior 

• Evidence-based practices. • Culturally competent practitioners. 

• Workforce 

• More dentists—a very expensive solution. • Expanded work settings and reimbursement models for dental hygienists. • New workforce settings and business models. • New models of oral health care professionals. 


82874-1.eps
14 

INSURANCE FOR ORAL HEALTH SERVICES—‘‘THE COMPREHENSIVE DENTAL

REFORM ACT OF 2013’’ 

• Extends comprehensive dental health insurance to millions of Americans. 

• A number of other components of this bill will really help improve oral health 

workforce and access to oral health care. 

NEW WORKFORCE MODELS—DENTAL THERAPISTS

• Dental Therapists are oral health care team members that can provide preventive and limited restorative care to patients under the direct supervision of dentists. 

• Over 90 years of evidence in over 50 countries that they are safe and effective 

oral health care providers. 

• Come from the local community, cultural competency. 

• Excellent capacity for case management, patient education, restorative and limited surgical care. Inexpensive to educate and hire. 

• Recent studies/reports in the United States clearly demonstrate quality, safety 

and cost effectiveness. 

• Currently in use in Alaska and Minnesota. About 15 other States are considering this model of care. 

• Being blocked by restrictive dental practice acts and vigorous opposition by organized dentistry. 

• Training grants authorized by Congress but appropriations blocked in recent 

years. 

• Native American Tribes in the ‘‘lower 48’’ would like to utilize Dental Therapists but are being blocked by Congress as a result of lobbying by dentists. 

WORKFORCE—CORPORATE MODELS

• Senate Report on Corporate Models of Dental Practice. 

• Corporate models are on the increase because of the efficiency and cost effectiveness. 

• Have the potential to provide lower cost care and better access to the underserved. 

• Senate report correctly drew attention to some equity-backed corporate models that have a profit motivation to over-treat patients. 

• But we should not overlook the role of large, not-for-profit models that have 

an excellent track record of care. 

SARRELL DENTAL CENTERS OF ALABAMA

A not-for-profit corporate model that works. 

• In 8 years, have grown to 15 sites providing care to nearly 500,000 Medicaid 

recipients. 

• Uses a combination of a ‘‘Culture of Caring,’’ evidence-based dental practices, 

innovative business approaches, marketing and community outreach. 

• Demonstrated a decline in the average Medicaid reimbursement from 

$328 in 2005 to $125 in 2012. 

• So, why not expand this model across the United States? 

• Strong opposition from the Alabama Dental Association that was only resolved 

by legislation and intervention by the FTC. 

• Many dental practice acts across the country prevent dental practices from 

being owned and managed by non-dentists, something done across the country by 

medical groups and hospitals. 

CLOSING AND THANK YOU

• Congress is lobbied by many members of the dental industry including dentists, 

dental schools, dental industry, insurance companies. 

• But who lobbies for the patient for increased access to preventive and therapeutic oral health services that can prevent pain and suffering, increase ability to 

learn and work, and eventually help lower health care costs. 

• I would suggest that we need you as elected Members of Congress to help 

us as patients. 

Senator SANDERS. Thank you very much. 

Mr. Nycz. 

15 

STATEMENT OF GREG NYCZ, EXECUTIVE DIRECTOR, FAMILY 

HEALTH CENTER OF MARSHFIELD, INC., MARSHFIELD, WI 

Mr. NYCZ. Good morning, Senator Sanders. 

And thanks for the kind introduction, Senator Baldwin. 

I want to thank the subcommittee for the opportunity to testify 

today on a topic I am passionate about, the need to improve access 

to dental care in our country. 

I’m here representing Family Health Center of Marshfield, the 

center that serves a large region in Wisconsin approximately the 

size of the State of Maryland. About a third of our residents are 

poor or near poor. 

Twenty years ago, I served on the Wisconsin Dental Association’s 

Access to Care Committee as their only non-dentist. In that role, 

my phone number was listed as a resource for people seeking dental care. I took many calls. 

One day, I picked up the phone, and it was a young mother, failing to hold back the tears as her child screamed in pain and sobbed 

uncontrollably. The mother broke down. She had been trying for 

days, calling over 30 dental offices for help, someone who would 

stop her child’s pain. 

Such conversations were not uncommon for me back then. But 

what made this conversation a life changer for me was that I came 

to realize as I spoke with her that she was not just bearing the 

burden of her child’s pain, but also the self-imposed pain that came 

with her conclusion that she was a failure as a mother. 

I’m proud of Wisconsin, and I’m proud of my country. But none 

of what that mother was enduring had to be, because it was all 

preventable, and there’s really no mystery associated with how to 

fix it. 

After a decade of frustration, trying to improve the system and 

using traditional routes, my board said, ‘‘Find another way. This is 

your top priority.’’ Ten years later—and I brought a picture to show 

this—we’ve served nearly 100,000 folks. Even we were surprised by 

the enormous response. 

Our patient origin map shows that in spite of the fact that we 

are located in northern Wisconsin, we’ve seen State residents from 

every county and 73 percent of our State’s zip codes. Our patients 

tell us where we are needed. 

When we established our Park Falls clinic, over 1,000 people 

traveled over 412,000 miles to get care with us at Park Falls, mostly from the Rhinelander area. Today, we have a clinic in 

Rhinelander as a result of that. 

The folks who lacked access, the elderly, those on Medicaid, and 

the uninsured poor, we knew about. But what surprised us was 

that veterans with limited incomes could not get care. Today, they 

now have a place to go. 

Those who journey the farthest are disproportionately people of 

all ages who have emergency dental needs and caregivers who 

bring their developmentally disabled loved ones for care at our 

sites—another group that is left behind. 

Recall the quote from Alice in Wonderland, ‘‘If you don’t know 

where you’re going, any road will get you there.’’ We knew to get 

to our preferred future, we would need societal investment. So we 

16 

have been relentless in looking for ways to maximize the value of 

our efforts for the taxpayer, not just the patients we serve. 

We learned that we could improve the performance of our job 

placement agencies by making job seekers with horrible oral decay 

more presentable and employable. One of our counties with about 

34,000 in population told us that they have about 100 such adults 

every year. 

We learned that annual savings on the medical care side possibly 

in the range of $2,000 to $3,000 are possible for patients with diabetes if we give them proper dental care. And we learned we could 

be a real alternative to the emergency room and the hospital by 

opening our doors to patients with dental emergencies from across 

the State. 

I would like to leave you with three thoughts. First, success will 

require that we fundamentally work to change our Nation’s perspective on the importance of oral health in its own right and the 

added value oral health brings to general health. 

Second, workforce matters. Over the next 20 years, Wisconsin 

may face 2.2 dentists retiring for each new dentist entering practice. And new graduates need to be better prepared to face more 

elderly patients with complex multiple medical conditions. 

Third and perhaps most importantly, at the community level, we 

are seeking to accomplish this by pursuing an integrative medicaldental model that leaves no one behind. This is the missions of all 

health centers. We are solving healthcare access problems one community at a time, and we’re in 9,000 communities. 

But the current demand for care is outpacing our growth. Over 

300 of us applied for funding to meet unidentified unmet dental 

needs in 2011. Unfortunately, a last minute budget deal cut $600 

million from planned health center funding, and there have been 

no opportunities to fund oral health expansion since then. 

Our Nation’s health centers are your health centers. The health 

center model has what it takes to solve the oral health disparity 

problems for a growing number of our Nation’s communities. And 

I appreciate Congress’ past support of health centers and ask that 

you continue to invest in our Nation’s health centers. Give us more 

work, for there is more work to be done. 

Thank you. 

[The prepared statement of Mr. Nycz follows:] 

PREPARED STATEMENT OF GREG NYCZ

Good morning Chairman Sanders, Ranking Member Burr, and distinguished 

members of the Subcommittee on Primary Health and Aging. My name is Greg Nycz 

and I want to thank you for the opportunity to testify today before the subcommittee. I am the executive director of Family Health Center of Marshfield, Inc. 

a federally and State-supported community health center. Our Center serves a 

10,354-square mile rural area in northern Wisconsin with 403,964 residents, 

125,229 of which have incomes at or below 200 percent of poverty. I greatly appreciate the opportunity you’ve extended to me to share insights accumulated over the 

last 20 years working with organized dentistry and then building our own dental 

capacity in an effort to assist our State in resolving significant oral health access 

problems for many of our residents. 

For most of the decade of the 1990s, I worked for change within organized dentistry in Wisconsin. The Wisconsin Dental Association, keenly aware of the access 

problems in the State’s Medicaid program, convened a committee to explore ways 

to resolve access problems and enable more of our State’s dentists to participate in 

the Medicaid program. They extended an invitation to me to serve on that comVerDate Nov 24 2008 16:39 Jul 29, 2016 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6621 S:\DOCS\20708.TXT DENISE
17 

mittee as the only non-dentist in order to get the perspective of a community health 

center director. At the time, there was no lack of passion or commitment from the 

committee members. Wisconsin’s Medicaid office staff were most helpful in streamlining some of the administrative impediments to greater dentist participation, and 

during the time of my tenure on the committee we were successful in obtaining an 

increase in State Medicaid rates. However, in spite of all these efforts, problems persisted and, following passage of the State Child Health Improvement Act and an annual stagnation in dental payment rates, access problems grew worse. 

In September 2001, shortly after the Surgeon General’s report on the oral health 

of the Nation, my board faced the prospect of continued deterioration in access to 

oral health services for our Medicaid and uninsured patients. They directed staff to 

prioritize solving the oral health access and disparity problems throughout our extensive rural service area. As staff set about the task of fixing the system, we studied the problems more closely, which eventually led us to a question. How do we 

solve a problem that is pervasive at the State and national level? From a health 

center perspective the answer to this question is one community at a time. So that 

is what we set about doing. Our State welcomed our involvement as did our major 

partner, Marshfield Clinic. An expanded State rural dental clinic grant program 

provided us with resources to build our first dental center in 2003. 

Family Health Center has had a long-term partnership with Marshfield Clinic, relying on, rather than duplicating some of its core infrastructure. While Marshfield 

Clinic is a large regionalized health system with most specialties in medicine represented, they like many other health systems lacked any dental health professionals. Given their size, reputation, and our desire to promote the integration of 

dentistry and medicine, Family Health Center approached Marshfield Clinic to partner with us on our dental initiative. We provided them with information on what 

amounted to a public health crisis in Wisconsin affecting many Clinic and Family 

Health Center patients, and suggested that together we could have a much larger 

impact on the problem throughout our collective service area than our organization 

could do on its own. Recognizing the scope of the problem, Marshfield Clinic leadership unanimously voted to lend its infrastructure and later additional funding in 

support of our initiative to reduce oral health disparities throughout the region. This 

Marshfield Clinic decision enabled the rapid expansion of our dental system which 

by October 1, 2013, will also include a 9th dental clinic on Ho-Chunk Nation land 

near Black River Falls, WI. 

Because of State taxpayer investment in our program and also because of strong 

evidence that literally tens of thousands of Wisconsin residents were going to emergency rooms every year for treatment of non-traumatic dental pain, we committed 

to caring for patients with emergency dental conditions from across the State. Figure 1 demonstrates that from the provision of our first dental service in temporary 

facilities in November 2002 through June 2013 we have cared for 95,535 unique patients. Strikingly, they have come from every one of Wisconsin’s counties and from 

73 percent of its zip code areas. We have treated patients from Wisconsin’s largest 

cities who traveled, in some cases hundreds of miles, to get to a dental center in 

communities as small as Neillsville with a population of 2,443. Patient origin maps, 

like that of Figure 1, both illustrate the breadth and scope of the dental access problem in Wisconsin as well as provide us with information about communities in need. 

In essence, the underserved population’s care seeking patterns inform us where we 

should consider placing our next dental center. 

To illustrate this point, we observed that within the first 15 months of opening 

our Park Falls dental center, 1,000 patients had driven an estimated 412,000 miles 

to receive their dental care there from us. Many of these patients were traveling 

from the community of Rhinelander, which is 67 miles from Park Falls. We investigated this pattern with Rhinelander community leaders, including the mayor, and 

learned we were only seeing the tip of the iceberg as many people in need couldn’t 

make the trip. A few years later we were able to open our 8th dental center in 

Rhinelander bringing quality dental services closer to many of our patients and offering an opportunity for dental care to many others who previously couldn’t make 

the trip. 

Our progress, and that of my health center colleagues in Wisconsin, has been 

spurred on by increased investment of State resources in the State rural dental clinic program, and through a doubling of our State’s community health center grant. 

Our State grant focuses on supporting the mission of all of Wisconsin’s 17 community health centers. This investment has paid huge dividends for State residents 

through greatly expanded access to dental care as shown in Figures 2 and 3, which 

mark the progress and growth of Wisconsin’s community health center dental facilities, patients served, and patient visits. 

18 

The dramatic progress of Wisconsin’s health centers in expanding oral health access to a growing number of Wisconsin residents is echoed in the steady progress 

health centers across the Nation have made in both incorporating oral health services into their programming and increasing the proportion of their patients who receive oral health services. In 2011, 78 percent of community health centers offered 

dental services at at least one site. This compares to Healthy People 2020’s baseline 

of 75 percent from 2007 with a nationally established target of 83 percent by 2020. 

The number of patients receiving dental services at health centers grew from 1.4 

million in 2001 to over 4.0 million in 2011, a 186 percent increase. Although this 

represented 20 percent of total health center patients, more work remains to be 

done to meet the national goal of 33.3 percent of such patients by 2020. There is 

robust evidence that health centers stand ready to do this work as reflected in the 

fact that more than 300 health centers applied for funding to meet identified unmet 

dental needs in 2011. Unfortunately, a last minute budget deal to keep the Federal 

Government running that year included a $600 million cut to planned health center 

funding. As a result, none of the 300 applications were funded. Since then, there 

have been no subsequent Federal funding opportunities for dental expansion for 

health centers due to limited appropriations. Indeed, there have been no funding opportunities period for existing health centers to expand their services since the Recovery Act. While this was disappointing, our resolve is strong. The health center 

community is ready, willing and able to leverage investments from our States and 

Congress to meet State and national goals. Our integrative approach to health care 

can create offsetting savings by substituting quality dental services for more expensive emergency room and/or hospital-based treatments that now result from current 

access barriers. As the rest of my testimony will demonstrate, our approach can also 

improve health and indeed, save lives. 

As the preface to the Surgeon General’s report stated, 

‘‘those who suffer the worst oral health are found among the poor of all ages 

with poor children and poor older Americans particularly vulnerable . . . Individuals who are medically compromised or who have disabilities are at greater risk 

for oral diseases and in turn oral diseases further jeopardize their health.’’ 

Our early experience confirmed the wisdom of this statement. At our ribbon cutting 

for our second dental center I read a short email to those in attendance. The author 

of the email reported things were going well, that they were grateful there was a 

dental clinic that would take their residents, and they were working on arrangements to send us some more patients. What made this short email remarkable was 

that the author was making arrangements to send his developmentally disabled 

residents to our dental center, which was 183 miles away. 

We quickly learned that accessing dental services for those with significant developmental or cognitive disabilities was even more difficult than the barriers faced by 

many low-income uninsured or publicly insured residents. Understanding the difficulties many disabled residents face in obtaining oral health services in our State, 

we entered into a Memorandum of Agreement with our State that in essence said 

‘‘we are open to and welcome the State’s disabled population.’’ Beginning with our 

second dental center, each dental center has been equipped with large treatment 

rooms and a wheelchair lift to help accommodate this high need population. 

We learned other lessons that surprised us. Local county Veteran’s Affairs officers 

informed us that low-income vets uninsured for dental care had great difficulty accessing care. We learned that VA benefits extended to those who are 100 percent 

service disabled and that a State program provided some help, but many dentists 

did not participate in the program because of paperwork issues. We learned that 

one of the largest constituent complaints voiced to local legislative offices was the 

inability to get dental care, and we learned that many elderly were foregoing care 

because of its cost. When we build a dental center and open our doors, our local 

legislators report that the phones fall silent regarding complaints on access to dental care. Our vets, the disabled, and the poor of all ages have a place to go. Access 

to dental care is no longer the issue it once was. The health center model leaves 

no one behind. 

It is our belief that any organization that accepts Federal or State taxpayer funds 

has a huge stewardship responsibility and a requirement to be accountable for the 

expenditure of funds. One of the ways we try to be accountable is to look for targets 

of opportunity to add value. To avoid increased emergency room use for non-traumatic oral pain, we work in many emergency patients from all over the State on 

a daily basis at all of our dental centers. We also believe one of the best services 

we can provide to our State is to assist our patients in leaving the Medicaid program altogether through job attainment or job promotion. To achieve this goal we 

accept referrals of job seekers from job placement agencies. Many individuals being 

19 

1Powell V, Din F, Acharya A, et al., Project on Clinical Data Integration Page 20, Contact 

points between medical and dental care/research—Version J: Categories (1–29) and references). 

retrained for predominantly service sector jobs have a difficult time getting hired 

or promoted if they have significant oral health problems. We eagerly accept such 

referrals in the hope that we increase such individuals’ opportunities to achieve 

gainful employment or promotion and leave Medicaid in favor of private employment-based insurance. In addition we have historically prioritized low-income pregnant women. The reason for this is evidence that periodontal disease may contribute 

to poorer birth outcomes. While the scientific community is still debating this topic, 

for the sake of these unborn children, we prefer to do everything possible that might 

help lead to a better birth outcome. 

We have made demonstrable progress. As Figure 4 shows, while Wisconsin was 

second to last in 2008 among all States in children on Medicaid who received a dental service, the three counties with our dental centers had access rates equivalent 

to those in the Nation’s top performing States. Unfortunately we are far from declaring victory. Our accountabilities to our supporters, including taxpayers and the 

communities we serve, demand that we do more to generate societal savings to help 

offset the cost of dental care to those who previously went without that care. What 

are our options to do better? 

There is a tremendous prevention potential in dentistry. We believe there is also 

a tremendous potential to improve health and reduce costs overall if we can bridge 

the chasm that exists between medicine and dentistry. We believe the bridge is 

through closer integration of medicine and dentistry using 21st century technology 

that can support virtual teaming between our health professionals and their staffs, 

and through practice changes that reinforce shared professional interests in patients 

and their health. We have begun acting on these beliefs and received support from 

like-minded partners. To this end I wish to acknowledge the significant support we 

have received from Delta Dental of Wisconsin in helping us create an integrated 

medical/dental electronic record to provide a platform to allow virtual teaming on 

patients. Delta Dental of Wisconsin has also provided support for oral health research and education initiatives at Marshfield Clinic’s Education and Research Divisions. I also wish to acknowledge the DentaQuest Foundation for their support in 

helping us learn about best practices for engaging our patients with diabetes and 

encouraging them to seek regular dental care. 

We have come to the conclusion that to get to a preferred future we have to fundamentally change how we view dentistry within the larger health care system. To 

illustrate this point, let’s consider a series of questions involving dermatology, a specialty that deals with problems of the skin: 

Why do we think we can afford adult dermatology in our Nation’s Medicaid 

program but not adult dental? Why is it that we don’t have separate dermatology insurance like we do for dental insurance? Why is it that we include dermatological care in our medical records but not dental care? Why do most medical care systems, many who tout most if not all medical specialties, exclude 

dentistry? Why do medical schools teach our future physicians to be concerned 

about infections anywhere in the body but the oral cavity? Why in Wisconsin, 

in spite of very low payment rates to physicians and dentists, do most physicians continue to treat Medicaid patients while most dentists do not? 

Other policy-oriented examples are the exclusion of dental benefits in Medicare 

and the limitations on dental benefits in the VA. A more recent example is the promotion of ‘‘primary care medical homes’’ a terminology that excludes dental. Why 

not ‘‘primary care health homes’’ which is a much more inclusive concept? (Incidentally, most federally qualified health centers would rightly consider themselves to 

be integrated primary care health homes). The separate and stark contrast between 

dentistry and medicine beginning with training and continuing through insurance 

and practice policies should increasingly be questioned in light of a growing body 

of scientific evidence linking oral and systemic health.1

Everyone is united in wanting our country to derive even more value from our 

health care system, with better quality at a lower price point. If that is the case, 

then why is there such reluctance to act? We can debate whether we can afford to 

have dental benefits covered under our Medicare program or whether all States 

should offer dental benefits to adults in their Medicaid programs. But if cost is the 

central issue holding us back, if cost is the driver in much of our decisionmaking, 

why don’t we act to lower costs when an evidence-base outlining on how it could 

be done exists? Consider the following. As a nation we fund medical research 

through the National Institutes of Health. That societal investment has helped us 

understand that connections exist between diabetes and periodontal disease and to 

20 

2http://www.bcbsm.com/pr/prl08–27–2009l71090.shtml. 3 Jeffcoat M, et al. CIGNA, Does Treatment of Oral Disease Reduce the Costs of Medical Care? 

Medscape Today. October 19, 2011. On-line: http://www.medscape.com/viewarticle/751609. 4https://secure.ucci.com/ducdws/dental.xhtml?content=dhc-conditions&s1=ucwellness-oralhealth-study&s2=results-ucwellness-oral-health-study. 5Mosen D, Pihlstrom D, Snyder J, Shuster E. Assessing the association between receipt of 

dental care, diabetes control measures and health care utilization. JADA January 2012 143(1): 

20–30. 6http://newsroom.cigna.com/articleldisplay.cfm?articlelid=1287. 

treat one without treating the other does have health and cost consequences. (Please 

refer to Attachment 1 for a concise summary of some evidence regarding periodontal 

disease and diabetes.) The value of our investment in research to our Nation’s taxpayers is magnified when we put the results of that research into practice. 

The private sector has responded and is attempting to leverage this knowledge: 

the public sector should as well. What seems to have driven the private sector to 

act was the emerging evidence, mostly from the past 10 years, that individuals with 

selected chronic health conditions or combinations of them benefit from improved 

oral health, specifically improved periodontal status, and that potentially large reductions in medical care costs associated with their chronic condition(s) follow closely and appear to be sustainable as long as good oral health is maintained. The 

emerging evidence appears strongest for individuals with diabetes (only) or in combination with cardiovascular disease, kidney disease or congestive heart failure. 

Savings of approximately 10 percent annually for individuals with diabetes receiving periodontal care were reported in a multi-year Michigan Blue Cross Blue Shield 

study. That study also found annual medical cost reductions ranging from 20–40 

percent for individuals with diabetes and at least one other chronic condition previously noted.2

A 2006–8 CIGNA study of 46,094 individuals with diabetes estimated annual medical cost savings of $2,483/person (23 percent) in year 3 for those who received 

dental care. Notably, study results suggested increasing annual cost savings as a 

function of continuing better oral health among those individuals with diabetes that 

received periodontal care at baseline (2006) and continued maintenance oral health 

care annually compared to those individuals that did neither.3

United Concordia and Highmark, Inc. reported average medical care cost savings of $1,814 per year over 3 years for individuals with diabetes who sought periodontal 

treatment and subsequent regular dental care during the 2007–9 study compared 

to individuals with diabetes who did not receive dental care during the study period. 

Another important study result was additional estimated cost savings of $1,477 per 

person per year among individuals with diabetes after they completed seven periodontal treatments and/or oral health maintenance visits. In subsequent analyses 

that examined the relationships between gum disease and other medical conditions, 

annual medical cost savings from reduced hospitalization and office visits associated 

with periodontal treatment were found for heart disease ($2,956), cerebrovascular 

disease ($1,029), rheumatoid arthritis ($3,964) and pregnancy ($2,430).4

A recent study in an HMO population provides further insight into the potential 

sources of savings associated with better oral health status among individuals with 

diabetes. Diabetes-specific hospital emergency department visits rates were more 

than 60 percent higher (16.2 percent vs. 10.1 percent) and diabetes-related hospitalization rates were more than 75 percent higher (14.8 percent vs. 8.3 percent) 

among individuals with diabetes who did not seek dental care compared to individuals that had two or more periodontal or prophylactic treatments annually for 3 

years.5

There is clear evidence that health insurers are ramping up their oral health programs that many established in 2005–7. Several major insurers have announced expanded oral health-related programs for their insureds that are pregnant and those 

with kidney disease, cerebrovascular (stroke) conditions, head and neck cancer and 

organ transplants.6 Leading health insurers seem to have concluded that supporting 

and even incenting better oral health access and care is good business. It should 

be so for our publicly supported programs as well. The taxpayers of this country 

should demand it. 

I urge the subcommittee to consider following the lead of these insurers by capitalizing on our Nation’s investment in the National Institutes of Health, and institute policy changes that would enable Medicare and Medicaid enrollees with such 

chronic conditions to access appropriate high quality oral health treatments. 

Another key point for the subcommittee to consider is that it is not enough to simply establish coverage or even more dental clinics, as many low-income Americans 

do not seek dental care until they have oral pain. While addressing pain and suffering is meritorious in its own right, avoiding that pain and suffering and more 

21 

expensive treatment interventions is our goal. The undervaluing of oral health in 

America is, from our perspective, one of the greatest health literacy challenges we 

have. Our health center is involved in a generational effort to address health literacy issues that shape the current practice among many high-risk, low-income populations. A major initiative is needed to help convince our residents of the importance of oral health to general health and of the importance of regular dental checkups in maintaining good oral health. Developing more reliable and internally consistent estimates of population access to oral health services should be considered 

part of that effort. I make this point because it appears that the proportion of children, adolescents and adults who use the oral health care system in the past year 

is actually well below what many people believe. The percent of residents aged 2 

and older who received a dental service in 2007 is estimated by Healthy People 2020 

to be 44.5 percent. Our national goal for 2020 is 49 percent. However, widely cited 

estimates based on health interview survey data using self-reported information is 

in the range of 20 percentage points higher. Although such widely diverse estimates 

cannot be reconciled without further work, I note that the higher estimate is based 

on self-report data that requires recall on long past events making such estimates 

generally less reliable than those based on observed expenditures. I urge the subcommittee to explore this information further as it has significant implications for 

dental workforce projections, as well as understating the need to integrate medicine 

and dentistry to help address the oral health literacy issue. 

We must strive for a future where people better understand the importance of 

daily oral hygiene, proper nutrition, and regular dental checkups not just to their 

oral health but to their overall health as well. We believe success in this effort is 

tied to convincing our medical colleagues to help educate their patients on the importance of good oral health care and regular dental checkups. This is made more 

difficult by the fact that our Nation’s medical schools by and large pay little attention to the oral cavity in medical student training. This is evidenced by the response 

to 2012 survey question by the AAMC of our Nation’s graduating medical students 

on, ‘‘How well do you feel that your medical school has trained you to address oral/ 

dental health topics?’’ Apparently, students were underwhelmed as 32.4 percent of 

the Nation’s graduates checked ‘‘not well trained at all’’ and only 1.3 percent 

checked ‘‘very well trained.’’ Our vision for the future is that our physician community treat the importance of regular oral health checkups on a par with their counseling of patients on the need to be immunized, receive clinical preventive services, 

exercise, and eat right. In addition to the virtual teaming I mentioned earlier, our 

dental teams should be aided by an integrated electronic medical record, to engage 

patients on the importance of receiving clinical preventive services in medicine. Currently we do blood pressure checks and non-fasting blood sugars under protocols in 

our dental centers. These efforts can have a direct impact on morbidity and even 

mortality in our patients as evidenced by a recent message one of our hygienists 

received from a dental patient: 

‘‘You know I thought that it seemed dumb that you would take blood pressure 

at the dentist office until I had a friend of mine come here and you guys took 

his blood pressure in hygiene and wouldn’t even see him. You sent him right 

over to the emergency room. Good thing you did, they took him into emergency 

surgery. I guess they said he was ready to pop.’’ 

We should expect this type of coordination in our health care system. Additional 

examples of teaming across medicine and dentistry are provided in Attachment 2. 

I’d like to conclude my testimony by sharing some observations regarding dental 

workforce and dental education issues. Early on, we recognized that to be successful 

in our dental initiative we could not ignore workforce and dental education issues 

that might confound our progress. Figure 5 indicates that given current rates of 

dental school production, the age distribution of dentists in Wisconsin portends a 

shortage of dentists. Over the next 20 years, 2.2 dentists are likely to retire for each 

new dentist entering practice. As if this is not bad enough, two factors may further 

aggravate the situation for northern rural communities. First, there currently exists 

a marked preference of dentists to locate in suburban or urban areas of our State 

relative to the less populated communities. Second, retiring dentists are predominantly male, while new graduates are gender balanced and female dentists in Wisconsin have shown an even more marked preference for suburban or urban practices. Rural Wisconsin loses on both of these. We are hoping to meet this challenge 

by establishing, in partnership with Marshfield Clinic, a dental residency program 

and by providing dedicated space within our dental facilities for dental students. 

As we continue to grow our dental system to enlist nearly 50 dentists in this work 

by years end, we can reflect on the opportunity we have had to hire dentists trained 

in over a dozen dental schools across the country. Most dental schools are urbanVerDate Nov 24 2008 16:39 Jul 29, 2016 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6621 S:\DOCS\20708.TXT DENISE
22 

based and specialty-oriented. Most provide students with less exposure than we 

would like to treating developmentally disabled patients and young children. Nationally, as I speak with my health center colleagues, not enough graduates are interested in careers in the safety-net. Ed O’Neil, director, UCSF, Center for the 

Health Professions, Center on Recommendations for Reform (3/7/07) said it best: 

‘‘For instance, in many specific locations the Nation is experiencing a raging 

epidemic of pediatric dental disease. In face of this reality, does it make sense 

to prepare more young men and women with the skills to serve the bungalowbased smile clinics that serve the suburbs? Instead, shouldn’t we align the 

training with the needs of community clinics to organize and deliver a broad 

range of preventative and therapeutic services to the population that is experiencing the epidemic?’’ 

As a nation we should not lose sight of the importance of oral health to general 

health, and the importance of oral health in its own right. What some of us take 

for granted is currently beyond the reach of many. Discussions I have had with 

many well-educated people on the problems lower income people face obtaining dental care usually result in surprise. They didn’t know. There is a reason the Surgeon 

General referred to this problem as a ‘‘silent epidemic.’’ 

I thank the subcommittee for this opportunity for me to share what we’ve learned 

and most importantly for taking up this subject, it may still be an epidemic but let 

it be silent no longer. 

23 

Figure 1 


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24 

Figure 2 


82874-3.eps
25 

Figure 3 


82874-4.eps
26 

Figure 4 

Figure 5 


82874-5.eps 82874-6.eps
27 

ATTACHMENT 1.—A BRIEF SUMMARY OF THE EVIDENCE BASE FOR INTERVENTION TO

IMPROVE ORAL HEALTH AMONG INDIVIDUALS WITH DIABETES

DIABETES AS A PANDEMIC THREAT TO ORAL HEALTH

Physiology does not respect the disciplinary divide that separates the medical 

from the dental care of the diabetic patient. Diabetes (DM) is a pandemic in the 

United States: in many counties, over 10 percent of people over 20 years old are 

affected.1 The disease is accompanied by wide-ranging health consequences that 

worsen if it is poorly controlled. To use the legal vernacular, it is established beyond 

a reasonable doubt that DM has a deleterious effect on periodontal disease (PD) and 

the evidence is mounting on the impact of periodontal health on diabetic control.2

The evidence supporting a link between PD and DM is so strong that PD has been 

classified as the 6th complication of diabetes.3 DM now affects nearly 26 million 

Americans and over the next decade, an estimated 40 million more adults could develop the condition, and its complications are expensive. Absent changes, the surge 

in new cases could add an estimated $512 billion to annual health care spending 

by 2021 . . . ’’.4 In spite of this knowledge, only 55.6 percent of the U.S. population 

aged 2 years and older with diagnosed diabetes had been to the dentist in the past 

year.5 Moreover, severe disparities exist in dental access based on income, insurance 

status, educational attainment and race. 

COMPREHENSIVE DESCRIPTION OF THE MODEL AND SUPPORTING EVIDENCE BASE

The Institute of Medicine (IOM), National Academy of Sciences, released a report, 

‘‘Dental Education at the Crossroads: Challenges and Change,’’ in January 1995, 

calling for greater collaboration between medicine and dentistry. The report said 

closer integration was needed between dentistry and medicine on all levels of the 

health care system: research, education and patient care. In 2000 Surgeon General 

David Satcher’s report entitled ‘‘Oral Health in America’’ was released. The report 

focused attention on a national problem which had gone largely unrecognized for 

decades: the oral health crisis. Dr. Satcher emphasized that oral health does not 

only encompass teeth. He underlined the importance of recognizing the integration 

between oral and systemic health and the profound mutual impact that one has on 

the other, stating that one cannot have systemic health in the absence of oral 

health. To emphasize this point, he summarized the existing evidence that points 

to important links between oral disease, such as PD, and systemic diseases such as 

DM, heart disease and stroke, respiratory health and fetal health (miscarriage and 

stillbirth). The Surgeon General further exposed disproportionate access to dental 

health care encountered by disparity-prone populations including low-income individuals, those with no insurance, children, the elderly, handicapped and institutionalized patients who experience what he dubbed the ‘‘silent epidemic’’ when referencing the high rate of oral disease prevalent among these populations. 

The report revealed how a struggling and stagnated dental industry that was experiencing workforce shortages exacerbated the problem by denying access to vulnerable populations without the ability to pay for, or access services. His report revealed how, in addition to the systemic ramifications of poor oral health, far reaching consequences were inflicted on those with limited or no access, including high 

social and economic cost to the individual, negative impact on quality of life and the 

burden this also placed on society. Importantly, the Surgeon General emphasized 

that this trend was reversible and preventable and pointed to the importance of 

bringing education and research to bear on the problem as actionable ways to advance oral-systemic health. Dr. Satcher called for further investigations into oralsystemic health connections, health disparity research, community-based, public 

health and behavioral health initiatives, health services research, and an expansion 

in diagnostic and treatment options which would emphasize proactive disease prevention. His report emphasized that for three decades improvement in oral health 

had been a focus area of U.S. Department of Health and Human Service’s Healthy 

People initiative and that solving the problem would require a concerted effort between the health care industry including professionals and health care entities, academia, the government, health insurers and patients. Notably, 13 years later, oral 

health remains a priority focus in Healthy People 2020, with many objectives remaining to be achieved.6

A chasm currently exists between our perceptions, financing, and delivery of oral 

health services and general medical services. It persists despite mounting evidence 

that it should not. Yet today, proportionately fewer of us annually access oral health 

services than medical services. Our oral health record for some of our most vulnerable citizens is abysmal. The elderly, where chronic disease is more prevalent, have 

the lowest rate of dental insurance of any age group.7 Poor children on Medicaid/ 

28 

CHIP have public dental insurance, but low reimbursement rates and other problems have left most without annual oral health services. Poor adults have even less 

coverage and access. 

This trail leads to an important question, ‘‘If the future is medical homes and 

ACOs, where is oral health in that calculus? Why isn’t it more prominent when evidence exists to support its inclusion in these new models/systems.’’ 

BRIEF SUMMARY OF THE EVIDENCE BASE

PD is a broad term encompassing a complex disease initiated by a variety of 

pathogens, largely anaerobic bacteria which establishes a niche in dental plaque 

that they lay down to protect themselves from exposure to oxygen. The disease is 

not a single entity and may, or may not exhibit a familial pattern of inheritance. 

PD may range from its mildest manifestation, gingivitis, a self-limited condition, to 

severe periodontal disease that is associated with pain, gum erosion, loosening of 

teeth (attachment loss) and bone loss below the affected tooth and eventually, if untreated, loss of the tooth. PD may be acute and resolve with appropriate treatment 

(scaling and root planing, sometimes supplemented by antibiotic therapy, and proper oral hygiene) or in a subset of patients, establish chronicity and refractoriness 

to treatment. PD is a highly prevalent condition among adults in the United States 

with an estimated 40 percent prevalence rate of moderate to severe disease.8 Research examining exacerbation of systemic disease in the presence of oral disease 

and vice versa has produced substantive evidence that such connections are real.9 10

Much research in the past two decades has explored the validity of the ‘‘focal infection theory’’ that promotes the possibility that organisms present at a focal infection 

site or their products may gain systemic access and become associated with promulgating other disease processes. PD represents such a focal infection and risks for 

systemic manifestations increase with establishment of chronicity. Of importance 

here is that with proper hygiene and regular dental care and education, this disease 

is largely preventable and its prevention and control could exert considerable far 

reaching impact on promoting systemic health at multiple levels. 

An extensive evidence base exists to support the reintegration of the mouth into 

the body for everyone.11 The impact of DM on PD was recognized nearly 50 years 

ago 12; Moreover, mounting evidence substantively supports mutual bidirectional exacerbation of these two conditions.13 14 15 In a systematic review of 48 studies undertaken since the 1960s, 44 studies reported increased prevalence, extent, severity or 

progression of PD in patients with DM.16 Interestingly, the observation by two independent studies in 1989 17 18 reported that infectious processes can establish insulin 

resistance in non-diabetics that can persist for 3 months following resolution of the 

infectious process, promoted the concept that PD also contributes to diabetic status. 

Notably, PD is also a risk factor for stimulating diabetes-associated complications.19 20 21 Adjusted for other risk factors, mortality risks related to ischemic heart 

disease and diabetic nephropathy were 2.3 and 8.5 times higher, respectively, for 

individuals with DM and severe PD compared to those with no PD; overall mortality 

risk from cardio-renal pathology was 3.5 times higher for those with DM and PD 

compared to subjects with no PD.20

The mechanism underlying this bacterial impact on glycemic control is attributed 

to dysregulation of insulin-mediated glucose uptake at the skeletal muscle level, inducing a state of systemic insulin resistance.22 Studies among Pima Indians with 

a high rate of DM 23 and in a population of Japanese patients with DM 24 strongly 

suggest that DM is a risk factor for PD, likely due to increased susceptibility of diabetic patients to infectious processes due to compromised immunocompetence related to irreversible formation of advanced glycation end products. Proteins mediating immunological functions become compromised due to non-enzymatically mediated glycation and multiple pathological mechanisms converge to induce what manifests as a heightened chronic proinflammatory state that simultaneously exacerbates both the DM and PD pathophysiological processes.22 25 26 Chronic systemic 

micro-inflammatory processes have been implicated as a common factor underlying 

both DM and PD, driving chronicity, progression and mutual exacerbation of these 

conditions in the absence of intervention. Importantly, micro-inflammatory processes 

which contribute to disease chronicity appear to be modifiable risk factors responsive to PD treatment and regular dental care as well as more advanced therapeutic 

regimes.27

Poor glycemic control is an important factor in PD progression and severity.28 29

Notably, outcomes of four recent systematic reviews and meta-analyses support the 

position that glycemic control improves periodontal health, and, conversely, improvement in periodontal health impacts positively on glycemic control. 30 31 32 33 34

Collectively, these results strongly support potential for simultaneous stemming of 

29 

epidemic prevalence of both PD and DM through cross disciplinary efforts that systematically target glycemic control and good oral care. Promoting interdisciplinary 

care processes is pivotal: studies evaluating dentists’ understanding of DM–PD bidirectional relationship showed that ≤60 percent promoted this with patients; physician awareness of PD/DM complications was low.34 Strikingly, interactions between 

dentists and physicians on oral-systemic patient management were measured at <15 

percent in a 2006 U.S. study.35

REFERENCES

1. Centers for Disease Control and Prevention. National Diabetes Surveillance 

System. 2009 [cited 2013 April 02]; Available from: http://apps.nccd.cdc.gov/ 

DDTSTRS/default.aspx. 

2. Taylor, G.W. and W.S. Borgnakke, Periodontal disease: associations with diabetes, glycemic control and complications. Oral Dis, 2008. 14(3): p. 191–203. 

3. Loe H. 1993. Periodontal disease. The sixth complication of diabetes mellitus. 

Diab Care 16:329–34. 

4. Vojta D, De Sa J, Prospect T, Stevens S, Effective Interventions for Stemming 

the Growing Crisis of Diabetes and Prediabetes: A National Payer’s Perspective. 

Health Affairs, 31, No 1 (2012): 20–6. 

5. Healthy People 2020, Summary of Objectives, Diabetes, D–8, Annual dental examinations. 

6. Koh, H. 2010. A 2020 vision for Healthy People. NEJM 362: 1653–56. 

7. MEPS Chartbook No. 17, Dental Use, Expenses, Dental Coverage, and 

Changes, 1996 and 2004, AHRQ, DHHS. 

8. Fuster V, Badimon L, Badimon JJ, 1992. The pathogenesis of coronary artery 

disease and the acute coronary syndromes NEJM 326: 242–50. 

9. Kim J and Amar S. 2006 Periodontal disease and systemic conditions: a 

bidirectional relationship. Odontol 94: 10–21. 

10. Pizzo G, Guiglia R, Lo Russo L, Campisi G. 2010. Dentistry and internal medicine: from the focal infection theory to the periodontal medicine concept. Eur J Internal Med 21: 496–502. 

11. Powell V, Din F, Acharya A, et al., Project on Clinical Data Integration Page 

20, Contact points between medical and dental care/research—Version J: Categories 

(1–29) and references. 

12. Belting SM, Hiniker JJ, Dummett CO. Influence of diabetes mellitus on severity of periodontal disease. J Periodontol 1964 35:476–80. 

13. Mealey BL, Rose LF. Diabetes mellitus and inflammatory periodontal diseases. Curr Opin Endocrinol Diabetes Obes. 2008;15:135–41. 

14. Taylor GW, Borgnakke WS. Periodontal disease: associations with diabetes, 

glycemic control and complications. Oral Dis. 2008;14:191–203. 

15. Nagasawa T, Noda M, Katagiri S, Takaichi M, Takahashi Y, Wara-Aswapati 

N, Kobayashi H, Ohara S, Kawaguchi Y, Tagami T, Furuichi Y, Izumi Y. Relationship between periodontitis and diabetes—importance of a clinical study to prove the 

vicious cycle. Intern Med. 2010;49:881–85. 

16. Taylor GW, Burt BA, Becker MP, Genco RJ, Schlossman M, Knowler WC. 

2001 Severe periodontitis and risk for poor glycemic control in patients with noninsulin dependent diabetes mellitus. J Periodontol 67: 1085–93. 

17. Sammalkorpi K. 1989. Glucose intolerance in acute infections. J Int Med 225: 

15–19. 

18. Yki-Jarvinen H, Sammalkorpi K, Koivisto VA, Nikkila EA. 1989 Severity, duration and mechanisms of insulin resistance during acute infections. J Clin 

Endocrinol Metab 69: 317–23. 

19. Jepsen S, Kebschull M, Deschner J. Relationship between periodontitis and 

systemic diseases. Bundesgesundheitsblatt Gesundheitsforschung Gesundheits 

schutz. 2011;54:1089–96. 

20. Saremi A, Nelson RG, Tulloch-Reid M, et al. Periodontal disease and mortality 

in type 2 diabetes. Diabetes Care 2005;28:27–32. 

21. Shultis WA, Weil EJ, Looker HC, Curtis JM, Shlossman M, Genco RJ, 

Knowler WC, Nelson RG. Effect of periodontitis on overt nerphropathy and endstage renal disease in type 2 diabetes. Diabetes Care. 2007 30: 306–11. 

22. Grossi SG, Genco RJ. 1998. Periodontal disease and diabetes mellitus: a twoway relationship. 3: 51–61. 

23. Nelson RG, Shlossman M, Budding LM, Pettitt DJ, Saad MF, Genco RJ, 

Knowler WC. 1990 Periodontal disease and NIDDM in Pima Indians Diabetes Care. 

13: 836–40. 

30 

24. Nishimura F, Kono T, Fujimoto C, Iwamoto Y, Murayama Y. 2000. Negative 

effects of chronic inflammatory periodontal disease on diabetes mellitus. J Int Acad 

Periodontol. 2: 49–55. 

25. Genco, R.J., Glurich, I., Haraszthy, V., Zambon, J., DeNardin, E. 1998. Overview of Risk Factors for Periodontal Disease and Implications for Diabetes and Cardiovascular Disease. Compendium of Continuing Education in Dentistry (Symposium Proceedings) 19: 40–4. 

26. Collin, HL, Uusitupa M, Nisanen L, Kontturi-Narhi V, Markkanen H, Koivisto 

AM. 1998, Periodontal findings in elderly patients with non-insulin dependent diabetes mellitus. J Periodontol 69: 962–66. 

27. Lalla E and Papapanou PN. Diabetes mellitus and periodontitis: a tale of two 

interrelated diseases. Nat Rev Endocrinol 2011 Jun 28 Epub ahead of print. 

28. Weidlich P, Cimo ̃es R, Pannuti CM, Oppermann RV. Association between periodontal diseases and systemic diseases. Braz Oral Res. 2008;22 Suppl 1:32–43. 

29. Cha ́varry NG, Vettore MV, Sansone C, Sheiham A. The relationship between 

diabetes mellitus and destructive periodontal disease: a meta-analysis. Oral Health 

Prev Dent. 2009;7:107–27. 

30. Darre ́ L, Vergnes JN, Gourdy P, Sixou M. Efficacy of periodontal treatment 

on glycaemic control in diabetic patients: A meta-analysis of interventional studies. 

Diabetes Metab. 2008;34:497–506. 

31. Janket SJ, Wightman A, Baird AE, Van Dyke TE, Jones JA. Does periodontal 

treatment improve glycemic control in diabetic patients? A meta-analysis of intervention studies. J Dent Res. 2005;84:1154–59. 

32. Simpson TC, Needleman I, Wild SH, Moles DR, Mills EJ. Treatment of periodontal disease for glycaemic control in people with diabetes. Cochrane Database 

Syst Rev. 2010:CD004714. 

33. Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment on glycemic 

control of diabetic patients: a systematic review and meta-analysis. Diabetes Care. 

2010;33:421–27. 

34. Al-Khabbaz AK, Al-Shammari KF, Al-Saleh NA. Knowledge About the Association Between Periodontal Diseases and Diabetes Mellitus: Contrasting Dentists 

and Physicians. J Periodontol. 2011;82:360–66. 

35. Kunzel C Lalla E Lamster IB. Management of the patient who smokes and 

the diabetic patient in the dental office. J Periodontol 2006 77: 331–40. 

ATTACHMENT 2.—EXAMPLES OF THE VALUE TO PATIENTS OF BETTER COORDINATION

BETWEEN MEDICINE AND DENTISTRY

Case example: A Family Health Center patient living in Clark County was referred to the Ladysmith Dental Center by his Marshfield Clinic Oncologist. His cancer treatments were negatively impacting on his oral health status, and as a result 

he began losing weight. The patient was initially scheduled for an emergency visit 

and followup dental care. All of his teeth needed to be extracted and he was fitted 

for dentures. To date, the patient has improved oral health and has gained 10 

pounds. 

Case example: An elderly woman on Medicare presented at our Ladysmith Dental 

Center with severe diabetes, which was not controlled well due to the condition of 

her teeth. She had driven over 4 hours one-way to get to our clinic. She had only 

a few teeth, which had to be extracted. Over several visits we were able to provide 

her with dentures and in a subsequent visit she reported that she is now eating 

better and has her diabetes under better control. 

Case example: Another diabetic patient presented at our Ladysmith Dental Center. The patient was jaundiced and very ill and had a large lesion on his leg for 

the past 4 years that would not heal. He also had severe oral health disease. Following a full mouth extraction and dentures, this patient has been back for routine 

care. He reports his blood glucoses are under control, he has good skin color, his 

skin lesion is healed and he is very happy. 

Case example: A 20-year-old female with no income presented as unemployed and 

depressed with very poor oral health. We provided extractions and dentures. She 

now has an improved self image and a job. 

Case example: A patient presented at our Ladysmith Dental Center as an emergency. She was in high school at the time of her first visit and she qualified for a 

full discount under our sliding-fee program. Due to the extensive dental care needed 

and her family’s inability to afford that care, she was not able to find a dentist that 

would see her. Her extensive dental care included root canals, crowns, and major 

fillings in the majority of her top teeth. To date, the cost of her care exceeds $5,000. 

She is now an established patient with the dental center and the majority of the 

work was completed in time for her senior picture. 

31 

Case example: A teenage child with spina bifida presented to clinic to establish 

care with a new pediatrician. The examination revealed multiple severe dental caries requiring extraction and repair. This child had just been hospitalized for many 

months to repair and heal her third sacral decubitus. Pediatrician requested prompt 

dental treatment to decrease the potential for additional infections that could jeopardize skin integrity. Pediatric care coordinator and special needs dental coordinator 

worked together to arrange dental treatment under anesthesia with appropriate 

skin pressure relief measures in place to prevent possible skin breakdown. Dental 

health was achieved, skin integrity was maintained and potential for additional infections due to decay and gum disease reduced. This child also had improved selfesteem and improved social interactions with peers. 

Case example: A teenage patient with special needs presented to the pediatrician 

for a well-check. Patient has profound cognitive impairment, no speech, aggressive 

behavior and is completely uncooperative with examinations. Patient had previously 

received dental care and treatment under anesthesia and was in need of a dental 

exam with cleaning again. Pediatrician requested additional specialty care examinations and procedures be done in conjunction with the scheduled dental service. Pediatric care coordinator and special needs dental coordinator were able to arrange eye 

exam, gynecological exam, ENT exam, blood draw for lab testing and vaccinations 

to take place while patient was anesthetized for the dental procedure. 

Senator SANDERS. Thank you very much, Mr. Nycz. 

Ms. Stallings. 

STATEMENT OF CATHI STALLINGS, MSW, FALLS CHURCH, VA 

Ms. STALLINGS. Good morning, Chairman Sanders and distinguished members of the subcommittee. My name is Cathi Stallings, 

and I am a social worker from Falls Church, VA. I am here as 

someone who knows firsthand that dental care is a luxury that 

many millions of us in America cannot afford. I have paid thousands of dollars for dental work and need much more. 

I, personally, am focused on this issue because I am not able to 

afford to pay the exorbitant cost for the dental work that I need. 

Since finding out the extent of my dental needs, I have spent many 

dark hours wondering how I will afford my future. 

Several years ago, I took out a bank loan to pay for a bridge that 

I needed. I was told a few months ago that the bridge needs to be 

replaced. I was quoted the price of $7,000 for this. The periodontist 

said he would give me a discount, but it didn’t matter. I couldn’t 

afford that, either. 

I have quite a few other dental issues. The insurance coverage with my job covers $1,290 per year, which doesn’t cover even one 

of the crowns I need, let alone anything else. Crowns have been 

quoted to me up $2,000 each. In the past 2 months, I’ve needed 

scaling and root planing for gum disease, as well as an emergency 

crown when one of my teeth cracked. 

As a social worker, I work with severely mentally ill clients, most 

of whom have not been able to afford to go to a dentist in many 

years. One issue for them is that numerous medications cause dry 

mouth, but with psychotropic medications, there can be a more severe effect, as it usually takes more than one medication to treat 

the mental health symptoms. Saliva helps in preventing dental 

pathologies, like cavities and gum disease, by the cleansing and 

antibacterial action. 

One of my clients has very few teeth left. He found out 2 weeks 

ago that he has three abscesses in his remaining teeth. His Medicaid benefits only provide extractions of teeth, but no dental services. If more of his teeth are pulled, he said he doesn’t know how 

he’ll be able to eat. 

32 

Another one of my clients receives general relief funds of $220 

per month to live on. I gave her information about a dentist who 

was providing a free emergency exam and x-rays. She went and 

found out that she needs scaling and root planing for her gum disease. The total price that was quoted to her for this procedure was 

$1,600. I then directed her to a lower cost dental service this summer, and she was told that they may have an opening in November, since there is such a long waiting list. 

This week, I was told by another client that he was told in 1999 

that he had 11 cavities. He has never been treated for any dental 

work in all these years. He said, ‘‘I guess I’m on my way to a root 

canal, because I do feel a sensation in my mouth.’’ 

I had an extremely unusual birthday this year. As I was preparing to go out and celebrate with my mother, I heard on the 

news about the Maryland Mission of Mercy clinic, where free dental services were being provided. Immediately, I ran out of my 

home, met my mom outside and told her, ‘‘We have to cancel my 

birthday. I have to go to Laurel, MD.’’ 

We went and were told they were full for the day, but that I 

could try again tomorrow. I knew that dental care was much more 

crucial than celebrating my birthday. So that evening, I went back 

to Laurel and arrived around 8 p.m. I was No. 2 in line. I was 

thinking that I wish I could have brought all my clients with me. 

Many others started to show up as time went on. We shared our 

stories of dental nightmares. I spent the night on the sidewalk, but 

I didn’t mind, because I was getting a great birthday gift. It turns 

out that the gift was seeing over 400 volunteers in action, giving 

their time and hearts to provide over $750,000 worth of free dental 

work that weekend. 

I wasn’t able to get the dental services I was hoping for, as they 

weren’t able to do specifically what I needed. But I came away with 

a scene that I will never forget—men and women of every race, 

creed, and color lined up for what seemed like a mile, in dire need, 

with the hope of being helped. It was truly heart-breaking for me 

to see. 

I have learned that the lack of adequate dental care can lead to 

diabetes, chronic heart disease, and strokes. These risks are scary 

for me and so many others. But you have the solution in your 

hands. 

I am a social worker. These are my clients. But on this issue, all 

of us are standing together in the same line, looking for help. I beg 

you to pass this legislation so that help can be provided to all. 

Thank you for your valuable time and attention to this critical 

matter. 

[The prepared statement of Ms. Stallings follows:] 

PREPARED STATEMENT OF CATHI STALLINGS, MSW 

Good morning Chairman Sanders and prestigious members of the subcommittee. 

I appreciate the opportunity to speak before you today. My name is Cathi Stallings, 

and I am a social worker from Falls Church, VA. 

I am here as someone who knows firsthand that dental care is a luxury that many 

millions of us in America cannot afford. I have paid thousands of dollars for dental 

work and need thousands more. 

I personally am focused on this issue because I am not able to afford to pay the 

exorbitant cost for the dental work that I need. 

33 

Since finding out the extent of my dental needs, I have spent many dark hours 

wondering how I will afford my future. Several years ago I took out a bank loan 

to pay for a bridge that I needed. I was told a few months ago that that bridge 

needs to be replaced. I was quoted the price of $7,000 for this, but the periodontist 

said he would give me a discount. 

I have quite a few other dental issues. The insurance provided with my job covers only $1,290 per year, which does not cover even one of the crowns I need, let alone 

anything else (they have cost me about $2,000 each). In the past 2 months, I’ve 

needed scaling and root planing for gum disease, as well as an emergency crown 

when one of my teeth cracked. 

As a social worker, I work with severely mentally ill clients, MANY of whom have 

not been able to afford to go to a dentist in years. Numerous medications cause dry 

mouth, but with psychotropic medications there can be a more severe effect, as it 

usually takes more than one medication to treat the mental health symptoms. Saliva helps in preventing dental pathologies, like cavities and gum disease, by the 

cleansing and antibacterial action. 

One of my clients has very few teeth left. He found out 2 weeks ago that he has 

three abscesses in his remaining teeth. His Medicaid benefits provide only extractions of teeth—no dental services. If more of his teeth are pulled, it will become increasingly difficult for him to eat. Another one of my clients receives General Relief funds of $220 per month to live 

on. I gave her information about a dentist who was providing a free emergency 

exam and x-rays. She went and found out that she needs scaling and root planing 

for her gum disease. The total price quoted to her for this procedure was $1,600. 

I then directed her to a lower cost dental service this summer, and she was told 

that they may have an opening in November, since there is such a long waiting list. 

Every day my clients pay for the consequences of their illness and their inability 

to support themselves. 

I had an extremely unusual birthday this year. As I was preparing to go out and 

celebrate with my mother, I heard on the news about the Maryland Mission of 

Mercy clinic, where free dental services were being provided. Immediately, I ran out 

of my home, met my mom outside and told her, ‘‘We have to cancel my birthday. 

I have to go to Laurel, MD.’’ 

We went and were told they were full for the day, but that I could try again tomorrow. I knew that dental care was much more crucial than celebrating my birthday. So that evening, I went back to Laurel and arrived around 8 p.m. I was No. 

2 in line. 

Many others started to show up as time went on. We shared our stories of dental 

nightmares. I spent the night on the sidewalk, but I didn’t mind, because I was getting a great birthday gift. It turns out that the gift was seeing over 400 volunteers 

in action giving their time and hearts to help give over $750,000 worth of free dental work that weekend. 

I wasn’t able to get the dental services I was hoping for, as they weren’t able to 

do specifically what I needed. But I came away with a scene that I will never forget—men and women of every race, creed and color lined up for what seemed like 

a mile—in dire need, with the hope of being helped. It was truly heart-breaking for 

me to see. 

I have learned that the lack of adequate dental care can lead to diabetes, chronic 

heart disease and strokes. These risks are scary . . . for me and so many others. 

But YOU have the solution in your hands. 

I am a social worker. These are my clients. But on this issue ALL of us are standing together in the same line, looking for help. 

I beg you to pass this legislation so that help can be provided. Thank you for your 

valuable time and attention to this critical matter. 

Senator SANDERS. Ms. Stallings, thank you very much. 

Dr. Hughes. 

STATEMENT OF DEBONY R. HUGHES, D.D.S., PROGRAM CHIEF, 

DENTAL HEALTH PROGRAM AND DEAMONTE DRIVER DENTAL PROJECT, PRINCE GEORGE’S COUNTY HEALTH DEPARTMENT, CHEVERLY, MD 

Ms. HUGHES. Good morning. I am a public health dentist. As 

Senator Sanders stated, I began my career in public health 21 

years ago in Vermont, and for the past 7 years, I have been the 

program chief of the dental health program for Prince George’s 

34 

County Health Department. Last fiscal year, we provided more 

than 3,200 clinic visits to children and pregnant women. 

In addition, we provide oral health education across the county 

and work with community organizations. Working with patients, 

clinicians, health administrators, and community organizations has 

given me insight on the state of oral health both locally and nationally. 

I would like to thank Chairs, Senator Sanders and Senator Burr, 

and committee members for this opportunity to share information 

about the climate and landscape of dental access and cost issues in 

my jurisdiction. 

Let me begin by telling you about some experiences that influence my remarks today and inspire my work. In Vermont, I lived 

in a small town with a population of approximately 8,000, and 

there were four private dental offices. At that time, Vermonters eligible for Medicaid did not have access to any of those four dental 

offices. 

With the help of a community organization, we were able to provide care and expand access to Medicaid-eligible residents. In 

Prince George’s County, the Health Department provides a similar 

safety net for dental care. 

Recently, I participated in my first Mission of Mercy. This 2-day, 

large-scale event provided free dental care to uninsured adults. 

Men and women camped out overnight, waiting to be served. Many 

received quality care, but patients should not have to endure such 

conditions to receive treatment. 

This experience affirmed my belief that dental care is not a luxury, but rather a necessity, and we must make it accessible to all 

adults. But achieving this goal will be difficult if we are unable to 

address rising operational costs of dentistry. 

Of course, we cannot talk about the high cost of dentistry without acknowledging the cost of dental education. It’s not uncommon 

for a dentist to graduate with a debt of over $200,000, and, arguably, education costs play a role in access and driving cost. 

But operating a practice is the true cost driver. For example, 

building out a dental office can cost up to $500,000 for equipment 

alone. Coupled with the escalating costs of staff salaries, insurance 

premiums, dental supplies, laboratory fees, and equipment upkeep, 

which are largely unknown to those outside the field of dentistry, 

a practice can experience staggering costs. My clinic recently had 

repairs on an x-ray unit, and the labor fee alone was $295.00 per 

hour. 

For many consumers who have neglected their dental care, extensive treatment is often required, and it can be expensive. For 

example, according to the American Dental Association’s 2011 survey of dental fees in the South Atlantic Region, the average cost 

of a root canal is $1,075. Add in the cost of a crown, and the fee 

increases an additional $1,079.00. Of course, the less expensive option is to have the tooth pulled, but this choice can lead to problems with chewing, speech, and appearance. 

Can dental costs be contained? This is a question I cannot answer. But it is important for consumers to know what drives their 

cost. As a public health dentist, I think about education, prevenVerDate Nov 24 2008 16:39 Jul 29, 2016 Jkt 000000 PO 00000 Frm 00038 Fmt 6633 Sfmt 6601 S:\DOCS\20708.TXT DENISE
35 

tion, outreach, and obtaining more resources to provide increased 

accessibility to care. 

In Prince George’s County, there is an established mobile health 

fleet that provides medical and dental care to public schools. The 

county health department operates the Deamonte Driver Dental 

Project, which is a mobile dental unit funded by the Maryland Office of Oral Health, providing care to children. 

We address the emergent needs and provide resources for families to establish a dental home. We work with volunteer dentists 

in the neighborhoods of the schools we service to provide a resource 

for families that will continue the efforts to make dental care easily 

accessible. 

Last fiscal year, the project provided care to more than 2,300 children on a budget of $180,000. Mobile units are not a panacea 

for treatment, but they are certainly a model for providing affordable dental care. 

Prevention is an important aspect of reducing costs for dental 

treatment. After the death of Deamonte Driver, Governor O’Malley 

assembled the Dental Action Committee. One of the recommendations was to institute school-based oral health screenings program. 

The Maryland Dental Action Coalition, formed from the original 

Dental Action Committee, received $172,000 from the Kaiser Foundation to develop a demonstration project to determine the feasibility of this type of program in Prince George’s County. 

The results of the project showed that it is vital to have a presence in the schools. Of 3,000 children screened, 200 were in the A 

category, potential Deamonte Drivers, which indicated that they 

had an immediate need, either infection or multiple decayed teeth. 

It is these types of programs that will address affordable accessibility. We need a stronger financial commitment to support the 

public health infrastructure so that the dental needs of all Americans can be met. 

Thank you again for the opportunity to address this crisis. 

[The prepared statement of Ms. Hughes follows:] 

PREPARED STATEMENT OF DEBONY R. HUGHES, D.D.S. 

Good morning. My name is Dr. Debony Hughes and I am a public health dentist. 

I began my career in public health 21 years ago in Vermont and for the past 7 years 

I have been the Program Chief of the Dental Health Program for Prince George’s 

County Health Department in Maryland. Last fiscal year, we provided more than 

3,200 clinic visits to children and pregnant women. In addition we provide oral 

health education across the county and work with community organizations. Working with patients, clinicians, health administrators and community organizations 

has given me insight on the state of oral health both locally and nationally. 

I would like to thank chairs Senator Sanders and Senator Burr and committee 

members for this opportunity to share information about the climate and landscape 

of dental access and costs issues in Prince George’s County. 

Let me begin by telling you about some experiences that influence my remarks 

today and inspire my work in Prince George’s County. 

In Vermont, I lived in a small town with a population of approximately 8,000 and 

there were four private dental offices. At that time, Vermonters eligible for Medicaid 

did not have access to any of those four dental offices. With the help of a community 

organization, we were able to provide care and expand access to Medicaid eligible 

residents. In Prince George’s County, the Health Department provides a similar 

safety net for dental care. 

Recently, I participated in my first Mission of Mercy, a large-scale event providing 

free dental care to uninsured adults. For 2 days dental professionals treated hundreds of adults each day. I was overwhelmed to see so many amassed to receive 

treatment. People slept overnight in hopes to receive care. Many received quality 

36 

care but I believe patients should not have to endure those types of conditions to 

receive treatment. 

These experiences reminded me that quality dental care is not a luxury, it is a 

necessity and we need to make it accessible and affordable for adults to receive the 

care they need and deserve. 

These experiences also tell me that this task will remain difficult if we are unable 

to address the escalating costs of dental education and the escalating operational 

costs of dentistry. 

There are several factors that influence the correlation of dental insurance coverage and utilization, access to care, and high costs of dental care which leads to 

more extensive and expensive treatments. 

Providing dental care is costly. When we talk about the high cost of dentistry, we 

need to look at the several aspects of care. First, let us consider the costs of a dental 

education. It is not uncommon for dentist to graduate with a debt of over $200,000. 

Establishing an office can cost up to $500,000 for equipment alone. The escalating 

costs of staff salaries, insurance premiums, dental supplies, laboratory fees and 

equipment upkeep are staggering and largely unknown to those outside the field of 

dentistry. Our clinic recently had a repair done on an X-ray unit. The labor fee 

alone was $295.00 per hour. 

For many people who have neglected their dental care for a variety of reasons, 

extensive treatment may be required. For example, a root canal, a procedure that 

requires removing the infected nerves in the root of a tooth can cost on average, 

of $1,075 according to the American Dental Association’s 2011 Survey of Dental 

Fees in the South Atlantic Region. This fee does not include the cost of the crown, 

which averages $1,079.00. The less expensive option is to have the tooth pulled 

which can lead to other problems that can affect chewing, speech and appearance. 

With these types of exorbitant costs to maintain a quality practice, the costs for 

dental procedures have to stay competitive with the supporting costs of the practice. 

Can these costs be contained? I am not in the position to answer this but it is important for consumers to know what drives the costs in dentistry. 

As a public health dentist, I think about education, prevention, outreach and obtaining more resources to provide increased accessibility to care. In Prince George’s 

County, there is an established mobile health fleet that provides medical and dental 

care to the public schools. The county health department operates the Deamonte 

Driver Dental Project (DDDP), which is a mobile dental unit. This project honors 

the legacy of Deamonte Driver by providing dental care to Title I schools, which includes the school he attended. The project, funded by the Maryland Office of Oral 

Health, allows us to provide care to insured and uninsured children. We address the 

emergent needs and provide resources for families to establish a dental home. We 

work with volunteer dentists in the neighborhoods of the schools we service to provide a resource for families that will continue the efforts to make dental care easily 

accessible. Last fiscal year the DDDP provided care to more than 2,300 children on 

a budget of $180,000. Mobile units are not a panacea for treatment but they are 

certainly a model for providing affordable dental care. 

Prevention is an important aspect of reducing costs for dental treatment. After the 

death of Deamonte Driver, Governor O’Malley assembled the Dental Action Committee (DAC). One of the recommendations was to institute school-based oral health 

screening programs. The Maryland Dental Action Coalition, formed from the original DAC, received $172,000 from the Kaiser Foundation to develop a demonstration 

project to determine the feasibility of this type of program in Prince George’s County. The results of the project showed that it is vital to have a presence in the 

schools. Of 3,000 children screened, 200 were in the A category which indicated that 

they had an immediate need, either infection or multiple decayed teeth. This indicated 200 more potential Deamonte Drivers. 

It is these types of programs that will address affordable accessibility. We need 

a stronger financial commitment to support the public health infrastructure so that 

the dental needs of all Americans can be met. 

Thank you again for the opportunity to address this crisis. 

Senator SANDERS. Thank you very much, Dr. Hughes, and come 

back to Bristol. We can use you. 

There’s a lot to go over. What I propose is that we can do this 

kind of informally. I would like to ask each of you questions, but 

at the end of the response, if others want to jump in and comment, 

that would be great. 

37 

Let me tell you a little story about Vermont. About 45 years ago, 

I moved to a small town in rural Vermont in what we call the 

Northeast Kingdom. I saw a kid there, a neighbor of mine. I’d 

never seen anything like it in my life. He was maybe 10 years of 

age, and all of his teeth were rotting in his mouth. I’d never seen 

anything like that in my life. 

It turned out that he was certainly not unique. We had a major 

problem in Vermont then. Over the years, in our State, we have 

made some significant progress, and we’ve done it primarily 

through the establishment of Federally Qualified Health Centers 

around the State. We now have 43 locations, eight FQHCs, and in 

our small State, about 25,000 people are getting treated, regardless 

of income, at the community health centers. 

We have established—and this is really a source of great satisfaction. In low-income areas, way up in the Northeast Kingdom— 

Dr. Hughes, you may remember—in the towns of Richford, in 

Plainfield, in Burlington, we have state-of-the-art dental clinics 

that I think are fairly cost-effective, because we have a number of 

dentists and dental technicians who are practicing there. We have 

a long way to go. 

Now, let me at least start off by saying this. What we have 

learned in Vermont is that every time you build—it’s like, ‘‘If you 

build it, they will come.’’ It’s like the baseball fields. What we have 

learned is you build a dental clinic, and guess what? People come. 

Dr. Catalanotto, is that your impression, that the need is out 

there, and if we build it, people will come? 

Mr. CATALANOTTO. Absolutely. I look at my own examples in 

Florida. At our dental school, which is very large, we have patients 

who travel 2 hours away, because they can’t find affordable care in 

their communities. When I went to Gadsden County next to the 

State capital of Tallahassee, on the day we did a school exam, one 

in five children reported pain that day of the exam. 

Senator SANDERS. One in five children? 

Mr. CATALANOTTO. One in five children on the day of the exam— 

this was about 5 years ago—reported pain, one in five, Senator. A 

young graduate of ours went to the county health department and 

took a job. She’s a pediatric dentist who gave up what she could 

have made in private practice to work in the county health department. Overnight, she made it a major success with large numbers 

of patients. So, yes, the need is out there. People will come if provided access to the services at an affordable cost. 

FQHCs are a wonderful partner in doing this. I will tell you, as 

an example, all of my dental students at the University of Florida 

spend approximately 6 weeks of their clinical year in an FQHC. 

Why do the FQHCs love that? It’s not the short-term labor they 

get. It’s that these students finally figured out, ‘‘This is a place I 

might practice.’’ It’s no longer the private practice model. They see 

the opportunity, sir. 

Senator SANDERS. Let me ask you a tough question, but it’s just 

between you and me. 

Mr. CATALANOTTO. Yes, sir. 

Senator SANDERS. I have the impression today that maybe there 

are some great dentists out there who see their job as treating people in need. But it is also no secret that there are a lot of dentists 

38 

who graduate dental school deeply in debt—and I want to talk 

about that in a moment—who are making a pretty penny by treating the upper middle class. If you look in the Yellow Pages, they’ve 

got a beautiful smile, and they do all the cosmetic dentistry. So we 

have a lot of dentists practicing cosmetic dentistry when kids are 

in pain. 

Mr. CATALANOTTO. Yes. 

Senator SANDERS. What do we do? What ideas do you have? And 

I should tell you we’ve tried substantially increasing funding for 

the National Health Service Corps, which you’re familiar with. 

What do we do to create the kind of dental workforce that we need 

so that we don’t have to be embarrassed that there are huge places 

in America where people—either there are not enough dentists, or 

there are not enough dentists treating low- and moderate-income 

people? What’s your ideas on that? 

Mr. CATALANOTTO. I can give you three answers. We do need to 

improve Medicaid reimbursement. In Florida, we have the worst 

Medicaid reimbursement in the United States. The result is that 

only 10 percent, approximately, of Florida dentists are accepting 

Medicaid. 

Senator SANDERS. Say that again. I want everybody to hear that. 

You have Medicaid, but only 1 in 10 dentists will take Medicaid patients. 

Mr. CATALANOTTO. That is all, but it’s because we have some of 

the lowest Medicaid reimbursements in the United States. No. 2, 

I think there is very clear data that things like National Health 

Service Corps scholarships and loan forgiveness programs are wonderful. There are some States that have them. 

We do not have them in Florida. I am happy to say that the Florida Dental Association has lobbied our State legislature, but our 

State legislature is just too cheap to do it. 

Third—and this is the longer-term solution—HRSA Title VII 

funding provides grants to dental schools. The newest set of grants 

is to help change the culture of the dental school and the culture 

of dental students. They focus on healthcare disparities. 

I am the principal investigator of one of those grants to the University of Florida College of Dentistry. And what we are doing is 

revamping our curriculum to produce students who are more culturally competent and sensitive to the needs of the underserved patients. They have more public health experience. I’ve been able to 

hire a public health dentist to add to my faculty. 

So now second-year dental students go out into a school-based 

setting, where they understand. They go into schools of poverty. 

They see the picture early in their dental education. Our goal and 

our hope is that they will become more sensitive to this issue after 

they graduate. 

Senator SANDERS. And are you finding—and we have the same 

issue—we had a hearing here on primary healthcare, getting doctors, young medical students, involved in primary healthcare. Are 

you finding that, given the opportunity, and if there were decent 

reimbursement rates, we would be able to attract more young people to serve lower income folks? 

Mr. CATALANOTTO. Yes. There’s no doubt. What I hear from the 

FQHCs is, 

39 

‘‘Frank, you’re sending the students to work for us. They are 

seeing the problem. They get a better appreciation of the needs 

of these kinds of patients, and they are going into those settings.’’ 

Yes, sir. 

Senator SANDERS. Thank you very much. 

Senator Franken has joined us, and I wanted Al to be able to 

give his opening remarks, if he’d like. 

STATEMENT OF SENATOR FRANKEN

Senator FRANKEN. There hasn’t been testimony yet? 

Senator SANDERS. Yes, everybody has testified, first round. But 

if you want to jump in and just—— 

Senator FRANKEN. Yes, I actually want to followup. Thank you, 

by the way, Mr. Chairman, for inviting me to attend this hearing. 

It’s a very important hearing. And I want to pick up where you 

were on dental care. 

In Minnesota, we became the first in the Nation to create a license for an advanced practice dental provider called a dental therapist. This was actually first started in the United States in Alaska 

to address the native population there, because in Alaska, to get 

a dentist, you would really only get a dentist once a year, who 

would fly in for a couple of days. 

But now they have dental therapists. Other OECD countries 

have dental therapists. I guess the ones who are in Alaska were 

trained in New Zealand or something. 

Dr. Catalanotto, in your written testimony, you emphasized the 

financial impact of the national dental care crisis, and you were 

just talking about the limited access to dental care and how it 

leads to wasteful spending. The GAO report released this morning 

notes that only 62 percent of Americans have dental coverage, and 

only about 40 percent of people have a dental visit in any given 

year. 

You also noted in your testimony that one important way to expand access to dental care would be for States to consider dental 

therapists, like Minnesota. Could you elaborate on that? And what 

can we in Congress do to support the expansion of that program 

and the expansion of the number of dental therapists? 

Mr. CATALANOTTO. Thank you, Senator. It’s a great question. 

Just by way of background, I have been to Alaska three times, 

looking at the dental therapist model. I have talked extensively 

with the folks in Minnesota that have both trained these dental 

therapist and then employed these dental therapists. 

Last week, I testified to the New Mexico legislature about dental 

therapists, and with me was one of the folks who employs dental 

therapists in Minnesota. I have read most of the literature on this. 

I am absolutely convinced that this is a cost-effective, safe, wonderful model to deliver care to people in need. 

The beauty of dental therapists is that they can do the kinds of 

simpler procedures that a dentist might do, but that allows the 

dentists to work at the top of the scope of their practice instead of 

at the bottom of the scope of their practice. They are inexpensive 

to educate. They usually come from the communities they go back 

40 

to serve—underserved ethnic minority groups. They are a wonderful solution. 

The difficulty comes from the opposition at the State level and 

then the national level, which I think was your question. At the 

State level, it’s restrictive dental practice acts that forbid these individuals. There are approximately 15 to 20 States that are now 

this close to legislation to get dental therapists in their States. 

But I would also add that it’s not just dental therapists. These 

restrictive dental practice acts also prevent dental hygienists who 

are excellent at providing some of the primary services needed— 

these dental practice acts restrict them from working at the top of 

their skill across many States. 

At the Federal level, the impediment that currently exists is that 

language was inserted into the health service reauthorization just 

a couple of years ago that prevents the first nation folks across this 

country who want to implement dental therapists—it prevents 

them from doing it because there’s language that says they cannot 

use Federal funds. This is a travesty. This is an affront to the sovereignty of the first nations. That is something that you could do 

at the Federal level. There’s not much you can do at the State level 

because of the individuality of dental practice acts. 

Senator FRANKEN. I just think this is incredible. 

Mr. Nycz, in Wisconsin, you would hire a dental therapist. Dental therapists, in studies, do the task they’re allowed to do as well 

as dentists. Am I right? 

Mr. NYCZ. Yes, that’s what the evidence shows. But, again, because of these State laws, we do not have access. And, of course, 

there are not many of them that have been minted. 

I’d like to circle back to the chairman’s point about, ‘‘If you build 

it, they will come.’’ The map that we showed shows that we’re taking care of close to 100,000 people who have come from all over the 

State. And I would add that maybe 140 to 150 from the good State 

of Minnesota have come to us for dental care. 

When we see people, when we open up a clinic—and this is why 

this is a little nuance—we get people with such horrible dental disease that young men and women just coming out of their dental 

training—many of them are kind of daunted by the task in front 

of them. We’ve had one dentist leave after 6 months, saying they’re 

not prepared for this kind of work. 

We had another dentist come and say, ‘‘You know, I’m not prepared for this.’’ She went back and got a year residency, and now 

she’s going to work for us starting October 1st. So there’s a training aspect. 

Dr. Michael McGinnis once wrote about the dirty dozen reasons 

why we don’t do prevention. One of his points was the primacy of 

the rescue. So I would say as it relates to dental therapists that 

we have dentists who can’t even do the job we put in from of them 

when they come right out of training, because they’re not used to 

that. 

But as a health center director, that’s what we’re faced with now, 

that primacy of the rescue. So I need well-trained dentists, trained 

even more than they get in their 4-year schools, to tackle that problem. 

41 

But I want to get over the top of that hill, and I want to have 

our population find that they can experience the same oral health 

level that more affluent people have. And it’s at that time, as our 

population gets healthier, that we have a responsibility to the taxpayers as well. We’ve built group dentistry practices, with five dentists, 10 dentists, with hygienists. 

And what I see over time is as our population gets healthier, we 

need to substitute in other providers who can handle the more routine things to allow our dentists to continue to handle and help out 

on those emergencies and the more complicated cases. So I see this 

more in our future, if these problems that we discussed can be resolved. 

Senator SANDERS. Let me jump in. 

Senator FRANKEN. I wanted to end on it, Mr. Chairman, if I 

might, because I have to go back to Judiciary. When we had testimony on this, we had a dental therapist who worked in a native 

village, in her own village. And she said that she was able to—because she had been from the village, when she would see kids in 

the village at the store or somewhere else, she’d say, ‘‘Brush your 

teeth every day.’’ 

So when you’re talking about this prevention piece, I think that 

it’s actually key that we have people who are more likely to go back 

to where they live. And I think that this is something I would really like to continue to pursue. 

Thank you, Mr. Chairman. 

Senator SANDERS. Thank you. 

Let me pick up where Senator Franken left off. What we’re really 

talking about is the workforce, in general, whether it’s dental 

therapists or dentists or hygienists. And let me throw this out to 

Dr. Hughes. 

What ideas do you have? Dr. Catalanotto made some suggestions, but is it your experience that we are not attracting the kind 

of practitioners that we need to take care of a population that has 

a whole lot of needs out there? 

Mr. HUGHES. Actually, in Maryland, we have seen an increase in 

providers participating in Medicaid. We currently have over 1,600 

providers. Our access issues deal more with adults not having coverage. And for those adults that do have Medicaid, the benefits are 

so limited that they cannot find a provider. 

Senator SANDERS. So what happens to them? 

Mr. HUGHES. They don’t get seen. 

Senator SANDERS. And when they’re in pain, what happens to 

them? 

Mr. HUGHES. They go to the emergency room, and then they are 

referred to the health department, and that’s my other issue. 

There’s not enough funding for public health infrastructure. Right 

now, I could easily have an adult program in the health department. But when there were budget cuts, one of the first things that 

was cut was the money for a dentist that was seeing the uninsured 

adult population. 

So we don’t have funding. We have the capacity, but we don’t 

have funding. We don’t have problems finding providers, but because we don’t have the funding, we can’t offer the services. 

42 

Senator SANDERS. Moving to what Ms. Stallings talked about. I 

think we have all seen pictures, whether it’s healthcare or dental 

care, of doctors who volunteer their time, pro bono, to treating folks 

who don’t have access. 

Actually, one of my staff members, Erica—I think it was last 

year you were in southern Virginia—and, Ms. Stallings, you mentioned something similar—where it really looked like a third-world 

country or maybe a fourth-world country, where there were people 

who had terrible health and dental problems and couldn’t find access to a doctor or dentist. 

It was hard to believe that this was the United States of America, where people were spending the entire night, waiting in line 

in order to get a tooth extracted or get a basic checkup to find out 

whether they had cancer or whatever it may be. It really did not 

look like America. 

Ms. Stallings, I gather you are familiar with that reality. Yes? 

Ms. STALLINGS. Oh, yes, definitely. 

Senator SANDERS. If you are a lower income American. You’re on 

Medicaid, but you don’t have access—Medicaid does not pay for a 

dentist. What happens to you? What do those people go through? 

Ms. STALLINGS. We have an office. One day, I had a client who 

was in severe pain. I took her to our main office. We got her an 

appointment. I believe it was in a couple of days. And we were told 

that they would pay up to $200. 

They have very limited funds, and, many times, the only option 

is clients waiting months on this waiting list to be able to be seen 

in the clinic where people are donating their time in their free off 

hours. But the wait list is incredibly long, and they have to wait 

for a long time often. 

Senator SANDERS. So many of your clients are going through 

their days in pain. 

Ms. STALLINGS. Well, it’s more—when they’re in severe pain, we 

definitely take action to get any treatment that we can possibly 

get. A lot of our clients do lose teeth, do have extractions, quite a 

few. If someone is really in pain, we try to do everything we can 

with the limited opportunities we have. 

Senator SANDERS. Let me go back to anybody here. 

Dr. Catalanotto, you raised this issue. 

We have a crisis. We don’t have the workforce to address the crisis. What role does the ADA, the American Dental Association, 

play in all this? And, by the way, we invited the ADA to be with 

us today, and they were going to be with us, but at the last minute 

they chose not to be here. Are they stepping up to the plate and 

addressing the issues that we’re talking about today? 

Mr. CATALANOTTO. In my opinion, in the last couple of years, 

there has been a shift in the national picture of the American Dental Association, in the leadership, and they are calling more and 

more attention to the access issue. But one of my arguments back 

to them would be, you need to lobby equally as hard for these access issues as you do for the business issues that concern you. I’m 

still not necessarily seeing that at this particular point. 

The State level is totally different. The State organizations are 

very independent of the national organization. So one example 

would be the American Dental Association has policies on better liVerDate Nov 24 2008 16:39 Jul 29, 2016 Jkt 000000 PO 00000 Frm 00046 Fmt 6633 Sfmt 6601 S:\DOCS\20708.TXT DENISE
43 

censing procedures. They support the policies that most dental education does. But at the State level, that’s not particularly happening. 

So easier reciprocity between the States is a national policy of 

the American Dental Association. It’s still impeded in some States, 

but it is getting better. I want to be positive about that. 

Senator SANDERS. Mr. Nycz, let me ask you a question. You guys 

are doing very well. I think we are doing well in Vermont as well 

in expanding access. If you had your druthers, have you done any 

computations as to what it would take in a State like Wisconsin— 

how many more facilities that you would need, how much more 

money you would require to provide, in a sense, universal dental 

care to the people in need? 

Mr. NYCZ. It is a big number. Our State asked us could our 

State’s health centers help them solve this problem, and how would 

we help them solve this problem. We said yes, if we stepped up and 

we had the resources, we could do that. 

When Governor Doyle came to one of our ribbon cuttings, he said 

that the approach we’re taking is building these group dental clinics. Many of my private sector dentist colleagues tell me that you’re 

never going to solve the problem by trying to get a dentist to establish a practice in this town of 1,000 and this town of 300 and so 

forth. You need to really somehow centralize that, usually to the 

county seat or a place where people can come. 

So that way, we can gain some efficiencies in a group practice 

kind of setting. It’s easier to recruit and easier to retain. Governor 

Doyle said to me when he shook my hand, 

‘‘I love this model. I’m wondering about how many of these 

we need. Could we have them within 50 miles apart so nobody 

goes more than 25 miles, or should it be 40 miles?’’ 

When we simulated this, it does cost a lot of money to do this. I mean, we were up in the $100 million range. He was a former 

attorney general, and he just said, ‘‘Well, these folks, particularly 

the folks on Medicaid, have a legal right to these services, and 

we’ve got to find a way to do that.’’ 

We’ve made great progress, as that map shows. In my written 

testimony, I show what, collectively, we’ve done in the State of Wisconsin, and Wisconsin has been a wonderful partner to this day. 

But the fundamental question you’re asking about cost—it is costly 

because we’ve neglected this, because we’ve had a population that 

does undervalue oral health and doesn’t fully understand the importance of oral health to general health. 

And we have the point that you made that around 42 percent, 

43 percent visit a dentist every year. It should be more. In the 

model that we’re trying to do—how do you capture savings? You 

can talk about people coming out of school with certain income targets and having to price things and all that. But the real savings 

on this is to raise the oral health profile of the American people. 

The prevention potential in dentistry is gigantic. All of this stuff 

can be prevented. So we’re engaged in this generational effort to 

try to make that difference. And places that could be helpful—we’re 

grateful in Wisconsin that we have adult dental in Medicaid. 

I’ve been saying, why don’t all States have adult dental? Why 

don’t we have adult dental in the exchanges? People say we can’t 

44 

afford it. But then I ask back and say, ‘‘Well, how do we afford 

adult dermatology?’’ We have to totally change our thinking and integrate these things. 

Senator SANDERS. You’re absolutely right, and that’s why we’re 

holding hearings like this, just to raise that consciousness. And you 

made the point, which is true, that if you expand access to dental 

care, it is an expensive proposition. But if you don’t expand access, 

it is an equally or perhaps more costly proposition. 

Who wants to say a word about people walking into an emergency room and how much that costs? 

Mr. CATALANOTTO. Senator, we did our own emergency room report in Florida. In 2010, 115,000 dental visits to the emergency 

room at a cost of $88 million. It prompted me to write an editorial. 

It was entitled, ‘‘Pay Me Now or Pay Me Later.’’ We’re paying for 

this. We are paying for this today, every day. Just the Medicaid cost alone from that $88 million was approxi- mately $30 million to $35 million. I did a rough calculation based 

on Florida Medicaid fees. I could have purchased 495,000 preventive visits, 495,000 preventive visits, rather than a wasted visit in 

a hospital emergency room where all they get is an antibiotic and 

pain medication, and they’re told to go see a dentist tomorrow. 

Well, they can’t find a dentist. 

Senator SANDERS. Which is why they’re there in the first place. 

Mr. Nycz. 

Mr. NYCZ. We’re opening a clinic in Black River Falls, WI, on HoChunk Nation land in a few weeks. The reason we’re there is because 1,000 folks were leaving that community to go to our dental 

clinics in other communities. We are grateful for Federal funds 

through the Community Health Center Program, which you have 

something to say about, that got us money to help build and equip 

that center. 

When we asked the public health department for a letter of support, they sent me a letter that said we have this 28-year-old—and 

this gets to the point that it’s not just the Medicaid program, and 

it’s one of the reasons why I think the health center model is so 

good. It’s the leave-no-one-behind model. 

A lot of this evolves into a talk about Medicaid. But as other panelists have pointed out, there are many people who don’t have Medicaid, or they have Medicaid with no dental coverage, or they have 

health insurance with no dental coverage. 

This 28-year-old who worked in the woods—no insurance, paycheck to paycheck, nothing in the bank—starts getting sicker and 

sicker and sicker. His sister starts to worry about him, and he’s 

just going downhill. She’s thinking he’s got a job in the woods, so 

he must have Lyme disease. 

They call the local clinic, and they say, ‘‘I’d like to make an appointment.’’ ‘‘Does he have insurance?’’ ‘‘No.’’ This is for physician 

care. They want a Lyme test. ‘‘Does he have any money for a down 

payment?’’ ‘‘No, he doesn’t.’’ ‘‘Well, we can’t give him an appointment.’’ 

He gets worse. She takes him to the public health department. 

They go, ‘‘Oh, my goodness. We’ve got to get you right to the hospital.’’ The hospital folks said he probably wouldn’t have survived 

another 12 hours—advanced jaw cancer, three abscesses, sepsis. 

45 

He’s alive today, thankfully. But how much money had to be spent 

in the system? 

And what haunts me is in that letter of support at the end, they 

said, ‘‘Both his sister and I agree that had you had one of these 

dental clinics here, this would not have happened.’’ 

Senator SANDERS. What we know—and it’s true of dental care 

and it’s true of healthcare as well—is if a Medicaid patient needs 

primary care, can’t find a primary healthcare provider and walks 

into an emergency room, it costs 10 times more than walking into 

a community health center. And I suspect the numbers are similar—but it’s not even similar, because, as Dr. Catalanotto pointed 

out, the emergency room in a hospital, in most cases, doesn’t really 

treat the dental problem as well, but just eases the pain and deals 

with the infection. 

Let me get back to one other issue—and, Dr. Hughes, jump in 

if you want to here. The cost of dental school is kind of off the 

charts. I remember last year in Rutland, VT, talking to two young 

dentists. One of them had graduated from Tufts, I think—well over 

$200,000 in debt. What are we going to do about that? 

Ms. HUGHES. How do we reduce dental school tuition? 

Senator SANDERS. If I graduated with $200,000 in debt, I probably would not be running to a community health center to make 

whatever I would make there. I’d probably figure out how I’m going 

to make as much money as I possibly can. Is that a fair statement? 

Ms. HUGHES. It is. However, if you work at the community 

health center, you’re likely eligible for loan repayment. That’s what 

we need to—I think it’s important to establish more of these types 

of programs. In Prince George’s County, we have a population of 

over 800,000 people. We only have one Federally Qualified Health 

Center and one Safety Net Clinic. 

Senator SANDERS. That’s all you have? 

Ms. HUGHES. That’s all we have. And there is only one dental 

shortage designation area in the county. So it is a daunting task 

to try to establish an area as a dental health shortage area, because it requires that you have surveys of all the dentists in the 

area and how they practice. That’s hard information to get. They 

get a survey, and they toss it to the side. So we have to improve 

that process. 

But I don’t know how to answer that question, how we reduce 

dental school cost. It’s costly to go to school. I mean, in dental 

school, we’re doing procedures. There’s the cost for the equipment. 

We’re not just sitting in lecture halls. We’re actually doing procedures. So that’s why the cost is elevated. 

Senator SANDERS. I want to get back to Dr. Catalanotto for a second. You raised an issue that we are familiar with, and that is the 

Sarrell situation in what, Alabama? 

Mr. CATALANOTTO. Yes, in Alabama, sir. 

Senator SANDERS. You see that as a potential model to provide 

cost-effective, quality dental care. Yes? 

Mr. CATALANOTTO. Yes, I do. 

Senator SANDERS. Say a few words about that. 

Mr. CATALANOTTO. They’ve grown from 1 to 15 clinics in about 

9 years with no grants, only on Medicaid fees. They do it because, 

first of all, the culture of caring. I can talk about that, but that’s 

46 

not the business issue. The business issue is they run it with a 

ruthless business model. The CEO was a Fortune 500 company 

president at the age of 31. He did this as a volunteer activity in 

his community, but now it has turned into a major not-for-profit 

business. 

Senator SANDERS. You’re convinced the quality is good? 

Mr. CATALANOTTO. I have been there three times. I have free 

rein to get up from my meeting and walk down the hall and walk 

into a clinic. Every time I walk in, the parent is in the room. Just 

before each visit, they take height, weight, blood pressure, and 

temperature and report it back to the parent. 

I walk into the room and I see toothbrush—I don’t see procedures being generated. I see prevention being emphasized. That’s 

the only way they could have reduced care from over $300 to $125 

annually. 

But what do they do? They use their facilities 50 hours, 60 hours 

a week. They have mass purchasing power from 15 clinics, so 

they’re able to get the most cost-effective pricing. They have a call 

center. 

Senator SANDERS. And how do they pay their dentists, reasonably well? 

Mr. CATALANOTTO. They pay their dentists very well, but not on 

production. The dentists are paid a straight salary, whether they 

do 15 amalgams or restorations in a day or whether they do five. 

They use this interesting model. The call center staff may get a 

bonus for keeping the chairs filled, because they call their patients. 

They treat their patients with dignity. There’s a common claim— 

oh, those Medicaid patients don’t keep their appointments. Sarrell 

Dental Center has a chair utilization rate of 99 percent, because 

they treat their patients with dignity. They treat them with respect. They make them feel—— 

Senator SANDERS. You’re telling me that they are making 

money? 

Mr. CATALANOTTO. They are making money. Now, they’re a notfor-profit, so they plow the money back into a new clinic. They just 

recently got themselves equipped to do some tele-dentistry. They do 

community service. They have great community outreach. Each 

clinic has a community person who goes out into the community, 

promoting care, promoting getting patients to go to the clinic and 

get their dental care. It’s a wonderful model. 

Senator SANDERS. And their staff feels good about working there? 

Mr. CATALANOTTO. The staff feels good. So many of their dental 

assistants, for example, are college-educated young men and 

women because of the economic situation. They care. Sarrell has 

now started—there’s just one or two—if you want to go to dental 

school, if you want to go to dental hygiene school, we will pay your 

way if you offer to come back and work here. 

Senator SANDERS. So they’re doing their own National Health 

Service Corps. 

Mr. CATALANOTTO. They have their own National Health Service 

Corps. And I can tell you I’m on their board, unpaid, on their board 

of directors. They want to expand out of State. They are restricted 

from doing this because the CEO is an MBA. 

47 

Senator SANDERS. Mr. Nycz, is there anything in that model we 

can learn from? 

Mr. NYCZ. I think health centers probably could learn from this 

model as well. But the task we’re faced with, though, is not just 

taking care of Medicaid on dental. We have to contend with adults. 

We have to contend with people with psychiatric problems. We 

have to contend with people with disabilities. So we have to be a 

little bit more well-rounded. 

For example, we could make our site more efficient if we didn’t 

include large treatment rooms and wheelchair lifts. We could make 

our site more efficient perhaps if we didn’t include space for training. So I think that we can learn from them, but their model is still 

fairly focused on a distinct population, and we have responsibility 

for everyone. 

Senator SANDERS. Is Sarrell mostly focused on kids? 

Mr. CATALANOTTO. It is only focused on kids because there are 

no adult benefits in the State of Alabama. So they only do children. 

He is absolutely right. It is a little different model. Now, they do 

some developmentally disabled. They have recently hired an oral 

surgeon. They have several pediatric dentists who can take children to the hospital. 

Senator SANDERS. But only treating kids. 

Mr. CATALANOTTO. But they only treat children through age 20. 

Senator SANDERS. Let me just say to Mr. Nycz and to everybody 

here that we’re going to do our best to focus more and more attention on this issue—why this hearing is so important. We’re going 

to do our best to fight for more money for the community health 

centers. 

We’re going to take a look at the issue of dental therapists. We 

are going to take a look at models which seem to be high quality 

and cost-effective. We want to deal with that. I think your point 

about philanthropy is great, that it is not a solution to a major, 

major crisis in this country. 

Dr. Hughes is here today, and she oversees the Deamonte Driver 

Dental Project. Maybe we’ll conclude—Dr. Hughes, tell us—because 

some people may have forgotten—who Deamonte Driver is and why 

the project is named after him. 

Ms. HUGHES. Deamonte Driver was the 12-year-old that died in 

Prince George’s County from an abscess. His parent was unable to 

access dental care. His Medicaid had lapsed, and she could not find 

a dentist to treat the child. He was taken to an emergency room 

and given treatment for sinusitis and other things and released, 

and then was rushed back to the hospital and had to have immediate surgery when they found that the bacteria had spread to his 

brain. 

Deamonte Driver died February 27, 2007. As a result, the Governor of Maryland said, ‘‘This cannot happen again.’’ The Dental 

Action Committee was formed, and seven recommendations were 

made. Also, from their actions, the Deamonte Driver Project was 

initiated. It is a mobile dental unit that goes to Title I schools 

throughout the county. We treat all children, insured and uninsured. 

One thing that we really don’t talk about is the children that are 

uninsurable. We have a large population, in the county and in the 

48 

State, of children that are uninsurable, and we see those children 

as well. 

By definition, a mobile unit in Maryland cannot be a dental 

home, and that is not our purpose. We work with families through 

case management to ensure that all children are in a dental home. 

We are there to treat emergent needs so that we don’t have another Deamonte Driver. 

As I talked about earlier, in our process, we are trying to establish statewide school screenings. Children are required when they 

go to school to have immunizations. Why are they not required to 

be seen by a dentist? 

So in our demonstration project, we saw that there were a number—it was vital that we were there. There are a number of children who, had we not seen them, could possibly be Deamonte Drivers. So we honor the legacy of Deamonte Driver by being in the 

schools. We also provide treatment at the school he attended. The 

program has been very successful, and it is welcomed by all the 

schools that we attend. 

Senator SANDERS. Dr. Hughes, thank you for the work that you 

do on that. I think to remember Deamonte Driver, our job is to 

dedicate ourselves to make very, very significant improvements to 

our dental care system so we never see another Deamonte Driver 

situation again in this country. 

I want to thank you all, not only for being here today, but each 

in your own individual way for playing such an important role in 

addressing this issue. Thank you very much. 

With that, let’s adjourn the hearing. 

[Whereupon, at 11:20 a.m., the hearing was adjourned.] 

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