|STUDENT FORUM COMMENTARY
|Year : 2016 | Volume
| Issue : 2 | Page : 70-72
Overcoming barriers to orthodontic treatment in the United States
School of Dental Medicine, University of Connecticut, Farmington, Connecticut, USA
|Date of Web Publication||9-Jun-2016|
10 Talcott Forest Rd APT L, Farmington, Connecticut 06032
Source of Support: None, Conflict of Interest: None
Underserved patients are at the highest risk for oral and overall health complications due to the many obstacles that prevent the group from receiving the most basic forms of health care. Receiving orthodontic care is even scarcer since most dental insurances regard it as an elective treatment, and only a limited number of orthodontists will treat these patients. The situation only worsens, as it appears that orthodontists in training intend to see even less of these patients in the future. Considerable changes need to be made. One change that needs to occur is within the dental training and education orthodontists receive. There needs to be a transition that encourages and promotes the development of skills necessary for treating underserved patients. Another change needs to occur in the restrictions that prevent specialists from participating in programs designed to provide relief in underserved areas. The events that would follow this change demonstrate the necessity for revisions in prohibitive policies against specialists. Finally, an initiative is needed to decrease costs associated with orthodontic treatment to make treatment more accessible, especially for patients with U.S. federally funded healthcare - Medicaid. Encouraging limited orthodontic treatment in mixed dentition (Phase I treatment) could aid in resolving this issue. The worsening situation among the underserved is connected to an unsustainable status quo. These issues need to be addressed and resolved to prevent any further onset and begin recovery.
Keywords: Dental education, interceptive treatment, Medicaid, student debt, underserved
|How to cite this article:|
Gutierrez T. Overcoming barriers to orthodontic treatment in the United States. Dent Hypotheses 2016;7:70-2
| Introduction|| |
Approximately, one-third of U.S. citizens, or about 108 million people, lack access to basic preventative services in oral health care.  A significant number has medical disabilities and chronic illnesses, reside in geographically isolated areas, possess limited literacy, remain confined to long-term care facilities, and/or earn income below 200% of the poverty level.  While both adults and children in these populations encounter numerous barriers in meeting their most basic dental care needs, the social health-care programs Medicaid and Medicare in the United States (U.S.) provide funding for some dental services including those it defines "medically necessary." Medicaid and Medicare coverage sometimes includes oral surgery but rarely endodontics, orthodontics, prosthodontics, and periodontics. ,
Of all the specialty care needed in underserved populations, orthodontics is often one of the most underrepresented in these populations.  Unfortunately, despite the demand for orthodontic care, the number of practitioners in the U.S. choosing to provide for the underserved remains low.  In 2015, there were approximately 5410 orthodontists employed in the U.S.  Few, however, choose to practice in underserved populations. While there could be many reasons for their choice, including financial, it may be an attitude of orthodontists about treating underserved populations.
| Attitudes of Orthodontic Residents for Treating Underserved Populations|| |
To find out if attitudes play a role, in 2009, Brown and Inglehart asked residents and orthodontists to answer a series of questions about how well they felt their graduate education prepared them for treating underserved patients. Most residents and orthodontists agreed that their classroom education prepared them well enough to treat different ethnic and racial backgrounds. These numbers decreased dramatically when they were asked how well they felt their graduate education prepared them for treating patients on Medicaid, pro bono cases, patients with special needs, patients with anomalies, and patients with developmental delays. These decreases in the perceptions of quality of education received correlated significantly with behavior toward treating underserved patients.  This survey suggests that a direct relationship exists between the education received and actual/projected professional behavior toward treating underserved patients. If the residents or orthodontists felt that they had not received a comprehensive education that prepared them for practice with underserved patients, then they were likely to have negative attitudes and intentions about treating these patients.
In 2011, Brown and Inglehart extended their study that compared attitudes and behavior of orthodontists and orthodontic residents concerning the treatment of underserved patients. One hundred and thirty-five residents and 568 orthodontists were asked to rate their attitudes toward treating underserved patients. Residents had a more positive attitude toward treating poor patients, pro bono cases, patients with craniofacial anomalies, or patients with mental retardation than practicing orthodontists. However, residents expressed less intent than practicing orthodontists to treat those same cases in the future. 
These results suggest that after graduation residents will be reluctant to provide orthodontic care to underserved patients. Residents expressed more positivity toward treating underserved patients, but they had less of intent to act on those attitudes in their future practice. Progression of this trend is indicative of a future with even fewer orthodontists practicing in underserved areas.
| Financial Considerations|| |
An additional factor preventing orthodontists from providing for the underserved is that in the U.S., recent graduates are likely to begin their careers with staggering debt incurred by the college, dental school, and residency. In 2016, a study found that 71% of respondents had over $200,000 in dental school debt, and 44% had orthodontic residency debt over $200,000.  These numbers suggest an orthodontist graduate would start out a career with over $400,000 in debt. The necessity to earn an income high enough to manage this debt could be an additional factor discouraging residents from practicing in underserved areas.
One reason the issue of funding for orthodontists in underserved areas primarily exists is because in the U.S. Government funded programs aimed to provide dental care to the underserved do not include specialists. The two main U.S. federal government programs created in response to the shortage of health-care professionals in underserved areas are the National Health Service Corps (NHSC) and the Health Professional Shortage Areas (HPSA). Both the NHSC and HPSA address the shortage of health professionals by offering to relieve a portion of their student loan debt in return for time commitments working in underserved areas. These U.S. federal programs exclude specialist including orthodontists from participation. ,
It would be helpful to change this exclusion policy. Orthodontists would benefit from these debt relief programs, and underserved patients would directly benefit from the rise in oral and overall health care through treatment. The government and states involved would indirectly benefit because the rise in overall health in this population would save the government from many high-cost expenses that normally occur from treating long-term diseases attributed to poor overall health. The U.S. tax paying citizens, who are the foundation for the funding of these programs, would benefit because the leftover money saved by the government and state could be implemented in maintaining and improving the infrastructures in communities.
| Medicaid Funded Phase I Orthodontic Treatment|| |
One problem Medicaid faces when financing orthodontic services is the high costs associated with treatment. In the U.S., traditional orthodontics can range from $3000 to $7350 per case.  Recently, an alternative treatment has been introduced. Phase I, or early interceptive treatment, is limited orthodontic treatment in mixed dentition usually after permanent first molars and incisors have erupted but before the remaining deciduous teeth are lost. , Goals of treatment in mixed dentition generally focus on skeletal rather than dental correction. 
In 2004, Theis et al. conducted a retrospective study examining the casts of one hundred and ninety-three patients that received Phase I treatment. The eligibility for receiving Medicaid-funded orthodontic treatment was compared before and after patients had undergone Phase I treatment. This comparison explored whether or not Phase I treatment could provide results significant enough to avoid the need of comprehensive treatment. Results revealed a decrease of 62% in the eligibility for Medicaid-funded orthodontic treatment after Phase I treatment, and up to 90% of cases presented with less need after Phase I treatment. 
The results from this study suggest that Phase I treatment could provide a cost-effective method to aid in meeting the needs of underserved patients. The U.S. Government should aim to increase the volume of Medicaid patients that receive early interceptive treatment. This change would decrease government expenses associated with costly orthodontic treatments and allocate more funds to having more patients.
| Conclusion/Recommendation|| |
Underserved patients are at the highest risk for oral and overall health complications due to the many obstacles that prevent the group from receiving the most basic forms of health care. Receiving orthodontic care is even scarcer since most dental insurances regard it as an elective treatment, and only a limited number of orthodontists will treat these patients. The situation only worsens, as it appears that orthodontists in training intend to see even less of these patients in the future. Considerable changes need to be made. One change that needs to occur is within the dental training and education orthodontists receive. There needs to be a transition that encourages and promotes the development of skills necessary for treating underserved patients. Another change needs to occur in the restrictions that prevent specialists from participating in programs designed to provide relief in underserved areas. The events that would follow this change demonstrates the necessity for revisions in prohibitive policies against specialists. Finally, an initiative is needed to decrease costs associated with orthodontic treatment to make treatment more accessible, especially for patients with U.S. federally funded healthcare - Medicaid. Encouraging limited orthodontic treatment in mixed dentition (Phase I treatment) could aid in resolving this issue. The worsening situation among the underserved is connected to an unsustainable status quo. These issues need to be addressed and resolved to prevent any further onset and begin recovery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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