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Vital Signs

Physicians sink their teeth into dental care

Under the watchful eye of Melanie Lawrence, center, fifth-grader Meghan Boardman, dressed up in doctor gear, checks out a kindergartener's teeth.

By Jennifer Durgin

Dr. Melanie Lawrence, a family physician in Bradford, Vt., is tired of seeing toddlers with teeth so decayed they need to be pulled. A few states over, in Maine, Dr. William Alto is "increasingly frustrated" that his patients often lack dental care because they can't afford it or can't get a dentist to see them.

Scope: Both Lawrence, an adjunct assistant professor at DMS, and Alto, a professor in the Maine-Dartmouth Family Medicine Residency, have taken action. The initiatives they're helping to spearhead are not related. In fact, until recently, they were unaware of each other's efforts. But both are aiming to improve the dental health of their patients, many of whom depend on Medicare or Medicaid or lack health insurance entirely. It's a new wrinkle for physicians, who used to consider patients' teeth to be beyond their scope.

Lawrence and her colleagues at Little Rivers Health Care are attacking the issue three ways:

  • They revamped their well-child checkups to include a basic dental screening, thanks in part to the work of second-year DMS student Thomas Hoke.
  • They're working with three other health centers in northern Vermont and Ronald McDonald House Charities to staff a mobile dental unit that will travel around the region and serve children and young adults up to age 21. The van is scheduled to go into service this fall.
  • They're going to conduct an unusual pilot study in three elementary schools, where fourth-graders coach kindergarteners in oral health. It's funded by the Dartmouth Center for Clinical and Translational Science.

In the study, four fourth-grade classes will learn how to take care of their teeth by avoiding sugary foods and brushing and flossing correctly. Then two of the classes will prepare and give a presentation to kin-dergar-teners. (The other two classes will be controls, to test the effect of having the older kids work with younger ones.) They'll use fake teeth to teach the kindergarteners how to floss and brush and show a PowerPoint presentation about oral health.

Mouths: In addition, the older kids will help the kindergarteners measure the plaque in their mouths by using disclosure tab-lets, chewable tablets that temporarily dye plaque red. And perhaps the best part for the fourth-graders will be dressing up in gloves and surgical masks.

"Any time you dress kids up in health-care paraphernalia, they get all excited and they think about what they are going to be when they grow up," says Lawrence, a former day-care director. "We're trying to hit a lot of things . . . role modeling a career [in health care] . . . a sense of social responsibility and teaching between students . . . and helping kids learn to take better care of their mouth." Lawrence and her colleagues will also be training the elementary schools' nurses, teaching them how to screen for dental problems.

While Lawrence is tackling dental health by teaching youngsters, Alto and his colleagues in the Maine-Dartmouth Residency program are targeting doctors-in-training. The program, which is based in Fairfield and Augusta, Maine, may be the only one in the country that teaches physicians how to extract teeth and perform basic dental procedures, such as fluoride varnishes.

Alto's patients often lack dental care because they can't afford it.

Maine-Dartmouth residents can also get an additional month of dental training at the Togus VA Medical Center in Augusta. That's thanks in part to a collaboration with dentist James Schmidt, now the president of the Maine Dental Association, who helped Alto build dental training into the residency.

Cavities: One goal of giving young doctors some dental training, Alto explains, is simply to get them interested in looking in the mouth for oral cancers and lesions, as well as cavities and other problems with the teeth. Research has shown that poor oral health may be linked to broader health issues, such as cardiovascular problems and premature labor, and may also be associated with diabetes, osteoporosis, eating disorders, and several other illnesses.

In March 2009, the New York Times profiled the Maine-Dartmouth dental initiative, noting that "Maine has one dentist for every 2,300 people. . . . Nationally there is one dentist for every 1,600 people."

Dentists are also in short supply in northern New Hampshire and northern Vermont. Most of the dentists in her area, says Lawrence, already have full practices. And since Medicare and Medicaid reimbursements for dental care are "not high," finding a dentist who will see a patient covered by those programs can be tough.

Bite: "Part of what makes this so urgent for me," says Lawrence, "is that every year at least two children in my practice under the age of five have two or more teeth extracted under general anesthesia." She's hoping the various efforts of her practice-and other initiatives like the one in Maine-will take a bite out of those numbers.

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