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Health board supports federal shortage designation

Low-income Missoula residents' lack of access to dental care is so severe that it constitutes a public health problem, the Missoula City-County Health Board decided unanimously Thursday.

The board reached its conclusion after hearing nearly two hours of testimony, mostly from agencies that provide medicine, job search, education, addiction services and other social services to poor people, but also from dentists.

Board chairman Missoula attorney Bill Rossbach said that although many Missoula dentists have seen Medicaid patients during the past year, the effort is not nearly enough to meet the need. For most of the uninsured low-income, the only choice is Partnership Health Center's all-volunteer dental clinic, where the waiting list is more than 1,050 people long.

"That leaves us with a huge access problem," said Rossbach.

He noted that representatives of about 30 agencies told the board in a public hearing that access to dental care is a top problem among their clients. In Missoula, the speakers said, lack of dental care is a factor in welfare recipients failing to find work, alcoholics and drug addicts failing in their recovery efforts, children doing poorly in school, people living with severe pain and even in at least one suicide.

"We're talking about thousands of people here who are facing these issues," Rossbach said. "Not just the 1,000 on the waiting list at Partnership Health Center."

The health board voted unanimously to write a letter to the federal Division of Shortage Designation, part of the Department of Health and Human Services, which is considering an application for a dental Health Professional Shortage Area designation for Missoula. The HPSA status gives an area a competitive edge for grants and also can bring recently graduated dentists to an area to help meet the federally established need; the new dentists receive financial aid during school in exchange for a given term of service.

The board's letter will also say:

  • The unmet need persists despite widespread local efforts.
  • The HPSA designation will further establish the need for success in competitions for funding.
  • The state should expand Medicaid eligibility, reimbursement and scope of care.
  • More emphasis should be placed on prevention, especially among children in low-income households.

The hearing was sparked by an unusual number of letters written by dentists protesting the HPSA application. Division of Shortage Designation director Jerilyn Thornburg requested additional information from the state's Primary Care Office and from Partnership, which is Missoula's community health center.

Some dentists wrote that Missoula does not have a shortage of dentists or a shortage of dental care for uninsured and Medicaid-insured patients. The Montana Dental Association's position is that the state does have an access problem for poor people, but an HPSA designation would not help the problem. Instead, it would distract attention from the real problem, which is that dentists are reimbursed for services to Medicaid clients by the state at rates that are below their costs.

Missoula dentist Kevin Miltko said at Thursday's hearing that the rates are a central problem.

"If you raise the reimbursement rates," he said, "I guarantee you will increase access."

Other solutions should be considered as well, Miltko said. For instance, fluoridation of the municipal water supply can decrease the need for dental care 40 percent to 60 percent by protecting children's teeth, he said. Seventy percent of U.S. communities have fluoridated water supplies.

Also, he said, dental disease is closely connected with nutrition. Yet programs distribute items that can lead to tooth decay, such as juice, and schools promote soft drinks with in-school pop machines. School groups sell candy to raise money.

"If we are ever going to solve this problem," Miltko said, "we are going to have to change the way we think about nutrition."

Missoula dentist Jill Thompson echoed Miltko's remarks and called for prevention efforts.

"Prevention, in terms of oral health, is so easy," she said. "We are remiss if we do not look at that. It is just so easy and so inexpensive."

Speaker after speaker told of calling every dentist in the telephone directory trying to find one to take a client with acute dental pain who has no insurance or Medicaid. Jennifer Carter, director of the Office of Public Assistance for Missoula and Mineral counties, said she has more than 1,350 people looking for work to become self-sufficient and leave the state's welfare program. Many have chronic dental decay that causes pain and blackens their teeth and causes them to fall out.

"To match an employer with a prospective employee," she said, "I can tell you that dental health is a must."

Warren Guffin, a physician in the St. Patrick Hospital emergency department for 23 years and medical chief of emergency services, said his department sees about 15 to 20 people a week - two to three a day - with dental pain. The physicians give antibiotics and limited pain medication and refer to a small list of dentists willing to see people who can't pay.

"The problem is it's a very small subset of dentists in the community who are willing to see people who might have a payment problem," he said.

"Bottom line from an emergency physician in this community, it's a big problem in this county."

The board will continue discussion of the issues at next month's meeting.

"We have to ask ourselves if we are going to be pathfinders in finding a way to solve this," said Carter of the Office of Public Assistance. "Can we find a way to break out of the box?"

Reporter Ginny Merriam can be reached at 523-5251 or at

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