Social Drivers of Oral Health: Economic Stability

By Damien Cuffie, DDS, MPH

While dental visits help to maintain oral health, social drivers (also called social determinants) influence being able to get care in the first place. There are five domains of social determinants of health, according to the US Department of Health and Human Services. Here at DentaQuest, we call the domains’ intersection with dental care the social drivers of oral health. 

Economic stability – or lack of it – is one such domain. The lower a person’s income, the higher their likelihood of experiencing negative oral health symptoms in the previous 12 months, according to survey results from the CareQuest Institute of Oral Health. 

Abundant research and numerous organizations show similar findings. For example, in “Health Equity Needs Teeth,” the American Medical Association Journal of Ethics states that members of poor and marginalized groups bear an inequitable oral disease burden in the US, with individuals living below 200% of the federal poverty level having more untreated cavities and fewer permanent teeth than those living above that threshold. 

Similarly, the Annual Review of Public Health’s “Disparities in Access to Oral Health Care” study found a higher likelihood of poor oral health among US residents who are low-income, uninsured, and/or members of underserved populations with “suboptimal” access to quality oral health care. Poverty appears as the main factor to influence disparity in caries in permanent teeth among adolescents, the study found, and race/ethnicity plus poverty contribute to continued oral health disparities among US youth and young children. Among adults, Medicaid oral care coverage varies widely across states, with many states limiting oral care only to emergency services or to specific populations (e.g., pregnant women). 

“While progress has been achieved in narrowing the oral health care gap for disadvantaged children over the past decade, the gap for every other age group has either stayed the same or widened,” the Annual Review of Public Health article says. Since Medicare dental coverage is narrow and many state Medicaid programs do not cover adult oral health care, adults pay an increasing portion of their dental expenditures out of pocket as they age; it’s unmanageable for Medicaid beneficiaries and seniors with limited incomes to pay out-of-pocket for dental care. Even when state Medicaid covers dental care, enrollees have difficulty finding providers because only 20% of dentists nationwide participate in the program. As a result, poor oral health is a greater likelihood for those who are low-income, uninsured, and/or those who belong to underserved communities. 

More perspective on how low income is a social driver of oral health comes from the US Centers for Disease Control and Prevention (CDC). Its Disparities in Oral Health report shows that dental care is more often unaffordable than other types of health care. According to CDC statistics: 

• About 40 percent of adults with low income or no private health insurance have untreated cavities.
• Low-income or uninsured adults are twice as likely to have one to three untreated cavities and three times as likely to have four or more untreated cavities, compared to adults with higher incomes or private insurance.
• 17% percent of older adults with low income have lost all their teeth.
• Children/youth between 6 and 19 years old from low-income homes are about 15% less likely to get sealants and twice as likely to have untreated cavities compared to peers from higher-income households.
   

Solving for Low Income as Social Driver of Oral Health 

Reducing oral health disparities requires multiple changes to the US health care system, including expanding dental insurance coverage and dental care access, says the Journal of Public Health Dentistry. The Journal of the American Medical Association (JAMA) similarly advocates for expanding dental coverage for adults on Medicaid in its editorial, Addressing Oral Health of Low-Income Populations—A Call to Action. 

Medicaid dental coverage for adults is associated with greater probability of yearly dental visits, JAMA says, plus positive outcomes such as increased tooth-saving, fewer extractions, and a reduction of unmet oral health needs. Furthermore, expanded Medicaid coverage for adults can promote greater prevention and help to avoid reliance on the unsustainable practice of Emergency Department visits for oral care. 

Changes only in practice and focus do not address deep-seated inequity, says the AMA Journal of Ethics. Rather, lasting change could come from reimagining health care delivery streams, integrating medical and dental services, and implementing a reimbursement system that emphasizes value and patient-centered outcomes. DentaQuest champions value-based care for its emphasis on prevention, holistic and personalized care, and proactive outreach strategies. 

Building community partnerships helps create sustainable improvements that help overcome inequalities in social drivers of oral health. Working with partners who are rooted in the community increases motivation, engagement, and accountability in affecting not only individual health, but also community-wide quality of life, according to a Center for Health Care Strategies learning collaborative supported by DentaQuest. 

Deeply committed to community partnerships, value-based care, and other approaches to address social drivers of oral health, DentaQuest, part of Sun Life U.S., focuses on improving the oral health of all.