Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

Reinstating MassHealth Dental Coverage is Just the Start of a Successful Intervention-

A Critique Emphasizing the Need For Social Change in Order to Improve Oral Health Outcomes-Kate Porta

Government-provided health services faced a budget reduction of $5.8 million in fiscal year 1996 (1). Part of the way the Massachusetts government chose to handle this budget reduction was to eliminate dental services covered through MassHealth. As a result, lack of dental coverage exacerbated the existing issues that already made it difficult for the population MassHealth serves to keep a healthy mouth.
Legislation was passed in January 2006 to reinstate these benefits in hopes to decrease health disparities and to improve the overall oral health of
Massachusetts. MassHealth (Medicaid) uses state and federal rules to determine who is eligible for benefits. People who are entitled to MassHealth need not only to be poor, but need to be pregnant, have at least one child under age 19, have been out of work for a long time, be disabled, or be HIV-positive. (Document of full benefits can be found at under ‘Dental Benefits Booklet’) (2,3). Although insurance coverage is a large contributing factor to receiving care, there are additional issues that will keep the low-income and disadvantaged population of Massachusetts from maintaining good oral health.
In 2000, the Surgeon General identified oral health as integral to general health (4). According to the CDC’s Behavioral Risk Surveillance System (BRFSS), rates of “visits to a dentist or dental clinic within the past year” have been steady for the past eight years (the earliest data available was from 1999) (5). This indicates that people are not visiting an oral health professional more often even though there has been an increase in scientific literature about the importance of oral health. With the reinstatement of dental benefits under MassHealth, the government expects to see a rise in this trend. However, despite this expansion of benefits, rates of dental decay, periodontal disease, tooth loss, and oral cancer may not improve because there are many social and behavioral aspects that keep people from visiting the dentist. Recent statistics show only 30% of people enrolled in Medicaid receives dental care (6). The population that MassHealth serves faces multiple barriers in achieving and sustaining oral health.

Access to health care is an important factor in determining health. Health disparities are exacerbated by social economic status (SES), which is a strong indicator of lifestyle and geographic location. These two factors largely determine the availability and ability a person has to access the care they need and deserve. Even if the cost of the care itself is covered by insurance, issues of transportation, time commitments, and the monetary obligations associated with each offset the value of having dental insurance.
A needs assessment survey was conducted at the Buffalo School of Dental Medicine in 2002. Finances, medical bills, transportation, housing, mental health, legal concerns, and family issues were reported as barriers to care. Only thirty-two percent of the patients had a top priority of “health” (7). The U.S. Surgeon General’s report identified impoverished individuals as being the most vulnerable to the difficulty of accessing dental care and as having the poorest oral health in the nation (8). These statements are supported by the recent death (February, 2007) of a young boy from a poor family due to tooth decay complications (9).
MassHealth eligibility is defined by income. Recipients are categorized as “poor” and do not have enough money to cover necessary life expenses. Direct transportation is expensive, especially in the city. A substantial taxi fee is required to traverse a short distance and the luxury of owning a car is offset by the high prices of parking garages, car insurance, and parking tickets. The Department of Health and Human Services attempted to address this issue, but was unsuccessful in its efforts. Information to assist with transportation and out of pocket costs associated with dental visits is available on the Mass.Gov website. However, much of the population that MassHealth serves does not have regular access to the internet; they are poor and many live in shelters. Additionally, the information is hard to find.

Disparities are prominently reflected in the geographical distribution of dentists (4), especially dentists that accept MassHealth payments. Nearly seventy five percent of dentists do not treat Medicaid-insured patients (4). There are about fifty five providers within the city of Boston that do provide dental care to MassHealth patients. Most of these providers are residents or students at one of the four dental schools of Boston: Boston University, Tufts, Harvard, and Forsyth. Although these sites do offer comprehensive dental care, patients are instructed to designate three hours of their time for an appointment (10). This is partly due to the fact that it is students providing the care, but mainly due to the fact that these providers attempt to fit everything that needs to be done into one appointment, with the expectation that the patient will not return for a second appointment or follow-up care. If an individual is a shift worker or a single parent, devoting at least three hours of the day to a dental visit is not an option.

These issues of access are realistic barriers to receiving care. MassHealth recipients do not posses the same income or have access to the same means as the majority of the population. It is unreasonable to expect positive oral health outcomes when additional resources are not provided along with dental coverage.


Self-efficacy plays a necessary role in explaining the disproportionate oral health status among MassHealth recipients compared to the general population. Self-efficacy is defined as “a person’s belief in his or her ability to take action” (11). Without the ability to carry out a behavior, one will not be able to perform that specific behavior. In order to execute an action, the actor needs to believe the task is accomplishable, and have a sense of self-efficacy.

Independent of insurance coverage, a person will not seek dental care if they believe the barriers are insurmountable. The issue of access presents an intrinsic difficulty, but when someone is cognoscente of the barriers they will have to face after they make a dental appointment, the only option for many people may be to not make the appointment at all. If an individual is disadvantaged, he or she cannot afford to get to the dentist, cannot take time off from work, and cannot bring children with them to a three hour appointment. If these are the issues people are facing, attempting to go to the dentist is futile. It will not happen, so it is not worth trying. Someone with this reasoning lacks self-efficacy.

Communication between the dentist and the patient is extremely important. An individual who can speak freely to and understand their oral health professional will be more likely to go to the dentist and to follow the dentist’s recommendations (12). Without the ability to communicate, a patient will not feel comfortable going to the dentist. Additionally, much of the oral health workforce is not prepared to offer culturally competent care to a variety of ethnicities, races, and lifestyles (4). Without the comfort of cultural competency and control of communication, an individual’s self-efficacy will decrease.

Although many behavior models are not sufficiently designed to predict behavior outcomes, they do provide a basic “map” of behavior characteristics. The Social Cognitive Theory is a behavior model that predicts behavior change according to the interactions that occur between individuals and their environment (11). All actions are results of the combination of individual interpretations and external factors. Therefore, when adverse environmental and social surroundings predispose an individual to lack self-efficacy, behavior change is inhibited.

Possessing self-efficacy is an important part of initializing and following through with behaviors. An individual cannot be expected to have control over their behavior when they are aware of the barriers that lack of time, transportation, cost, and communication create. Issuing dental coverage alone does not empower the recipients to go to the dentist.

Patient Knowledge and Perceptions

According to the health belief model, intention leads to behavior change. There needs to be some aspect of perceived susceptibility and perceived severity of the consequences in order for this transition to occur (11). People, even if they have coverage, will not go see a dentist if they do not know they need to or are not aware of the detriment that often arises from not seeing an oral health professional regularly.

Often, the general public does not appreciate the importance of oral health and perceives it as independent from and secondary to general health (4). Yet, oral health is an indicator and predictor of total health and quality of life (8). 75% of 3000 adults interviewed during a survey reported an enhancing of or reduction of quality of life due to oral health status (13). Additionally, oral health is associated with certain health conditions. Pregnant women who have gum disease are seven times as likely to deliver their babies earlier than women who have healthy gums (14). The prevalence of gingivitis and periodontal disease in diabetics is double that of people not suffering from diabetes (15). HIV-positive men, women, and children are more prone to dental caries as well as opportunistic infections in the mouth compared to people who are HIV-negative (16). Most people are unaware of these connections between oral health and overall health and do not understand the severity of the consequences that can occur when teeth are not brushed or flossed and an oral health professional is not visited regularly.

A recent survey of low-income women administered in a day shelter in downtown Boston found that 65% of the participants were unaware that tooth decay is an infectious disease and 60% were unaware that illnesses such as diabetes and HIV put you at higher risk of developing periodontal disease (17). Without the knowledge of these connections, people will not feel susceptible to the adverse outcomes that transpire from poor oral health and not attending to the health and hygiene needs of one’s mouth. In a cross-sectional study of 1200 older adults, 57% had a clinical need for a dental checkup as determined by a dentist, with 49% in need of immediate care. However, only 38% reported having a need for dental care. Social economic status was found to be a significant factor in the population that misjudged their need of dental care. Perceptions of need for dental care play a key role as to whether people will seek dental care (18).

The new MassHealth bill does not include a widespread effective public awareness campaign to educate about the connection between oral health and total health. Fact sheets (2) that contain sparse information about oral health are posted on the Member Services webpage, which is electronically linked to the MassHealth web page. This coupled with the fact that not everyone has access to the internet and that the fact sheets are difficult to locate make it unlikely that they will be effective.

The state’s effort to battle dental disease by providing dental insurance coverage through MassHealth fails to include an important educational component that addresses the combination of social demographic characteristics, beliefs, perceptions of oral health, and the presence of disease as contributing factors to receiving care. According to the behavior model, without perceived susceptibility or severity of consequences, behavior will most likely not change even if other enablers exist. The lack of need perception inhibits an individual’s ability to utilize existing health care services (18).


Many factors interact with one another to make a person able and willing to go to the dentist besides dental insurance coverage. To ensure that people receive the care they need, the variety of social issues revolving around the barriers that limit access to oral health care need to be addressed.

The solution to equal and adequate health care transcends the issue of insurance coverage. Disparities have to be eliminated to ensure equal health outcomes across the population. Providers, politicians, and recipients of dental care need to work together to increase social awareness about oral health and to raise the issue that total health reform cannot be delivered in the form of a single bill. Reinstating dental coverage to people who are poor only begins to solve this problem.


1. Meyer, Jack, and Silow-Carroll, Sharon, Policy Options to Ensure Access to Health Care for People Leaving Welfare for Work, Economic and Social Research Institute, Washington D.C., September 1996.

2. MassHealth Dental Portal, Department of Health and Human Services, Commonwealth of Massachusetts,

3. Official Website of the Commonwealth of Massachusetts, Department of Health and Human Services, Commonwealth of Massachusetts,

4. Haden, N. et al, Improving Oral Health Status of All Americans: Roles and Responsibilities of Academic Dental Institutions, Journal of Dental Education, May 2003, 563-583.

5. Behavioral Risk Factor Surveillance System, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia,

6. Centers for Medicaid and Medicare Services, Department of Health and Human Services, United States,

7. Zittle-Palamara, Kimberly, et el, Improving Patient Retention and Access to Oral Health Care: The CARES Program, Journal of Dental Education, 69:912-918.

8. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General-executive summary, Rockville, MD, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2002.

9. Otto, Mary, For Want of a Dentist, Washington Post, February 28, 2007, B01.

10. Raffi Miller, DMD, Boston University School of Dental Medicine, Personal Interview, October 27, 2007.

11. Edberg, Mark, Essentials of Health Behavior, Massachusetts, Jones and Bartlett Publishers, 2007.

12. Fadiman, Anne, The Spirit Catches You and You Fall Down, New York, New York: Farrar, Straus and Giroux, 1997.

13. McGrath, C. et el., Measuring the Impact of Oral Health on Life Quality in Two National Surveys, Community Dentistry and Oral Epidemiology, 2002, 30: 254-259.

14. Jeffcoat, Marjorie et el., Periodontal Disease and Preterm Birth: Results of a Pilot Intervention Study, Journal of Periodontology August 2003, 74:1214-1218.

15. Ryan, Maria, Carnu, Oana, and Kamer, Angela, The Influence of Diabetes on the Periodontal Tissues, Journal of American Dentistry, October 2003, 134: 34S-40S.

16. Abel, S.N. et el. Principles of Oral Health Management for the HIV/AIDS Patient, U.S. Health Resources and Services Administration (HRSA) Bureau of HIV/AIDS. 2000.

17. Office of Oral Health, Results of a Dental Needs and Awareness Survey at the Women’s Lunch Place, Boston Public Health Commission, 2007.

18. Astrom, Anne and Kida, Irene, Perceived Dental Treatment Need Among Older Tanzanian Adults- A Cross Sectional Study, BMC Oral Health, 2007, 7:9.

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