"Disparity" is the single word that best describes oral health in America today. More and more Americans, especially low-income and underserved citizens of all ages, continue to suffer from a range of oral diseases and disabilities that, ironically, are overwhelmingly preventable.

In an earlier Community Voices Commentary, former Surgeon General David Satcher highlights the "hidden epidemic" of dental and oral diseases across the country. He reminds us that eliminating oral health disparities "is not only good for our country, it is fundamentally right."

To achieve oral health equity, it is essential to empower communities so that they can set appropriate oral health and dental care goals. Community empowerment requires active engagement of public policymakers -- everyone from a State's Governor and US Senators to local health department program officials.

Policymaker engagement is necessary for three reasons. First, legislators and program administrators control and manage our communal resources. They determine where these resources are distributed and whether they go to support oral health. Second, effective programs at the local level often require meaningful public-private partnerships as described by the Surgeon General. Thirdly, many public health initiatives to improving oral health can only be implemented by the government. Community fluoridation, school sealant programs, oral health monitoring and surveillance, expansion of safety-net facilities, and Medicaid and SCHIP management all require government action. 

CRAFTING POLICY

Over recent years, support has been expanded for progressive oral health policy. As a result, we have turned the corner on oral health activity by establishing oral health as a bona fide public policy issue. Our government representatives have awoken to the problems of poor oral health and limited access to dental care. Notable strides have been made in addressing these disparities.

A roadmap for additional work in the policy arena for communities to gain access to the resources they need to craft local solutions is being laid out.

• For the first time, the US Congress has recently taken meaningful action on oral health disparities. Two General Accounting Office reports and the Surgeon General's Report, Oral Health in America, made the case that oral health disparities are real and consequential, that Medicaid has failed its promise to provide effective dental coverage for the poor, and that structural barriers to delivering equitable dental care are manifold.
• In 2002, nine separate dental access bills were introduced to address coverage, safety net, workforce, and prevention for both the population at-large and for special populations.
• The first-ever Senate hearing on children's oral health highlighted the issues and cited Community Voices projects as examples of effective local activism.
• President Bush signed into law the "Health Care Safety Net Amendments of 2002" which included "grants for innovative primary dental programs." This new grant program can be used to establish or expand community-based dental facilities, fluoridate community water supplies, support school oral health programs, boost dentist participation in Medicaid, and recruit dentists to underserved communities.
   
  With the active support of constituents who care about oral health, Congress can now appropriate funds for these new grants.

State policymakers are now aware of oral health as an important public policy issue. National policymaker organizations representing governors, legislators, health commissioners, Medicaid directors, and other key constituents have raised this problem with their members.
 
Some states -- including AL, DE, GA, MI, NC, and TN -- have made remarkable progress in improving their dental Medicaid programs so that more dentists are available to serve beneficiaries in communities. Others have focused on workforce issues including expanding functions for dental assistants, community-based preventive practice for dental hygienists, and incentives for practice in underserved communities. Some have focused on prevention including school sealant programs, community fluoridation, and public education. And many have joined with private sector authorities and activists in "oral health summits," coalitions, and task forces. Through all of these activities, oral health is beginning to resonate with growing numbers of public officials. But getting attention is only the first step. Much remains to be done.

STRUCTURAL BARRIERS

There are profound structural barriers that have yet to be addressed.

• Lack of dental coverage
• For every American without health insurance, there are 2.5 who lack dental coverage 108 million people. Perversely, those with the best quality coverage have the least treatment needs and those with the greatest needs have the worst coverage, if any.
• Adult dental benefits in Medicaid are rapidly disappearing across the nation.
• Too many Americans, particularly the poor, are still losing all of their teeth because basic dental repair is unavailable to them leaving them compromised in their ability to chew, speak clearly, or access many types of jobs.
• Too often the oral health of institutionalized and nursing home residents is scandalously poor.
• Shortage of dental professionals
• The dental workforce is declining as more dentists retire than graduate.
• African Americans and Latinos are grossly underrepresented in all of the dental professions.
• There is a growing shortage of dental school faculty and a lack of dentist training for the special needs of those who are vulnerable by virtue of age, handicap, or social condition.
• Translating science into practice
• Sound science that points to effective oral disease management and control has too often not translated into common practice and risk-based care is yet in its infancy.
• Stretching an already strained dental safety net
• The dental safety net is woefully inadequate to meet the dental care needs of those who already seek care in community health centers, school dental programs, hospitals, and dental schools.
• Some new governmental policies, like the Health Insurance Flexibility and Accountability program and the Health Professions Workforce performance measure, have unintended consequences that can worsen rather than improve access to dental care.
• With few exceptions, little has been done to integrate dental systems of care with medical and social service systems for the most vulnerable among us.

These problems suggest that improving dental access is complex and daunting. Yet with the increased attention of policymakers, much can be done to make things better, even in the short term.

RECOMMENDATIONS
Public-private partnerships, at the community level, can establish and ensure a clear standard of minimally acceptable oral health and dental access for all. This includes availability of emergency services to relieve oral pain and infection. Safety-net facilities can partner with the private sector to expand their reach and ensure complementary services. Communities can shed light on the particular oral health needs of young children, frail elderly, adult handicapped, migrants and other uniquely vulnerable groups.

Communities can reduce disease burden through effective prevention using fluoridation, sealants, and education campaigns that target sound nutrition and diets (including removal of soda and candy from school vending machines), tobacco cessation, and oral health promotion.

Communities can "raise the stakes" by actively engaging policymakers to support programs like the recently enacted federal grants to states that bring resources to communities to improve coverage, the safety-net, workforce, and prevention. They can "raise the stakes" with dental and dental hygiene educators regarding who they train and how well they train them to serve the underserved. They can "raise the stakes" with local health care provider groups including dentists, hygienists, physicians, hospitals, and nurses to promote "systems-think" for improving oral health. They can "raise the stakes" by requiring greater accountability from those publically elected officials that are charged with preserving the nation's health and welfare.

Most importantly, communities need to continue highlighting the significance of oral health. In this way, communities can garner the support of policymakers and work toward achieving equitable oral health and dental care in every community across the nation. Community action is critical in filling the growing disparity gap in oral health.

Burton L. Edelstein, DDS. MPH  is the Founding Director of Children's Dental Health Project, Washington DC, and the Director of Division of Community Health, Columbia University School of Dental and Oral Surgery, New York, NY.