David M. Krol, MD, MPH, FAAP, is a senior program officer on the Human Capital team, the goal of which is to develop and maintain a diverse, well-trained workforce, and create the next generation of leaders in health and health care. At the center of his interests is a passion for eliminating oral health disparities. Building on work he began as an assistant professor of Pediatrics and Health Policy and Management at Columbia University in 2001, Krol discusses placing the nation on a path to dramatically improved oral health.
Q: As a pediatrician, how did you become so engaged in oral health policy and care?
A: When I was completing my Robert Wood Johnson Foundation [RWJF] Clinical Scholar [1999-2001] fellowship, I wanted to make an impact on child health and health policy. Shortly after that, I met Burton Edelstein, DDS, MPH, a former [RWJF] Health Policy Fellow [1996-1997]. He was also the founding president of the Children’s Dental Health Project. He convinced me that the issues surrounding oral health represented a microcosm of the problems we were seeing throughout the health care system.
I decided to join him at Columbia in their Oral Health Policy Center. I have been working in oral health policy ever since, though I am still only one of a handful of pediatricians in the field.
Q: Many people think they only need to see a dentist when they are in pain or a tooth is visibly damaged. Why is it so important to have healthy teeth and protect the body from periodontal (gum) disease?
A: Oral health is a critical part of overall health. Periodontal disease has been associated with preterm birth, poor hemoglobin A1C [average blood sugar] test results in people with diabetes, and may be linked with atherosclerotic vascular disease. Vanessa Grubbs, MD, MPH, a Harold Amos Medical Faculty Development Program scholar, recently reported that it may also advance chronic kidney disease.
Periodontal disease is an ongoing source of inflammation in the body because it’s a chronic infection. As a result, it can throw off blood sugars, or aggravate other health problems as it progresses or goes untreated.
Dental caries [tooth decay] is also an infectious disease. Many people do not think about how close a tooth abscess is to the brain, but that makes the disease even more dangerous to our health. In rare cases, such as the Deamonte Driver tragedy, infection from a dental abscess can spread to the brain.
Q: How does poor oral health affect children?
A: By the time a child develops a cavity, they have already had an infection for a long time. Even if we fix the hole in the tooth, that disease-causing environment is still in the mouth. The child runs the risk of continued dental disease for the rest of their lives.
In some cases, small children with severe dental decay may have to be put under full anesthesia so that a dentist can rehabilitate their mouth. We should not reach the point where we have to take a surgical approach to a dental problem.
Q: Will the Affordable Care Act (ACA) help to resolve oral health disparities?
A: It will make things much better for children than it will for adults. Dental services are part of the list of essential health benefits that must be offered; however, the law and subsequent regulations do not require it to be purchased when offered separately on the insurance exchanges. For adults, millions more adults will be covered by Medicaid, but there is no guarantee of dental benefits.
These provisions are certainly a victory for advocates, but it’s a setback that most adults will not have access to dental benefits. For children, every state but Utah has selected the dental benefits outlined in either the state's CHIP program or the Federal Employees Dental and Vision Insurance Program as the benchmark for the pediatric dental portion of their essential health benefits.
Q: What are the Foundation’s key oral health priorities and projects?
A: A large part of the effort is aimed at increasing the diversity and cultural competency of a new generation of dentists. We are accomplishing that through several Human Capital programs.
The Summer Medical and Dental Education Program works with students from groups that are underrepresented in medicine and dentistry. The program includes an intensive, academic enrichment course that also gives pre-med and pre-dental school students an opportunity to participate in clinical rotations and seminars.
The National Dental Pipeline Learning Institute is a combined effort of the American Dental Education Association and the University of the Pacific Arthur A. Dugoni School of Dentistry that is supported by the Foundation. The Learning Institute offers mentorship and participatory education to dental school/community organization partnerships who develop and carry out a project related to the Dental Pipeline goals. Those goals include increased recruitment of underrepresented minority and low-income students, improved cultural competency of all dental graduates, and expanding the use of community-based dental education.
The Foundation’s Harold Amos Medical Faculty Development Program also recently expanded to include dental school junior faculty.
In addition, we just published a series of synthesis reports on an evaluability assessment of 25 programs around the country that use innovative workforce models to address clinical and community-based barriers to preventive oral health care.
Q: When announcing its November 18 Prevention Summit, the American Dental Association released a statement that said: “We cannot drill, fill and extract our way out of this [oral health] crisis.” What were they trying to tell us?
A: As I mentioned, once you reach the point of filling cavities, a child or adult already has the disease of dental caries. That’s why we need to take an upstream approach to preventing oral health problems before they begin.
That means comprehensive prevention for a child that includes a healthy diet, good dental hygiene, judicious use of fluoride, and early checkups with a dentist. It also means preventing transmission of disease-causing bacteria, and poor dietary and dental hygiene habits across generations.
But oral health professionals cannot accomplish this alone. Providers, community members, soda manufacturers, policy-makers, and others have to work with us. It takes a village to address the multiple factors that contribute to oral health disease and disparities. As we work toward a culture of health, everyone must keep this fact in mind: Oral health is an essential part of our overall health. It cannot be ignored.