Dept. of Unintended Consequences: Hepatitis B in West Virginia

Via ProMED Mail comes a news report that about 2,000 people in 5 states are being sought by health departments so they can be checked for hepatitis B infection. The potential source: the Mission of Mercy Dental Clinic, a free dental-care fair held just about a year ago in Berkeley County in the far north-east corner of West Virginia. The potentially infected include 1,137 people who were treated at the two-day clinic and 826 of the volunteers who worked there, from West Virginia, Washington, D.C., Virginia, Maryland, Pennsylvania and North Carolina. Three patients and two volunteers have already been diagnosed. The virus in four of the five matched on molecular fingerprinting, suggesting a common source; the fifth patient refused further testing.

Hepatitis B is blood-borne, so on the surface, this is a story of the tragic consequences of some failure somewhere in the clinic's infection-control procedures. (One reason why it caught my eye, since I'm interested in healthcare-associated infections.) Except that it's not -- or not only. It's important to unpick why such an extraordinarily large number of people may have been exposed at one time. Looked at through that lens, it becomes a story about what can happen when we don't fund basic health care in a timely way.

Some background: West Virginia is one of the poorest states in the country and has some of the highest rates of the usually recognized diseases of poverty: tobacco use, chronic kidney disease, asthma, cardiovascular disease. (Look for West Virginia on these CDC maps of incidence of heart disease and stroke.) But it also has extraordinarily high rates of another health problem that ought to be linked in the public mind to low socioeconomic status, but usually isn't: untreated dental disease. Eric Eyre of the Charleston Gazette (disclosure: a friend and fellow Kaiser Foundation Fellow) took a year-long close look at dental disease in the state in 2006-07 (slideshow, stories). If you're squeamish, I advise skipping the one about the woman yanking her own teeth with pliers after a few shots of moonshine.

Dental disease -- that's not just cavities, but tooth loss, bone loss, abscess, Ludwig's angina, septicemia in the most serious cases -- isn't only a problem for West Virginia, though it happens to be worst there. It's a problem all over the US because, without ever intending to, we've allowed dental care to become a primarily cash-based form of medicine.

If you have a job, you may have dental insurance, though it's a less-common employment benefit than health insurance, and covers comparatively less of the cost of any procedure. If you don't have a job, dental care is entirely out of pocket. If you're poor enough to be on Medicaid, whether or not you have dental coverage depends on which state you live in, because Medicaid dental coverage for adults falls under the portion of Medicaid funded by the states, not the federal government. In the past 12 months, California, Hawaii, Massachusetts, Michigan, Minnesota, North Carolina, and Washington state all cut or tried to cut their contributions to dental Medicaid from their state budgets. If you're the child of a poor family, you are hypothetically entitled to Medicaid-funded dental care, though that depends on being able to find a local dentist willing to accept Medicaid reimbursement; last year, the Government Accountability Office said that children have trouble finding Medicaid-accepting dentists in 43 out of 50 states.

Net result: Untreated dental disease is now the most common disease of childhood, five times more common than asthma according to a 2000 Surgeon General's report, and emergency room visits for dental crises are rising steadily. ERs are not the right place to treat dental problems -- they don't fill cavities or do extractions, though they can drain abscesses and give antibiotics and pain meds -- but as with so much else in US medicine, ERs offer a mandated clinic of last resort when there's nowhere else to go. (For more about the interplay between dental care and ER overcrowding, here's a story I wrote for the June Annals of Emergency Medicine.)

All of that explains why thousands of people from a wide swath of the East Coast were so desperate for free dental care that they were willing to stand in line overnight in a high school parking lot. (The first free dental clinic in West Virginia had to close its doors early after it got 1,100 patients in the first 2 hours.) And also why hundreds of dental-care professionals and students and community volunteers were so eager to help. And why they're all now waiting by the mailbox, wondering whether they're in line for a letter that will tell them where to get tested for infection with a life-long chronic disease.

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i want to ask if you can help me i have an interview soon and ma by ask me what i should to do with hepatitis patient i am study a dental assistant would you to help me pleeeeeeeees

Great post. And so glad to see you here as a Scibling! Your fan over at Speakeasy Science.

Good post, but you should be aware that Berkeley County is presently part of the outer suburbs of Washington, and its poverty profile is far more urban than you'd think. The rural/white/meth/moonshine area of WV is mainly in the central part of the state.

Hi, Anon â Thanks for the note. I actually did know that; one of my siblings (actual sibling, not, you know, Scibling) lived in WV for a number of years. Sorry if I gave the impression that this clinic served only the rural; given the wide geographical area from which it drew patients, that can't be true. (Eric Eyre's work, which I referenced, did cover mostly rural dental disease, IIRC.) But, given this clinic's location, it's possible that its clients also included former white-collar workers who lost dental insurance when they lost their jobs and then had a crisis or an exacerbation of a chronic problem â blown-up abscess, broken tooth...

Liz, absolutely. And Driver was one of two kids known to have died of untreated dental disease that year. The other was Alex Callender in Mississippi one month later. Same issue: no dentists who took Medicaid; abscessed teeth; spread of infection to the brain.

Unhelpful, hard, pitiless thing to say: my kids and I go for an annual check but never need dental treatment. Because we own toothbrushes and use them.

Maybe if they distribute toothbrushes and teach schoolkids how to use them properly? Just a thought.

OurSally, your kids probably don't use methamphetamines. Google "meth mouth" for the unsavory details. And I'm guessing your family can afford not to rely on processed food that is cheap and convenient--and has a high proportion of the sugar and flour that mouth bacteria feast on. Teeth brushing does help, of course.

Disclaimer: I am not a dentist.

By David in Brooklyn (not verified) on 08 Jun 2010 #permalink

That's a good point sally. As we know, brushing teeth prevents 100% of cavities. Now, if you could return to fantasy land, the rest of us would like to concern ourselves with reality.

I appreciate your bringing attention to the ludicrous situation of lack of dental care in this country. What I don't get is why you are not screaming louder about the fact. What I really don't get is why more people aren't screaming really loud about this being the case. But I am truly puzzled by most of those commenting on your blog--they seem oddly "indifferent"--if that's the correct word, or at least not genuinely connected to how desperate a person can become. A year or so ago, I was so driven to desperation by combination of pain of an abscessed tooth, lack of money to pay a dentist and whacked out state induced by what painkillers I could attain that I very nearly carried out contemplated suicide.--elesjaydepawa

By Lisbeth Jardine (not verified) on 08 Jun 2010 #permalink

My dentist friends would be happy to treat MA and Medicaid patients, if they were paid enough. The reimbursement rates are a half to a third of standard rates. Sure the government deserves a price break, but bureaucrats tend to diminish the needs of medical and long-term care providers with low, frozen or declining rates. The cost shifting onto private dental plans is unfair taxation. We even had bureaucrats come to our day centers for the developmentally disabled (try to find a dentist for a DD person) and want our untrained staff to "screen" people for serious conditions. Then they testify to their local legislature with a straight face about how much money they saved. I know about it, we're enduring the Wisconsin experiment in managed long-term care for the elderly and people with physical and developmental disabilities. Deficient funding and services is just a hot potato looking for a home. The politicians are delaying an audit of the program until after the fall election season for their convenience and to the detriment of effected citizens.

By Badgerberling (not verified) on 08 Jun 2010 #permalink

Way to go Maryn,
I am also an ex newspaper man (25 years!) now working as a cashier at a grocery store. I did it for so many years even though I saw the end coming because I beleive newspapers are the lifeblood of democracy.
I don't have health or dental insurance. The really pathetic part of all this is that was preventable. We could completely wipe out these dental problems with the 12 BILLION we spend on unnecessary vitamin and mineral supplements each year.
BUT, we live in a democracy and people want the system the way it is. Obamacare will fail and fail miserably because it will not address the real issues like this, in fact, I predict the insurance companies and the doctors "manage" the regulations such that they make even more money. We need better democratic processes, like are being tried in California before we will fix these problems. Best to you, keep up the good work!

By Karl Spain (not verified) on 09 Jun 2010 #permalink

Oursally - I'm delighted you and yours lead pure enough lives to avoid reality. Don't make the assumption that others take no care of themselves.

Sometimes sh*#% happens. Like last year when my then 10yo - despite 2x/day brushings and regular dental care - spent 4 days hospitalized for eikenella corrodens tooth abcess.

Lack of basic preventive dental care is so frustrating and so short sighted.

I worked with an agency that helped people and we could direct them to dental clinics -- unfortunately there aren't a lot of clinics. And where I lived there were large portions of the state where counties either had no clinics, clinics that only handled children, or only handled emergency extractions.

I took calls from individuals with no dental insurance, no money, and abscessed teeth and infections but no place to turn, I'm talking about people calling saying their faces were swollen and hot, that they'd been to the emergency room and got some antibiotics but now they had to find some place to get their teeth taken care of.

Or I would hear about attempts to contact clinics only to find out there were months long waits for emergency appointments.

Or there were people who fell in the employed with no dental insurance or really crappy insurance who needed dental work done but they couldn't afford it and they made too much money to qualify for clinics.

And it's only gotten worse as unemployment has gone up.

By another anon (not verified) on 10 Jun 2010 #permalink

Of course, everyone ignores the way dental training is set up.

It's not like being a doctor (to which it is usually, and bizarrely, equated). After a significantly shorter training on one specific area of the body, with a nod to other areas (cardiovascular issues such as endocarditis) my schoolfriends who trained as dentists moved straight into private practice. The expectation was that within 3-5 years they would be picking up the same salary that a consultant surgeon would reach after 10-15 years of postgraduate training (but the dentists, of course, would work only office hours).

Unlike doctors, who spend another decade or so 'in training' on low salaries, doing all the grunt work and repetitive procedures, thus ensuring that the medical system remains affordable. In the UK there is currently a gap of only 500 pounds between the starting salary of a doctor and a nurse.

Dentists scream that they're not being paid enough for each procedure - but apart from all the other stuff I'm called on to do, I carry out procedures in the ED every day and take home the equivalent of $60 000 a year, which is far, far less than the majority of dentists. Plus I carry likely 100X the medicolegal risks, as I'm dealing with life-threatening issues many times a day.

The bottom line is that much of what dentists do could be carried out by technicians - filling of minor cavities, routine checks etc etc. After all, to do the serious stuff as an orthodontist you need to qualify in medicine as well - which kind of says it all (there were two budding orthodontists with me at medical school, and the only part of the course they walked was head and neck anatomy and local anaesthetic pharmacology. Everything else they had to learn from the ground up.)

People need to wake up to the fact that there is a vast amount of protectionism in dentistry, far more than you'll see in medicine or veterinary science. That's why it's so expensive.

Tassie, I am a 70 yr old DDS, retired an working to train dental assistants on the high school level.
When I was in practice in 2000, overhead was 65-70% even for a mom & pop practice with 1 assistant& 1 hygienist - my wife at the front desk. I netted $110,000 for me and my wife working the typical 4 1/2 day dental week.
Orthodontics, a specialty, concentrates on dental principles of tooth movement. Training technicions to perform dental skills alone would leave the already unsuspecting public at greater risk to poor health
When the country stresses health and education and supports it with funding, we will be better off. Some spoiled dentists must remember that their 1st duty is to treat patients and not just fill teeth. Tye public must also in my view, demand the highest training standard available at dental schools for their welfare.