From Foresight, No. 50
published 2007
Editor’s Note: This summer, Kentucky’s most visible advocate for oral health, Dr. Jim Cecil, will retire from his post with the Department of Public Health where he has worked under contract since 2001. On loan from the University of Kentucky (UK) where he has been a faculty member since 1996, Dr. Cecil is a public health dentist, an epidemiologist with a background in research and development. Recruited to help Kentucky rebuild its public health capabilities, Dr. Cecil has worked to raise public awareness of the state’s oral health status and institute programs to moderate the ill effects of poor oral health. A retired Navy epidemiologist, Dr. Cecil is a native Kentuckian from Pewee Valley and a graduate of the UK College of Dentistry and Bellarmine University. He plans to work part-time with the UK College of Public Health to develop a new maternal-child health program.
What do you see as the major issues confronting the state in regard to oral health?
Dr. Cecil: The biggest one I see . . . is access to care, either preventive care or restorative care. During the 1980s, Kentucky, like a lot of other states, most other states, lost a lot of public health funding . . . Trying to build that back is almost impossible. Now there’s another proposed round of federal cuts going to the public health sector . . . In the past 10 years, Congress re-upped much of those programs, but they’re flat, so we’re working with 1990 dollars, with a 2007 problem.
There’s associated problems too with 2,200 dentists in Kentucky and only about 1,000 who have contracts with Medicaid. Half our children in Kentucky are Medicaid eligible or KCHIP eligible or living at or just above the poverty level. So we’ve got 1,000 dentists who have contracts, but only about 500 actually see a significant number of patients, so that’s really an access problem. When we the dentists, the American Academy of Pediatric Dentists, recommend that children see a dentist at one year of age, who’s going to do that? It’s not the dentist, because most general dentists won’t see a child under age three or four, just because of behavioral problems, just because they don’t know how to handle kids. Most dentists, I think, like to treat people who are compliant and not very sick.
Is the access issue really one of a lack of people having dental insurance?
Dr. Cecil: That’s part of it. It’s a multivariant kind of problem. About two and a half to three times the number of people who don’t have medical insurance in this country—44 million people in the U.S.— so about 130 million or so don’t have dental insurance. It’s probably even worse in Kentucky because a lot of our small industries don’t offer coverage. For instance, the University of Kentucky doesn’t . . . pay for dental coverage. We offer a plan to ourselves, but we have to pay for it totally. A lot of companies, including the state, have some kind of a plan, but at least the one the state has right now, is not particularly attractive to me.
Our Kentucky Health Insurance Research Project survey found that more than half of respondents said they had dental insurance. Does that seem accurate?
Dr. Cecil: Some bad data . . . Oftentimes in surveys people tell you what they think you want to hear. I’ve done a lot of surveys in my life, but you have to be careful how you interpret those.
To your knowledge what’s the quality of dental insurance in Kentucky?
Dr. Cecil: It’s not very good, actually. We’re one of those states that dental insurers really don’t like to come to. Dental insurance is not really insurance; it’s really a prepayment system. If you go in to get a crown you’ll still have to pay 50 percent of the cost of that crown. Except for a couple of plans, the dental insurance market is not robust here.
How does Kentucky differ from other states in regard to oral health?
Dr. Cecil: Well, you have high unemployment, high poverty, and even with people on Medicaid in Kentucky, less than 30 percent use the dental benefit. They might overuse the medical benefit but they underuse the dental. Part of that is related to how people who live in the Medicaid system relate to the future, I think; most people living in poverty don’t think about the future. They don’t plan for the future, they plan the day . . . and they’re not worried about five years from now. The consequences of not taking care of teeth occur in the future, they don’t occur at the moment. It’s a slow process that takes a long time for people to either feel the pain or see the results of infection.
The rural environment is associated with poor dental health as well, for the same reasons: access to care, access to prevention, and reduced incomes. Again, their perspective of the world is a whole lot different from that of people who live in Lexington, Louisville, Frankfort, or other places.
Also, we not only have a shortage of dentists, we have a poor distribution of dentists. If you look at how dentists and dental workers are distributed throughout the state, look at Northern Kentucky, Paducah, Owensboro, Louisville, Lexington, and that’s where 80 percent of them work. So that leaves a big, open, rural, hard-to-get-to area.
The states around us, except for West Virginia, have pulled themselves up by the boot straps dentally, I think. Tennessee, for instance, has a safety net network, accessible to almost every county, as a result of a lawsuit against Medicaid by a social activist in North Carolina. They sued Medicaid . . . because they were not meeting their EPSDT (Early Periodic Screening, Diagnosis, and Treatment) goals, a child health component of Medicaid. The court found that they weren’t meeting their goals, and the result was for, in perpetuity, the dental program in the state of Tennessee would get at least $14 million a year to maintain the safety net clinics.
Is that state allocation matched?
Dr. Cecil: Yes, in Kentucky, it’s a three-to-one match. I’ve made a proposal to do that over the next ten years. I think we can have the same system for just $1.6 million a year. It’s not a lot of money. Illinois did the same thing. They set up safety net clinics all over the state. Indiana raised their fees for dentists up to the market value, and, of course, their budget tripled. A lot more people were getting seen, though. Ohio has just recently done that, brought the fee up to market value. Our fees are at about the 5th to 25th percentile, which means that 95 to 75 percent of the fees are higher than what the Medicaid fee is. That’s why they’re so unattractive . . . to private practitioners.
Are dentists under the same kind of pressure that physicians are under, that is, to form groups to be more profitable?
Dr. Cecil: They are, but we’ve got counties that have one dentist or no dentist. Fulton County has no dentist at all. So UK has set up a safety net in that county. But dentists like practicing alone. There are some pressures to be more efficient, but dentists don’t care about that. The research in the dental profession indicates that the way dentists practice . . . is because they identify a dollar figure that they want to hit per year, and that’s their goal . . . not to see more patients. It’s not to save the world, those kind of things. It’s almost directly related to a figure that they’re aiming for each year, and they structure their practice to do that, unlike physicians. Physicians do it differently. I know they do.
When I interview our dental students, our student dentists coming into the dental school, it’s a totally different world. When I went to dental school, and you were asked why do you want to be a dentist, it was, “Oh, I like to help people . . . I like to work with my hands . . . I like to work alone,” etc. Now they say, “I just want to be rich.” All the aesthetic dentistry—polishing teeth, making teeth whiter—is appealing. And most of the time they say, “I don’t want to see sick people.” If you’re dentally ill, you’re sick, you’re not well at all, so it’s a whole different world. Dental education is changing that way too. We’re changing to accommodate them.
What part of the market for dentists now is comprised of cosmetic dentistry?
Dr. Cecil: I have no idea, but a lot of us old guys think it’s too much. I was talking to a dentist in Lexington who has been there for years, a good practitioner who teaches. He was just dismayed at people who come to associate with him. They want to make white teeth, they want to put on veneers, they want to do botox injections, which are legal.
We waste so much money in our health care system it’s unbelievable. If we scrape that 30 percent we waste off the top and just dedicate it to getting care to people, we’d be much better off, even if we still have those problems inherent in a bureaucracy. I was in Navy medicine a long time, and there is some bureaucracy you have to deal with, but you know how to navigate through it. Most people don’t know how to navigate through a fragmented, complex, almost incomprehensible system.
Why should policymakers care about the oral health of the people in Kentucky?
Dr. Cecil: Dental, oral health is a health issue, and it affects a lot of other health issues that confront us: heart disease, stroke, diabetes, obesity, preterm babies, on and on and on . . . One of these days, I hope that dentistry will be more involved, in a holistic kind of way, in preserving and insuring the health of our patients.
But it’s also an economic development issue. [To illustrate] I’ll tell you a story. There’s an organization in Berea that’s called New Opportunity School for Women. They teach women who are usually out of abusive relationships . . . give them tools to gain entry into the marketplace, usually in some entry-level job. Some years ago, the director got hold of me . . . and said they’ve got a real problem . . . half of the women don’t get jobs because of their teeth. So a couple of us dentists, faculty members, went down there, did some examinations, and provided an entrée for them to get health care or dental health care through the college. That’s an economic development issue in my opinion.
It’s a health issue, but maybe overriding that or even overburdening that is economic development . . . we suffer from having those kind of diseases. Kids can’t learn so our dropout rate in high school is huge. Half of our kids in Kentucky have dental caries or decay. Little bitty kids, two- to four-year-olds, almost half of them have some tooth decay. And they carry those diseases to the next stages of their lives.
In Kentucky we get three sets of teeth: our baby teeth, our permanent teeth, and then our plastic teeth—if we’re lucky. Medicaid does a good job of taking teeth out, but we don’t provide dentures for people who have lost all their teeth. And so that’s why we’re the most toothless state in the nation.
Does Medicaid try to preserve a tooth that’s decayed?
Dr. Cecil: For children, yes, it’s a nice benefit. For adults, no.
What usually happens when an adult arrives in an emergency situation?
Dr. Cecil: If they’re in pain, they’re going to have the tooth extracted, rather than a root canal or something like that. So our culture, if you will, promotes poor oral health. My father, when I was a student dentist, had periodontal disease, and I said, “Dad you’ve got to do something about it.” He did, he went and got all his teeth taken out. And it really just broke my heart because he had money, so it wasn’t a money issue, but it was his culture. You know, his mom had dentures when she was 30, and his dad had dentures when he was 40, and all his brothers and sisters had dentures. It doesn’t have to be that way, of course.
Teeth are important, not just for aesthetics and health, but I think there’s some self-confidence that goes with being whole. There have been studies done where people have their teeth removed, and they go through a mourning process, a grieving process very much like people who lose their hands. It lasts a long time, and, of course, they have to go through all the stages of grief. You do that every time you lose a tooth. It’s like losing a finger or a nose or an ear . . . so it’s not as innocuous as we let ourselves believe over time.
But as we see from the Washington, D.C., story where a young boy died from an infection that started with a decaying tooth and went to his brain . . . society paid $250,000 despite the fact that he died. So there’s a tremendous loss—human loss, societal loss, and the family is just never going to be the same.
One wonders how many conditions like that are never publicized or talked about.
Dr. Cecil: Two years ago at UK we had four adults in the hospital on respirators because of oral problems. They all lived, but society’s cost for that was huge.
In the case of a person with periodontal disease who smokes or uses tobacco, the mouth doesn’t heal; you can’t control the periodontal disease. Whatever is in tobacco keeps wounds from healing, so if you’re a smoker and you cut your hand, it’s going to take twice as long for that cut to heal. In the mouth it’s even more difficult; it just never heals. So that infection doesn’t hurt, you don’t have a lot of pain sometimes, but it gets huge.
It’s estimated that if a person with moderate periodontal disease had the amount of inflammation in the mouth on their palm, it would be about the same as having the palm red and oozing and pussy. So you’re not talking about an insignificant amount of tissue damage that the body’s trying to deal with, yet you add smoking on top of that, and you add the use of alcohol, non-nutritious diets. All these things that we are telling ourselves we need to do for general health relate to oral health as well. And you can’t be healthy if you don’t exercise. Exercise helps the mouth actually to keep the blood flowing and keep the tissues building. If you don’t exercise, the blood pools . . . the body’s connected to the mouth and the teeth; that’s the problem.
So it’s more than just a health problem or dental health problem; it’s a total health problem. It’s an economic development issue; it’s a self-confidence issue. I think people that are successful in life have most of their teeth most of the time. Maybe George Washington was an exception, but you read the accounts of his last two decades of life, he was miserable 100 percent of the time, and it related to his teeth. My understanding is he kept one of his teeth even though it was wobbly for all of his life just so he could say he wasn’t totally without teeth. It probably aggravated his pain and infection.
How does a disproportionately poor state such as ours overcome the high cost of access to dental care?
Dr. Cecil: I think you can do it by being efficient, and dental practice in the private sector is not very efficient. For instance, if we had more school-based health centers where you can deliver efficient care on site without worrying about transportation . . . The proposal I made to Congress was exactly that: set up safety nets throughout the state, attach those to hospitals because a lot of these people need hospital care because of their dental problems; have relationships with both the health departments and other institutions, as well as the universities; and spend some money, and I think you can do it. We’ve done it at UK. We’ve got three centers, in Hazard, Madisonville, and Morehead. They’re almost self-sufficient after a couple to three years.
We built them with earmarks . . . earmarks fell this year so we’re trying to save them, but they’re working on special issues with oral health, like diabetes, preterm babies, heart disease, and how to create systems to treat those things. And I think the Medicaid system needs to inject oral health into some of these disease management programs. The one for preterm babies indicates or guides the pregnant mom, the second person they should see after they see their physician is a dentist and get their gums in good shape, get them going, create the environment where preterm babies are less likely. We’re doing that, and so far the indicators are that, compared to women who don’t go through prenatal care with dental care, the preterm baby rate is lower, not by a whole lot but it’s lower. And that care is really cheap. A preterm baby costs $100,000 the first year. If you spend $400 on getting your gums fixed, the disparity is huge.
How do these clinics become self sufficient?
Dr. Cecil: By being efficient, by using Medicaid properly, and through the use of auxiliaries. In our state, Kentucky, we have what’s called expanded duty, auxiliaries (dental assistants) who can do a lot of things that only dentists in other states can do . . . and nondentists are cheaper than dentists. They’re specially trained; they have to go to about another year of school to do expanded duties, and they’re recognized by the Board of Dentistry. So if you have everybody in the office, even a private office, working to make money or to have a revenue stream, instead of just the dentist, then you can become more and more self-sufficient. You also can buy in bigger bulk if you’re a part of the safety net.
While I go examine kids and write an order . . . the hygienist can come behind me at a separate time and provide all the care and I don’t have to be there. I don’t have to supervise her directly. So that’s a lot cheaper too. Her costs are about half what the dentist costs. If the dentist is the only one doing care, that’s not efficient. That’s how we run our general practice (at UK and UofL clinics). Private practice is very inefficient. The dentist is the only one doing the care and must be involved in everything.
What do these clinics look like?
Dr. Cecil: Let me describe the one in Hazard because it’s actually a little more mature. UK has a Rural Health Center in Hazard. It’s attached or right next door to the Appalachian Regional Hospital. In that center, they’ve got a UK family practice residency.... that trains residents, using the hospital and the facilities at that rural health center. About six years ago we got a grant from HRSA (Health Resources and Services Administration) to build a new building, and they put in six dental operating rooms, incorporating dentistry into medicine in a big way. So now they have 2.5 dentists, I think, and a couple hygienists, and some assistants. We’re seeing a lot of patients that aren’t being seen by the private sector, mostly Medicaid or uninsured.
Two years ago they got a donation of a mobile van which is worth about $400,000, so they’ve attached that and use that for the school health programs. They take the van out to schools. They see really sick kids back in the clinic; routine kids they see to all that stuff, prevention as well as routine treatment, in the van. And so they’re efficiently using their people. Dentists aren’t in the van except when they’re doing treatment. And they don’t do sealants in the van; hygienists do sealants with portable chairs in the schools. When I mean self-sustained ability, you have to be a little innovative on how you use high-cost people for high-cost things and low-cost people for low-cost things. I think that’s how you can maintain these safety nets over time.
Is this the New Zealand model?
Dr. Cecil: That’s very controversial. For the last 50 years, New Zealand and Australia and Saskatchewan have used what they call dental nurses in the school setting, mostly women who are part of remote villages or tribes. They have gone to New Zealand for this training and come out of there treating only children, but they do fillings, simple extractions on baby teeth, a lot of prevention and health prevention . . . but the dentist who supervises them is 1,000 miles away. Now with telehealth, it’s a lot easier to supervise. That’s been suggested for some of our needs here in the United States, and it’s actually being undertaken in Alaska.
Organized dentistry is pretty much against this, as you might expect. They think it takes care away from their private practitioners, but there aren’t any practitioners who are going to fly around Alaska in midwinter to treat poor kids, so at UK we’re kind of straddling the fence right now.
But, politically, I don’t see that happening very soon although the American Dental Association has come to a negotiated agreement with the Alaskan tribes, kind of a waiver. So I don’t know how it’s actually going to end . . . I think eventually we’ll have that kind of practitioner. If we had that in Kentucky, we could do a lot of stuff. We could have dental clinics in most every school district because you’d only need one dentist to supervise a bunch of them . . . Physicians went through this earlier in our history when nurse practitioners came about . . . in the 1970s. They went through the same political mess that we’re going through in dentistry. They lost eventually, nurse practitioners won, and they’re accepted by most physicians as being very competent and very helpful in their practices. And they make money for them too.
Are there states that really understand what the problem is, that have made great progress by being innovative? Are there any exemplar states out there?
Dr. Cecil: Yes, I think Tennessee is one . . . They have a dental clinic available to almost every county, a regional setup, regional dental directors, as well as (public health) dentists at these places, so theoretically everybody has access.
I would say Ohio is next, and part but not all of Michigan. A few years ago, they . . . did an experiment. In the most rural part of the state they gave everybody the Delta Dental Card, looks just like the Delta Dental Card that somebody who worked for General Motors would get. And they paid the same rates as Delta Dental, but it was only for these 30 counties. As you might expect, a lot of kids got treated, the budget quadrupled, it almost went broke, and now they’re trying to get out of it. But it worked. That’s how you got the private sector involved, [by paying] a reasonable fee.
In our state and in most states, the overhead for dental practice is around 70 percent, which means that every time a patient misses an appointment, the dentist incurs some cost just by having to set up and be ready. With no patient paying . . . there’s no reimbursement. That’s not true for medicine. If you’re a family practice physician, you can add one more ten-minute exam to your schedule for the day and you won’t incur a lot of overhead cost. That’s not true for dental practice. Dental practice is a lot like a small hospital practice. Very high overheads, lots of equipment, lots of staff, and if you don’t meet those overhead costs, you really run the risk of not being able to survive. So when the Medicaid fee is at the 25th percentile and your overhead is 70 percent, every time a [Medicaid] patient comes in and the Medicaid rate is paid, you’re still not making your costs.
What’s the average cost of a full set of dentures, and do we have any programs to help people offset that cost?
Dr. Cecil: We do actually. The Kentucky Dental Association has a denture program, and dentists voluntarily provide that service. Sometimes it’s free, sometimes it’s $200. The University of Kentucky has a denture program, and I think a full set of dentures is $250. There’s a limit on how many they will provide each year.
I think the university’s fee schedule for a patient covered under their plan would probably pay $1,400. That’s the cost now. The plan would pay half of that and the person would pay the other half. But it’s not cheap. If you go to a private practitioner in Lexington, not connected with the university, you’re probably talking about $2,000 to $3,000.
What role does the Kentucky Dental Board play?
Dr. Cecil: Their mission is to protect the health and safety of Kentuckians from the evildoers . . . They do a good job in substance abuse, and Kentucky also has a good program for practitioners who are abusing different substances, from drugs to alcohol . . .
But they mostly act on complaints, so if somebody has a bad experience with a dentist, then they’ll hear about it, there’ll be an investigation, and they will either reprimand the guys or take their license away. I think every year we lose 20 or so dentists . . . because of some action taken against their license.
One of the big issues is Medicaid fraud . . . It’s not 100 percent of the dentists, it’s not even 2 percent of the dentists, but the ones who are doing it are just egregious in how they collect fees . . . For example, there was a pediatric dentist who was making what we call “flippers,” for babies, for kids that lose their front teeth too early because of accidents or their care. So he was making this device that clipped to the back baby teeth, it was on a wire, it was ugly, but the parents wanted it and he was charging Medicaid $300 for each one of these and it takes about ten minutes to make. It’s useless, it doesn’t help, so it doesn’t enhance the appearance, it doesn’t keep space from being lost for permanent teeth, which is one of the reasons we make appliances for little bitty guys. This is just outright fraud.
What role does the Kentucky Dental Association play?
Dr. Cecil: Almost 80 percent of Kentucky’s dentists belong to the KDA, which is unusually high for professional associations. Why is the participation so high? The KDA does lobby for dental issues involving their members and I believe do a commendable job in advocating for the underserved in this state. Since the KDA is the advocate for the private practicing dentists mostly, they attempt to provide support for politically acceptable issues.
If we were going to build a safety net infrastructure in our state, you have suggested that federally qualified clinics, community health centers, and the health departments would be the logical providers.
Dr. Cecil: We don’t have very many at all and only a handful of the ones we do have dental capability, so . . . I was hoping during this [presidential] administration we would get more federally qualified health centers and more community health centers because the dollars were there to do that. Communities just didn’t take [the president] up on it.
It is a very cumbersome process. Actually, I sat on the review board in Washington. We saw, I would say, ten a year. And the ones that are successful are not in rural areas but in New York City, Los Angeles, Chicago . . . where there’s more infrastructure already in the community.
Isn’t it ironic where the need is most acute we expect an infrastructure to be in place?
Dr. Cecil: We’re always on the wrong end of the scale. We don’t have a big black population or Hispanic; we’re getting one, but one of the criticisms by the National Institute of Health and HRSA (Health Resources Service and Administration), for instance, is that we don’t have a minority population, so we don’t create programs for minorities. Well, if you look at Appalachia, that’s a minority. If you look at white poor people in western Kentucky, that’s a minority. They need to change their definition of a minority as black, Hispanic, Asian, or people of color to one that includes impoverished folks in Appalachia and Western Kentucky.
Was there a pivotal time when the state changed policy directions or missed a key opportunity to improve oral health?
Dr. Cecil: I think most of us public healthers would look at the 1980s as . . . where we lost. Part of it was . . . because we were really confident that TB (tuberculosis) had been eradicated essentially, and small pox. Then we found out that TB was coming back in a different form, resistant to antibiotics. A lot of the infectious diseases now are making a reemergence.
What strategies should the state use to remedy the current poor status of oral health?
Dr. Cecil: It’s funny because I think there is a strategy and this harkens back to an earlier time . . . when my argument was that we don’t have a private sector out there in dentistry that’s going to support the treatment needed, much less the preventive needs, and public health needs to be both of those until the private sector can take on that responsibility. And the private sector has not and probably cannot since the private sector is based on demand for care and not need for care. So I think we have the need, and our position should be that the state will try to provide those services because nobody else will. I think . . . like AIDS . . . oral health is a public health problem, and our citizenry is not able to meet its goals and objectives to become successful.
What effects do you see the aging of the population having on oral health?
Dr. Cecil: That’s a big issue. People are keeping their teeth longer, which means as they get older they’re apt to have more and more oral health needs, and more and more of us are taking drugs that affect oral health negatively. I think we dentists like to treat the healthy adult in their early and middle years, but somebody has got to treat those elder folks. A colleague is trying to find money to do some trials in nursing homes and show staff how to take care of elders’ teeth. Whether they’re alert or not, if you let those infections get out of control, their heart disease goes wild, their diabetes becomes uncontrollable, so it’s necessary to keep those structures healthy, even in old people. Taking their teeth out is not the answer, and that is an answer, but I don’t think that is a humane way to treat our elders. I wouldn’t want my mother to have to go through that at her age. So aging is going to be an issue, and we’re not adapting as professionals to those changes. I don’t see it happening. Education and curricular change are very slow, and it takes a long while to get a faculty to look at what’s really going on.
Do you see the increased focus on cosmetic dentistry as encroaching on the availability of dentists over time?
Dr. Cecil: I do. Also, not only is the population aging, the dentists are aging. About half the dentists in Kentucky are 50 or better, and we’re not replacing them. We have two dental schools, and I think about 30 graduates stayed in the state last year, and the rest of them left for various reasons. Some may come back, but if you’re not replacing yourself, then chances are you’re going to get further and further behind as the population grows.
Do you see issues just over the horizon that you think are going to pop up in the next five to ten years, maybe even further out, with respect to oral health trends, that we could do some things now to get our arms around these issues?
Dr. Cecil: I think dentists are going to have to be trained more as partners with physicians on the medical side of the house, so we treat patients collectively. Somebody who has periodontal disease and heart disease we ought to be treating with a heart-oral health kind of complex. I think we’re going to find more and more of those diseases, particularly infectious diseases, that are related to the inflammation and infection in oral diseases, and we’d better be prepared for that. Physicians are not, dentists are not right now, even though I spend a lot of my time trying to get the message out to both sides. I gave a presentation the other day to pediatricians at UK, and they looked at me in dismay and said, “What are you talking about, just teeth?” And I said, “Well, let’s look at the infection to oral cavity in kids and adults. Could you live in that mess if it were on your hand? Would you go see a doctor about it, would you go seek care for that?” The linkages between all the diseases and our training need to change to address those issues.
I think we’re going to see some new emerging diseases, not just in oral cavity, but it’s going to affect the oral cavity. For example, . . . viruses are making comebacks, and I think that we need to be aware of them. Pandemic flu is another one dentists are going to be involved with eventually. What do you do with people who are infected with pandemic influenza? You don’t send them to the hospital because they’re going to infect everybody in the hospital. One of my suggestions has been that, if we have an epidemic or pandemic, maybe we ought to send them to dentist offices because they’re little hospitals and they can isolate people and see to their nutrition, they can provide medicines, surgery if needed and we won’t infect a 200- or 1,000-bed hospital. So we have to think a little more globally than we do now, than dentists do, about how we’re situated. We’re not solo practitioners any more because of the insults being made on our society all the time. Infectious diseases, terrorism, I think our role is going to change.
The opinions expressed in this interview do not necessarily represent the views of the Kentucky Long-Term Policy Research Center or its Board of Directors.