A controversial state educational testing program has supplied the Colorado press with extraordinary editorial opportunities—and, through analogy, provided insight in evaluating the recommendations of the recently released "Oral Health in America: A Report of the Surgeon General."

Colorado legislators have proposed that teachers be rated according to their students’ performances on standardized tests. One newspaper writer, arguing that these legislators were "misguided," used an interesting tongue-in-cheek analogy to make her point. She "reported" on a program that would gauge dentists’ effectiveness by the caries levels in their young patients.

The number of cavities in each patient at different ages would be recorded, wrote the columnist. On the basis of these numbers, the dentists then would be rated on a scale from "excellent" to "unsatisfactory." Just as has been proposed in the case of Colorado teachers, these ratings would tell parents who the best dentists were. Furthermore, she wrote, it ostensibly would "encourage the less effective dentists to get better, and poor dentists who don’t improve could lose their licenses."

The columnist went on to describe the response of a hypothetical dentist who had been subjected to this "let’s improve the oral health of everybody" program.

"That’s terrible," she "quoted" him as saying. "That’s not a fair way to determine who is practicing good dentistry. So much depends on things we can’t control.

"For example," the hypothetical dentist continued, "I work in a rural area with a high percentage of patients from deprived homes. Many of the parents I work with don’t bring their children to see me until there is a problem. Also, many of the parents let their kids eat too much candy, and many of my patients have well water, which is untreated and has no fluoride in it.

"My work is as good as anyone’s," the dentist said in conclusion, "but my average cavity count is going to be higher than a lot of other dentists’ because I choose to work where I am needed most."

The columnist’s summation: "A performance evaluation that ignores the vastly different conditions under which people work is unfair and doomed to fail."

We in dentistry know well how true this is.

Difficulties in accessing dental care, especially for underprivileged children, have received nationwide attention with the recent publication of the surgeon general’s report. While citing dramatic improvements in oral health during the past 50 years, the report pointed to a "silent epidemic" of oral disease that "burdens" some population groups.

These "profound" health disparities, the report continues, are to be found primarily among "those without the knowledge and resources to achieve good oral care." Specifically mentioned were poor Americans, especially children, the elderly, members of racial and ethnic groups, and those with disabilities and complex health conditions.

Disadvantaged children’s oral health has dramatically improved. In the 1970s, children at or below the poverty line had 2.14 untreated carious permanent teeth. By the 1990s, that statistic had dropped dramatically to 0.46, a 78 percent reduction. Similar reductions were noted for primary teeth.

Nevertheless, challenges remain. In a recent issue of Pediatrics, a nationwide study of unmet health needs showed that 7.3 percent (4.7 million children) experienced at least one unmet need for health care annually. Those in need of dental care topped the list with 5.3 percent (3.4 million); the percentage with unmet medical needs was 1.6 percent.

The surgeon general’s report calls for a national partnership that would provide "opportunities for individuals, communities and the health professions to work together to maintain and improve the nation’s oral health."

It is encouraging that oral health is now receiving the attention warranted by its importance to overall health. But expectations should be tempered with reality. Not all Americans, even those who have the resources to achieve optimum oral health, will avail themselves of the opportunity. For some, it will take years of innovative programming before oral health becomes a major priority.

Still, there are many actions that can be taken to break down existing barriers to obtaining dental care—adequate payment to dentists, for example. In many states, Medicaid is underfunded, in some instances paying the provider less than overhead costs.

Compounding the payment issue are administrative constraints and snafus that frustrate even the most committed dentist. Eligibility verification, inordinate payment delays and complicated preauthorization requirements often find dentists treating without even bothering to submit a claim.

Increasing dentist reimbursement does appear to increase provider participation. One state appears to be aggressively attacking the reimbursement issue by enrolling its residents who are eligible for the Children’s Health Insurance Program in private dental insurance programs that pay the dentist’s usual-and-customary fee, with no patient copayment.

For those enrolled, utilization rates approximate those of patients with private dental insurance. But even with extensive recruitment initiatives, enrollment has lagged behind expectations.

Thus, even with insurance, some children have unmet oral health needs. This suggests that insurance alone is not sufficient to close the gap between higher-and-lower income children.

Income, education, ethnicity, immigration, acculturation, language, public transportation, location of the health facility, travel costs, child care, parent(s) taking time off work—these are just a few of the factors that affect access.

The same energies dedicated to achieving sufficient provider remuneration also need to be directed at removing barriers to access. Even assuming uniform access and utilization, it is still conceivable that differences in oral health status may continue. As evidence, consider recently published research that points to the relationship between lead ingestion and dental caries. This research offered evidence that significant amounts of dental caries could be attributed to moderate and high lead levels in children.

While one report is not sufficient to establish a cause-and-effect relationship, the strength of the lead-caries association may help explain the higher caries rate noted in certain populations.

The surgeon general’s report on America’s oral health paints a generally positive picture of our country’s oral health status. While it points out the past success of American dentistry, it also encourages public-private partnerships to take oral health to the next level. This lofty goal will not be achieved in minutes, days or months. It will require vision, leadership energy, resources, persistence and commitment.

It’s simply not simple—but ultimately worthwhile.