Temporary Dentures for People Experiencing Homelessness

Through a variety of programs, community partnerships, and services, the Los Angeles County (LAC) Department of Public Health (DPH) works to advance the conditions that support optimal health and well-being for all persons in LAC.  LAC DPH's vision is Healthy People in Healthy Communities.  Los Angeles County, the most populous county in the United States, encompasses over 4,000 square miles, has 88 incorporated cities, about 130 unincorporated areas, and is home to a racially, culturally, and linguistically diverse population of nearly 10 million.  In 2021, 48% were Hispanic/Latinx, 28% were White, 16% were Asian, and 8% were Black/African American.[1] 

As with many large urban areas, LAC is challenged with a growing population of people experiencing homelessness (PEH).  In September, the Los Angeles Homeless Services Authority (LAHSA) released the results of the 2022 Homeless Count.  There are nearly 69,150 PEH in LAC which is a 4.1% rise compared to 2020.^[2]  PEH populations are particularly vulnerable to barriers regarding access to health care including oral health care.  Oral health conditions such as missing teeth and tooth decay may contribute to anxiety and insecurity when engaging in social activities, seeking or retaining employment, and could lead to a reduced quality of life.[3] In LAC, 34% of adults 18+ have had a permanent tooth removed due to dental disease and lower income adults are significantly more likely to have missing teeth compared to higher income adults.^[4] There is a high prevalence of missing teeth and need for removable dentures among PEH.[5]

LAC DPH's Oral Health Program (OHP) strives to foster a community where oral health is recognized as essential for overall health and where everyone has the opportunity to achieve optimal health and well-being.  OHP explored and invested in an innovative way to address some of the challenges PEH face in obtaining dental care through the Temporary Dentures for People Experiencing Homelessness project.   OHP partnered with Western University College of Dental Medicine (Western), a local YMCA and Lava Mae, a non-profit organization that provides mobile showers and hygiene services to PEH, to launch a dental internship program. Through this internship, PEH can receive temporary partial dentures in one appointment. In addition, clients receive oral hygiene instruction and dental resources. The services are provided at the Lava Mae mobile shower site located at the Weingart East Los Angeles YMCA, a site that is well-known and frequented by the PEH community. 

The project goals are two-fold: 1) to increase access to dental services by providing dental care in a location where vulnerable populations are also receiving other essential services such as meals, clothing, and showers and 2) to increase the dental workforce in community-based settings by exposing students to working with underserved populations and encouraging the continuation of work in underserved communities after graduation. This model was made possible by leveraging partnerships to increase equitable access to care for the most vulnerable in our community to address their unmet oral health needs.   

[1] http://publichealth.lacounty.gov/epi/docs/2021-LAC-Population_Provisional.pdf

[2] The Los Angeles Homeless Services Authority, 2022 Greater Los Angeles homeless count.

[3] https://nhchc.org/wp-content/uploads/2021/07/OH-and-BH_NHCHC-NNOHA-6.2.21162.pdf

[4] Behavioral Risk Factor Surveillance System (BRFSS), 2020, https://www.cdc.gov/brfss/brfssprevalence/

[5] Seirawan H, Elizondo LK, Nathason N, Mulligan R. The oral health conditions of the homeless in downtown Los Angeles. J Calif Dent Assoc 2010; 38(9): 681-8

The Temporary Dentures for People Experiencing Homelessness project was developed to create an innovative oral health service access point to better reach this underserved population.  The project brings dental services to a location the community frequents and trusts.  Community organizations such as the YMCA, and Lava Mae assist in bridging trust between the dental student providers and the community they serve.  

This model calls for a paradigm shift to effectively meet the needs of the targeted population. The dental service is brought to the community outside the traditional four-walls of a clinic or office.  Oral health screenings and temporary dentures are provided once a week while Lava Mae, food distribution, and clothing donation events are held at the YMCA.  All dental equipment and supplies are portable and transported to the site by Western faculty and students.  Clients can receive their temporary denture within hours of being seen by the Western students and faculty.  If provided in a traditional dental setting, this service would require four appointments but having a one-day appointment ensures that the clients will receive their dentures as it can be a challenge for PEH to return for an additional appointment let alone multiple appointments. 

This innovative collaboration brings together two non-profit organizations, an academic institution, and a DPH program to provide dental services to a vulnerable population outside of the traditional clinical settings in conjunction with other essential services such as meal, clothing, and shower services.

Lava Mae is a nonprofit organization that delivers mobile showers and hygiene services to PEH.  They deliver their services on the streets of San Francisco, Oakland, and Los Angeles, in locations that PEH frequent.  In 2019, the OHP learned about a project that was taking place at the Lava Mae San Francisco site where PEH received a same day temporary partial denture.  After learning more details about the project and the many benefits to the Lava Mae clients, the OHP team decided to replicate this project in LAC.  OHP recognized that the LAC model would be best implemented as a dental student internship since OHP did not have the manpower to directly staff the project.  The OHP reached out to Western because (1) their dental school provides many student rotation opportunities throughout LAC and (2) the OHP has a good working relationship with Western.  After several meetings with Lava Mae, the site that was most appropriate for this project was the Weingart East LA YMCA.  The next step was to meet with the Weingart East LA YMCA administration.  After meeting, the OHP recognized they would be the perfect oral health champions as they provide the community with much needed services.  The OHP was the pivotal connector that designed the program and coordinated all partners to implement and sustain the project.

Lava Mae provides services at the Weingart East LA YMCA once a week during the YMCA's food distribution and clothing donation events.  The YMCA provides programs and services that are inclusive and welcoming to all.  OHP manages the student internship program and each semester, 3-4 fourth-year dental students are recruited by Western and selected by OHP to become interns.  The candidates go through the County's onboarding process and attend a training course developed by Western on how to fabricate a temporary denture in one appointment.  Interns are supervised by a Western faculty dentist, and OHP provides the equipment, supplies, and resources for the project. 

The total startup cost, which included equipment and consumable supplies, was approximately $3000.  The annual cost of restocking the consumable supplies is approximately $360.  The workforce is provided by student interns and the supervising faculty dentist.  To date, students have committed approximately 200 hours to this project.

As mentioned in the overview, the goals are two-fold: 1) to increase dental access to the community by ensuring that services are provided where vulnerable populations are receiving other essential services such as food, clothing, and showers and 2) to increase the dental workforce in community-based settings by exposing students to working with underserved populations and encouraging the continuation of work in underserved communities after they graduate.

Initially, the project consisted of fabricating a denture to replace missing upper front teeth. However, due to multiple requests, the project expanded to include replacing missing lower front teeth.  Since September 2021, 50 clients have been screened, and 21 clients were eligible to receive a denture.  All of the eligible clients received their denture due to the same-day process.  Clients receiving a denture ranged in age from 29 to 76 years, with the average age of 57.  Most of the clients were Hispanic/Latinx and Spanish speaking and most were from the food distribution event.  Clients built trust in the student providers once they saw that the students were providing continued services every week and learned that the service was of no-cost to them.  Based on conversations with the clients, students learned that the participants either have Medi-Cal (Medicaid) or no insurance.  Further evaluation is needed to determine if clients know that Medi-Cal includes dental benefits.  One client commented, I am happy and surprised that someone can put back a tooth without asking for too many things.”  As the project continues, there has been growing interest and word of mouth from the community that this service is provided at the site.  Although follow-ups on referrals to dental clinics was not tracked, some clients did seek dental care.  One client even sought dental treatment at Western.

There is growing interest by students to participate in the project.  The number of student applicants has increased from three to eight per semester. Students that completed an internship exit interview questionnaire indicated they would consider employment with public health and felt that they made significant contribution towards the program.  One student said that what they liked most about the internship was giving patients a reason to smile”.  Another student said, How even a temporary solution can provide people so much confidence to smile. Many of the people needed more than we could have provided on-site but did not have the means to go to a dental clinic. I was glad we were able to bring even a temporary solution to them.”  One intern plans to continue the internship next semester.  Western will conduct a one-year follow up with participating dental students to determine if they are working in community-based settings and/or with underserved populations.

All partners are invested in the project to ensure that it is sustainable after initial development.  The project enabled the YMCA and Lava Mae to provide more services and resources to their clients, and the OHP increased access to care to an underserved population.  These non-profit organizations are trusted by the community and are instrumental partners to enhancing access to care.  Western dental students received experiences in community settings that are beyond the traditional clinical settings.  Clients were able to receive their temporary partial dentures in one appointment at a site where they can receive other essential services.  This same-day procedure reduces missed appointments as 100% of the dentures fabricated were delivered.  The partial dentures give clients an opportunity to smile with confidence which may increase their quality of life.  OHP continues to provide financial support by restocking dental supplies and liaising with partners.

A comprehensive cost/benefit analysis cannot be determined as many benefits (i.e., improved self-confidence and quality of life, future employment) cannot be quantified.  Since the Medi-Cal Dental Program does not offer the same service, we used the most comparable procedures (Dental codes: D0140, D0330, D5211, and D5421) for approximately 3- 4 dental visits to create a temporary partial denture.  According to the Medi-Cal Dental Schedule of Maximum Allowance[1], these procedures amount to an estimated $335.  This project saves patient time (3-4 appointments) and money ($335).

Due to the success of the project and interest in serving another location, Western and OHP are planning to expand the project to an additional Lave Mae site in Lincoln Park in 2023. The internship project offers an innovative way to increase dental care access to populations that have challenges in obtaining oral health services and provides an opportunity for students to expand their interest in serving underserved populations in community-based settings.

[1] https://dental.dhcs.ca.gov/MCD_documents/providers/SMA_CDT22_Nov_22.pdf