An annual report card that looks at the which states have the healthiest teeth and gums in the U.S., ranks Montana 43 overall. On the other hand, the report produced by the personal finance website WalletHub, said the state is third for the most dentists per capita.

In an interview with the Association of Health Care Journalists, WalletHub analyst Jill Gonzalez said academic experts “helped establish the 25 key metrics most representative of the overall dental health of a state.”

That included everything from highest and lowest percent of adults and adolescents who visited a dentist in the past year to the highest and lowest dental treatment costs, highest and lowest sugar-sweetened beverage consumption and highest and lowest percent of adult smokers.

Montana’s low ranking is tied, in part, to three daunting statistics:

• It has the highest percent of adults with poor or fair oral condition.
• The state is tied for second with West Virginia for the highest percent of adults who experienced oral pain in the last year.
• The state ranked among the worst for the highest percent of adults with low life satisfaction due to oral condition.

While all of the data in the report card is important, Gonzalez said, it isn’t all considered equally.

“For instance, the Dental Treatments Costs, the Poor or Fair Oral Condition and Pain Due to Oral Condition metrics have double weight, since the costs and the oral condition of a state’s population were considered the most important indicators of dental health,” she said.

By comparison, Montana’s neighbor to the east, North Dakota, ranked 2nd overall for dental health, ranking third lowest for the percent of adults who experienced oral pain in the past year and coming in first for the lowest percent of adults with low life satisfaction due to oral condition.

According Gonzalez, a key driver of oral health in a state is if policies are in place to support adequate oral hygiene. That includes subsidized options for the public and if it’s included as basic coverage in all health insurance policies.

In Montana, there is no mandate for dental insurance to be included as part of basic coverage. Al Garver, executive director of the Montana Dental Association, suggests another factor also plays a part.

“The single greatest driver that affects access is the low reimbursement rate for Medicaid that’s even less than cost,” Garver said. “Dentists are losing money on most Medicaid patients, but they accept as many as they can.”

Some dentists, including Brewer Dental Center in Billings, participate in Dentistry from the Heart, where, for one day a year, they offer basic services for free to kids and adults. And children in low-income families can be covered for dental care through the Healthy Montana Kids program.

The dental clinic at RiverStone Health in Billings provides a sliding-fee scale for its dental patients, based on income and the number of people in a household, said Dr. Amy Gustafson, dentist and associate dental director at RiverStone.

“A big portion of our patients are without insurance,” Gustafson said. “That sliding-fee can help them with the cost of care.”

There are other dental clinics in Montana that offer similar sliding-fee scales, including in Butte, Missoula and Bozeman, she said.

Accessing dental care is important for more than just keeping a pretty smile, Gustafson said. The most obvious is the ability to eat healthy food, but there are other issues.

“When one part of the body is unhealthy, it can lead to other ailments,” she said.

People with diabetes tend to have other health issues such as periodontal disease, Gustafson said. Dental bacteria can cause inflammation in the arteries of the heart.

Fear can keep people away from dentists, she said. But waiting until a tooth aches to get treatment only makes things worse.

“It’s much better to go when you’re not having pain and catch things early because the fix is simpler than waiting until it causes pain,” she said. “By the time something starts to hurt, we’re usually at a much more challenging place.”

One other factor may be involved in the state’s poor oral health rating: a lack of fluoride in the drinking water. According to the Center for Disease Control and Prevention, drinking fluoridated water helps keep teeth strong and reduces cavities by about 25 percent both in kids and adults.

Fluoride is naturally present in most drinking water. Levels in the Yellowstone River, the source of city water, average 0.4 parts per million. Under a fluoridation program, that level would be increased to 0.7, what is considered the optimal level.

The CDC has named community water fluoridation one of 10 great public health achievements of the 20th century. Yet only three communities in Montana, Scobey, Bozeman and Miles City, add fluoride to their public water systems.

Three times in the past 51 years, Billings residents have voted against adding fluoride to the city water supply, the last vote taking place in November 2002.