by Pete Fos and Linnae Hutchison
While safe and effective prevention measures exist for the most common dental diseases,1 i.e., dental caries and periodontal diseases, there are disparities in access to and utilization of these measures. The goal of the Healthy People 2010 oral health focus area is to prevent and control oral and craniofacial disease, conditions, and injuries, and improve access to related services.2 According to the Rural Healthy People 2010 survey, oral health ranked in fifth place among the 28 Healthy People 2010 focus areas, receiving priority ratings from about 35 percent of the respondents.3 It was rated as a priority most frequently by state organizations, rural health centers and clinics, and local public health agencies; it was least frequently identified as a priority by hospitals. No significant differences emerged in this regard across geographic regions.
The report describes methods to address the following Healthy People objectives:2
· 21-1. Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth.
· 21-2. Focus on untreated dental caries. The objective is to reduce the proportion of children, adolescents, and adults with untreated dental decay.
· 21-3. Increase the proportion of adults who have never had a permanent tooth extracted because of dental caries or periodontal disease.
· 21-4. Reduce the proportion of older adults who have had their natural teeth extracted.
· 21-5. Reduce periodontal disease.
· 21-6. Increase the proportion of oral and pharyngeal cancers detected at the earliest stage.
· 21-7. Increase the proportion of adults who, in the past 12 months, report having had an examination to detect oral and pharyngeal cancers.
· 21-8. Increase the proportion of children who have received dental sealants to their molar teeth.
·
21-9. Increase
the proportion of the
· 21-10. Increase the proportion of children and adults who use the oral health care system each year.
· 21-12. Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year.
· 21-13. Increase the proportion of school-based health centers with an oral health component.
· 21-14. Increase the proportion of local health departments and community-based health centers, including community, migrant, and homeless health centers that have an oral health component.
Dental caries is the most common chronic disease suffered by children.1 More than 50 percent of all children experience dental caries by the age of eight years, and about 80 percent of all children have dental caries by age 18.4 Compounding the problem is the fact that 25 percent of children in the U.S. have not seen a dentist by age six.1
While the incidence of dental caries in permanent teeth has significantly decreased in school-aged children since 1970, a disparity exists in prevalence of dental caries across socioeconomic and geographic subgroups in the population. Low-income children have two times greater prevalence of dental caries when compared to other children. While dental sealants have been proven effective in reducing the incidence of dental caries among children, only 3 percent of poor children have dental sealants compared to 23 percent of children overall.2 Racial disparities are also striking. Among children, 36 percent of African Americans and 43 percent of Hispanics have untreated dental caries, compared to 26 percent of whites.2
Periodontal disease is positively correlated with age across all socioeconomic and geographic subgroups in the population. Periodontal disease is more frequently found in African Americans and low-income adults. Thirty-five percent of adults with less than a high school education have periodontal disease compared to 28 percent of high school graduates, and only 15 percent of those with high school and some college.5
Oral and pharyngeal cancers account for approximately 2 to 4 percent of all cancer cases in the United States.6 Overall, men have an incidence rate 2.6 times that of women with 14.8 per 100,000 versus 5.8 per 100,000 among women. African Americans have a higher rate than whites (12.4 per 100,000 and 9.7 per 100,000, respectively). In particular, African-American males have the highest reported rates.
A distinct disparity is seen in the survey data between urban and rural areas, revealing dental caries among children and adults to be more prevalent in rural populations than in urban populations. In 1999, rural adults were less likely than urban adults to have had a dental visit in the past year. Within urban areas, 67.1 percent of the total survey sample had a dental visit in the past year. In rural areas, only 58.3 percent of the sample survey had a dental visit in the past year. Studies also indicate that children in rural areas have more dental caries experience than urban children.7
The age-adjusted prevalence rate
of edentulism, total tooth loss, in the
Oral health directly affects general health. Oral diseases and conditions are not limited to the oral cavity and supporting structures, but they affect the entire body and body systems. Associated health problems include pre-term low birth weight babies, cardiovascular disease, diabetes, and respiratory disease.
About 30,000 new cases of oral and pharyngeal cancers are diagnosed annually, along with the occurrence of about 7,500 deaths.9 While being a relatively rare occurrence, these cancers carry one of the lowest survival rates of all. Eighty-two percent of these patients will survive at least one year after diagnosis, while only 50 percent will have a survival of greater than five years.10
Overall, the trend in the proportion of persons who experienced a dental visit in the past year has remained constant over recent years, and the same is true for most subgroups. But, disparities among subgroups in the population are observable across urban/rural areas, race, ethnic group, age, and income level. The causes of the oral health disparity between urban and rural areas can be traced to several factors that can be categorized as access to care and utilization, economic, and dental resources.
Challenges to access to care include lack of dentists, inadequate supply of dentists who accept Medicaid or other discounted fee schedules, reluctance by dentists to participate in managed care programs, socioeconomic nature of rural populations (poverty, low educational attainment, cultural differences, lack of transportation), and absence of a coordinated screening and referral network.11
Ability-to-pay, including access to health and dental insurance, is an important determinant of receiving adequate and necessary dental care. According to the Surgeon General’s report, children with dental insurance are 2.5 times more likely to receive dental care than children without dental insurance. However, less than 20 percent of children with Medicaid insurance coverage receive one dental visit each year.1
Income level is a major factor contributing to utilization of access to care. Adults living in poverty (income at 200 percent of the federal poverty level or below) are less likely to receive dental care than wealthier adults. Among people who are considered non-poor (incomes 200 percent or greater than the Bureau of the Census poverty threshold), 72 percent had a dental visit the past year.12 Among the near poor (incomes of 100 percent to less than 200 percent of the poverty threshold), the percentage dropped to 48.5 percent in 1999. Among the poor (incomes below the poverty threshold), the percentage is even lower at 46.2 percent having a dental visit the past year.12
A significant barrier to oral health care in rural areas is the lack of an adequate dental workforce. The distribution of dentists in large metropolitan areas is over 60 per 100,000. In rural cities, the ratio is 40 dentists per 100,000; and in rural non-city areas, it decreases to about 30 per 100,000 population. This disparity may become more serious as the supply of dentists decreases due to declining numbers of dental students and an increase in the number of retiring dentists.13
PROPOSED SOLUTIONS
A number of approaches have been utilized in an attempt to improve the oral health status of the United States¾especially for at-risk populations. Partnerships between states and dental providers have been attempted to increase access to care through Medicaid. “Health commons” is an approach that has been used for low-income rural populations.14 “Health commons” is a creative, community-based approach that is designed to develop collaborative activities in an attempt to solve oral health problems in disadvantaged populations. “Health commons” sites are integrated primary care practices that include medical, dental, behavioral, social, and public health services.
It has been found that children who participate in Head Start have high rates of dental caries.15 Given this finding, another method proposed to address the oral health dilemma is expansion of the Head Start programs to target areas in which children demonstrate unmet need as well as move toward a comprehensive, integrated treatment program.15
Another mechanism that may prove effective in improving oral health is dental insurance reforms. Less than 20 percent of all Medicaid children receive preventive dental services each year.16 Additionally, Medicaid programs in most states do not provide any adult dental services. Expansion of Medicaid coverage and improvement of access to Medicaid dental services could have a beneficial effect in eliminating the disparity seen in rural areas, provided expansion includes addressing the lack of dental providers.
Flouridation or alternative methods to deliver fluoride (toothpastes, mouth rinses, and professionally applied gels) may also improve the oral health status of rural areas. Benefits from fluoridated community water supplies have been reported to range from an 11 to 40 percent reduction in dental caries.17 Dental sealants have also been proven to be a cost-effective preventive strategy.
Finally, improving oral health is contingent on the availability of professionals, especially in underserved areas. Given the decreasing trend in the number of dental care professionals, other health care professionals must be included in the dental team. A coordinated, collaborative effort is needed to address the disparity in oral health status throughout the nation. Several potential efforts include involving pediatricians and others in the oral health care of children. Establishment and/or expansion of school-based dental services utilizing school nurses may also prove valuable in improving children’s oral health.
Regarding oral and pharyngeal cancers, over three-fourths of these cancers are present in areas readily visible or palpatable during an oral examination. Regular examinations by a health professional offer primary and secondary prevention opportunities by diagnosing the cancer in its early stages.18
While the overall oral health status has improved in this nation over the past 30 years, there is a stark contrast in oral health and dental caries experience among specific subgroups in the population. These groups include rural populations, racial and ethnic minorities, low-income populations, elderly, and special needs populations.
The overriding cause of
this disparity seems to be access to care. There are many determining factors
for access to care, including: income, educational attainment, area of
residence, dental workforce, and dental insurance. An interaction effect exists
among these factors, compounded by specific subgroup characteristics. Many efforts
have been undertaken to improve access to care, with some success. Ultimately,
it is important to recognize and understand that no one intervention will
successfully eliminate the existing oral health disparity in the
The following models for practice are examples of programs utilized to address this rural health issue.
1.
2.
3. Gamm, L.; Hutchison, L.; Bellamy, G.; et al. Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health 18(1):9-14, 2002.
4. Kaste, L.M.; Selwitz, R.H.; Oldakowski, R.J.; et al. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. Journal of Dental Research 75:631-641, 1996.
5. Cho, I. Disparity in our nations
health: Improving access to oral health care for children.
6. Centers for Disease Control and Prevention (CDC). Oral Cancer: Deadly to Ignore. 2002. <http://www.cdc.gov/OralHealth/factsheets/oc-facts.htm>June 4, 2002.
7.
8. Eberhardt, M.S.; Ingram, D.D.; Makuc,
D.M.; et al. Urban and Rural Health Chartbook.
9. Silverman, S. Demographics and occurrence of oral and pharyngeal cancers. The outcomes, the trends, the challenge. Journal of the American Dental Association 132:7S-10S, 2001.
10. American Cancer Society. What are the key statistics about oral cavity and oropharyngeal cancer? 2001. <http://www.cancer.org/eprise/main/docroot/cri/cri_2_3x?dt=60>June 4, 2001.
11. National Rural Health Association. Rural Clinician Quarterly 10(2), 2001.
12. Burt, B.A., and Eklund, S.A. Dentistry, Dental Practice, and the Community, 5th ed. Philadelphia, PA: W.B. Saunders Co., 1999, 205-206, 237-258.
13.
14. Beetstra, S.; Derksen, D.; Ro, M.; et al. A “health commons” approach to oral health for low-income populations in a rural state. American Journal of Public Health 92(1):12-13, 2002.
15. Edelstein, B.L. Access to dental care for Head Start enrollees. Journal of Public Health Dentistry 60(3):221-229, 2000.
16.
17. Newburn, E. Effectiveness of water fluoridation. Journal of Public Health Dentistry 49:279-289, 1989.
18. CDC. Current trends examinations for oral cancer¾United States, 1992. Morbidity and Mortality Weekly 43(11):198-200, 1994.
19.
20.
Chapter Suggested Citation
Fos, P., and Hutchison, L. (2003). The State of Rural Oral Health. Rural Healthy People 2010: A
companion document to Healthy People 2010. Volume 1.
MODELS FOR PRACTICE
FOCUS AREA: ORAL HEALTH
Program Name: Choptank Community Health System’s Oral Health Prevention Program
Location:
Problem Addressed: Oral Health
Healthy People 2010 Objective: 21-1, 21-8, 21-10, 21-12
Web Address: None
The Eastern Shore of Maryland suffers from a disproportionately high incidence of children’s dental disease compared with national averages. To combat this problem, the Choptank Community Health System (CCHS) embarked on an innovative approach to not only provide primary dental services to an otherwise underserved population but also oral health prevention services. By using a school-based oral health prevention program combined with the establishment of a dedicated dental clinic for restorative and diagnostic care, CCHS has begun to address the serious oral health problem facing this underserved rural community.
Blueprint: The
school-based oral health prevention program is delivered in two rural counties
of
Employed by
CCHS, a Federally Qualified Health Center (FQHC), are two part-time dental
hygienists and a dental assistant who provide services three days per week in
The dental programs are designed to deliver oral health prevention services to low-income children living in rural areas, regardless of their ability to pay. All children enrolled in the school-based wellness center program are eligible to receive services through the school-based dental programs. Children requiring diagnostic and restorative care are referred to their family dentist or the Choptank Community Dental Clinic, which opened in 2001.
Making a Difference: During the initial pilot period of March
through May 2001, approximately 58 percent of
The program has
expanded to a second elementary school in
Beginnings:
In the state of
SBDP was
initiated in spring 2001 in two locations:
Year One initial funding for the Caroline County SBDP came from a
grant from the Maryland Governor’s Office for Children, Youth, and Families
through the Caroline Human Services Council. The Caroline County SBDP received
approval for Year Two funding from the same grant source. In
Challenges and Solutions: Recruitment of allied dental health professionals is the
foremost challenge facing the program.
To its funding challenge, SBDP, which operates under CCHS (a FQHC), is able to bill all third-party insurers and to bill medical assistance programs at the FQHC rate, which is cost based. It is anticipated the program will be self-sustaining in the future through third-party reimbursements.
To promote the dental program, a variety of dissemination channels are utilized including newsletter mailings, brochures, direct mailings, assistance through the Eastern Shore Oral Health Outreach Project, and local publicity.
Scott Wolpin, DMD, Dental Director and
Brie Breland, RN, MPH, Program Development Director
Choptank Community Health System’s Oral Health Prevention Program
Phone: (410) 754-7583
Fax: (410) 754-7719
MODELS FOR PRACTICE
FOCUS AREA: ORAL HEALTH
Program Name: FirstHealth of the
Location:
Problem Addressed: Oral Health
Healthy People 2010 Objective: 21-1; 21-2a, b, c; 21-8; 21-10; 21-12; 21-14
Web Address: http://www.firsthealth.org
The FirstHealth of the Carolinas Dental Health Program serves
five counties in central
Blueprint: The
FirstHealth of the Carolinas Dental Health Program
delivers dental health services through three established clinics to five nonmetropolitan counties in central
Making a Difference: FirstHealth Dental Program opened the first of three clinics in 1998. To keep the doors open, it embarked on a diligent mission of seeking financial sustainability. In addition to maintaining strong relationships with charitable foundations, FirstHealth also seeks funding through national, state, and local resources. A significant portion of FirstHealth’s funding was obtained through the Community Voices Initiative of the W.K. Kellogg Foundation.
FirstHealth utilizes a variety of performance measurements including process, outcome, and perception indicators. By tracking the number of patient encounters, health care coverage status, and demographics, the data revealed that as of April 2002, the three centers had treated almost 65 percent of the approximately 12,000 underserved and uninsured children in the service area. This is in stark contrast to the state average of 22 percent. Outcome indicators reveal that the centers increased by 600 percent the number of children receiving sealants, transitioned more than 30 percent of children into preventive maintenance status, and achieved a no-show rate of 16 percent. Comparatively, the national no-show rate is 30 percent. The program also monitors financial indicators. As anticipated, FirstHealth’s expenses exceed revenues by 9 percent; however, the difference is supplemented by grants and the FirstHealth Community Benefit Program.
Finally, FirstHealth is a pioneer in the use of nontraditional providers as a mechanism to address the shortage of dental providers. FirstHealth offers training sessions to pediatricians and family practitioners, which are designed to instruct these providers on applying fluoride varnishes to small children’s teeth. To date, 140 physicians, nurses, and clinical staff have been trained to deliver this service.
Beginnings: FirstHealth Dental Health Program began with a
public outcry from public health hygienists and school nurses to FirstHealth of the Carolinas, which is a not-for-profit,
integrated health care system serving the mid
Three clinics
(one full time and two part-time) were opened in the nonmetropolitan
counties of
Challenges and Solutions: FirstHealth of the
FirstHealth also realized that since the patients
were not privately insured, a deficit was inevitable. Therefore, FirstHealth subsidizes the program through the FirstHealth Community Benefit Program. FirstHealth
has also pursued a variety of other funding sources including the American
Dental Association,
Another challenge encountered by the program was uncertainty by local dentists as to the need for FirstHealth to provide dental services. However, the task force (which included local dentists) reviewed data on the dental crisis and determined the need for FirstHealth’s Dental Program.
FirstHealth Dental Program utilizes a variety of channels to publicize its program to clients at the community and state level. The program also pursues policy changes in order to have the greatest impact on improving access. Locally, FirstHealth works closely with local schools and provides informational materials to every elementary school child. The program has also implemented a variety of other creative publicity measures targeting local, state, and charitable sponsors.
Sharon Nicholson Harrell, DDS, MPH, FAGD
FirstHealth of the
Phone: (910) 692-5111
MODELS FOR PRACTICE
FOCUS AREA: ORAL HEALTH
Program Name: Miles
for Smiles
Location: Western
Slope Region of
Problem Addressed: Oral Health
Healthy People 2010 Objective: 21
Web Address: http://www.kindsmiles.org
Miles for Smiles provides
comprehensive dental services and school-based dental education to children and
families residing in the western slope region of
Blueprint: Miles for Smiles is a collaborative effort between Denver, Colorado-based KIND (Kids in Need of Dentistry); Southwest Community Resources (SCR) under which Miles for Smiles is housed; Montrose Memorial Hospital, which provides oversight of the mobile clinic and non-profit dental clinic; Northwest Colorado Dental Coalition; and Catholic Charities.
Miles for Smiles delivers comprehensive dental services and school-based dental education to children ages 0 to 18. These children fall through the safety net between public assistance (Medicaid) and private insurance. The mobile clinic functions as a full-service dental office including two operatories, x-ray, lab, sterilization system, and computer network for medical records and scheduling. A full-time staff dentist, dental assistant, and dental technician travel with the unit. A program director oversees the program while volunteer dentists, hygienists, dental assistants, and community volunteers aid in the program’s delivery at the local level.
Although the mobile unit travels to 16 counties, the program is operated locally through the involvement of each community. The local community is responsible for daily operations and ensuring continued community support, partnerships, and local financial sustainability. The key players at the community level include a local advisory board, sponsoring organization, local dental professionals, and a local coordinator. The local program coordinator is responsible for scheduling appointments; determining patient eligibility; coordinating and scheduling local dental professionals; invoicing, billing, and monthly reporting to KIND; and coordinating oral health education programs, marketing, outreach, and public awareness. Given the vast service area, it is impossible for the unit to provide after hours and emergency care. Therefore, local dental professionals play a vital role by providing emergency and after-hours dental services when the unit is out of town. Local dental professionals also donate in-kind storage space, supplies, equipment, and provide assistance with fundraising and community partnering. KIND staff provide supervisory support and expertise in the operation of the program.
Making a Difference: The program contracts out the evaluation component. Process, program, and outcome evaluations are conducted. The process evaluation component looks at timelines, support, and collaboration. The program evaluation looks at patient demographics, number of visits, types of follow-up, and number of dental caries. Finally, the outcome evaluation concentrates on determining if the program has made a difference in the clients served. Variables included in this measure are dental health access, dental disease, and decay. Since the program’s initiation, the Miles for Smiles unit has visited 11 communities, provided $246,000 worth of service, and seen over 600 children. For approximately half of the new patients, the mobile unit visit is the first visit to a dentist.
Beginnings: In
a 1994 study of the oral health status of Coloradoans, nearly 300,000
underserved children needed restorative care, and over 50 percent of
Denver-based
Kids in Need of Dentistry is the parent organization for Miles for Smiles. KIND
is a non-profit charitable organization founded in 1912 and is the oldest
dental charity in the country. Until 1997, KIND focused on delivering dental
services to metropolitan
Challenges and Solutions: The western slope of
To address the
problem of a lack of dentists, the program posted position opening notices at
54 dental schools, the
Another obstacle is the lack of data regarding school absences and emergency room visits attributable to dental problems. To address this problem, the program developed an oral health classification scheme for each patient, which allows patients to be tracked at each dental visit.
While the program is relatively new, the program’s oral health education campaign has received endorsement by the Colorado Dental Hygienists Association.
Michelle Thornton
Miles for Smiles
Phone: (877) 544-5463 ext. #4
Fax: (303) 733-3670
MODELS FOR PRACTICE
FOCUS AREA: ORAL HEALTH
Program Name:
Location:
Problem Addressed: Oral Health
Healthy People 2010 Objective: 21
Web Address: None
Seal a Smile, part
of the Price County Health Department, is an oral health program providing
services to all second and seventh grade students in public, private, and home
schools, as well as the uninsured and underinsured in
Blueprint: Seal a Smile delivers services through the schools, Price County Health Department, and Head Start. Seal a Smile provides several programs including:
Seal a Smile is staffed by one paid staff member, donated time by three staff members of Price County Health Department’s Dental Health Program, and volunteer staff consisting of six dentists, nine registered dental hygienists, and five dental assistants. The WIC program, Prenatal Care Coordination program, and Family Planning and Medical Assistances are all part of the Health Department and provide referrals and support staff to the Seal a Smile Program.
Making a Difference: For the 2001-2002 school year, 255 students (68 percent of the student population) received dental screening services; 183 students (73 percent of students screened) received sealants, with a total of 800 sealants applied. Placing the sealants represents a $20,000 cost savings to parents. The dental sealant program retention rates for second and seventh graders was 98 percent. These numbers reflect a significant increase in program utilization and services provided each year since the program’s inception.
Beginnings:
Seal a Smile began in
September 1999 and was fully implemented in October 2000 in response to the
need for children’s dental care. The problem of dental access was identified by
the Health Department through needs assessments and lack of providers who would
accept
Challenges and Solutions: The greatest challenge for the program is finding continued
funding. The overall goal of the Price County Health Department is to continue
the Seal a Smile Program as long as funding is available. The potential to
charge for some services through the State of
A second challenge is in finding a dentist who will accept children identified as acute care clients, including low-income children. Additionally, a dentist is needed to conduct the state-law-required prescription examinations on the children in the schools, giving dental hygienists permission to place the sealants. There is overwhelming evidence that the Seal a Smile program would become a permanent program if it was possible to overcome the challenge of finding a dentist to take clients through the program’s case management services.
Future plans for
the program include beginning a Fluoride Varnish Program through the WIC and
Health Check programs and an Elder Care Dental Health Program. Public
presentations, writing to
Nancy Rublee or Tracy Ellis
Phone: (715) 339-3054
Fax: (715) 339-3057
MODELS FOR PRACTICE
FOCUS AREA: ORAL HEALTH
Program Name: Rural Health Dental Clinic
Location:
Problem Addressed: Oral Health
Healthy People 2010 Objective: 21
Web Address: None
The Rural Health
Dental Program of northwestern
Blueprint: The
Rural Health Dental Program, through its outreach efforts, serves nearly
one-third of the northwestern portion of
The program
provides complete oral health treatment and prevention services, with the
exception of endodonics and orthodonics.
Due to the lack of major industry, most families live below the federal poverty
level, and most communities lack a water fluoridation system. Although families
qualify for public assistance, low reimbursement to providers prevents many
from accepting medical assistance patients. Therefore, this population is
extremely vulnerable to oral disease. To provide this service, four clinics are
located throughout the area and housed in consortium member agency buildings (
Staffing has expanded over the course of the past five years to include four part-time dentists, two full-time dentists, two full-time dental hygienists, four full-time dental assistants, and a director. The patient population includes low-income families (below 185 percent of federal poverty level), individuals with disabilities, and those living in supervised-care facilities.
Making a Difference: In 2002, the program anticipated over 6,000 visits. The clinics historically report 4,000 patient encounters per year, and each clinic has a waiting list of over 300 patients. As part of the program’s evaluation and assessment, patients are tracked by age, ethnicity, disability, income level, and type of services received.
Beginnings: The program began in 1996 in response to the frustration of the CESA 11 Head Start health coordinator in finding dental providers for Head Start children. Annual dental exams are required for children enrolled in the Head Start program; however, due to low reimbursements, many dental providers stopped accepting medical assistance patients. The coordinator applied for and received a three year Federal Rural Health Outreach Grant. Continuation funding for 1999-2001 was facilitated by the region’s U.S. Congressman. Funding for the center for 2002-2003 is through establishment of funding as a state budget line item.
Challenges and Solutions: The primary challenge is the difficulty in recruiting dentists to work with this patient population. Another challenge involves educating state and federal policymakers as to the need to expand medical assistance funding to encourage dental providers to accept more of these patients. The program is 50 percent self-sustaining through Medicaid reimbursement. Unfortunately, costs continue to exceed revenue.
The program has
received numerous awards and recognitions, including the Wisconsin Public
Health Association Distinguished Service to Public Health Award (1998); Head
Start Award for Promoting Oral Health (1998); and Wisconsin Maternal and Child
Health Coalition Achievement Award (1999). It was named as one of
Sharon Haugerud
Rural Health Dental Clinic
Phone: (715) 986-2020
Fax: (715) 986-2041