THE U.S. ORAL HEALTH WORKFORCE IN THE COMING DECADE

WORKSHOP SUMMARY

Tracy A. Harris, Rapporteur

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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THE U.S. ORAL HEALTH WORKFORCE IN THE COMING DECADE WO R K S H O P S U M M A RY Tracy A. Harris, Rapporteur Board on Health Care Services

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. This study was supported by Contract No. 07-1587 between the National Acad- emy of Sciences and the California HealthCare Foundation and Contract No. HHSH250200446009I to HHSH250G6054 (#10) between the National Academy of Sciences and the Department of Health and Human Services. Any opinions, find- ings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-13904-5 International Standard Book Number-10: 0-309-13904-X Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2009. The U.S. oral health work- force in the coming decade: Workshop summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PLANNING COMMITTEE FOR THE WORKSHOP ON THE SUFFICIENCY OF THE U.S. ORAL HEALTH WORKFORCE IN THE COMING DECADE1 DAVID N. SUNDWALL (Chair), Executive Director, Utah Department of Health MARCIA BRAND, Associate Administrator for Health Professions, Health Resources and Services Administration DANIEL DERKSEN, Professor and Senior Fellow, RWJF Center for Health Policy at the University of New Mexico LEN FINOCCHIO, Senior Program Officer, California HealthCare Foundation SHELLY GEHSHAN, Director, Advancing Children’s Dental Health Initiative, Pew Center on the States ELIZABETH MERTZ, Program Director, Center for the Health Professions, University of California, San Francisco Study Staff TRACY A. HARRIS, Senior Program Officer JOI D. WASHINGTON, Senior Program Assistant ROGER HERDMAN, Board Director, Board on Health Care Services 1 IOM planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteur and the institution. 

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: MYRON ALLUKIAN, JR., American Association for Community Dental Programs DUSHANKA KLEINMAN, University of Maryland, College Park, School of Public Health PETER MILGROM, Northwest/Alaska Center to Reduce Oral Health Disparities, University of Washington WENDY E. MOURADIAN, University of Washington School of Dentistry CHRISTINE NATHE, University of New Mexico, Division of Dental Hygiene Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by ii

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iii REVIEWERS coordinator CARMEN GREEN, of the University of Michigan Medical School. Appointed by the Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review com- ments were carefully considered. Responsibility for the final content of this report rests entirely with the author and the institution.

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Contents 1 INTRODUCTION 1 Role of the Institute of Medicine, 2 Workshop Charge and Approach, 2 2 THE CONNECTION BETWEEN ORAL HEALTH AND OVERALL HEALTH AND WELL-BEING 5 3 CURRENT ORAL HEALTH NEEDS AND THE STATUS OF ACCESS TO CARE 9 Early Life Cycle, 9 Older Adults and People with Disabilities, 12 Rural Populations, 14 Indian Health Service, 16 African American Populations, 18 Hispanic Populations, 19 Reaction and Discussion, 19 4 CURRENT DEMOGRAPHICS AND FUTURE TRENDS OF THE ORAL HEALTH WORKFORCE 23 The Dental Workforce, 23 The Nondental Oral Health Workforce, 28 Reaction and Discussion, 34 5 CURRENT DELIVERY SYSTEMS 39 Private Practice, 39 ix

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x CONTENTS Medicaid-Focused Practices, 42 Community Health Centers, 43 Reaction and Discussion, 45 6 END-OF-DAY DISCUSSION: DAY 1 47 Discussants’ Panel, 47 Reaction and Discussion, 50 7 CHALLENGES OF THE CURRENT SYSTEM 53 Creating Future Leaders, 53 Regulatory Challenges, 55 Financing Challenges, 59 Challenges in Quality Assessment in Private Practice, 62 8 THE ETHICAL PRINCIPLES AND OBLIGATIONS TO INCREASING ACCESS 67 What Is the Problem?, 67 What Defines the Basic Standard of Care?, 68 Whose Responsibility Is It to Provide Needed Services?, 68 Conclusions, 69 Reaction and Discussion, 70 9 THE INTERNATIONAL EXPERIENCE 71 Children’s Oral Health: International Successes, 71 Dental and Oral Health Therapists in Australia, 74 Oral Health Care Professions in the Netherlands, 76 Reaction and Discussion, 78 10 WORKFORCE STRATEGIES FOR IMPROVING ACCESS 81 Community Dental Health Coordinator, 81 DENTEX: The Dental Health Aide Therapist in Alaska, 82 Oral Health Practitioner, 84 Registered Dental Hygienists in Alternative Practice and Virtual Dental Homes, 86 Oral Health Impact Project, 89 Health Commons, 91 Pediatric Oral Health Educator, 92 Reaction and Discussion, 94 11 END-OF-DAY DISCUSSION: DAY 2 97 Discussants’ Panel, 97 Reaction and Discussion, 100

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xi CONTENTS 12 A CHARGE TO IMPROVE CHILDREN’S ACCESS TO ORAL HEALTH SERVICES 103 13 REFRAMING THE SYSTEM 107 Federal Government, 107 State Department of Health, 109 Working with State Legislators, 111 State Government, 111 Health Policy, 113 Dental Education, 115 Advocacy, 116 Media, 118 Reaction and Discussion, 119 14 CONCLUDING REMARKS 125 REFERENCES 129 APPENDIXES A Workshop Agenda 133 B Planning Committee Biographies 139 C Speakers and Moderators 145 D Workshop Participants 149 E Submitted Comments and Questions 159

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