3

The Oral Health Care System

While the connections between oral health and overall health and well-being have been long established, oral health care and general health care are provided in almost entirely separate systems. Oral health is separated from overall health in terms of education and training, financing, workforce, service delivery, accreditation, and licensure. In the United States, medical and dental education and practice have been separated since the establishment of the first dental school in Baltimore in 1840 (University of Maryland, 2010). The financing of oral health care is characterized by a similar divide. For example, private health plans typically do not cover oral health care, and the benefits package for Medicare excludes oral health care almost entirely. These separations contribute to obstacles that impede the coordination of care for patients.

This chapter provides an overview of the oral health care system in America today—where services are provided, how those services are paid for, who delivers the services, how the workforce is educated and trained to provide these services, and how the workforce is regulated. The role of the U.S. Department of Health and Human Services (HHS) in oral health education and training, as well as in supporting the delivery of oral health care services, will be addressed in Chapter 4 of this report. Detailed examination of the role HHS plays in overseeing safety net providers such as Federally Qualified Health Centers (FQHCs1) was charged to the concurrent Institute of Medicine (IOM) Committee on Oral Health Access to

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1 A Federally Qualified Health Center (FQHC) is any health center that receives a grant established by section 330 of the Public Health Service Act (42 U.S.C. §254b).



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3 The Oral Health Care System While the connections between oral health and overall health and well- being have been long established, oral health care and general health care are provided in almost entirely separate systems. Oral health is separated from overall health in terms of education and training, financing, work- force, service delivery, accreditation, and licensure. In the United States, medical and dental education and practice have been separated since the establishment of the first dental school in Baltimore in 1840 (University of Maryland, 2010). The financing of oral health care is characterized by a similar divide. For example, private health plans typically do not cover oral health care, and the benefits package for Medicare excludes oral health care almost entirely. These separations contribute to obstacles that impede the coordination of care for patients. This chapter provides an overview of the oral health care system in America today—where services are provided, how those services are paid for, who delivers the services, how the workforce is educated and trained to provide these services, and how the workforce is regulated. The role of the U.S. Department of Health and Human Services (HHS) in oral health education and training, as well as in supporting the delivery of oral health care services, will be addressed in Chapter 4 of this report. Detailed ex- amination of the role HHS plays in overseeing safety net providers such as Federally Qualified Health Centers (FQHCs1) was charged to the con- current Institute of Medicine (IOM) Committee on Oral Health Access to 1 A Federally Qualified Health Center (FQHC) is any health center that receives a grant established by section 330 of the Public Health Service Act (42 U.S.C. §254b). 81

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82 ADVANCING ORAL HEALTH IN AMERICA Services. Therefore, this committee limited its examination of the safety net in this current report. SITES OF ORAL HEALTH CARE The current oral health care system is composed of two basic parts— the private delivery system and the safety net—and there is little integration of either sector with wider health care services. The two systems function almost completely separately; they use different financing systems, serve different clientele, and provide care in different settings. In the private delivery system, care is usually provided in small, private dental offices and financed primarily through employer-based or privately purchased dental plans and out-of-pocket payments. This model of care has remained relatively unchanged throughout the history of dentistry. The safety net, in contrast, is made up of a diverse and fragmented group of providers who are financed primarily through Medicaid and the Children’s Health Insur- ance Program (CHIP), other government programs, private grants, as well as out-of-pocket payments. In addition, some oral health care, especially for young children, has begun to be supplied by nondental providers in settings such as physicians’ offices, which is discussed later in this chapter. This section gives a brief overview of the basic settings of oral health care by dental professionals— namely, dentists, dental hygienists, and dental assistants. The professionals themselves will be discussed later in this chapter. The Private Practice Model The structure of private practice provides dentists with considerable au- tonomy in their practice decisions (Wendling, 2010). Private practices tend to be located in areas that have the population to support them; thus, there are more practices located in urban areas than in rural, and more practices in high-income than in low-income areas (ADA, 2009b; Solomon, 2007; Wall and Brown, 2007). About 92 percent of professionally active dentists work in the private practice model (ADA, 2009d) (see Box 3-1 for defini- tions of types of dentists). Among all active private practice dentists (whose primary occupation was private practice), about 84 percent are independent dentists, 13 percent are employed dentists, and 3 percent are independent contractors (ADA, 2009d). About 60 percent of private practice dentists are solo dentists (Wendling, 2010). In addition, 80 percent of all active pri- vate practitioners and 83 percent of new active private practitioners are in general practice, while the remainder work in one of many specialty areas (see Table 3-1). Dentists in the private practice setting see a variety of patients. The

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83 THE ORAL HEALTH CARE SYSTEM B OX 3-1 Types of Dentists A professionally active dentist is primarily or secondarily occupied in a private practice, dental school faculty/staff, armed forces, or other federal service (e.g., Veterans Administration, U.S. Public Health Service); or is a state or local government employee, hospital staff dentist, graduate student/intern/resident, or other health/dental organization staff member. An active private practitioner is someone whose primary and/or second- ary occupation is private practice. A new dentist is anyone who has graduated from dental school within the last 10 years. An independent dentist is a dentist running a sole proprietorship or one who is involved in a partnership. A solo dentist is an independent dentist working alone in the practice he or she owns. A nonowner dentist does not share in ownership of the practice. An employed dentist works on a salary, commission, percentage, or associate basis. An independent contractor contracts with owner(s) for use of space and equipment. A nonsolo dentist works with at least one other dentist and can be an independent or nonowner dentist. NOTE: Each of these types can be either general or specialty practitioners. SOURCES: ADA, 2009b,d. patients of independent general practitioners are spread relatively evenly across the age spectrum and equally divided by gender (ADA, 2009b). About two-thirds (63 percent) of their patients have private insurance; only about 7 percent receive publicly supported dental coverage, and the remain- ing 30 percent are not covered by any dental insurance (ADA, 2009b). Similarly, independent dentists’ billings primarily are from private insur- ance and direct patient payments (44 percent and 39 percent, respectively) (ADA, 2009c). Nearly two-thirds of independent dentists (63 percent) and slightly more than half of new independent dentists (58 percent) do not have any patients in their practices covered by public sources (ADA, 2009b). However, in 2006, Bailit and colleagues estimated that 60 to 70 percent of underserved individuals who get care do so in the private care system (Bailit et al., 2006). While there is some disagreement as to whether dentists who care for patients with public coverage are considered part of

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84 ADVANCING ORAL HEALTH IN AMERICA TABLE 3-1 Percentage Distribution of Active Private Practitioners by Practice, Research, or Administration Area, 2007 Practice, Research, or All Active New Active Administration Area Private Practitioners Private Practitioners General practice 80.1 83.3 Orthodontics and dentofacial 5.7 4.7 orthopedics Oral and maxillofacial surgery 3.7 1.9 Periodontics 2.8 1.7 Pediatric dentistry 3.0 4.4 Endodontics 2.6 2.6 Prosthodontics 1.6 0.8 Public health dentistry 0.3 0.4 Oral and maxillofacial pathology 0.1 0.1 Oral and maxillofacial radiology 0.0 0.0 Missing specialty area 0.1 0.1 SOURCE: ADA, 2009d. the safety net, opportunities to expand care for vulnerable and underserved populations in private settings cannot be overlooked. The Oral Health Safety Net Some segments of the American population, namely socioeconomically disadvantaged groups, have difficulty accessing the private dental system due to geographic, financial, or other access barriers and must rely on the dental safety net (if they are seeking care) (Bailit et al., 2006; Brown, 2005; Wendling, 2010). While the term safety net may give the impression of an organized group of providers, the dental safety net comprises a group of unrelated entities that both individually and collectively have very limited capacity (Bailit et al., 2006; Edelstein, 2010a). One estimate of the current capacity of the safety net suggests that 7 to 8 million people may be served in these settings annually, and approximately another 2.5 million could be served with improved efficiency (Bailit et al., 2006). However, the safety net as it exists simply does not have the capacity to serve all of the people in need of care, which is estimated to be as high as 80 to 100 million individu-

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85 THE ORAL HEALTH CARE SYSTEM als (Bailit et al., 2006; HHS, 2000). While there is a perception that the care provided in safety net settings is somehow inferior to the care provided in the private practice setting, there are no data to support this assumption. In fact, there are very little data regarding the quality of oral health care provided in any setting (see later in this chapter for more on quality assess- ment in the oral health care system). Common types of safety net providers include FQHCs, FQHC look- alikes,2 non-FQHC community health centers, dental schools, school-based clinics, state and local health departments, and community hospitals. Each type of provider offers some type of oral health care, but the extent of the services provided and the number of patients served varies widely and the safety net cannot care for everyone who needs it (Bailit et al., 2006; Edelstein, 2010a). Private sector efforts to supplement the safety net include the organization of single-day events to provide free dental care. In 2003, the ADA established the annual Give Kids a Smile Day; in 2011, the ADA estimated the event would involve about 45,000 volunteers providing care to nearly 400,000 children (ADA, 2011a). Another example includes the Missions of Mercy, which are often organized by state dental societies or private foundations. At these events, thousands of individuals have waited in lines for hours to receive care (Dickinson, 2010). These types of single- day events provide temporary relief to the access problem for some people, but they do not provide a regular source of care for people in need. PAYING FOR ORAL HEALTH CARE Multiple challenges exist in the financing of oral health care in the United States, including state budget crises, the relative lack of dental cover- age, a payment system (like in general health care) that rewards treatment procedures rather than health promotion and disease prevention, and the high cost of dental services. Expenditures for dental services in the United States in 2009 were $102.2 billion, less than 5 percent of total spending on health care, a proportion that has remained fairly constant for the last two decades (CMS, 2011c). Demand for dental care may vary with the economic climate of the country (Guay, 2005; Wendling, 2010). For example, the recent recession was identified as a key factor contributing to 2009 having the slowest rate of growth in health spending (4 percent) in the last 50 years (Martin et al., 2011). Notably, expenditures on dental services had a negative rate of 2 FQHC look-alikes must meet all of the statutory requirements of FQHCs, but they do not receive grant funding under section 330 and are eligible for many, but not all, of the benefits extended to FQHCs.

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86 ADVANCING ORAL HEALTH IN AMERICA growth (–0.1 percent) in 2009, down from a positive rate of growth of 5.1 percent in 2008. Typical sources of health care insurance—Medicare, Medicaid, CHIP, and employers of all sizes—often do not include dental coverage, especially for adults. Employment status of adults ages 51–64 is a strong predictor of dental coverage (Manski et al., 2010c), and “routine dental care” is specifically excluded from the traditional Medicare benefits package. High- income older adults are more likely to have dental coverage than are other older adults (Manski et al., 2010c). In any case, individuals with dental coverage often incur high out-of-pocket costs for oral health care (Bailit and Beazoglou, 2008). Estimates regarding the severity of uninsurance for dental care include the following: • In 2000, the surgeon general’s report estimated that 108 million people (about 35 percent of the population) lacked dental coverage (HHS, 2000). • A recent estimate based on enrollment in private dental plans found 130 million U.S. adults and children lack dental coverage (NADP, 2009). • In 2004, 34 percent of adults ages 21–64 and about 70 percent of adults ages 65 and older lacked dental coverage (Manski and Brown, 2007). • Nearly 25 percent of people who have private health insurance lack dental coverage (Bloom and Cohen, 2010). Overall, rates of uninsurance for oral health care are almost three times the rates of uninsurance for medical care—34.6 percent (Manski and Brown, 2007) versus 14.7 percent (CDC, 2009). Financing of oral health care greatly influences where and whether indi- viduals receive care. For example, the national Medical Expenditure Panel Survey (MEPS) data show that in 2004, 57 percent of individuals with pri- vate dental coverage had at least one dental visit, compared to 32 percent of those with public dental coverage and 27 percent of uninsured individuals (Manski and Brown, 2007). At the individual level, insurance coverage and socioeconomic factors play a significant role in access to oral health care (Flores and Tomany-Korman, 2008; GAO, 2008; Isong et al., 2010; Liu et al., 2007). Financing also has an effect on providers’ practice patterns, in part due to the low reimbursement rates of public insurers. Previous studies have shown that like in medicine, dentists’ practice patterns are associated with financial incentives (Atchison and Schoen, 1990; Naegele et al., 2010; Porter et al., 1999). The following sections give a general overview of how care is financed in the United States.

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87 THE ORAL HEALTH CARE SYSTEM Private Sources As shown in Table 3-2, dental care is financed primarily through private sources, including individual out-of-pocket payments and private dental plans. In 2008, dental services accounted for 22 percent of all out-of-pocket health care expenditures, ranking second only to prescription drug expen- ditures (see Figure 3-1). Employers can add a separate oral health product to their overall cov- erage package, but often they do not. In 2006, 56 percent of all employ- ers offered health insurance, but only 35 percent offered dental insurance (Manski and Cooper, 2010). The availability of dental coverage through one’s employer is associated with the size of the establishment; that is, the larger the number of employees overall, the higher the incidence of stand- alone dental plans available to employees (Barsky, 2004; Ford, 2009). Higher-paid workers are also more likely to have access to and participate in stand-alone dental plans (Barsky, 2004; Ford, 2009). Employees are more likely to be offered access to medical insurance than dental insurance, and a higher percentage of employees will take advantage of available dental benefits as compared with the percentage of employees who take advantage of available medical benefits (BLS, 2010b). TABLE 3-2 National Health Expenditures by Type of Expenditure and Source of Funds, 2009 Percentage Total from Out- Percentage Percentage Type of Spending of-Pocket from Private from Public Expenditure (billions) Payments (%) Insurance (%) Insurance (%) Dental services 102.2 41.6 48.9 9.1 Physician and 505.9 9.5 47.0 33.5 clinical services Home health care 68.3 8.8 7.4 80.2 Nursing and 137.0 29.1 7.7 56.2 continuing care Prescription drugs 249.9 21.2 43.4 33.9 Hospital care 759.1 3.2 35.0 53.2 NOTES: Public insurance includes Medicare, Medicaid, CHIP, the Department of Defense, and the Department of Veterans’ Affairs. Totals do not reach 100% as some expenditures were attributed to “Other Third Party Payers and Programs.” SOURCE: CMS, 2011b.

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88 ADVANCING ORAL HEALTH IN AMERICA Medical Supplies Hospital: Inpatient Prescription Drugs Hospital: Outpatient/ER Physician’s Services Other Professional Services Dental Services FIGURE 3-1 Out-of-pocket health care expenditures, 2008. SOURCE: BLS, 2010a. Public Sources Of the $102.2 billion in dental expenditures, nearly 91 percent came from private funds (e.g., private insurance and out-of-pocket payments), and only 9 percent came from public funds (e.g., state and federal funds) (CMS, 2011b). In comparison, public funds account for about one-third of physician and clinical services (see Table 3-2). However, the reported national expenditure levels likely undercount the total public funds spent on improving oral health, because that total represents only the costs as- sociated with direct services delivered by dentists (to the exclusion of the broader definition of oral health) and does not account for care provided in settings such as hospitals and nursing homes. While a much lower per- centage of funds for dental services come from public sources as compared to the funding of many other services, the government may, in fact, have a very important role to play for those who cannot afford to pay for care. Public sources are an important source of coverage for many vulnerable and underserved populations, but a recent report from the U.S. Govern- ment Accountability Office (GAO) found that finding providers to care for Medicaid populations “remains a challenge” (GAO, 2010). Low reim- bursement by public programs is often cited as a disincentive for providers’ to participate in publicly funded programs (Damiano et al., 1990; GAO, 2000; Lang and Weintraub, 1986; McKnight-Hanes et al., 1992; Venezie et al., 1997). Studies have shown, though, that in order to significantly in- crease participation rates, increased reimbursement is necessary but often

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89 THE ORAL HEALTH CARE SYSTEM requires additional efforts such as decreasing the administrative burdens of participation; changing provider perceptions of participating; and fostering relationships among state Medicaid staff, the state dental association, and local dentists (Borchgrevink et al., 2008; GAO, 2000; Greenberg et al., 2008; Wysen et al., 2004). Medicaid and CHIP Dental coverage is required for all Medicaid-enrolled children under age 21 (CMS, 2011a). This is a comprehensive benefit, including preven- tive, diagnostic, and treatment services. According to data from the Kaiser Family Foundation, Medicaid provides health care coverage to nearly 30 million children while CHIP covers an additional 6 million (KFF, 2011). Further, they note that together, Medicaid and CHIP provide health care coverage for one-third of children and over half (59 percent) of low-income children. However, exact documentation of these numbers may be challeng- ing due to how enrollees are counted (e.g., at a point in time versus at any time in a given period). Regarding the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program, by law,3 states must cover any Medicaid-covered service that would reasonably be considered medically necessary to prevent, cor- rect, or ameliorate children’s physical (including oral) and mental condi- tions. In contrast, Medicaid dental benefits are not required for adults, and even among those states that offer dental coverage for adult Medicaid re- cipients, the benefits are often limited to emergency care (ASTDD, 2011c). In FY2008, Medicaid spending on dental services accounted for 1.3 percent of all Medicaid payments (CMS, 2010b). CHIP is a federally funded grant program that provides resources to states to expand health coverage to uninsured, low-income children. Mil- lions of children have received coverage for medical care, and a portion of those have also been covered for dental care (Brach et al., 2003). The Chil- dren’s Health Insurance Program Reauthorization Act (CHIPRA)4 enacted in February 2009 requires all states to provide dental coverage to children (but not including their parents) covered under CHIP. Medicare As increasing numbers of baby boomers become eligible for Medicare, considerable attention is being paid to how these aging adults will pay for 3 42 U.S.C. §1396d(r)(3). 4 Children’s Health Insurance Program Reauthorization Act of 2009, Public Law 3, 111th Cong., 1st sess. (February 4, 2009).

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90 ADVANCING ORAL HEALTH IN AMERICA and obtain oral health care (Ferguson et al., 2010; Manski et al., 2010a,b,c; Moeller et al., 2010). In the year 2000, almost 77 percent of dental care for older adults was paid by out-of-pocket expenditures, and 0.4 percent was covered by Medicaid (Brown and Manski, 2004). Medicare explicitly excludes coverage for routine dental care, specifically “for services in con- nection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth.”5 In the initial Medicare program, “routine” physical checkups and routine foot care were excluded; comparatively, all dental services were excluded, not just “routine” dental services (CMS, 2010a). In 1980, Con- gress made an exception for “inpatient hospital services when the dental procedure itself made hospitalization necessary” (CMS, 2010a). Box 3-2 delineates the extent of the exclusion of oral health care from the Medicare program. Federal Systems of Care In addition to the public programs noted above, the federal government both directly provides and pays for the oral health care of several distinct segments of the U.S. population. This includes care provided both in public and private settings through the various branches of the military, the Bureau of Prisons, the Department of Homeland Security, and the Veterans Admin- istration. The role of the federal government in providing care is discussed more fully in Chapter 4. Impact of Health Care Reform Between now and 2014, several provisions of the Patient Protection and Affordable Care Act (ACA)6 will affect dental coverage. For example, provisions address coverage of oral health services for children and the expansion of Medicaid eligibility. Table 4-4 in Chapter 4 highlights some of the key provisions that will affect dental coverage. THE DENTAL WORKFORCE Traditionally, a combination of dentists, dental hygienists, and dental assistants directly provide oral health care. Dental laboratory technicians create bridges, dentures, and other dental prosthetics. In addition, new and evolving types of dental professionals (e.g., dental therapists) are being pro - 5 Social Security Act, §1862(a)(12). 6 Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess. (March 23, 2010).

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91 THE ORAL HEALTH CARE SYSTEM B OX 3-2 E xclusions (and Exceptions) to Dental Coverage Under Medicare Services Excluded Under Part B A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth (e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw). A secondary service that is related to the teeth or structures di- rectly supporting the teeth unless it is incident to and an integral part of a covered primary service that is necessary to treat a nondental condition (e.g., tumor removal) and it is performed at the same time as the covered primary service and by the same physician/dentist. In those cases in which these requirements are met and the secondary services are covered, Medicare does not make payment for the cost of dental appliances, such as dentures, even though the covered service resulted in the need for the teeth to be replaced, the cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth (e.g., alveolar process). Exceptions to Services Excluded Exceptions include the extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease, as well as an oral or dental examination performed on an inpatient basis as part of comprehensive workup prior to renal transplant surgery or performed in a rural health clinic/FQHC prior to a heart valve replacement. SOURCE: CMS, 2010a. posed and, in some instances, used to provide some oral health care. The extent to which all of these professionals interact can vary greatly. The surgeon general’s 2000 report expressed concerns about a declining dentist-to population ratio, an inequitable distribution of oral health care professionals, a low number of underrepresented minorities applying to dental school, the effects of the costs of dental education and graduation debt on decisions to pursue a career in dentistry, the type and location of practice upon graduation, current and expected shortages in personnel for dental school faculties and oral health research, and an evolving curriculum with an ever-expanding knowledge base. (HHS, 2000) Unfortunately, these concerns continue today. The following section will focus on the traditional dental workforce in terms of its demographic profile, basic education and training, and racial

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130 ADVANCING ORAL HEALTH IN AMERICA DesRoches, C. M., and A. Jha. 2009. On the cusp of change: Health information technology in the United States, 2009. Princeton, NJ: Robert Wood Johnson Foundation. Dickinson, T. D. 2010. The MOM experience: Pathways to collaboration and conversation. Presentation at meeting of the Committee on Oral Health Access to Services, Washington, DC. March 4, 2010. Dodds, J., W. Vann, J. Lee, A. Rosenberg, K. Rounds, M. Roth, M. Wells, E. Evens, and L. H. Margolis. 2010. The UNC-CH MCH leadership training consortium: Building the capacity to develop interdisciplinary MCH leaders. Maternal and Child Health Journal 14(4):642-648. Douglass, A. B., M. Deutchman, J. Douglass, W. Gonsalves, R. Maier, H. Silk, J. Tysinger, and A. S. Wrightson. 2009a. Incorporation of a national oral health curriculum into family medicine residency programs. Family Medicine 41(3):159-160. Douglass, A. B., J. M. Douglass, and D. M. Krol. 2009b. Educating pediatricians and family physicians in children’s oral health. Academic Pediatrics 9(6):452-456. Dower, C. 2009. Regulatory challenges to improving oral health care in the U.S. Presentation at the IOM workshop The U.S. Oral Health Workforce in the Coming Decade, Wash- ington, DC. February 10, 2009. Dulisse, B., and J. Cromwell. 2010. No harm found when nurse anesthetists work without supervision by physicians. Health Affairs 29(8):1469-1475. Dunning, J. M. 1958. Extending the field for dental auxiliary personnel in the United States. American Journal of Public Health 48(8):1059-1064. Dyer, J. A. 2003. Multidisciplinary, interdisciplinary, and transdisciplinary: Educational mod- els and nursing education. Nursing Education Perspectives 24(4):186-188. Edelstein, B. 2010a. The dental safety net, its workforce, and policy recommendations for its enhancement. Journal of Public Health Dentistry 70(Supp. 1):S32-S39. Edelstein, B. 2010b. Training new dental health providers in the U.S. Battle Creek, MI: W.K. Kellogg Foundation. Evans, A. W., R. M. A. Leeson, and A. Petrie. 2005. Correlation between a patient-centred outcome score and surgical skill in oral surgery. British Journal of Oral and Maxillofacial Surgery 43(6):505-510. Fales, M. H. 1958. The potential role of the dental hygienist in public health programs. American Journal of Public Health 48(8):1054-1058. Ferguson, D. A., B. J. Steinberg, and T. Schwien. 2010. Dental economics and the aging population. Compendium of continuing education in dentistry (Jamesburg, NJ : 1995) 31(6):418-420, 422, 424-425. Ferullo, A., H. Silk, and J. A. Savageau. 2011. A national survey of oral health curriculum in all U.S. allopathic and osteopathic medical schools. Academic Medicine 86(2):252-825. Fiset, L. 2005. A report on quality assessment of primary care provided by dental therapists to Alaska natives. Seattle, WA: University of Washington School of Dentistry. Flores, G., and S. C. Tomany-Korman. 2008. The language spoken at home and disparities in medical and dental health, access to care, and use of services in U.S. children. Pediatrics 121(6):e1703-e1714. Ford, J. L. 2009. The new health participation and access data from the National Compensa- tion Survey. http://www.bls.gov/opub/cwc/cm20091022ar01p1.htm (accessed December 27, 2010). Formicola, A. J., J. McIntosh, S. Marshall, D. Albert, D. Mitchell-Lewis, G. P. Zabos, and R. Garfield. 1999. Population-based primary care and dental education: A new role for dental schools. Journal of Dental Education 63(4):331-338. Formicola, A J., H. Bailit, T. Beazoglou, and L. A. Tedesco. 2005. The Macy study: A frame- work for consensus. Journal of Dental Education 69(11): 1183-1185.

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