1

Introduction

Access to oral health care is essential to promoting and maintaining overall health and well-being. When individuals are able to access oral health care, they are more likely to receive basic preventive services and education on personal behaviors. They are also more likely to have oral diseases detected in the earlier stages and obtain restorative care as needed. In contrast, lack of access to oral health care can result in delayed diagnosis, untreated oral diseases and conditions, compromised health status, and, occasionally, even death. Unfortunately, access to oral health care eludes many Americans.

A significant portion of the U.S. population is not adequately served by the current oral health care system, and millions of Americans have unmet oral health needs (Bloom et al., 2010; Brown, 2005; HHS, 2000). This is especially true for the nation’s vulnerable and underserved populations. Commonly studied populations include but are not limited to

Racial and ethnic minorities, including immigrants and non-English speakers (Bloom et al., 2010; Cruz et al., 2004; Edelstein and Chinn, 2009; Pleis et al., 2010);

Children, especially those who are very young (Dye et al., 2010; Edelstein and Chinn, 2009; GAO, 2008);

Pregnant women (Silk et al., 2008; Steinberg et al., 2008);

People with special health care needs (Anders and Davis, 2010; Armour et al., 2008; Havercamp et al., 2004; Owens et al., 2006);

Older adults (Dye et al., 2007; Manski et al., 2004, 2010);



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1 Introduction A ccess to oral health care is essential to promoting and maintaining overall health and well-being. When individuals are able to access oral health care, they are more likely to receive basic preventive services and education on personal behaviors. They are also more likely to have oral diseases detected in the earlier stages and obtain restorative care as needed. In contrast, lack of access to oral health care can result in delayed diagnosis, untreated oral diseases and conditions, compromised health status, and, occasionally, even death. Unfortunately, access to oral health care eludes many Americans. A significant portion of the U.S. population is not adequately served by the current oral health care system, and millions of Americans have unmet oral health needs (Bloom et al., 2010; Brown, 2005; HHS, 2000). This is especially true for the nation’s vulnerable and underserved populations. Commonly studied populations include but are not limited to • Racial and ethnic minorities, including immigrants and non– English speakers (Bloom et al., 2010; Cruz et al., 2004; Edelstein and Chinn, 2009; Pleis et al., 2010); • Children, especially those who are very young (Dye et al., 2010; Edelstein and Chinn, 2009; GAO, 2008); • Pregnant women (Silk et al., 2008; Steinberg et al., 2008); • People with special health care needs (Anders and Davis, 2010; Armour et al., 2008; Havercamp et al., 2004; Owens et al., 2006); • Older adults (Dye et al., 2007; Manski et al., 2004, 2010); 17

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18 IMPROVING ACCESS TO ORAL HEALTH CARE • Individuals living in rural and urban underserved areas (Maserejian et al., 2008; Vargas et al., 2002, 2003a,b,c); • Uninsured and publicly insured individuals (GAO, 2008; Liu et al., 2007); • Homeless individuals (Conte et al., 2006; Gibson et al., 2003); and • Populations of lower socioeconomic status (Bloom et al., 2010; GAO, 2000; Vargas et al., 1998). For example, in 2009, 4.6 million children did not obtain needed dental care because their families stated that they could not afford it (Bloom et al., 2009), and people with disabilities are less likely to have seen a dentist in the past year than people without disabilities (Armour et al., 2008). Although other health conditions frequently draw attention in health policy and health services discussions, oral health issues seldom rise to the top of the national health and health policy agenda. As a result, oral health concerns have persisted as a major, largely preventable, health problem across the life span. BARRIERS TO ORAL HEALTH CARE ACCESS The factors that contribute to problems with access to oral health care are numerous and complex. These include social, cultural, economic, structural, and geographic factors, among others. A thorough review of these factors is included in the chapters that follow. For example, dental coverage (discussed in Chapter 5) is correlated to access to and utilization of oral health care (AHRQ, 2010; Decker, 2011; Sohn et al., 2007). One recent report found that individuals who lacked dental insurance were about two-thirds less likely than people with private insurance to have had a dental visit within the last year (16.1 percent compared with 50.9 percent) (AHRQ, 2010). In addition, poor oral health literacy of both individuals and all types of health care professionals (discussed in Chapter 2) contrib- utes to poor access because individuals may not understand the importance of oral health care or their options for accessing such care (Caspary et al., 2008; Gussy et al., 2008; Jones et al., 2007; Kutner et al., 2006; Sakai et al., 2008). Likewise, the geographic distribution of oral health professionals in relation to the general public (discussed in Chapter 3) has a consider- able impact on access to oral health care (HHS, 2000; IOM, 2009b). For example, as of March 2011, there were 4,639 dental Health Professional Shortage Areas (HPSAs) (a geographic area, population group, or facility with a shortage of dental professionals) (HRSA, 2011). An estimated 9,642 additional dentists would be required to meet the need of unserved popula- tions in these areas (based on a 3,000:1 population-to-practitioner ratio). It

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19 INTRODUCTION should be noted that making estimates of underservice and unmet need are complicated and that shortcomings in the current criteria and methodolo- gies used to make HPSA designations have been identified (GAO, 2006). For example, the dental HPSA criteria have not recently been updated and may not adequately capture broader issues of access to care, including a greater focus on indicators of need as opposed to simple population to provider ratios (Orlans et al., 2002). However, population-to-provider data are continuously collected and will likely serve as the basis for estimates of underservice and unmet need until improved methodologies and criteria are developed. THE CONSEQUENCES OF POOR ORAL HEALTH The consequences of insufficient access to oral health care and resultant poor oral health—at both the individual and population levels—are far reaching. Nontreatment of dental caries,1 for example, may be associated with inappropriate use of emergency departments (Cohen et al., 2011; Davis et al., 2010). Moreover, strong evidence documents the clear link- ages between oral health and respiratory disease (Scannapieco and Ho, 2001), cardiovascular disease (Blaizot et al., 2009; Offenbacher et al., 2009; Scannapieco et al., 2003; Slavkin and Baum, 2000), and diabetes (Chávarry et al., 2009; Löe, 1993; Taylor, 2001; Teeuw et al., 2010). Lack of access to oral health care also contributes to the profound and persistent oral health disparities that exist in the United States. For example, dental caries—a chronic, infectious, and largely preventable disease—disproportionately affects racial/ethnic minority groups (Flores and Tomany-Korman, 2008; HHS, 2000; Nash and Nagel, 2005), rural populations (Skillman et al., 2010; Vargas et al., 2003a,b,c), children (Dye et al., 2010), individuals with special health care needs (Owens et al., 2006), and low-income populations (Vargas and Ronzio, 2006), among others. A recent analysis of the National Survey of Children with Special Health Care Needs found that 8.9 percent of children with special health care needs were unable to obtain needed dental care (Lewis, 2009). EFFORTS TO IMPROVE ACCESS TO ORAL HEALTH CARE Multiple agencies within the Department of Health and Human Services (HHS) and other federal departments have sought to develop resources and strategies to improve access to and quality of oral health care for vulnerable populations. Programs administered by the Health Resources and Services 1 The term dental caries is used in the singular and refers to the disease commonly known as tooth decay (Dorland’s Illustrated Medical Dictionary, 31st ed., s.v. “caries”).

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20 IMPROVING ACCESS TO ORAL HEALTH CARE Administration (HRSA), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration, the Indian Health Service (IHS), the National Institute of Dental and Craniofacial Research, and other agen- cies have focused on multiple dimensions of the service system: building the supply of dental professionals; strengthening state capacity and dental public health infrastructure; providing direct oral health care to selected populations (including veterans, military personnel and their families, in- carcerated individuals in federal prisons, Native Americans and Alaska Natives, migrant and homeless populations, pregnant women, low-income children and adolescents, and others); and developing population-based services such as fluoridation of drinking water. In addition, federal agencies provide technical assistance on oral health issues to state and local health departments, support national surveys and examinations to assess the sta- tus of children’s oral health, sponsor basic and applied research, sponsor public education materials and programs, and develop consumer protection services such as regulation of devices and pharmaceuticals used in dentistry. In other areas, federal funds finance the provision of oral health services by public and private dental professionals through health insurance programs such as Medicaid and the Children’s Health Insurance Program (CHIP). In addition to the federal-level strategies described above, stakeholders across the country have been encouraged to increase the resources avail- able to meet the oral health needs of the public and take action to address the poor oral health status of vulnerable and underserved populations. For example, the private sector has sponsored several types of voluntary pro- grams to care for these populations. The Missions of Mercy projects are short-term, temporary clinics, staffed by volunteer dental professionals that are set up in easily accessible locations to provide oral health care to un- derserved populations on a first-come, first-served basis. Another example is the American Dental Association’s (ADA’s) Give Kids A Smile Day. This annual program includes regional one-day events that provide education, screening, preventive, and clinical (e.g., restorative) services to underserved children. Donated Dental Services, a program of the National Foundation of Dentistry for the Handicapped, assists volunteer dentists and laborato- ries in providing care to older adults and individuals with special health care needs. Collectively, these and other efforts have temporarily mitigated some of the burden related to inadequate access to oral health care, but they have been insufficient in fully addressing existing challenges and underlying problems. What is lacking at present is a systems-level approach that can establish priorities among multiple and fragmented efforts and focus public resources on priority areas of need in the areas of service delivery, system capacity, and public health infrastructure. Within the context of these previous efforts and the persistent chal- lenges to achieving good oral health and reducing oral health disparities,

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21 INTRODUCTION there is a clear need to reexamine the way oral health care is delivered to vulnerable and underserved populations, and to design strategic policies that support the health care professionals and programs that serve these populations. This report examines these needs, highlights the successes that have been achieved, and makes recommendations for the work that remains to be done. STUDY CHARGE, SCOPE, AND APPROACH The 2000 surgeon general’s report Oral Health in America raised the profile of oral health issues nationally; it continues to be cited frequently, and it is viewed as a benchmark for oral health system reform. However, there is also a growing recognition among policy makers and other stake- holders that little has changed in the intervening years. Access to oral health coverage and oral health care remains disparate and inadequate to meet the need; oral health status among many population groups remains poor; avoidable oral health complications continue to occur with great frequency; the worlds of dentistry and medicine remain substantially divided; and oral health continues to be marginalized in many crucial respects. Study Charge In light of these issues, in the fall of 2009, with support from HRSA and the California HealthCare Foundation, the National Research Council (NRC) and the Institute of Medicine (IOM), through collaborative efforts between the Board on Children, Youth, and Families and the Board on Health Care Services, formed the Committee on Oral Health Access to Services to assess the current oral health care system with a focus on the delivery of oral health care to vulnerable and underserved populations. Fur- ther, the committee was asked to provide a vision of how oral health care for these populations should be addressed by public and private providers (see Box 1-1). Scope This committee was tasked with describing a delivery system better able to provide access to oral health care to vulnerable and underserved popu- lations. The committee recognizes that, while access to care is one critical component needed to improve oral health outcomes and reduce oral health disparities, it is not an end in and of itself. Improving access will, however, help provide needed services to the millions of Americans for whom oral health care is currently out of reach. The committee was not asked to make recommendations to improve oral health outcomes and reduce oral health

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22 IMPROVING ACCESS TO ORAL HEALTH CARE BOX 1-1 The Committee on Oral Health Access to Services Statement of Task The IOM-NRC Board on Children, Youth, and Families, in collabora- tion with the Board on Health Care Services, will undertake a study to • ssess the current U.S. oral health system of care; A • xplore its strengths, weaknesses, and future challenges for the de- E livery of oral health care to vulnerable and underserved populations; • escribe a desired vision for how oral health care for these popula- D tions should be addressed by public and private providers (including innovative programs) with a focus on safety net programs serving populations across the life cycle and Maternal and Child Health Bu- reau (MCHB) programs serving vulnerable women and children; and • ecommend strategies to achieve that vision. R disparities among vulnerable and underserved populations. Recommen- dations of this nature are beyond the scope of this study. Moreover, the focus of this study is directed specifically on those populations that are not served by the current system. The committee was not asked to examine or make recommendations on how the overall oral health care system might be improved. This, too, goes beyond the scope of this study. Therefore, the committee limited its examination to those issues directly related to improving access to oral health care and has sought, through the careful and thorough examination of available evidence, the best and most realistic paths to pursue. The committee does not suggest that the findings, conclusions, and recommendations within this report will resolve all problems related to access to oral health care in this country. Nor is this report intended to supplant effective and innovative initiatives currently under way at the community, state, and national levels (a number of which are highlighted in the chapters that follow). Instead, this report is intended to complement those efforts as a part of a larger solution that will require efforts from a variety of stakeholders. As directed by the statement of task, the committee sought oppor- tunities to improve access to oral health care through both public- and private-sector actions. While a number of the recommendations are geared toward state and federal agencies, the recommendations require action and support from the private sector to be successful. Some of the recommenda-

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23 INTRODUCTION tions designate priority areas within current funding levels; others call for new or increased state and federal investments. Recognizing the vital role that the private sector will play in improving access to oral health care, the committee has identified areas where private investments and support from the private sector are needed. These actions and investments are included as suggested strategies for implementation following each recommendation. It is also important to note that this study was conducted at the same time that the IOM’s Committee on an Oral Health Initiative study was under way. While the two studies have related statements of task, the two projects had separate committees, meetings, and report review processes. The two committees were not made aware of the other’s conclusions or recommendations. Advancing Oral Health in America, the report from the Committee on an Oral Health Initiative, was released in April 2011. A brief summary of the report’s key findings, conclusions, and recommendations is included in Appendix D. Study Approach The study committee included 15 members with expertise in dentistry and dental hygiene, dental public health, pediatric dentistry, pediatrics, fam- ily medicine, obstetrics/gynecology, health law, health policy, nursing, pre- natal care, neonatal and infant health, public health, health disparities, and health finance. (See Appendix E for biographies of the committee members.) A variety of sources informed the committee’s work. The committee met in person five times and during two of those meetings held public workshops to obtain vital input from a broad range of relevant stakeholders including parents and patients; oral health care professionals; public and private insurers; local, state, and federal agencies; and research experts. In addition, the committee commissioned four papers on various topics (see Appendix B). The committee conducted a review of the literature to identify issues that affect underserved populations who are most vulnerable to oral disease and the role of the safety net providers, both public and private, who serve them, with a specific focus on the provision of oral health care to women and children. The committee made every effort to include the most up-to-date re- search published in peer-reviewed journals. However, strong evidence was sometimes found in older studies; as these studies had not been replicated in recent years, they were the only available sources of data. In other cases, large-scale studies have not been done, and so the committee looked to available data from smaller-scale studies, such as case reports. Finally, in some instances, the committee cited secondary sources such as reports. In such cases, the committee referred back to the original citations to assess the quality of the evidence.

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24 IMPROVING ACCESS TO ORAL HEALTH CARE In addition, the committee was limited by what was available in the published literature. For example, the committee found that there were ar- eas of research (e.g., oral health financing, quality measures) that were con- siderably less developed than other areas (e.g., preventive care). Through its review of evidence, the committee also became aware of the existence of newer data in several key areas that have not yet been fully analyzed. The committee was not equipped to or charged with conducting data analysis, and so the most current published data analyses are included in the report. The evidence included in the report is almost exclusively focused on the United States. However, in cases in which the committee determined that it was important to include relevant international research, this research is cited. In the chapters that follow, the committee evaluates available relevant data, identifies specific gaps in the literature, and addresses the need for additional research in its recommendations in Chapter 6. In approaching its charge, the committee sought to gain an understand- ing of the full spectrum of influences, challenges, and opportunities facing the delivery of oral health care services to vulnerable and underserved populations. This chapter describes why such efforts are necessary and provides an overview of key issues related to the committee’s charge, each of which is expanded upon, in greater detail, in the chapters that follow. In addition, one of the committee’s early tasks was to establish guiding principles, reach consensus on how to define several key terms, and to determine how to approach the task of assessing the current oral health system of care in the United States. GUIDING PRINCIPLES To guide its deliberations on improving access to oral health care among vulnerable and underserved populations, the committee began with two well-established and evidence-based principles: 1. Oral health is an integral part of overall health and, therefore, oral health care is an essential component of comprehensive health care. 2. Oral health promotion and disease prevention are essential to any strategies aimed at improving access to care. These principles are woven throughout the text of this report and are fundamental to the recommendations. The committee strongly believes that these two principles need to be better understood by the general public and policy makers and emphasized to improve access to oral health care with the ultimate goal of improving oral health outcomes for vulnerable and underserved populations.

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25 INTRODUCTION DEFINITIONS OF KEY TERMS This section provides definitions of several key terms that are relevant to this report. Access Many other reports have examined issues related to access to health care. The current challenges to understanding and measuring access to oral health care in the United States are similar to those that apply to access to all health care services. Therefore, the committee chose to focus on previous definitions of access to health care. An earlier NRC-IOM committee developed an enduring definition of access, as set forth in the report Access to Health Care in America: “the timely use of personal health services to achieve the best possible health outcomes” (IOM, 1993). Other work has broadened this definition to un- derscore issues specific to health care disparities (AHRQ, 2010; Bierman et al., 1998). For example, the 2009 Agency for Healthcare Research and Quality (AHRQ) National Healthcare Disparities Report includes concepts such as an individual’s ability to gain entry to the health care system and appropriate sites of care to receive needed services. The report also stated that having access to providers who meet the needs of individual patients was an essential component of access to care (AHRQ, 2010). This committee endorses a broad definition of access as applied to oral health care. Moreover, the committee finds that in order to promote and maintain overall health individuals require access to quality oral disease preventive services at regular intervals and treatment services when needed. Because access is seldom as straightforward as adequate availability of ser- vices and providers, this report thoroughly examines the various barriers to care that inhibit timely receipt of services. In addition, the committee contends that the implicit goal in improving access is improving access to quality oral health care—care that is safe, timely, effective, efficient, equi- table, and patient centered (IOM, 2001). This concept of quality should be applied wherever the term access is used in the pages that follow. Finally, the broad definition of access described above underscores both the avail- ability and use of care. The committee concludes that these are essential components of access. Therefore, strategies to improve access are necessar- ily broader than simply improving an individual’s or population’s ability to “get in the door.” This concept is echoed throughout the report.

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26 IMPROVING ACCESS TO ORAL HEALTH CARE Oral Health The Surgeon General’s report Oral Health in America firmly estab- lished that oral health care encompasses more than dental care, and that a healthy mouth is more than just healthy teeth (HHS, 2000). The World Health Organization captures this broader definition of oral health in the following way: “Oral health is a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity” (WHO, 2010). To ensure that the recommendations of this report are applied to their fullest extent, the committee has chosen to endorse a broad definition of oral health that aligns with the definitions above. Moreover, as described ear- lier, oral health is fundamental to overall health. Therefore, the committee encourages readers of this report to keep this underlying premise in mind whenever they encounter the term oral health in the pages that follow. Oral Health Care Workforce This report considers the oral health care workforce broadly—that is, to be inclusive of all the members of the health care workforce who are, or could be, involved in oral health care. Traditionally, a combination of den- tists, dental hygienists, dental assistants, and others (dental professionals) contribute to oral health care. As oral health has become increasingly rec- ognized as part of overall health, nondental health care professionals (e.g., nurses, pharmacists, physician assistants, physicians) have become involved in the prevention, diagnosis, and treatment of oral diseases. In addition, in efforts to expand oral health access, new types of dental professionals (e.g., dental therapists) have evolved, and expanded scopes of practice have been explored for existing professionals. Together, all of these professionals are recognized in this report as oral health care professionals. Vulnerable and Underserved The committee’s charge specifically refers to improving access for vul- nerable and underserved populations. These are individuals and popula- tions that are systematically excluded from obtaining oral health care. However, there are no universally accepted definitions for these two groups. Vulnerability, for example, may be temporal in nature. That is, an indi- vidual or a community may experience pervasive and lasting vulnerability (e.g., persistent poverty or chronic illness) or may become vulnerable for a discreet period of time (e.g., during pregnancy or following a catastrophic event). Likewise, whether an individual or a community is considered underserved may change over time. For example, individuals residing in a

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27 INTRODUCTION designated HPSA are considered to be underserved. If a health care profes- sional moves to the area, it may lose its HPSA designation, and its residents will no longer be considered underserved. The reverse situation, of course, would also be true. Given the complex and variable nature of these designations, the com- mittee determined early in the study process it would consider vulnerable and underserved populations in terms of a general set of characteristics. These groups would include those who are made vulnerable by or under- served due to • Financial circumstances, • Insurance status, • Place of residence, • Health status, • Age, • Personal characteristics, • Functional or developmental status, • Ability to communicate effectively, and • Presence of chronic illness or disability (IOM, 2000a; President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998). This list is not meant to be exhaustive. Similarly, the vulnerable and un- derserved populations discussed in the chapters that follow should not be viewed as comprehensive. They have been included as examples based on the amount of data and evidence available in the literature. Additional fac- tors and characteristics that contribute to whether individuals and popula- tions are underserved such as the supply of trained professionals available to provide care are also examined in this report. NOTABLE PAST WORK The committee drew important lessons from the collection of efforts aimed at improving access to oral health care. The following review of notable past work highlights the breadth of efforts over time and calls at- tention to the range of engaged stakeholders. The Institute of Medicine Over 30 years have passed since the IOM’s first significant look at oral health issues, Public Policy Options for Better Dental Health (IOM, 1980), in which the committee was charged to consider the inclusion of dental services under national health insurance plans. At that time, the IOM found a substantial unmet need for dental care in the United States and that

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30 IMPROVING ACCESS TO ORAL HEALTH CARE their strategic plans. Notably, the American Academy of Pediatrics (AAP) identified oral health as one of its four strategic priority areas of which ac- cess to care is a major component. In 2008, the AAP convened a National Summit on Children’s Oral Health to examine strategies to overcome bar- riers to children’s access to oral health care services in the United States (AAP, 2011b). The meeting was attended by an array of stakeholders from medical, dental, and other health organizations; advocacy organizations; and federal agencies. The findings from this meeting were published as a collection in a special issue of Academic Pediatrics on children’s oral health and have helped inform the work of AAP’s broader Oral Health Initiative (AAP, 2011a). The Society of Teachers of Family Medicine (STFM) has supported the role of primary care providers in oral health promotion and disease prevention. In 2005, the STFM Group on Oral Health developed Smiles for Life, a comprehensive oral health curriculum for primary care providers including physicians, physician assistants, and nurse practitioners (Douglass et al., 2010). This curriculum was developed with guidance from dentists, physicians, and educators through a series of regional consortia. It addresses oral health education across the life cycle and includes online training modules on the needs of underserved and vulnerable populations among other topics (Douglass et al., 2010). Foundations A number of philanthropic organizations have also made access to oral health care a significant part of their work. The following are examples of several recent foundation-led initiatives. The Pew Charitable Trusts established the Pew Children’s Dental Cam- paign to raise awareness and promote policies that ensure children have ac- cess to oral health care. In 2010, the campaign released a report, The Cost of Delay: State Dental Policies Fail One in Five Children, that underscored the issue of inadequate access to oral health care for low-income children (Pew Center on the States, 2010). The Cost of Delay found that two-thirds of states were doing an inadequate job of ensuring that children have ac- cess to basic, preventive dental care. A follow-up study in 2011, The State of Children’s Dental Health: Making Coverage Matter, found that “while many states improved their performance on one or more of the Pew’s policy benchmarks, too many still fall short” (Pew Center on the States, 2011). The Robert Wood Johnson Foundation (RWJF), in collaboration with the California Endowment and the W.K. Kellogg Foundation, created the Pipeline, Profession, and Practice: Community-Based Dental Education2 2For information on participating schools, funding levels, activities, accomplishments, and community partners, see the RWJF project website at http://www.dentalpipeline.org.

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31 INTRODUCTION initiative to increase the time that senior dental students spend in com- munity settings providing care to underserved populations; and to increase enrollment of low-income and underrepresented minority students in den- tal school (Bailit and Formicola, 2010). Evaluations of the dental pipeline program found that among pipeline schools, there were increases in first- year enrollment of underrepresented minority students (up 54 percent) (Andersen et al., 2009), increases in the number of days senior students spent in community sites (Formicola et al., 2010), and substantial numbers of services provided through extramural rotations (Atchison et al., 2009). The W.K. Kellogg Foundation recently announced plans to invest over $16 million in the Dental Therapist Project, in Kansas, New Mexico, Ohio, Vermont, and Washington, to improve oral health access in underserved communities (W.K. Kellogg Foundation, 2010). This announcement fol- lowed on the heels of a recently released evaluation of the Alaska Native Tribal Health Consortium’s Alaska Dental Health Aide Initiative (spon- sored by the W.K. Kellogg Foundation, the Rasmuson Foundation, and the Bethel Community Services Foundation). The evaluation (self-described as an “in-depth case study”) assessed the performance of dental health aide therapists practicing in remote Alaskan villages. The evaluation found that “the therapists are performing well and operating safely within their scope of practice” (under the general supervision of dentists) (Wetterhall et al., 2010). DentaQuest Foundation supports the National Interprofessional Ini- tiative on Oral Health which focuses on the education and training of health care providers from primary care disciplines (e.g., family medicine, pediatrics, nursing, physician assisting, obstetrics and gynecology, and internal medicine). And, in Massachusetts, DentaQuest helped lead a state- wide coalition of stakeholders to create a state plan for oral health that addresses barriers to care, oral health disparities, and community-based prevention. The U.S. Department of Health and Human Services HHS supports a broad array of oral health activities focused on im- proving the nation’s oral health, including • Oral health financing, • Research, • Workforce development, • Public health action, • Quality initiatives, and • Technology (HHS, 2010).

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32 IMPROVING ACCESS TO ORAL HEALTH CARE BOX 1-2 E xamples of Current HHS Efforts to I mprove Access to Oral Health Care The Administration for Children and Families (ACF) Oral health activities in the ACF center on its Head Start program, which is operated through the Office of Head Start. For example, ACF requires Head Start programs to determine whether a child has received age- appropriate preventive dental care within 90 days of the child entering the Head Start program.a The Agency for Healthcare Research and Quality (AHRQ) AHRQ contributes to oral health research by collecting data, funding both intramural and external research, and disseminating innovations in health care delivery. AHRQ collects information on oral health care needs, access, and expenditures through the Medical Expenditure Panel Survey. The Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) The CDC and the NIH are developing a comprehensive Oral Health Surveillance Plan that will allow HHS to create a “report card” for oral health in the United States (HHS, 2010). In addition, the CDC provided $6.8 million in FY 2010 to 19 state oral health programs to support evidence-based prevention programs (e.g., community water fluori- dation and school-based sealant programs), surveillance of oral dis- ease burden, and to develop plans to improve oral health and address disparities. The CDC/National Center for Health Statistics (NCHS) NCHS contributes to oral health research by collecting, analyzing, and disseminating data. NCHS collects information on oral health status and access to services through the National Health Interview Survey and the National Health and Nutrition Examination Survey. The Centers for Medicare and Medicaid Services (CMS) CMS is reviewing state Medicaid dental programs for innovative prac- tices that have increased access to dental care among children and will be sharing the information about those practices with other states (HHS, 2010). CMS has also set goals to increase the rate of children who are enrolled in Medicaid or CHIP and to increase the percentage of these children who receive dental sealants (CMS, 2010). CMS plays an important role in financing oral health care, particularly for low-income children (described in Chapter 5). The Health Resources and Services Administration (HRSA) Bureau of Primary Health Care (BPHC) The BPHC allocates capital and operating funds to federally funded community health centers that receive grants under §330 of the Public Health Service Act (HRSA, 2010a). These health centers provide oral

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33 INTRODUCTION health care services to low-income individuals both directly and through referrals to private professionals.b BPHC also manages the Service Ex- pansion in Oral Health grants that provided additional funding to Fully Qualified Health Centers to expand oral health care services (Anderson, 2010). Bureau of Clinician Recruitment and Service The Bureau of Clinician Recruitment and Service manages the National Health Service Corps, which provides scholarships and loan repay- ment to clinicians, including dentists and dental hygienists, who agree to serve for 2–4 years in Health Professional Shortage Areas (HRSA, 2010b). The HIV/AIDS Bureau The HIV/AIDS Bureau sponsors several activities to improve the oral health care of persons with HIV/AIDS through both education of stu- dents and residents, as well as grant funding to increase opportuni- ties for provision of oral health care to this population. For example, the Ryan White Special Projects of National Significance Oral Health Initiative funds 15 demonstration sites for up to 5 years to support or- ganizations using innovative models of care to provide oral health care to HIV-positive, underserved populations in both urban and nonurban settings (Anderson, 2010). Maternal and Child Health Bureau (MCHB) The MCHB sponsors two centers focused on oral health: the National Maternal and Child Oral Health Resource Center (OHRC) and the Na- tional Oral Health Policy Center (OHPC). Specific activities include the OHPC Children’s Dental Health Project that provides information and support to federal, state, and local programs and policy makers to promote policies that address disparities in children’s oral health (Na- tional Maternal and Child Oral Health Policy Center, 2010). The MCHB also funds a number of oral health activities through Title V Block/ Formula Grants, Special Projects of Regional and National Significance (SPRANS) grants, and Community Integrated Service Systems (CISS) discretionary grants. Indian Health Service (IHS) The IHS is working with community partners such as Head Start; the Special Supplemental Nutrition Program for Women, Infants, and Chil- dren (WIC) Program; nurses; doctors; and community health represen- tatives to reduce the prevalence of early childhood caries in American Indian/Alaska Native children. SOURCE: HHS, 2010. a Code of Federal Regulations, Office of Human Development Services, Depart- ment of Health and Human Services, title 45, sec. 1304.20 (2009). b  42 U.S.C. §254b.

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34 IMPROVING ACCESS TO ORAL HEALTH CARE A review of past and present HHS oral health activities was addressed by the previously mentioned concurrent study by the IOM Committee on an Oral Health Initiative. Box 1-2 provides an overview of several current efforts within HHS, by agency, that are directly related to improving access to oral health care. ORGANIZATION OF THE REPORT This report reviews the literature on the oral health status and the deliv- ery of oral health care to vulnerable and underserved populations; presents the committee’s findings; and offers recommendations to both public and private entities for investing in, strengthening, and improving the delivery of care to individuals who are currently unable to access oral health services. The report has six chapters. Chapter 2 provides an overview of oral health status and its connection to overall health. It also provides a closer examination of oral health status by specific subpopulations and establishes the extent of unmet oral health care needs among these populations. Finally, the chapter describes factors that differentially influence oral health status and utilization of oral health care services in the United States. Chapters 3, 4, and 5 frame the challenges and types of solutions that are typically used to improve access for vulnerable and underserved popu- lations within the context of the resources that are currently available. To that end, Chapter 3 focuses on the characteristics of the oral health care workforce that may help improve access to oral health care; Chapter 4 describes the variety of settings in which oral health care is, or could be, provided; and Chapter 5 provides an overview of the various sources and mechanisms of financing for oral health care in the United States and de- scribes the impact these expenditures have on access to care. Each of these chapters also includes examples of innovative strategies designed to increase access to oral health care. Finally, Chapter 6 provides a vision of access to quality oral health care across the lifespan that addresses the multitude of needs and barriers to care described in the preceding chapters. The chapter also presents the committee’s recommendations for specific actions that should be taken to achieve this vision and additional strategies that will be needed in the near term and over time with an eye toward what can be achieved and sustained during periods of transformation (e.g., health care reform) and in a climate of significantly limited resources. The report includes several appendixes. Appendix A provides a list of acronyms used throughout the report, and Appendix B contains the authors and titles of the papers commissioned by this committee. Appendix C lists the agendas for the March and July committee workshops. A brief summary of Advancing Oral Health in America, the report from the Committee on

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35 INTRODUCTION an Oral Health Initiative, is included in Appendix D. Finally, Appendix E contains biographical sketches of the committee members and IOM project staff. REFERENCES AAP (American Academy of Pediatrics). 2011a. Oral health initiative. http://www.aap.org/ oralhealth/ (accessed March 16, 2011). AAP. 2011b. Results of the AAP national summit on children’s oral health and Academic Pediatrics’ special issue on children’s oral health. http://www.aap.org/oralhealth/summit/ (accessed March 16, 2011). ADA (American Dental Association). 2007. American Indian and Alaska Native Oral Health Access Summit: Summary report. Santa Ana Pueblo, NM: American Dental Association. ADA. 2008. Report on the June 23, 2008, Medicaid Provider Symposium. Chicago, IL: American Dental Association. ADA. 2009. Proceedings of the March 23–25, 2009, Access to Dental Care Summit. Chicago, IL: American Dental Association. AHRQ (Agency for Healthcare Research and Quality). 2010. 2009 National healthcare dis- parities report. Rockville, MD: U.S. Department of Health and Human Services. Anders, P. L., and E. L. Davis. 2010. Oral health of patients with intellectual disabilities: A systematic review. Special Care in Dentistry 30(3):110-117. Andersen, R. M., P. L. Davidson, K. A. Atchison, J. J. Crall, J.-A. Friedman, E. R. Hewlett, and A. Thind. 2009. Summary and implications of the dental pipeline program evaluation. Journal of Dental Education 73(Supp. 2):S319-S330. Anderson, J. R. 2010. HRSA oral health programs. Paper presented at 2010 Dental Manage- ment Coalition, June 27, Annapolis, MD. Armour, B. S., M. Swanson, H. B. Waldman, and S. P. Perlman. 2008. A profile of state-level differences in the oral health of people with and without disabilities, in the U.S., in 2004. Public Health Reports 123(1):67-75. Atchison, K. A., A. Thind, T. T. Nakazono, D. Wong, J. J. Gutierrez, D. C. Carreon, and R. M. Andersen. 2009. Community-based clinical dental education: Effects of the pipeline program. Journal of Dental Education 73(Supp. 2):S269-S282. Bailit, H., and A. Formicola. 2010. Preface: About the dental pipeline program. Journal of Dental Education 7(10):S5-S6. Bierman, A. S., E. S. Magari, A. M. Jette, M. Splaine, and J. H. Wasson. 1998. Assessing ac- cess as a first step toward improving the quality of care for very old adults. Journal of Ambulatory Care Management 21(3):17-26. Blaizot, A., J. N. Vergnes, S. Nuwwareh, J. Amar, and M. Sixou. 2009. Periodontal diseases and cardiovascular events: Meta-analysis of observational studies. International Dental Journal 59(4):197-209. Bloom, B., R. Cohen, et al. 2009. Summary health statistics for U.S. children: National Health Interview Survey, 2008. Hyattsville, MD: National Center for Health Statistics. Bloom, B., R. Cohen, and G. Freeman. 2010. Summary health statistics for U.S. children: National Health Interview Survey, 2009. Hyattsville, MD: National Center for Health Statistics. Brown, L. J. 2005. Adequacy of current and future dental workforce: Theory and analysis. Chicago, IL: American Dental Association. Caspary, G., D. M. Krol, S. Boulter, M. A. Keels, and G. Romano-Clarke. 2008. Perceptions of oral health training and attitudes toward performing oral health screenings among graduating pediatric residents. Pediatrics 122(2):e465-e471.

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36 IMPROVING ACCESS TO ORAL HEALTH CARE Chávarry, N., M. V. Vettore, et al. 2009. The relationship between diabetes mellitus and destructive periodontal disease: A meta-analysis. Oral health & preventive dentistry 7(2):107-127. CMS (Centers for Medicare and Medicaid Services). 2010. Written testimony of CMS to the Committee on an Oral Health Initiative. Available in Committee on Oral Health Access to Services’ public access file. Cohen, L. A., A. J. Bonito, C. Eicheldinger, R. J. Manski, M. D. Macek, R. R. Edwards, and N. Khanna. 2011. Comparison of patient visits to emergency departments, physician offices, and dental offices for dental problems and injuries. Journal of Public Health Dentistry 71(1):13-22. Conte, M., H. L. Broder, G. Jenkins, R. Reed, and M. N. Janal. 2006. Oral health, related behaviors and oral health impacts among homeless adults. Journal of Public Health Dentistry 66(4):276-278. Cruz, G. D., R. Shore, et al. 2004. Effect of acculturation on objective measures of oral health in Haitian immigrants in New York City. Journal of Dental Research 83(2):180-184. Davis, E. E., A. S. Deinard, and E. W. H. Maïga. 2010. Doctor, my tooth hurts: The costs of incomplete dental care in the emergency room. Journal of Public Health Dentistry 70(3):205-210. Decker, S. L. 2011. Medicaid payment levels to dentists and access to dental care among children and adolescents. Journal of the American Medical Association 306(2): 187-193. Douglass, A. B., R. Maier, et al. 2010. Smiles for Life: A National Oral Health Curriculum. 3rd Edition. Retrieved April 26, 2011, from www.smilesforlifeoralhealth.com. Dye, B. A., S. Tan, V. Smith, B. G. Lewis, L. K. Barker, G. Thornton-Evans, P. I. Eke, E. D. Beltran-Aguilar, A. M. Horowitz, and L. Chien-Hsun. 2007. Trends in oral health status: United States, 1988-1994 and 1999-2004. Hyattsville, MD: National Center for Health Statistics. Dye, B. A., O. Arevalo, and C. M. Vargas. 2010. Trends in paediatric dental caries by poverty status in the United States, 1988-1994 and 1999-2004. International Journal of Paedi- atric Dentistry 20(2):132-143. Edelstein, B. L., and C. H. Chinn. 2009. Update on disparities in oral health and access to dental care for America’s children. Academic Pediatrics 9(6):415-419. 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. Formicola, A. J., K. C. D’Abreu, and L. A. Tedesco. 2010. Underrepresented minority dental student recruitment and enrollment programs: An overview from the dental pipeline program. Journal of Dental Education 74(Supp. 10):S67-S73. GAO (Government Accountability Office). 2000. Dental disease is a chronic problem among low-income populations. Washington, DC: U.S. General Acccounting Office. GAO. 2006. Health professional shortage areas: Problems remain with primary care shortage area designation system. Washington, DC: U.S. General Accounting Office. GAO. 2008. Extent of dental disease in children has not decreased, and millions are estimated to have untreated tooth decay. Washington, DC: U.S. Government Accountability Office. Gibson, G., R. Rosenheck, J. Tullner, R. Grimes, C. Seibyl, A. Rivera-Torres, H. Goodman, and M. Nunn. 2003. A national survey of the oral health status of homeless veterans. Journal of Public Health Dentistry 63(1):30-37. Gussy, M. G., E. B. Waters, E. M. Riggs, S. K. Lo, and N. M. Kilpatrick. 2008. Parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural Victoria. Australian Dental Journal 53(1):52-60.

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37 INTRODUCTION Havercamp, S. M., D. Scandlin, and M. Roth. 2004. Health disparities among adults with developmental disabilities, adults with other disabilities, and adults not reporting dis- ability in North Carolina. Public Health Reports 119(4):418-426. HHS (U.S. Department of Health and Human Services). 2000. Oral health in America: A report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services. HHS. 2010. HHS Oral Health Initiative 2010. http://www.hrsa.gov/publichealth/clinical/ oralhealth/hhsinitiative.pdf (accessed August 19, 2010). HRSA (Health Resources and Services Administration). 2010a. Bureau of Primary Health Care. http://www.hrsa.gov/about/organization/bureaus/bphc/ (accessed December 22, 2010). HRSA. 2010b. NHSC loan repayment. http://nhsc.hrsa.gov/loanrepayment/ (accessed Decem- ber 22, 2010). HRSA. 2011. Designated health professional shortage areas (HPSA) statistics. http://ersrs. hrsa.gov/ReportServer?/HGDW_Reports/BCD_HPSA/BCD_HPSA_SCR50_Smry&rs: Format=HTML3.2 (accessed March 14, 2011). IOM (Institute of Medicine). 1980. Public policy options for better dental health. Washington, DC: National Academy Press. IOM. 1992. The second fifty years: Promoting health and preventing disability. Washington, DC: National Academy Press. IOM. 1993. Access to health care in America. Washington, DC: National Academy Press. IOM. 1994. Careers in clinical research: Obstacles and opportunities. Washington, DC: Na- tional Academy Press. IOM. 1995. Dental education at the crossroads: Challenges and change. Washington, DC: National Academy Press. IOM. 1996. Primary care: America’s health in a new era. Washington, DC: National Academy Press. IOM. 1997. Dietary reference intakes. Washington, DC: National Academy Press. IOM. 2000a. America’s health care safety net: Intact but endangered Washington, DC: Na- tional Academy Press. IOM. 2000b. Extending Medicare coverage for preventive and other services. Washington, DC: National Academy Press. IOM. 2001. Crossing the quality chasm: A new health system for the 21st century. Washing- ton, DC: National Academy Press. IOM. 2002. The future of the public’s health in the 21st century. Washington, DC: The Na- tional Academies Press. IOM. 2004a. Health literacy: A prescription to end confusion. Washington, DC: The National Academies Press. IOM. 2004b. In the nation’s compelling interest: Ensuring diversity in the health-care work- force. Washington, DC: The National Academies Press. IOM. 2005a. Advancing the nation’s health needs: NIH research training programs. Washing- ton, DC: The National Acadmies Press. IOM. 2005b. Quality through collaboration: The future of rural health care. Washington, DC: The National Academies Press. IOM. 2008. Retooling for an aging America: Building the health care workforce. Washington, DC: The National Academies Press. IOM. 2009a. Adolescent health services: Missing opportunities. Washington, DC: The Na- tional Academies Press. IOM. 2009b. The U.S. oral health workforce in the coming decade: Workshop summary. Washington, DC: The National Academies Press.

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38 IMPROVING ACCESS TO ORAL HEALTH CARE IOM. 2009c. America’s uninsured crisis: Consequences for health and health care. Washing- ton, DC: The National Academies Press. Jones, M., J. Y. Lee, and R. G. Rozier. 2007. Oral health literacy among adult patients seeking dental care. Journal of the American Dental Association 138(9):1199-1208. Kutner, M., E. Greenberg, Y. Jin, and C. Paulsen. 2006. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: National Center for Health Statistics. Lewis, C. W. 2009. Dental care and children with special health care needs: A population- based perspective. Academic Pediatrics 9(6):420-426. Liu, J., J. C. Probst, A. B. Martin, J.-Y. Wang, and C. F. Salinas. 2007. Disparities in dental insurance coverage and dental care among U.S. children: The National Survey of Chil- dren’s Health. Pediatrics 119(Supp. 1):S12-S21. Löe, H. 1993. Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 16(1):329-334. Manski, R. J., H. S. Goodman, et al. 2004. Dental insurance visits and expenditures among older adults. American Journal of Public Health 94(5):759-764. Manski, R. J., J. Moeller, et al. 2010. Dental care expenditures and retirement. Journal of Public Health Dentistry 70(2):148-155. Maserejian, N. N., M. A. Tavares, C. Hayes, J. A. Soncini, and F. L. Trachtenberg. 2008. Rural and urban disparities in caries prevalence in children with unmet dental needs: The New England children’s amalgam trial. Journal of Public Health Dentistry 68(1):7-13. Nash, D. A., and R. J. Nagel. 2005. Confronting oral health disparities among American Indian/Alaska Native children: The pediatric oral health therapist. American Journal of Public Health 95(8):1325-1329. National Maternal and Child Oral Health Policy Center. 2010. About us. http://nmcohpc. net/?page_id=2 (accessed December 22, 2010). Offenbacher, S., J. D. Beck, et al. 2009. Results from the Periodontitis and Vascular Events (PAVE) Study: A pilot multicentered, randomized, controlled trial to study effects of periodontal therapy in a secondary prevention model of cardiovascular disease. Journal of Periodontology 80(2):190-201. Orlans, J., E. Mertz, and K. Grumbach. 2002. Dental health professional shortage area meth- odology: A critical review. San Francisco, CA: UCSF Center for the Health Professions. Owens, P. L., B. D. Kerker, E. Zigler, and S. M. Horwitz. 2006. Vision and oral health needs of individuals with intellectual disability. Mental Retardation and Developmental Dis- abilities Research Reviews 12(1):28-40. Pew Center on the States. 2010. The cost of delay: State dental policies fail one in five children. Washington, DC: Pew Center on the States. Pew Center on the States. 2011. The state of children’s dental health: Making coverage matter. Washington, DC: Pew Center on the States. Pleis, J. R., B. W. Ward, and J. W. Lucas. 2010. Summary health statistics for U.S. adults: National Health Interview Survey, 2009. Hyattsville, MD: Department of Health and Human Services. President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 1998. Quality first: Better health care for all Americans. Final Report to the President of the United States. Washington, DC: The President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Sakai, V. T., T. M. Oliveira, T. C. Silva, A. B. S. Moretti, D. Geller-Palti, V. A. Biella, and M. A. A. M. Machado. 2008. Knowledge and attitude of parents or caretakers regarding transmissibility of caries disease. Journal of Applied Oral Science 16(2):150-154.

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39 INTRODUCTION Scannapieco, F. A., and A. W. Ho. 2001. Potential associations between chronic respiratory disease and periodontal disease: Analysis of National Health and Nutrition Examination Survey III. Journal of Periodontology 72(1):50-56. Scannapieco, F. A., R. B. Bush, et al. 2003. Associations between periodontal disease and risk for atherosclerosis, cardiovascular disease, and stroke. A systematic review. Annals of Periodontology 8(1):38-53. Silk, H., A. B. Douglass, J. M. Douglass, and L. Silk. 2008. Oral health during pregnancy. American Family Physician 77(8):1139-1144. Skillman, S. M., M. P. Doescher, W. E. Mouradian, and D. K. Brunson. 2010. The challenge to delivering oral health services in rural America. Journal of Public Health Dentistry 70(Supp. 1):S49-S57. Slavkin, H. C. and B. J. Baum 2000. Relationship of dental and oral pathology to systemic illness. Journal of the American Medical Association 284(10):1215-1217. Sohn, W., A. Ismail, A. Amaya, and J. Lepkowski. 2007. Determinants of dental care visits among low-income African-American children. Journal of the American Dental Associa- tion 138(3):309-318. Steinberg, B. J., L. Minsk, J. I. Gluch, and S. K. Giorgio. 2008. Women’s oral health issues. In Women’s health in clinical practice. Totowa, NJ: Humana Press. Pp. 273-293. Taylor, G. W. 2001. Bidirectional interrelationships between diabetes and periodontal diseases: An epidemiologic perspective. Annals of Periodontology 6(1):99-112. Teeuw, W. J., V. E. A. Gerdes, et al. 2010. Effect of periodontal treatment on glycemic con- trol of diabetic patients: A systematic review and meta-analysis. Diabetes Care 33(2): 421-427. Vargas, C. M., and C. R. Ronzio. 2006. Disparities in early childhood caries. BMC Oral Health 6(Supp. 1):S3-S7. Vargas, C., J. Crall, and D. Schneider. 1998. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. Journal of the American Dental Association 129(9):1229. Vargas, C. M., B. A. Dye, et al. 2002. Oral health status of rural adults in the United States. Journal of the American Dental Association 133(12):1672-1681. Vargas, C. M., B. A. Dye, and K. L. Hayes. 2003a. Oral health care utilization by U.S. rural residents, National Health Interview Survey 1999. Journal of Public Health Dentistry 63(3):150-157. Vargas, C. M., C. R. Ronzio, and K. L. Hayes. 2003b. Oral health status of children and adolescents by rural residence, United States. Journal of Rural Health 19(3):260-268. Vargas, C. M., J. A. Yellowitz, and K. L. Hayes. 2003c. Oral health status of older rural adults in the United States. Journal of the American Dental Association 134(4):479-486. Wetterhall, S., J. D. Bader, B. B. Burrus, J. Y. Lee, and D. A. Shugars. 2010. Evaluation of the dental health aide therapist workforce model in Alaska. Research Triangle Park, NC: W.K. Kellogg Foundation, Rasmuson Foundation, Bethel Community Services Foundation. WHO (World Health Organization). 2010. Oral health. http://www.who.int/topics/oral_health/ en/ (accessed December 3, 2010). W.K. Kellogg Foundation. 2010. W.K. Kellogg Foundation supports community-led efforts in five states to increase oral health care access by adding dental therapist to the dental team. http://www.wkkf.org/news/Articles/2010/11/WK-Kellogg-Foundation-Supports- Community-Led-Efforts.aspx (accessed March 16, 2011).

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