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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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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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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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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.
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