For decades, the U.S. Department of Health and Human Services (HHS) has shown a fluctuating commitment to making oral health a national priority. More than 10 years ago, the surgeon general’s landmark report Oral Health in America described the poor oral health of our nation as a “silent epidemic.” Today, oral diseases remain prevalent across the country, especially in vulnerable and underserved populations. Oral health has been shown to be inextricable from overall health, yet oral health care is still largely treated as separate and distinct from broader health care in terms of financing, education, sites of care, and workforce. While the surgeon general’s report has been credited with raising awareness of the importance of good oral health, oral health still remains largely ignored in health policy.
STUDY CHARGE AND APPROACH
In 2009, the Health Resources and Services Administration (HRSA) approached the Institute of Medicine (IOM) to provide recommendations for a potential oral health initiative (Box S-1).
The committee recognized that many important factors influence the oral health of Americans, including settings of care, workforce, financing, quality assessment, access, and education, and focused attention to these areas on how they relate to possible or current HHS policies and programs. The committee was also cognizant of the sizable role that other non-HHS stakeholders play in the oral health care system, including those in the private sector and at the state and local levels. Consequently, the recommendations contained within this report will not on their own resolve many
IOM Committee on an Oral Health Initiative
Statement of Task
• Assess the current oral health care system for the entire U.S. population.
• Examine preventive oral care interventions, their use and promotion.
• Explore ways of improving health literacy for oral health.
• Review elements of a potential HHS oral health initiative, including possible or current regulations, statutes, programs, research, data, financing, and policy.
• Recommend strategic actions for HHS agencies and, if relevant and important, other actors, as well as ways to evaluate this initiative.
of the problems that exist in the oral health care system. Instead, this report should be viewed as a complementary piece of a larger solution that will require efforts throughout the oral health community and beyond. This report therefore uses the term oral health in its most comprehensive sense—as the responsibility of the entire health care system.
Several major developments during the course of this study challenged the committee. In particular, after the project had already begun, HHS announced the launch of the Oral Health Initiative 2010 (OHI 2010), a cross-agency effort to improve coordination within HHS toward improving the oral health of the nation. HHS considers this current IOM study as part of the initiative. The committee decided to acknowledge the OHI 2010 but not to let its current structure limit their recommendations.
ORAL HEALTH TODAY
In recent decades, advances in oral health science broadened understanding not just of healthy teeth but of the health of the entire craniofacial-oral-dental complex and its relation to overall health. Scientifically, we have moved into a postgenomic era and expanded our understanding of oral conditions to also include their often complex, multigene, and hereditary bases. Despite these advances, Oral Health in America identified dental caries1 as “the single most common chronic childhood disease.” While
1 The term dental caries is used in the singular and refers to the disease commonly known as tooth decay.
there have been notable successes, dental caries remains a common chronic disease across the life span in the United States and around the world. There is a measure of tragedy in this situation because dental caries is a highly, if not entirely, preventable disease.
There are a wide range of both acute and chronic conditions that manifest themselves in or near the oral cavity, including inherited, infectious, neoplastic, and neuromuscular diseases and disorders. This report focuses predominately on dental caries and periodontal diseases, which cause significant morbidity.
THE ORAL-SYSTEMIC CONNECTION
The surgeon general’s report referred to the mouth as a mirror of health and disease occurring in the rest of the body in part because a thorough oral examination can detect signs of numerous general health problems, such as nutritional deficiencies, systemic diseases, microbial infections, immune disorders, injuries, and some cancers. In addition, there is mounting evidence that oral health complications not only reflect general health conditions but also exacerbate them. For example, periodontal disease may be associated with adverse pregnancy outcomes, respiratory disease, cardiovascular disease, coronary heart disease, and diabetes.
Popular attention to the connection between oral health and overall health increased dramatically in 2007 with the death of Deamonte Driver, a 12-year-old Maryland boy who died when bacteria from an untreated tooth infection spread to his brain. Driver’s death transformed the oral health discussion as more people—including members of Congress—recognized the potential seriousness of untreated oral disease. His enduring story has contributed to the sustained interest in oral health seen in recent years.
THE CURRENT ROLE OF HHS
HHS’ efforts to improve oral health and oral health care have been wide ranging, but the priority placed on these endeavors, including financial support, has been inconsistent. Enduring areas of attention include support for community water fluoridation, research on the etiology of oral diseases, dental education, oral health financing, workforce demonstrations, oral health surveillance, and recruitment of oral health care professionals2 to work in underserved areas. For example, HHS oversees the provision of oral health care to select populations through the Indian Health Service
2 In this report, the committee uses the term oral health care professional to refer to any health care professional who provides oral health care. This may include, but not be limited to, dental hygienists, dentists, nurses, physician assistants, and physicians.
and Federally Qualified Health Centers. The Centers for Medicare and Medicaid Services (CMS) finances oral health care through Medicaid and Children’s Health Insurance Program (CHIP) programs. HHS supports the oral health workforce through school loan repayment programs and demonstration projects in innovative workforce models. HHS also monitors oral health and oral health care through surveys conducted by the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ), and it advances the scientific evidence base for oral and craniofacial health through the work of the National Institute of Dental and Craniofacial Research. HHS also plays a role in the assessment of evidence for preventive services, such as through AHRQ’s convening of the U.S. Preventive Services Task Force and the CDC’s convening of the Task Force on Community Preventive Services.
Despite the breadth of these efforts, it is often assumed that HHS has a fairly minor role in and very little leverage to influence the day-to-day functioning of the oral health care system in America. Data indicate that only 9 percent of dental expenditures come from public insurance (compared with 34 percent for physician and clinical services and 34 percent for prescription drugs). However, data on dental expenditures do not reflect the financial input of HHS in the broader definition of oral health since this calculation only reflects the services performed by dentists (as opposed to care provided by nondental health care professionals). In addition, those who are covered by public funds are often the most vulnerable populations; therefore, HHS’ role is extremely important for those who cannot afford to pay for oral health care. Finally, as described previously, HHS has significant financial investments in other aspects of oral health beyond paying for services. So while the government does not currently have as large a role in financing oral health care services as for other health care services, it does, in fact, have a great role to play in the support of the overall oral health care system.
LEARNING FROM THE PAST
While the surgeon general’s report was highly successful in many respects, it did not lead to a direct and immediate change in the government’s approach to oral health. This may have been due to broader environmental factors, including immediate national crises; changes in the economy that affect state and federal budgets; competing health care priorities; a tendency to blame individual behaviors alone for poor oral health; a lack of political will; or simply the long-standing failure to recognize oral health as an integral part of overall health. Within HHS, changes in administrations, workforce turnover, lack of oral health champions, insufficient funding and staffing, and the overall lack of oral health parity may all have contributed
to the disappointing results. Given that HHS’ resources are currently limited, that the scope of the challenge is substantial, and that solutions will require the involvement of multiple stakeholders, one of the most important roles HHS can play is in providing leadership and direction for the country.
In considering a “potential HHS oral health initiative,” the committee developed a set of organizing principles (see Box S-2) based on areas in greatest need of attention as well as approaches that have the most potential for creating improvements. It will be HHS’ responsibility to adapt the current structure of the OHI 2010 to these principles and the recommendations that follow.
The committee outlines seven recommendations that as a whole comprise what will be referred to as the new Oral Health Initiative (NOHI) to distinguish it from and build upon the current initiative. The recommendations provide advice for setting intermediate, measurable goals, but the committee concluded that ultimately HHS should use the goals and objectives of Healthy People 2020 as the continuing mission of the NOHI. Healthy People 2020 is an existing and well-accepted set of benchmarks for the country and was developed by a strong collaboration of multiple partners. Creating a new set of goals would only contribute to the redundancy and fragmentation that is often criticized regarding government programming. The relevant goals and objectives are not just in the oral
Organizing Principles for an HHS Oral Health Initiative
1. Establish high-level accountability.
2. Emphasize disease prevention and oral health promotion.
3. Improve oral health literacy and cultural competence.
4. Reduce oral health disparities.
5. Explore new models for payment and delivery of care.
6. Enhance the role of nondental health care professionals.a
7 Expand oral health research, and improve data collection.
8. Promote collaboration among private and public stakeholders.
9. Measure progress toward short-term and long-term goals and objectives.
10. Advance the goals and objectives of Healthy People 2020.
aNondental health care professionals includes, but is not limited to, nurses, pharmacists, physician assistants, and physicians.
health section; the NOHI should embrace the goals and objectives of the health communication and health information technology section as well as oral health-related topics in other sections. Building upon Healthy People 2020 gives the NOHI a foundation for sustainability and the ability to change goals and objectives depending upon achievements in improving oral health. More importantly, as better measures of quality in oral health are developed, more sophisticated goals can be set.
Establishing and Evaluating the Oral Health Initiative
The committee concluded that HHS has the ability and opportunity to play a vital role in the current oral health enterprise. This initiative can succeed if it has clearly articulated goals, is coordinated effectively, is adequately funded, and has high-level accountability.
RECOMMENDATION 1: The secretary of HHS should give the leader(s) of the new Oral Health Initiative (NOHI) the authority and resources needed to successfully integrate oral health into the planning, programming, policies, and research that occur across all HHS programs and agencies.
• Each agency within HHS that has a role in oral health should provide an annual plan for how it will integrate oral health into existing programs within the first year.
• Each agency should identify specific opportunities for public-private partnerships and collaborating with other agencies inside and outside HHS.
• The leader(s) of the NOHI should coordinate, review, and implement these plans.
• The leaders(s) of the NOHI should incorporate patient and consumer input into the design and implementation of the NOHI.
The identification of specific leadership for the NOHI is necessary to establish accountability. Measurable objectives could focus on shorter-term or intermediate measures of departmental performance such as implementation of new programs and collaborations or demonstrated impact on oral health status and access. The leader(s) of the NOHI would be responsible for oversight of all of these plans, including looking for overarching areas for collaboration and learning both from within HHS and from external partners. Finally, the NOHI needs to ensure that patient and consumer perspectives are recognized and appreciated in future oral health planning.
Focusing on Prevention
Among the most important contributions HHS can make to improve oral health is to promote the use of regimens and services that have been shown to promote oral health, prevent oral diseases, and help manage those diseases. Too often, oral health care focuses more intently on treating disease once it has become manifest. A focus on prevention may help to reduce the overall need for treatment, reduce costs, and improve the capacity of the system to care for those in need.
The committee concluded that (1) preventive services have a strong evidence base for promoting oral health and preventing disease; and (2) HHS is a key provider of oral health care, especially for vulnerable and underserved populations through the safety net.
RECOMMENDATION 2: All relevant HHS agencies should promote and monitor the use of evidence-based preventive services in oral health (both clinical and community based) and counseling across the life span by
• Consulting with the U.S. Preventive Services Task Force and the Task Force on Community Preventive Services to give priority to evidentiary reviews of preventive services in oral health;
• Ensuring that HHS-administered health care systems (e.g., Federally Qualified Health Centers, Indian Health Service) provide recommended preventive services and counseling to improve oral health;
• Providing guidance and assistance to state and local health systems to implement these same approaches; and
• Communicating with other federally administered health care systems to share best practices.
The committee emphasizes that preventive services should be provided by all types of health care professionals who are competent to do so, including nondental health care professionals. Assistance to state and local health systems could include both financial assistance and technical assistance. HHS will also need to evaluate the adequacy of and support needed for the public health infrastructure to carry out these activities—both at the federal and the state level.
Improving Oral Health Literacy
The public and health care professionals are largely unaware of the basic risk factors and preventive approaches for many oral diseases, and
they do not fully appreciate the connection between good oral health and overall health and well-being. For example, the fact that dental caries is both infectious and preventable is not well known, and despite decades of robust evidence about the safety and efficacy of community water fluoridation, segments of the population remain wary of its use.
The committee concluded that the oral health literacy of individuals, communities, and all types of health care providers remains low. This includes lack of understanding about (1) how to prevent and manage oral diseases, (2) the impact of poor oral health, (3) how to navigate the oral health care system, and (4) the best techniques in patient–provider communication.
RECOMMENDATION 3: All relevant HHS agencies should undertake oral health literacy and education efforts aimed at individuals, communities, and health care professionals. These efforts should include, but not be limited to:
• Community-wide public education on the causes and implications of oral diseases and the effectiveness of preventive interventions;
Focus areas should include
The infectious nature of dental caries,
The effectiveness of fluorides and sealants,
The role of diet and nutrition in oral health, and
How oral diseases affect other health conditions.
• Community-wide guidance on how to access oral health care; and
Focus areas should include using and promoting websites such as the National Oral Health Clearinghouse and www.healthcare.gov.
• Professional education on best practices in patient–provider communication skills that result in improved oral health behaviors.
Focus areas should include how to communicate to an increasingly diverse population about prevention of oral cancers, dental caries, and periodontal disease.
The committee did not find enough evidence specifically in the oral health literacy and behavioral change literature to recommend exact strategies for delivering needed messages; the examples within the recommendation have the most evidence supporting the need for outreach and are therefore worthwhile areas for HHS to focus on. To be effective, literacy and education efforts should be carried out in accordance with standards for culturally and linguistically appropriate services.
Enhancing the Delivery of Oral Health Care
The adequacy of the oral health workforce, in terms of its size and capabilities, is difficult to assess. However, it is apparent that the current system is not meeting the needs of many citizens, particularly the most vulnerable populations. The nondental health care workforce has little education and training in the basics of oral health care and oral health literacy (e.g., being able to recognize oral diseases and disorders, teaching patients about self-care, understanding basic risk factors, applying topical fluorides). Dental professionals3 and other health care professionals are trained separately and often do not learn how to work in collaborative teams, including the appropriate use of referrals in both directions. In addition, while professionals from underrepresented minority populations often care for, or are expected to care for, a larger proportion of underserved populations, efforts to increase the diversity of the dental professions have not had substantial impact. These and other challenges have resulted in persistent disparities in access to care along racial, socioeconomic, and urban and rural lines.
Oral health care is predominantly provided by dentists in the private practice setting. Efforts to use new sites of care or types of professionals have been controversial and polarizing. For example, the Indian Health Service recently gained some experience with using dental therapists to target populations that for a variety of reasons (e.g., geographic location) have difficulty accessing oral health care. While the most recent evaluation of these dental therapists was limited to five sites, early results have been promising in terms of the quality of care provided, improved access, and patient satisfaction. Concerns have been expressed about the quality of care provided in alternative settings or by new types of professionals, but data on the quality of care and long-term outcomes related to the provision of care by all types of oral health care professionals are almost wholly lacking. Without further research and evaluation on the delivery of oral health care by a variety of health care professionals, including a comparison of the quality of that care as compared to the care of dentists, better workforce models cannot be developed.
The committee concluded that (1) nondental health care professionals are well situated to play an increased role in oral health care, but they require additional education and training; (2) interprofessional, team-based care has the potential to improve care-coordination, patient outcomes, and produce cost savings, yet dental and nondental health care professionals are rarely trained to work in this manner; (3) new dental professionals and
3 The term dental professionals is typically used to include dentists, dental hygienists, dental assistants, and dental laboratory technicians. It may also include new and emerging professionals as they become part of the health care workforce.
existing professionals with expanded duties may have a role to play in expanding access to care; and (4) efforts to broaden the diversity of the oral health care workforce have not produced marked changes.
RECOMMENDATION 4: HHS should invest in workforce innovations to improve oral health that focus on
• Core competency development, education, and training, to allow for the use of all health care professionals in oral health care;
• Interprofessional, team-based approaches to the prevention and treatment of oral diseases;
• Best use of new and existing oral health care professionals; and
• Increasing the diversity and improving the cultural competence of the workforce providing oral health care.
In addition to the training and composition of the oral health workforce, more needs to be done to improve the delivery and financing of oral health care. Significantly fewer Americans have dental coverage than health coverage, which is important because dental coverage is a major predictor of utilization. Challenges in federal financing include the almost complete exclusion of oral health care from the Medicare program and the limited numbers of professionals willing to care for Medicaid populations (often due to low reimbursement rates and high administrative burden). Many other Americans may be considered to be underinsured.
Because oral health care is integral to the overall health of individuals and the population, ideally it would be part of every health plan (e.g., Medicare); however, current political and economic barriers make this highly unlikely. Not enough research has been done to determine if alternative payment structures might offer incentives to deliver the most effective services efficiently, or to determine if coverage of preventive services results in long-term cost savings. In addition, as more members of the overall health care workforce become competent and licensed to deliver care, research will be needed for how they will work and be reimbursed.
The committee concluded that (1) distinct segments of the U.S. population have challenges with accessing care in typical settings of care; (2) lack of dental coverage contributes to access problems; (3) newer financing mechanisms might help contain costs and improve health outcomes; and (4) new delivery models need to be explored to improve efficiency.
RECOMMENDATION 5: CMS should explore new delivery and payment models for Medicare, Medicaid, and CHIP to improve access, quality, and coverage of oral health care across the life span.
One option for this endeavor is through the Center for Medicare and Medicaid Innovation that seeks to identify, support, and evaluate models of care that improve quality of care while also lowering costs.
While much is known about the prevention and management of oral diseases, evidence is lacking for many important aspects of oral health. For example, not enough is known about the best ways to decrease the significant oral health disparities or the best ways to change oral health behaviors. In addition, very few quality measures exist for oral health care, leading to little evidence not only about the quality of the services themselves but also about their ultimate relationship to long-term improvements in oral health. Quality assessment efforts in oral health lag far behind analagous efforts in medicine, most notably in the lack of a universally accepted and used diagnostic coding system for dentistry.
Data sharing and surveillance activities are a central piece of what HHS can contribute to the U.S. oral health care system. Federal agencies, both inside and outside HHS, provide oral health services and collect data on oral health and oral health care; consolidating the data collected by all these sources would be useful in performing secondary research. However, much effort would be needed to make all of these data standardized and usable.
The committee concluded that a more robust evidence base in oral health is needed overall. Efforts are needed most toward (1) generating new evidence on best practices; (2) improving the usefulness of existing data; and (3) evaluating the quality of oral health care (including outcomes).
RECOMMENDATION 6: HHS should place a high priority on efforts to improve open, actionable, and timely information to advance science and improve oral health through research by
• Leveraging resources for research to promote a more robust evidence base specific to oral health care, including, but not limited to,
oral health disparities, and
best practices in oral health care and oral health behavior change;
• Working across HHS agencies—in collaboration with other federal departments (e.g., Department of Defense, Veterans Administration) involved in the collection of oral health data—to integrate, standardize, and promote public availability of relevant databases; and
• Promoting the creation and implementation of new, useful, and appropriate measures of quality oral health care practices, cost and efficiency, and oral health outcomes.
The committee supports the direction of new funding toward research, but in a time of limited resources, HHS needs to prioritize oral health research when deciding on distribution of existing resources.
Finally, the committee concluded that an effective NOHI needs an ongoing process for maintaining accountability and for measuring progress toward achieving specific goals of improved oral health.
RECOMMENDATION 7: To evaluate the NOHI the leader(s) of the NOHI should convene an annual public meeting of the agency heads to report on the progress of the NOHI, including
• Progress of each agency in reaching goals;
• New innovations and data;
• Dissemination of best practices and data into the community; and
• Improvement in health outcomes of populations served by HHS programs, especially as they relate to Healthy People 2020 goals and specific objectives. HHS should provide a forum for public response and comment and make the final proceedings of each meeting available to the public.
This meeting can be an opportunity to report both on short-term and intermediate goals (as set by the individual agencies per Recommendation 1) and progress on Healthy People 2020 goals and objectives (the overall mission of the NOHI). It is also a means to share best practices and new knowledge and to get public feedback. This meeting need not preclude additional meetings that HHS might hold internally without a public presence.
LOOKING TO THE FUTURE
As this committee looks to the future of HHS’ involvement in oral health, questions arise regarding long-term viability both of maintaining oral health as a priority issue and the likelihood of the recommendations of this report coming to fruition. In this vein, the committee has identified three key areas that are needed for future success: strong leadership, sustained interest, and the involvement of multiple stakeholders.
The Importance of Strong Leadership
Compared to previous HHS efforts to improve oral health, the OHI 2010 involves many more HHS agencies and programs at multiple levels. The NOHI further calls for each agency to involve individuals at the staff level, a strategy that veterans of previous initiatives have said can be helpful. However, this also presents the challenge of organizing and directing multiple agencies that are highly autonomous and may not always act in concert. The NOHI presents an additional challenge in that it calls for the increased involvement of and collaboration with leaders from the private sector and other segments of the public sector. The committee believes that the current leadership at HHS is capable of meeting these challenges.
Regardless of how an initiative is structured, much of its long-term viability depends on the interests and efforts of the individuals leading the agencies and HHS, which can change in unpredictable ways over time. For example, a key factor may be whether it can survive a change in presidential administrations, particularly one involving a change in parties. Long-term viability depends on HHS itself making and keeping oral health a priority issue. While the OHI 2010 reflects yet another attempt to enhance the prominence of oral health in HHS, several warning signs have arisen that could contribute to a loss of momentum. For example, in early 2011, the committee learned of the proposed downgrading of the CDC’s Division of Oral Health into a branch of the Division of Adult and Community Health. In addition, despite the announcement of the OHI 2010, the CDC’s Division of Adolescent and School Health does not list oral health among the “important topics that affect the health and well-being of children and adolescents” and the Administration on Aging does not have any specific initiatives related to the oral health of older adults. Similar to the need for consistent messages to patients and health care professionals about the importance of oral health, HHS needs consistent messaging within its own organization that oral health is a priority across the life span.
Involving Multiple Stakeholders
While HHS should look for ways to be a leader, a range of stakeholders have roles in the success of the NOHI. Collaboration with and learning from the private sector; other public sector entities at the local, state, and national levels; and patients themselves is essential toward achieving the goal of improving the oral health care and, ultimately, the oral health of the entire U.S. population.
In discussions with this committee, HRSA expressed a desire for recommendations that could be acted upon quickly, but also have enough flexibility to allow HHS to choose among several methods of implementation. The approach and details of the previously outlined recommendations do just this. Many of the recommendations are not necessarily “new”; as the title of this report suggests, the challenges and strategies illuminated by Oral Health in America remain the areas that have the strongest evidence for actions by HHS to advance oral health in America.
The recommendations provided in this report align with the current HHS Strategic Plan for Fiscal Years 2010–2015. Some of the specific objectives and strategies of this plan include ensuring access to quality, culturally competent care for vulnerable populations; strengthening oral health research; and promoting models of oral health care that use a variety of new and existing health care professionals. The recommendations of this report also align with the mission of HHS: “to enhance the health and well-being of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services.”
Bringing disparate sectors together to effect significant change is a daunting task, but it is well suited to the mission and responsibilities of HHS. This report focuses on the role HHS can play in improving oral health and shaping oral health care in America—in particular, on the ways in which HHS can have the most impact. There are many reasons that HHS should seize this opportunity. However, most important is the burden that oral diseases are placing on the health and well-being of the American people.