Poor oral health remains a serious national health problem.
—Garth Graham, Deputy Assistant Secretary for Minority Health,
Office of Minority Health
Launch of the 2010 HHS Oral Health Initiative, April 26, 2010
This chapter describes previous and current oral health reform efforts and oral health activities initiated at the federal level, focusing in particular on cross-agency initiatives within the U.S. Department of Health and Human Services (HHS). It also describes the current HHS Oral Health Initiative and provides recommendations for the future focus of this effort. Appendix B includes organizational charts of the key HHS agencies and divisions involved in oral health.
The earliest recognition of the impact of poor oral health in America dates back to concerns for the oral health of the nation’s military, but the government’s involvement in oral health care was limited. In the 18th and 19th centuries, the military considered oral health care to be the responsibility of the individual soldier, and this care was primarily provided by civilian dentists, or, on an emergency basis, by ill-trained army physicians (King and Hynson, 2007). By the mid-1800s, predecessors of the American Dental Association (ADA) began to press government leaders about the lack of access to oral health care for the nations’ soldiers and sailors. Finally, in 1911, after numerous hearings and many failed bills, President Taft signed legislation creating the U.S. Army Dental Corps (King and Hynson, 2007).
Perhaps the U.S. government’s first notable role in establishing the importance of oral health within federal-level health agencies was in 1931 when the U.S. Public Health Service (USPHS) created a Dental Hygiene Unit at the National Institutes of Health (NIH) and designated Dr. H.
Trendley Dean as the first dental research scientist (NIH, 2010). Dr. Dean examined the epidemiology of communities that presented with “mottled enamel” (i.e., fluorosis), but further research also suggested a benefit from fluoride in community drinking water on the prevalence of tooth decay. In 1944, a Dental Health Section was established for the first time within the Department of Health, Education, and Welfare (DHEW), predecessor to the modern-day HHS, under the Bureau of State Services, predecessor to the today’s Health Resources and Services Administration (HRSA) (National Archives, 2010). In 1945, Grand Rapids, Michigan, with the support of Dr. Dean and the NIH, became the first city in the world to add a controlled level of fluoride to its community water supply (NIDCR, 2010f). On June 24, 1948, President Harry Truman signed Public Law 80-755, the National Dental Research Act, and thereby created the National Institute for Dental Research, predecessor to the current National Institute for Dental and Craniofacial Research (NIDCR), as well as the National Advisory Dental Research Council (NIH, 2010). By 1950, the results of the first 5 years of the Grand Rapids study confirmed that optimal water fluoridation was a safe, effective, and economical method for helping to prevent dental caries, and the Public Health Service adopted a policy of encouraging community water fluoridation (Lennon, 2006).
Strengthened by the success of the water fluoridation studies, by the mid-1960s, oral health care’s position in the federal bureaucracy expanded when a Division of Dental Health (later called Division of Dentistry) was established within DHEW. Its director served as dental advisor to President Johnson’s Office of Economic Opportunity, the agency responsible for administering programs such as Head Start (Diefenbach, 1969). The division administered a variety of programs centered on dental education, the dental workforce, dental caries prevention, and the use of fluorides. The work of the Division of Dental Health might be considered the first major oral health “initiative” conducted by the federal government.
At this time, programs such as Head Start discovered that oral health care was one of the services most requested by impoverished families (Diefenbach, 1969). Social Security Amendments of 1965 and 1967 required the inclusion of dental care in its program and also allowed for the development of special projects aimed at the oral health of children (Coker, 1969). At the same time, the advancing scientific understanding that tooth decay and periodontal disease are bacterial infections that can be controlled through preventive measures brought a growing sense of optimism that the prevalence of these conditions could be radically reduced over time. Through funding incentives, the Division of Dental Health sought to en-
courage dental schools to teach prevention and to establish departments of preventive dentistry. However, when the division’s funding was later eliminated, virtually all of the participating dental schools either eliminated these departments or collapsed them into others.1
In the 1960s, the federal government also sought to improve access to oral health care through expansions and innovations in the oral health workforce. For example, the Health Professions Educational Assistance Act of 1963 provided the first federal support for dental education (Diefenbach, 1969).2 The act (and later amendments) improved the financial base of existing dental schools, initiated new school construction, and sought to produce nearly 1,000 additional dental graduates within only a few years. In addition, the Health Manpower Act of 1968 provided even more funding to improve and expand training programs under Title VII of the Public Health Service Act.3
At this time, DHEW began to estimate the status of the dental workforce as part of its estimation of the health workforce (NCHS, 1968). DHEW was also actively involved in promoting workforce innovations (e.g., the use of nondentist personnel) such as dental auxiliary utilization, otherwise known as four-handed dentistry, and dental school-based training in expanded auxiliary management (TEAM) programs (Gladstone and Garcia, 2007; Johnson, 1969). These educational initiatives were designed to spur the adoption of team care in dentistry, with each member of the dental team working up to the capacity of his or her training, in order to provide more care at less cost. The Indian Health Service embraced the team care concept and demonstrated the effectiveness and efficiency of dental assistants in expanded functions in several sites, then expanded their utilization wherever it was practical (Abramowitz and Berg, 1973). In addition, an early innovation to integrate dental and nondental health care professionals is noted in the creation of craniofacial teams—in 1962, the National Institute for Dental Research funded the first multidisciplinary study of cleft palate at the University of Pittsburgh Health Center (NIH, 2010).
In an article appearing in the June 1969 issue of the American Journal of Public Health and the Nation’s Health, Dr. Viron Diefenbach, then director of the Division of Dental Health of the Public Health Service, asserted that the 1960s would be remembered as a time of astounding scientific advances, and also one in which public policy began to address the striking inequalities in access to health care (Diefenbach, 1969). Specifically, he
1 Personal Communication, A. Horowitz, University of Maryland, September 14, 2010.
2 Health Professions Educational Assistance Act of 1963, Public Law 129, 88th Cong., 1st sess. (September 24, 1963).
3 Health Manpower Act of 1968, Public Law 490, 90th Cong., 2d sess. (August 16, 1968).
expressed optimism for “revers[ing] the spiral of dental illness in the United States” (Diefenbach, 1969).
In the early 1970s, the federal government made substantial investments in the entire health care workforce. By the early 1970s, rural states had approached Congress about the worsening crisis due to the lack of health care professionals available to care for rural communities. In response, in 1970, the Emergency Health Personnel Act4 created the National Health Service Corps (NHSC). Since 1972, the NHSC has assigned USPHS Commissioned Corps officers or civil servants to provide care in underserved areas (HRSA, 2010d). Amendments to this law in the 1970s and 1980s allowed for both scholarships and loan repayment in order to attract more health care professionals to serve in the NHSC (HRSA, 2010d). In addition, President Nixon signed the Comprehensive Health Manpower Training Act of 1971, which continued the federal government’s involvement in the financing of health professions education, including dental education.5 This law strove not just to increase numbers but also “to improve the distribution of such personnel—both geographically and by medical specialty—and to promote the more effective use of health manpower” (Woolley and Peters, 2011b). Later, President Ford signed the Health Professions Educational Assistance Act of 1976.6 This law did not focus on increasing numbers, but rather on better distribution, both by specialty area as well as geographic location. The law included special provisions for education and training of general dentists and expanded function dental auxiliaries and revised and expanded the NHSC (Woolley and Peters, 2011a).
In addition to workforce investments, one major activity that did launch in the early 1970s was the National Caries Program (NCP). The program was housed within the NIH, and its goal was to substantially reduce the prevalence of dental caries in the United States (Harris, 1992). The NCP expenditures for the first year of operation exceeded $6 million, with $2 million in grants, $3 million in contracts, and $900,000 in laboratory and clinical research (Harris, 1992). The NCP continued until 1984.
While investments in the workforce overall were substantial and DHEW oral health activities had been successful, attention to oral health in particular was waning. A later review of HHS oral health programs found that
4 Emergency Health Personnel Act of 1970, Public Law 623, 91st Cong., 2d sess. (December 31, 1970).
5 Comprehensive Health Manpower Training Act of 1971, Public Law 157, 92d Cong., 1st sess. (November 18, 1971).
6 Health Professions Educational Assistance Act of 1976, Public Law 484, 94th Cong., 2d sess. (October 12, 1976).
“the oral health activities of the department, and the resources devoted to those activities, have been disaggregated, dispersed, reduced drastically, or altogether eliminated since 1972” (Interim Study Group on Dental Activities, 1989). Since then, multiple agencies within HHS have been responsible for various programs related to oral health, and the need for integration of these activities across the department has become a recurring theme.
Healthy People (1979–Present)
In 1979, Surgeon General Julius B. Richmond issued Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, which highlighted the dramatic impact of public health efforts in fighting communicable diseases and laid out a national agenda for the future role of public health efforts in noninfectious diseases—that is, health promotion and disease prevention (DHEW, 1979). This report highlighted dental health as a “prominent threat to the good health of children” and identified “fluoridation and oral heath” as one of 15 priority areas. It also illustrated goals along the age continuum, namely, to reduce deaths among infants, children, young adults and adults, and to reduce the number of sick days among older adults.
That same year, the Office of Disease Prevention and Health Promotion was established under the purview of Assistant Surgeon General Michael McGinnis, who also had borne responsibility for the development of the surgeon general’s report.7 In 1980, this office, working closely with the Centers for Disease Control and Prevention (CDC) and the other agencies of the USPHS, oversaw the production of Promoting Health/Preventing Disease: Objectives for the Nation (known as Healthy People 1990), which outlined 226 objectives to achieve significant improvements in the health of the nation by 1990 (USPHS, 1980). Objectives tended to be chosen, in part, based on whether they were measurable, whether improvement was considered possible or likely, whether there were science-based interventions, and whether they were easily understood both by health care professionals and the general public (Andersen and Mullner, 1990; McGinnis, 2010). While important, the presence of ongoing data sources was not a precondition for these objectives, with the expectation being that the objective would drive data collection8 (McGinnis, 2010).
While Healthy People 1990 had a mortality-based framework, Healthy People 2000 focused on the broader goals of increasing the span of healthy life, reducing disparities, increasing access to preventive services, and age-
7 Personal Communication, M. McGinnis, Institute of Medicine, July 30, 2011.
8 As this did not fully come to fruition, Healthy People 2020 required the existence of or the commitment to develop a tracking source.
specific targets (McGinnis, 2010). As the number of individual objectives was growing, Healthy People 2000 identified about 20 priority areas, one of which was oral health (HHS, 1991). Healthy People 2010 changed its focus yet again, to concentrate on increasing the quality and years of healthy life and eliminating health disparities. Oral health was identified as one of 28 “focus areas” (HHS, 2005).
Overall, the Healthy People goals are intended to be used as a guide for the nation, not just for the use of the federal government. Partners in the development of Healthy People goals and objectives include federal agencies, the Healthy People Consortium (an alliance of non-federal stakeholders committed to supporting Healthy People goals), and public-private partnerships developed through memorandums of understanding (MOUs). For Healthy People 2010, HHS had MOUs with the American Association for Dental Research and the Academy of General Dentistry (HHS, 2003b). (Healthy People 2010 and 2020 are also discussed in general in Chapter 2 as well as later in this chapter.)
In 1980, the Division of Dentistry consolidated with Division of Associated Health Professions to form the Division of Associated and Dental Health Professions under the Bureau of Health Professions (National Archives, 2010). During the 1980s, federal activity was proceeding along many different tracks, largely in an uncoordinated manner. Preparations for the second national health objectives report (Healthy People 2000) were under way, which engaged the participation of agencies across the department. Also, in 1987, Congress directed the National Institute for Dental Research to develop a multiagency national plan for improving the oral health of adults (especially older adults) that would engage both the public and private sectors to address education, research, and delivery of oral health services (Gershen, 1991; Interim Study Group on Dental Activities, 1989; NIH, 2010). The Maternal and Child Health Bureau (MCHB) took the lead in conducting a workshop examining children’s access to oral health care (HRSA, 1990).
Through the Omnibus Budget Reconciliation Act of 1989 (OBRA 1989),9 Congress initiated significant changes in the MCHB block grant program. In addition, Congress codified previous regulatory requirements applicable to the Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefits for individuals under age 21. Prior to 1989, dental coverage had been a regulatory requirement; the 1989 amendments
9 Omnibus Budget Reconciliation Act of 1989, Public Law 239, 101st Cong., 1st sess. (December 19, 1989).
mandated dental services provided at intervals meeting reasonable standards of dental practice as well as at medically necessary intervals, and consisting of relief of pain and infections, restoration of teeth, and maintenance of dental health10 (OIG, 1996). Finally OBRA 1989 also mandated that all state Medicaid programs increase their eligibility levels to 133 percent of the federal poverty level (FPL) and give states the option to increase it to 185 percent of the FPL.
The Meskin Report (1989)
As part of the appropriations process for fiscal year 1988, the congressional appropriations committees in both the House and the Senate mandated a study of the oral health activities of HHS (Interim Study Group on Dental Activities, 1989; USPHS, 1989). The objectives of that study, now known as the Meskin report (after chairman Lawrence H. Meskin), resemble the charge that has been put forward to this Institute of Medicine (IOM) committee—namely, “to address the identification of appropriate goals and priorities in oral health” and “to consider appropriate organizational and administrative arrangements for achieving maximum coordination” (Interim Study Group on Dental Activities, 1989). As a result of this mandate, HHS formed the Interim Study Group on Dental Activities to identify goals and priorities in the areas of oral health research, education, prevention, and service provision. The appointed study group consisted of 12 members representing both the public and private sectors, along with four HHS agency representatives who served as consultants. All 12 of the study group members were dentists, with the exception of then executive director of the ADA.
To inform this study, an inventory of oral health activities within HHS was conducted by a contractor and presented to HHS in January 1989 (USPHS, 1989). The group also solicited input from 30 individuals and organizations including the ADA, the American Association of Public Health Dentistry (AAPHD), the American Association of Dental Schools, state departments of health, and the World Health Organization. This process identified a number of needs within HHS, including:
• A strengthened central focus;
• An increased federal government leadership role;
• Better coordination among agencies;
• Identification of agencies’ oral health goals;
• Dental presence in all agencies;
• Strengthened regional offices;
10 42 U.S.C. §1396d(r)(3).
• Greater input from states;
• Greater interaction with national dental organizations;
• More input from private dentistry;
• Increased access for underserved and special populations; and
• Greater prevention orientation (USPHS, 1989).
The Interim Study Group on Dental Activities submitted its report, Improving the Oral Health of the American People: Opportunity for Action, to the USPHS in March 1989, and this was subsequently submitted to the House of Representatives Appropriations Committee in May 1989 (Interim Study Group on Dental Activities, 1989; USPHS, 1989). The report began by noting the dramatic improvements in the scientific understanding of oral disease in the post–World War II era. It said that these developments had “caused a fundamental shift in the focus of dentistry from the repair and replacement of teeth to the prevention of disease and the preservation of the natural dentition for a lifetime” (USPHS, 1989). “Indeed,” the report continued, “leaders in the dental community now talk of the prospect of essentially eliminating caries and periodontal disease in the early decades of the 21st century” (USPHS, 1989).
The question was how to realize this potential—specifically, how HHS could be structured to promote this objective. The study group found that
decentralization in recent years has resulted in severe fragmentation of the remaining oral health programs, decreased interagency communication, and limited opportunities for collaboration among the various [d]epartmental programs, despite the fact that they share the goal of improving the oral health of the [n]ation. Decreased collaboration leads to duplication of efforts in some areas and absence of efforts in other areas, and results in uncoordinated oral health programs which lack direction or purpose. The attainment of a unified program is hindered primarily by the lack of a clear focus for the [d]epartment’s oral health activities. No single entity has been empowered and enabled to coordinate oral health activities. . . . The [s]tudy [g]roup was unable to identify within the [d]epartment . . . a discernible oral health policy. (USPHS, 1989)
The study group’s recommendations (see Box 4-1) included that HHS name an individual to serve as the focal point of oral health activities throughout the department. This would be a full-time position within the USPHS at the level of the Office of the Assistant Secretary for Health. They stated that the individual needed to have clearly visible administrative and policy responsibility, serving as the principal oral health advisor to the secretary of HHS. The group recommended that the individual should be advised by a formally chartered committee with representatives primarily from the private sector, along with ex officio representatives from the U.S.
Meskin Report Recommendations
• Establish a focus for oral health activities in the Department of Health and Human Services with clearly visible administrative and policy responsibility.
• The individual serving as the focus for oral health activities in the DHHS should be advised by a formally chartered committee.
• Establish a strong, clearly identified, oral health presence in any DHHS agency that regularly conducts oral health activities.
SOURCE: USPHS, 1989.
Departments of Defense (DOD) and Veterans Affairs (VA). The group also emphasized that all HHS agencies with oral health activities should have a strong, clearly identified oral health presence.
The Oral Health Coordinating Committee (1990)
Due, in part, to the findings of the Meskin Report, on February 26, 1990, then Assistant Secretary for Health James Mason established the Oral Health Coordinating Committee (OHCC) to help coordinate federal activities in improving oral health (USPHS, 2002). The chief dental officer of the USPHS was delegated the leadership of the OHCC on behalf of the assistant secretary of health; however, this person had (and still has) full-time responsibilities elsewhere within HHS. The Meskin committee’s recommendation that one person serve in a dedicated full-time role as a focal point for oral health policy within HHS was not adopted. The OHCC continues to draw its leadership and its staffing from the operating divisions within HHS, but it has neither line authority nor its own budget (Bailey, 2010). The Meskin committee had also recommended that the advisory committee have significant private-sector representation; however, the OHCC was not structured to include this point of view.
In 1996, the Office of the Inspector General (OIG) released a report indicating many children were not receiving EPSDT services that were supposed to be available through Medicaid (OIG, 1996). Approximately 80 percent of the states attributed the problem to a shortage of dentists willing to accept Medicaid patients. The OIG offered a single recommendation on how this should be addressed at the federal level: “The department should convene a work group that, at a minimum, would include the HCFA
[Health Care Financing Administration], HRSA, [the Administration for Children and Families], [the Office of Public Health and Science], and [the HHS Assistant Secretary for Planning and Evaluation] to develop an integrated approach to improve dental access and utilization for EPSDT eligible children (OIG, 1996).” The assistant secretary of health and the NIH responded that the existing OHCC could adequately serve this purpose without creating a new workgroup. The OIG agreed, and revised its recommendation to state that “with expanded membership, the existing PHS Oral Health Coordinating Committee Working Group could fulfill this need” (OIG, 1996). The recommendation indicated that the workgroup should consider ways to encourage professional volunteerism, support demonstrations aimed at increasing provider participation in Medicaid, and improve outreach to eligible families. Over the course of the remainder of the 1990s and then through most of the 2000s, however, the members of the OHCC served more as senior advisors rather than having a role in developing a plan as suggested by the OIG.
The HRSA-HCFA Initiative (1998–2001)
The HRSA-HCFA Oral Health Initiative aimed to improve collaboration at the national level in order to improve access to oral health care at the local level. Goals of the initiative were to
• Eliminate disparities and barriers to care,
• Respond to unmet needs for clinical services,
• Increase the number of dental professionals,
• Expand the dental public health infrastructure,
• Restructure and increase coordination among federal oral health programs, and
• Coordinate federal initiatives with key partners in the dental community (HHS, 2000c).
The initiative included three main types of activities: integrating activities within and between federal agencies, partnering with stakeholders, and sharing scientific data (HHS, 2000c). For example, HRSA and HCFA sought interagency collaborations to provide information to communities based on information gathered from efforts such as the National Health and Nutrition Examination Survey (NHANES) and Healthy People (HHS, 2000c). Other state and regional activities included oral health summits and workshops, regular conference calls with state dental directors, on-site reviews of state programs, recruitment of dental consultants, and solicitation of federal funds for dental programs (HHS, 2000c).
The HRSA-HCFA initiative continued for 3 years and was arguably
one of the HHS’s most successful and far-reaching oral health initiatives. In testimony to this IOM committee, the incoming president of the ADA, Raymond Gist, praised the HRSA-HCFA effort, saying that it was a “sweeping oral health initiative” (Gist, 2010). He said that the effort not only highlighted and boosted HRSA’s oral health programs, it also recognized that HRSA needed to forge a closer relationship with (what is now) the Centers for Medicare and Medicaid Services (CMS) and programs such as Head Start. Longer-term objectives for the HRSA-HCFA initiative had been to “expand funding for dental programs in community health centers, increase the number of grants for sealant programs, expand the number of loans and scholarships for dental students willing to practice in underserved areas, support development of state infrastructures, provide GIS mapping for all states” to enable them to assess oral health care infrastructure at county and subcounty levels, “simplify the designations for Health Professional Shortage Areas, and change federal policies that restrict provider enrollment and access to care” (HHS, 2000c). However, the HRSA-HCFA initiative ended after the transition in administrations following the 2000 presidential election.
The Surgeon General’s Report (2000)
On May 25, 2000, the USPHS issued its landmark report Oral Health in America: A Report of the Surgeon General (HHS, 2000b). The report alerted the nation of a “silent epidemic” of oral disease in America and brought attention to the deep disparities in oral health status as well as who receives adequate oral health care services nationwide. The report also helped to reframe the term oral health, so that it not only includes dental care and teeth but also overall oral health, including periodontal disease, oral cancer, and craniofacial issues such as cleft palate. In reviewing the existing body of knowledge on oral health issues at that time, the surgeon general noted that safe and effective measures existed to prevent the most common oral diseases—dental caries and periodontal disease. For example, the report noted that good oral hygiene practices such as simple brushing and flossing can prevent gingivitis and that the effectiveness of water fluoridation for the prevention of dental caries had been proven for decades. But the report also found that lifestyle choices such as tobacco use, excessive alcohol use, and poor dietary choices can be detrimental to oral health. Overall, the report’s major message was that oral health is essential to general health and well-being and can be achieved by all Americans. However, not everyone is achieving the same degree of oral health (HHS, 2000b). In conjunction with the release of this report, the surgeon general held two meetings focusing on children’s oral health. The “Surgeon General’s Workshop,” held March 19–21, 2000, involved 80 invited experts who were
charged with developing an action plan (NIDCR, 2001). This was followed by a national, multidisciplinary meeting of more than 700 people on June 12–13, 2000, entitled “The Face of a Child: Surgeon General’s Conference on Children and Oral Health,” wherein the participants considered the recommendations of the workshop group (NIDCR, 2000, 2001).
The report called for the development of a national oral health plan and provided components of that plan that contributed to the development of the National Call to Action to Promote Oral Health (discussed below). The framework for the plan centered on efforts to change perceptions about oral health among providers, policy makers, and the public; strengthening the evidence base for oral health services; building an effective health infrastructure to meet oral health needs; removing barriers to care; and employing public–private partnerships. The surgeon general’s report was highly discussed 10 years ago and continues to be heavily cited in the literature. In an examination of oral health policy development subsequent to the release of the surgeon general’s report, Crall stated, “Evidence suggests that accomplishments in the area of oral health policy development have been modest but positive, but a significant amount of work remains to be done to address oral health disparities” (Crall, 2009). In a presentation to this committee, Dushanka Kleinman attributed the successful impact of Oral Health in America to the personal experience and interest of HHS leaders, a focus on oral health (not just dentistry), the ability to build on existing HHS activities, and the inclusion of and appeal to nontraditional partners (Kleinman, 2010). However, she also noted limitations due to the lack of an implementation plan with specific goals and measures, the lack of capacity within the federal health care workforce to work on and lead these issues, and the lack of an accountable central body at HHS.
The National Call to Action (2003)
Three years following the release of the surgeon general’s report, HHS developed a National Call to Action to Promote Oral Health (HHS, 2003c). Partnering with voluntary and professional organizations, private and government agencies, foundations, and universities, HHS defined a vision to “advance the general health and well-being of all Americans by creating critical partnerships at all levels of society to engage in programs to promote oral health and prevent disease.” The effort to advance this “National Call to Action” was again led by the NIDCR as the lead federal agency but also engaged senior oral health experts at several HHS agencies to assist in its development. In addition, the report defined goals to reflect those of Healthy People 2010, namely: promote oral health, improve quality of life, and eliminate oral health disparities. Finally, the report specified five necessary actions to improve oral health (see Box 4-2) under the as-
Five Actions of the National Call to
Action to Promote Oral Health
• Change perceptions of oral health.
• Overcome barriers by replicating effective programs and proven efforts.
• Build the science base and accelerate science transfer.
• Increase oral health workforce diversity, capacity, and flexibility.
• Increase collaborations.
SOURCE: HHS, 2003c.
sumption that all actions should be science based, culturally sensitive, integrated into overall health and well-being activities, and routinely evaluated. Nearly a decade later, while improvements have been made, these actions are still needed.
In the sections below, the roles of individual HHS operating divisions and staff divisions are discussed. Examples are taken from public sources of information and given to highlight some of the major work of these entities but are not necessarily exhaustive of every role the entities have in improving oral health and oral health care. Appendix B includes a chart of the key HHS agencies currently involved in oral health.
Administration for Children and Families
Oral health activities in the Administration for Children and Families center on its Head Start program, which is operated through the Office of Head Start. The Administration for Children and Families 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.11
If a child has not received appropriate care, the Head Start program must help the parents make arrangements for the child to receive it.12 Ap-
11 Code of Federal Regulations, Office of Human Development Services, Department of Health and Human Services, title 45, sec. 1304.20 (2009).
propriate care is determined by the state’s EPSDT program and periodicity schedule. Head Start programs must also obtain or arrange for testing, examination, and treatment for children with known or suspected dental problems, and develop and implement a follow-up plan for any problems identified. To foster access to oral health for children enrolled in Head Start, in 2006, the Office of Head Start invested $2 million in grants to 52 Head Start, Early Head Start, and Migrant/Seasonal Head Start programs for the Head Start Oral Health Initiative; grantees received supplemental funding for 4 additional years (Del Grosso et al., 2008). While grantees reported successfully developing partnerships with community organizations and providers who would serve Head Start children, educating staff about the importance of oral health, and incorporating oral health education into the curriculum, they reported that they likely could not sustain much of the oral health programming when the grant funding ended (Del Grosso et al., 2008). The Office of Head Start partners with other HHS agencies and outside organizations to improve access to oral health care services for children who participate in Head Start.
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality (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 (MEPS). MEPS contains two major parts: the household component and the insurance component (AHRQ, 2010). In the household component, MEPS asks individuals about demographic characteristics, oral health conditions, oral health status, access to dental care, charges and source of payments for dental care, satisfaction with care, and dental insurance coverage. Information from the household component is sometimes supplemented with information from the individuals’ health care providers. In the insurance component, MEPS collects information from employers about the types of insurance plans they offer to their employees. AHRQ researchers use MEPS data for intramural research and also make the data available to researchers outside the federal government. AHRQ also funds extramural research on oral health care expenditures, insurance coverage, and access to care. AHRQ disseminates innovative practices in quality improvement through its Innovations Exchange website (www.innovations.ahrq.gov). Activities must meet certain criteria to be included on the site, including aiming to improve one of the domains of quality as defined by the IOM (effectiveness, efficiency, equity, patient-centeredness, safety, and timeliness). The website also includes a compilation of tools for assessing, measuring, promoting,
and improving the quality of health care. AHRQ’s role in convening the U.S. Preventive Services Task Force is discussed later in this chapter.
Centers for Disease Control and Prevention
At the CDC, most oral health activities occur in the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Division of Oral Health. Additionally, the National Center for Health Statistics (NCHS) collects important data on the oral health of the United States population through NHANES (see Chapter 2) and the National Health Interview Survey (NHIS), which collects information on dental visits and unmet dental needs; periodically it fields a module in oral health (CDC, 2010i; NCHS, 2010). The CDC analyzes these data and publishes reports on these analyses. The CDC’s role in convening the Task Force on Community Preventive Services is discussed later in this chapter.
National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health
The NCCDPHP’s activities fall into four categories: state support, monitoring oral health, research and education, and guidelines and recommendations (CDC, 2010b). Between 2009 and 2013, the NCCDPHP will provide support and funding to 19 state oral health programs to help them develop state oral health plans, monitor oral diseases and risk factors, and develop and evaluate disease prevention programs (CDC, 2010c). The NCCDPHP also provides training, resource development, and technical assistance to all states through partnerships with national organizations such as the Association of State and Territorial Dental Directors (ASTDD), the Children’s Dental Health Project, and Oral Health America (CDC, 2010e). To supplement these activities, the NCCDPHP maintains an Oral Health Resources website that includes resources for enhancing state oral health infrastructure, links to state oral health plans, and surveillance data (CDC, 2010f).
The NCCDPHP monitors oral health indicators, such as oral diseases, use of preventive measures, and dental visits. Through the National Oral Health Surveillance System, the NCCDPHP collaborates with ASTDD to track nine indicators of oral health, including dental visits, untreated tooth decay, and dental sealants (CDC, 2010j). The NCCDPHP also works with states to track water fluoridation (CDC, 2010k). Building on this effort, and as part of HHS’ new Oral Health Initiative (described later in this chapter), the NCCDPHP, the NCHS, and the NIDCR will develop a comprehensive National Oral Health Surveillance Plan (HHS, 2010g). The plan will allow HHS to create a “report card” for oral health in the United States
(HHS, 2010g). The role of the CDC in prevention is discussed further later in this chapter.
Centers for Medicare and Medicaid Services
As the largest insurer of children in the United States, Medicaid and the Children’s Health Insurance Plan (CHIP) play a critical role in ensuring children’s access to oral health services. Medicaid includes mandatory dental insurance for children through the EPSDT dental benefit.13 States must provide dental care to children insured by Medicaid “at intervals which meet reasonable standards of . . . dental practice, as determined by the state after consultation with recognized . . . dental organizations involved in child health care.”14 States are also required to provide dental care to children insured by CHIP.15 In contrast, while states may elect to provide dental coverage to adults insured by Medicaid, they are not required to do so.
As the federal administrator of state Medicaid and CHIP plans, CMS monitors state Medicaid programs through the CMS-416 form, which requires states to report specific measures, including the total number of children eligible for EPSDT who received any dental service, preventive dental services, and dental treatment services (CMS, 1999). In response to criticism from the Government Accountability Office that data collected through CMS-416 were incomplete, inconsistent, and often based on unreliable information, CMS recently updated the form to include questions such as the number of children who receive an oral health service from a nondentist, the total number of children receiving any dental or oral health service, and the number of children (ages 6–9 years and 10–14 years) who have received a protective sealant on at least one permanent molar tooth (CMS, 2011; Mann, 2009).
CMS has two goals related to oral health. The first is to increase the rate of children who are enrolled in Medicaid or CHIP who receive any preventive dental service by 10 percent over a 5-year period (CMS, 2010c). This goal will be applied with respect to each state’s measured access rate as well as to the overall national rate. CMS’s second goal is to increase the national rate of children ages 6–9 and 10–14 who receive a dental sealant on a permanent molar tooth by 10 percent over a 5-year period (CMS, 2010c). The baseline and progress for these goals will be based on data from the CMS-416 form and from the annual CHIP report.
CMS is working to improve guidance to states on oral health issues.
13 42 U.S.C. §1396d(r)(3).
15 Children’s Health Insurance Program Reauthorization Act of 2009, Public Law 3, 111th Cong., 1st sess. (February 4, 2009).
The agency has established two advisory groups—the CMS Oral Health Technical Advisory Group and the EPSDT work group—to guide their dental policies (Mann, 2009). The technical advisory group is examining the effects of recent legislation on oral health programs, considering improvements to the CMS-416 annual reports, providing guidance to states about the EPSDT dental benefit, and improving materials used to inform beneficiaries of their Medicaid dental benefits (GAO, 2009). The EPSDT work group will help the agency prioritize and design projects to improve EPSDT services, including dental services (Mann, 2009). CMS anticipates that the work group may assist the agency in updating the state Medicaid manual, and provide training and support to state Medicaid and CHIP programs. The work group will comprise representatives from other federal agencies, states, a variety of health care professions, consumer groups, advocacy organizations, and researchers (Mann, 2009). In addition, CMS will be reviewing state Medicaid dental programs for innovative practices that have increased access to dental care and will be sharing the information about those practices with other states (HHS, 2010g).
CMS is also working directly with families whose children are insured by Medicaid and CHIP to educate them about oral health and connect them with oral health professionals. The Children’s Health Insurance Program Reauthorization Act (CHIPRA)16 requires HHS to develop a program to educate parents of newborns whose birth was funded by Medicaid or CHIP about the risks and prevention of early childhood caries. To connect more children with Medicaid providers, CMS developed the Insure Kids Now! website, which includes a current list of dentists and health care providers in each state (CMS, 2010b).
In testimony to the IOM committee, CMS identified the following initiatives it plans to undertake:
• Identifying state Medicaid dental programs that have demonstrated higher dental utilization rates and unique initiatives, and sharing those via the CMS Medicaid Promising Practices website as well as through national meetings with state partners;
• Identifying and promoting use of quality measures for access and health outcomes related to oral health services through collaboration with the Dental Quality Alliance and AHRQ;
• Providing state peer-to-peer learning opportunities to share successful strategies and lessons learned from state activities implemented to improve utilization rates through national policy academies, all-state conference calls, and other mechanisms;
16 Children’s Health Insurance Program Reauthorization Act of 2009, Public Law 3, 111th Cong., 1st sess. (February 4, 2009).
• Identifying ways that federal and state governments can encourage the expansion of the availability and supply of qualified oral health care professionals, including new mid-level practitioners, through collaboration with other HHS agency partners, the IOM, and others involved in current research in this area;
• A “Call-to-Action” request to states to develop action plans for breaking down barriers to children receiving oral health services and providing extensive technical assistance to states;
• Encouraging State Medicaid and CHIP participation in partnerships with state and local oral health organizations, including provider groups, advocacy groups, dental health professional organizations, and dental schools through incentives such as possible funding for meetings and travel costs to promote cooperation and coordination of service delivery;
• Enhancing outreach to beneficiaries through several strategies, including: federal-state education materials that provide a consistent message and information on the importance of oral health care, public service announcements, encouraging cross-agency collaborations at the state level for broad distribution of educational materials, and encouraging public-private partnerships for implementing beneficiary incentives to obtain services through the potential provision of educational materials and related expenses for distribution of materials;
• Assessing opportunities for advancing oral health initiatives as part of the prevention initiatives created under the new Patient Protection and Affordable Care Act (ACA);17
• Assessing opportunities for advancing oral health initiatives as part of the health information technology provisions of CHIPRA and the American Recovery and Reinvestment Act of 2009 (ARRA);18
• Leveraging new CHIPRA quality grants to states to foster the development of additional state-level approaches to ensuring access and quality of oral health care;
• Enhancing federal guidance to states on ensuring children’s access to preventive and follow-up care through EPSDT, including oral health;
• Developing a strategy for oversight and compliance reviews if needed to ensure that particularly those states that have the lowest dental utilization rates are taking steps to come into compliance with EPSDT program requirements, including oral health; and
17 Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess. (March 23, 2010).
18 American Recovery and Reinvestment Act, Public Law 5, 111th Cong., 1st sess. (February 17, 2009).
• Ongoing CMS collaboration with other federal agencies, including the CDC and HRSA, to provide comprehensive support and incentives to state efforts (CMS, 2010c).
While CMS is greatly involved in the oral health care of children, it is significant to note that the Medicare program, the primary source of health care coverage for adults over age 65, largely excludes oral health care. Medicare coverage and exclusions are discussed in Chapter 3.
Food and Drug Administration
The U.S. Food and Drug Administration (FDA) has responsibility to protect and advance public health. Their role includes assurance of “the safety, efficacy, and security” of drugs, biological products, and medical devices; advancement of innovations that make medicines “more effective, safer, and more affordable”; and provide the public with the “accurate, science-based information” needed to improve health (FDA, 2011a). The scope of drugs, devices, and other products regulated by the FDA is quite broad: for example, e.g., drugs, medical devices, biological products, food supply, cosmetics, tobacco products, and products that emit radiation (FDA, 2011a). The FDA approval process is challenging due to a balance needed between getting newer products to the market quickly and identifying concerns for patient safety. In recent years, the FDA approval process has been criticized as being slow and ineffective, but there has also been recognition of the broadening charges to the FDA without commensurate funding (IOM, 2007a,b, 2010a,c, 2011).
As with health care in general, the FDA regulates oral health devices, drugs, and products. For example, by law, the FDA regulates dental devices, including diagnostic devices (e.g., X-ray systems), prosthetic devices (e.g., dental amalgam, implants), surgical devices (e.g., dental drills), therapeutic devices (e.g., orthodontic appliances), and many other products (e.g., toothbrushes, dental floss).19 Other forms of regulation include approval and labeling of prescription drugs (e.g., injectible forms of anesthesia) and over-the-counter products (e.g., toothpastes) (FDA, 2011b). The FDA also issues alerts regarding recall of products with concerns for patient safety.
Health Resources and Services Administration
Many of HRSA’s bureaus and offices provide funding for oral health care activities; Appendix B includes a chart of the key HRSA agencies in-
19 Code of Federal Regulations, Food and Drug Administration, Department of Health and Human Services, title 21, sec. 872.1–872.6890 (2010).
volved in oral health. In her presentation to this IOM committee, HRSA Administrator Mary Wakefield noted that HRSA programs collectively provide some oral health services to more than 3 million people (Wakefield, 2010). She also noted the recent creation within her office of an Office of Special Health Affairs, and within that, the Office of Strategic Priorities. This office acts as the HRSA administrator’s primary advisor on oral health (as well as other major health issues), sets HRSA goals, and coordinates oral health activities within HRSA as well as among HHS agencies and other federal agencies (Anderson, 2010).
HRSA also maintains and operates 10 regional offices through its Office of Regional Operations (HRSA, 2011e). In addition to supporting HRSA’s basic mission of improving the health care safety net, increasing quality of care, reducing disparities, and advancing public health, the Office of Regional Operations has the following core functions: (1) provide leadership to regions, states, and territories regarding HRSA’s mission, goals, priorities and initiatives; (2) assess environmental trends in health care and recommend ways to improve HRSA policies and programs; (3) foster collaborations between HRSA and state health care leaders; (4) improve HRSA’s alignment with public and private programs that are pursuing common goals; (5) provide technical assistance to HRSA grantees; and (6) support the recruitment and retention of primary health care providers in the health professional shortage areas (HRSA, 2011e).
Bureau of Primary Health Care
The Bureau of Primary Health Care (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). Federally Qualified Health Centers (FQHCs) encompass both federally funded health centers and “look-alike” health centers that meet all of the §330 federal requirements but do not receive federal grants. Preventive dental services are a requirement of all federally funded health centers.20 Health centers provide oral health care services to low-income individuals both directly and through referrals to private professionals.21 BPHC also manages the Service Expansion in Oral Health grants that provided additional funding to FQHCs to expand oral health care services. FQHCs serve more than 3 million dental patients and employ approximately 2,300 dentists, 900 dental hygienists, and 4,300 other dental personnel (Anderson, 2010).
20 42 U.S.C. §254b(b)(A)(i)(III)(hh).
21 42 U.S.C. §254b.
Bureau of Clinician Recruitment and Service
The Bureau of Clinician Recruitment and Service manages the previously discussed NHSC, which provides scholarships and loan repayment to clinicians, including dentists and dental hygienists, who agree to serve for 2–4 years in health professional shortage areas (HRSA, 2010e). In FY 2009, 464 dentists and 66 dental hygienists served in the NHSC (Anderson, 2010).
Bureau of Health Professions
The Bureau of Health Professions (BHP) plays an important role in developing the oral health workforce. BHP sponsors grants to support the health workforce, through training and diversity grants for health professional schools and students, and grants to states to support oral health workforce activities (HRSA, 2011a). In addition, BHP designates the Health Professional Shortage Areas. BHP sponsors the Advisory Committee on Training in Primary Care and Dentistry, which makes recommendations about workforce policy and program development in BHP (see Chapter 3 for more information on recent recommendations from this committee).
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 students and residents as well as grant funding to increase opportunities for provision of oral health care to this population (HRSA, 2011d). For example, the Ryan White Special Projects of National Significance Oral Health Initiative funds 15 demonstration sites for up to 5 years to support organizations 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
The Maternal and Child Health Bureau (MCHB) sponsors two centers focused on oral health: the National Maternal and Child Oral Health Resource Center (OHRC) and the National Oral Health Policy Center (OHPC). The OHRC collaborates with federal, state, and local agencies, national and state organizations and associations, and foundations to gather, develop, and share information and materials on oral health (OHRC, 2010a). The OHRC also collects, reviews, and disseminates Head Start oral health technical and programmatic information and materials
(OHRC, 2010b). The OHPC at the Children’s Dental Health Project provides information and support to federal, state, and local programs and policy makers to promote policies that address disparities in children’s oral health (OHPC, 2010). The ACA authorized MCHB grants for early childhood home visitation programs designed to improve maternal and child health, among other goals.22 This program, if adequately funded and managed, would be an opportunity to educate parents about the transmissibility and prevention of dental caries.
Indian Health Service
The Division of Oral Health of the Indian Health Service (IHS) provides oral health care and promotes oral health improvements for American Indians and Alaska Natives (AI/AN). The IHS directly employs dentists and dental hygienists through the USPHS and the Federal Civil Service, but it has struggled to recruit and retain this workforce (Halliday, 2010). Many AI/AN communities are small, which makes it difficult for them to support a full-time dentist, and they are geographically isolated, which makes them difficult for traveling dentists to reach. A majority of AN, for example, live in villages that are not connected to the rest of the state by roads (Nash and Nagel, 2005). A major challenge to the IHS system is the high staff vacancy rate (Blahut, 2009). In October 2010, there were 52 vacancies for dental professionals (including 3 dental hygiene positions) in IHS facilities (USPHS, 2010b).
In early 2010, the IHS began an Early Childhood Caries (ECC) Initiative (IHS, 2010b). Through the initiative, the IHS is working with community partners such as Head Start, the Women’s, Infants, and Children’s Program, and nurses, doctors, and community health representatives to reduce the prevalence of ECC in AI/AN children by 25 percent by fiscal year 2015. Other goals of the initiative are to increase access to dental care for 0- to 5-year old AI/AN children by 10 percent in FY 2010 and 50 percent by FY 2015; to increase the number of children 0–5 years old who receive a fluoride varnish treatment by 10 percent in FY 2010 and 25 percent by FY 2015; and to increase the number of sealants among children 0–5 years old by 10 percent in FY 2010 and 25 percent by 2015.
The IHS is piloting several other projects designed to improve the oral health of AI/AN populations, including using chemotherapeutics to treat ECC, nonsurgical intervention for the treatment of periodontal disease in diabetic and prediabetic patients, and implementing electronic dental re-
22 Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess. (March 23, 2010).
National Institutes of Health
Most of the oral health activities at the NIH occur in the NIDCR. The NIDCR’s work is guided by four goals articulated in its strategic plan: using the best science to solve problems in oral, dental, and craniofacial health; strengthening the pipeline of researchers dedicated to solving problems in oral, dental, and craniofacial health; identifying innovative clinical research avenues to improve oral, dental, and craniofacial health; applying rigorous, multidisciplinary research approaches to eliminate disparities in oral, dental, and craniofacial health (NIDCR, 2010d). Extramural and intramural research supported by the NIDCR provides much of the scientific basis for the practice of dentistry.
In excess of 75 percent of the NIDCR’s budget funds extramural research grants (NIDCR, 2010b). The NIDCR supports extramural research in oral and craniofacial biology, clinical research, and translational genetics and genomics. Recently, the NIDCR has funded several notable projects in oral health disparities. In fiscal year 2009, oral health disparities activities made up 14 percent of NIDCR’s extramural research budget.24 These activities include five Centers for Research to Reduce Disparities in Oral Health, where researchers from diverse disciplines partner with communities to research disparities in early childhood caries and oral cancers (NIDCR, 2010a). Using funds from ARRA, the NIDCR funded several developmental projects on oral health disparities, including a study examining gaps in access to dental care for pregnant women, a study that examines how a low dental literacy population interprets dental health prevention information, a study that examines the acceptability and feasibility of a community-based Latino lay health worker, or promotora, and a study that examines the predictors and outcomes of the age of a child at the first preventive dental visit for children enrolled in Medicaid.23 The remainder of NIDCR’s budget is used for intramural research and research management and support among its eights branches (NIDCR, 2010e).
The NIDCR and the CDC Division of Oral Health cosponsor the Dental, Oral, and Craniofacial Data Resource Center, which provides several resources for the research and policy-making communities, including a catalog of surveys related to oral health, descriptions of national and state oral
23 Personal communication, C. Halliday, Indian Health Service, June 7, 2010.
24 Written testimony of NIDCR to the Committee on an Oral Health Initiative is in the committee’s public access file.
health surveys, and a tool for generating tables and statistical analysis based on the national and state oral health surveys (NIDCR and CDC, 2010).
The NIH offers several loan repayment programs for health professionals (including dentists) in which, in exchange for repayment of student loans, the professionals agree to perform relevant research over a given period of time. This research may be performed outside of the NIH at qualified locations or within the NIH (for NIH employees) (NIH, 2009b).
Office of the Assistant Secretary for Health
The Office of the Assistant Secretary for Health, formerly known as the Office of Public Health and Science, has a major role in oral health care in that it oversees the Commissioned Corps of the USPHS. The Surgeon General directly oversees the operation of the USPHS. The USPHS has 6,500-plus professionals (including dentists) who lead the nation’s public health programs and advance public health science (USPHS, 2010a). As of 2008, there were 376 dentists serving in the USPHS (USPHS, 2008). The primary areas dental officers work in within the USPHS are clinical dentistry (including direct patient care), dental forensics (in disasters), and oral health education (USPHS, 2010e). USPHS dental officers may work within HHS agencies (e.g., IHS, HRSA) or within agencies (e.g., U.S. Coast Guard, Bureau of Prisons). As part of the USPHS compensation package, dental officers may be eligible for repayment of dental school loans (USPHS, 2010d).
The surgeon general appoints a chief professional officer for each of the individual professional categories of the USPHS Commissioned Corps. The role of the chief dental officer is to provide leadership and coordination for dental officers and to advise the Office of the Surgeon General and HHS on the recruitment, assignment, deployment, retention, and career development of USPHS dentists (USPHS, 2008). Chief dental officers have 4-year terms, and they typically retain substantial responsibilities in the agency from which they were selected. For example, Dr. William Bailey, the current chief dental officer, serves in a dual role as a dental officer within CDC’s Division of Oral Health (ADA, 2010).
Within the USPHS, the Dental Professional Advisory Committee (DePAC) “provides advice and consultation . . . on issues related to professional practices and personnel activities of Civil Service and Commissioned Corps dentists” (USPHS, 2010c). The DePAC provides this assistance to the surgeon general, the chief dental officer of the USPHS, and dental program directors. Membership of the DePAC reflects many of the USPHS agencies and operating divisions. Their goals include assistance in recruitment, training, and use of USPHS dentists; development of reports and position papers; promotion of utilization of oral health professionals; promotion
of cooperation and communication among oral health professionals; and promotion of oral health in all USPHS agencies and programs.
The assistant secretary of health has another major role in oral health as the colead for a new HHS oral health initiative that is discussed later in this chapter.
Chapter 2 documented the evidence base establishing the key role of prevention in many oral diseases. HHS plays a key role in promoting the adoption of evidence-based preventive oral health services, including those provided at the national, state, community, and personal levels. The previous sections have already touched upon some ways in which HHS promotes prevention in oral health care, such as FDA’s role in regulating oral health products and therapies. Two other significant roles include AHRQ’s convening of the USPSTF and CDC’s convening of the TFCPS. The USPSFT reviews clinical research to assess the merits of preventive interventions. The USPSTF makes recommendations about which services should be incorporated into routine medical care, based on the strength of the evidence (USPSTF, 2010). Table 4-1 highlights a number of recent recommendations, conclusions, and statements made by the USPSTF that relate to craniofacial and oral health for both children and adults. The committee notes that significant time has passed since the USPSTF determined that there was insufficient evidence to make recommendations for routine risk assessment of children and oral cancer screening for adults. It urges the task force to consider whether sufficient evidence has been published since 2004 to make conclusive recommendations.
The CDC convenes the TFCPS, which is similar to the USPSTF but focuses on community preventive services (Task Force on Community Preventive Services, 2010). Table 4-2 describes oral health–related community-level interventions recommended by the TFCPS.
Other CDC Activities
The NCCDPHP supports research that investigates and improves prevention of oral diseases. Recently, the NCCDPHP supported research on the effectiveness of dental sealants (Griffin et al., 2008, 2009; Oong et al., 2008). The NCCDPHP also publishes guidelines and recommendations for best practices in oral health (CDC, 2010d). It promotes water fluoridation, has established infection control guidelines for practitioners, and has made recommendations for a variety of prevention programs, including school-based dental sealant programs, population-based interventions to prevent and control dental caries and oral and pharyngeal cancers,
USPSTF Oral Health-Related Recommendations, Conclusions, and Statements
|May 2009||Recommend all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 ug) of folic acid.||A|
|April 2009||Recommend clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.||A|
|April 2009||Recommend clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.||A|
|April 2004||Recommend primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride.||B|
|April 2004||Conclude that the evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease.||1 Statement|
|February 2004||Conclude that the evidence is insufficient to recommend for or against routinely screening adults for oral cancer.||1 Statement|
|1996||The USPSTF recognizes the importance of preventing dental and periodontal disease. However, it has determined that there is no new evidence regarding the role of the primary care clinician in counseling for dental services. The USPSTF will not update its 1996 recommendation.|
SOURCE: USPSTF, 2010.
and sports-related craniofacial injuries (CDC Fluoride Recommendations Work Group, 2001; Gooch et al., 2009; Kohn et al., 2003; Task Force on Community Preventive Services, 2001). The CDC also provides grants and technical assistance to states for developing oral health infrastructure, including water fluoridation (CDC, 2010h). The ACA included several provisions that will improve the CDC’s ability to assist the states in preventing
TFCPS Oral Health–Related Recommendations
|Preventing Dental Caries|
|Community water fluoridation||Recommended|
|State- or community-wide sealant promotion||Insufficient evidence|
|School-based or -linked sealant delivery programs||Recommended|
|Preventing Oral and Pharyngeal Cancers|
|Population-based interventions for early detection||Insufficient evidence|
|Preventing Oral and Pharyngeal Cancers|
|Population-based interventions to encourage use of helmets, facemasks, and mouth guards in contact sports||Insufficient evidence|
SOURCE: CDC, 2010g.
oral disease, if funded.25 The bill requires the CDC to establish a 5-year oral health campaign related to prevention and award grants to all states, territories, Indians, Indian tribes, tribal organizations, and urban Indian organizations to develop school-based sealant programs. In addition, the ACA will improve the surveillance capabilities of the CDC and states by authorizing oral health infrastructure grants to all states and improvements to the oral health components of several national health surveys.
Chapter 2 documented the basics of health literacy and the status of the oral health literacy of both health care professionals and the general public. The federal government has a role to play in improving oral health literacy and has several specific actions that target the general health literacy of both the public and health care professionals.
AHRQ Health Literacy Universal Precautions Toolkit
AHRQ developed the Health Literacy Universal Precautions Toolkit to help primary care providers improve communication with people of all literacy levels (DeWalt et. al., 2010). The toolkit provides methods to improve spoken communication, written communication, self-management,
25 Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess. (March 23, 2010).
and supportive systems, and is aimed at all employees in a primary care office, from the receptionist to the physician. Examples of tools include using the teach-back method, in which health care professionals ask the patient to repeat back information to assure that the patient understands; assessing the phone system and procedures to ensure that telephone communications are friendly and understandable for all patients; designing easy-to-read materials; creating patient-centered action plans; and connecting patients to community resources. Because it is often unclear to professionals which patients have low health literacy, the toolkit encourages them to take “universal precautions,” in other words, to use the tools with all patients regardless of their perceived literacy level.
Healthy People 2010/2020 Health Communications Objectives
Recognizing the importance of health communication to improving public health and health care, HHS has included health communications objectives in the last two versions of Healthy People. Healthy People 2010 included six health communications objectives, which Healthy People 2020 has expanded to 13 (see Box 4-3) (HHS, 2000a, 2010c). Encouragingly, two of the Healthy People 2010 goals were archived because the objectives have been met. The new goals reflect the increased use of health information technology and the advent of personalized medicine.
HHS National Action Plan to Improve Health Literacy
In May 2010, HHS released the National Action Plan to Improve Health Literacy, which aims to situate health literacy improvement in the context of public health. Over a 3-year period, more than 700 individuals and organizations representing health care, public health, education, consumers, social services, communication, and the media participated in the effort. The plan starts out with a vision for a society that
• Provides everyone access to accurate and actionable health information,
• Delivers person-centered health information and services, and
• Supports lifelong learning and skills to promote good health (HHS, 2010i).
In addition, the plan defines seven goals to improve health literacy (see Box 4-4).
While not specific to oral health, this plan is certainly important to the attention needed to effect an improvement of oral health literacy for both
Healthy People 2020: Health Communication and
Health Information Technology Proposed Objectives
1. Improve the health literacy of the population.
2. Increase the proportion of persons who report that their health care providers have satisfactory communication skills.
3. Increase the proportion of persons who report that their health care providers always involved them in decisions about their health care as much as they wanted.
4. Increase the proportion of patients whose doctor recommends personalized health information resources to help them manage their health.
5. Increase the proportion of persons who use electronic personal health management tools.
6. Increase individuals’ access to the Internet.
7. Increase the proportion of adults who report having friends or family members whom they talk with about their health.
8. Increase the proportion of quality, health-related websites.
9. Increase the proportion of online health information seekers who report easily accessing health information.
10. Increase the proportion medical practices that use electronic health records.
11. Increase the proportion of meaningful users of health information technology.
12. Increase the proportion of crisis and emergency risk messages intended to protect the public’s health that demonstrate the use of best practices.
13. Increase social marketing in health promotion and disease prevention.
SOURCE: HHS, 2010c.
patients and professionals, especially considering that oral health is a part of general health.
National Standards on Culturally and Linguistically Appropriate Services
Recognizing the increasing diversity of the U.S. population and the increasing disparities in health status and access to health care for diverse populations, the HHS Office of Minority Health published National Standards on Culturally and Linguistically Appropriate Services (CLAS standards) in 2001 (see Box 4-5). Organizations both inside and outside HHS have adopted the CLAS standards as a tool to evaluate the cultural
Goals of the National Action Plan to Improve Health Literacy
1. Develop and disseminate health and safety information that is accurate, accessible, and actionable.
2. Promote changes in the health care system that improve health information, communication, informed decision making, and access to health services.
3. Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level.
4. Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community.
5. Build partnerships, develop guidance, and change policies.
6. Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy.
7. Increase the dissemination and use of evidence-based health literacy practices and interventions
SOURCE: HHS, 2010i.
competence of health care. For example, while the use of CLAS standards is not mandatory in Medicare, in 2008, Congress asked the OIG to examine Medicare provider and plan compliance with these standards (OIG, 2010). The Joint Commission, which accredits a variety of health care organizations and programs, also incorporated the CLAS standards into its accreditation requirements (The Joint Commission, 2008).
Web-Based Information and Training
HRSA already has made the effort to share and disseminate information on cultural competence. On its own website, HRSA maintains a portal on “Cultural Competency and Health Literacy Resources for Health Care Providers” (http://www.hrsa.gov/culturalcompetence/). This website is a repository for assessment tools, culture- and language-specific information, technical assistance, and training curricula. The website also includes web-based training tools. The Office of Minority Health also maintains content on its website related to cultural competency that includes training tools “for physicians and others” (OMH, 2010).
In part, improving the knowledge of individuals needs to start with the education of children in the importance of oral health. In 2002, the House of Delegates of the Academy of General Dentistry adopted a policy in this regard:
Resolved, that the Academy of General Dentistry advocates incorporation of oral health education into primary and secondary curricula with measurable outcomes, as a proven and cost-effective disease prevention and universal health promotion program. (Halpern, 2010)
The 2004 IOM report Health Literacy: A Prescription to End Confusion noted that “the U.S. educational systems offer a primary point of intervention to improve the quality of literacy and health literacy” (IOM, 2004). The report also noted that “public educational systems in the United States are influenced by national policy and funding, but remain under the jurisdiction of and are funded by states and localities.” While most elementary, middle, and high schools require health education classes, these programs lack consistency (IOM, 2004). In addition, given the breadth of topics that need to be covered in these classes, many teachers are unprepared to teach specific topics (Peterson et al., 2001). The percentage of states that require school districts to teach health education increased from 61 percent to 75 percent between 2000 and 2006 (Kann et al., 2007). In 2006, 74.5 percent of elementary schools, 54.6 percent of middle schools, and 55.1 percent of high schools included oral and dental health as a required part of the health education curriculum (Kann et al., 2007).
The National Center for Education Statistics, part of the Department of Education, collects data and produces reports on the status of American education (http://nces.ed.gov/). The Department of Education may be able to play a role in providing guidance to states on best practices for improving health literacy through the public school system. (See later in this chapter for more on the role of the Department of Education in oral health.)
Grants for Oral Health Literacy Research
NIH and AHRQ have partnered to fund grants for health literacy research (NIH, 2011). These grants were first announced in 2004 and have been renewed through 2013 (NIH, 2006, 2011). In the past, these grants have been used to fund research on a wide variety of health literacy topics, including developing instruments for oral health literacy assessment, assessing the oral health knowledge, opinions, and practices among Latinos, and assessing the health promotion activities in a dental clinic (NIH, 2009c).
National Standards for Culturally and Linguistically
Appropriate Services in Health Care
Standard 1: Health care organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.
Standard 2: Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.
Standard 3: Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.
Standard 4: Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.
Standard 5: Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.
Standard 6: Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).
Standard 7: Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.
HHS is involved in training the oral health workforce and the health workforce more broadly. Several agencies within HHS continue to support training and educating the oral health workforce, particularly the workforce that cares for underserved populations, including children, older adults, and
Standard 8: Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.
Standard 9: Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.
Standard 10: Health care organizations should ensure that data on the individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.
Standard 11: Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.
Standard 12: Health care organizations should develop participatory, collaborative partnerships with communities and use a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.
Standard 13: Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.
Standard 14: Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.
SOURCE: OMH, 2001.
people with special needs (Ng et al., 2008). HRSA provides grants to dental and hygiene schools and residency programs through Title VII and workforce grants to states. CMS provides graduate medical education (GME) funding to hospitals and dental schools for training dental residents through Medicare. NIH supports dental researchers through grants and fellowships.
HHS also supports some interdisciplinary training and care through Title VII grants as well as funding from recent health reform legislation.
Public investment in dental education is driven by the belief that education has a broad impact on the number and quality of dentists that are available to serve the oral health needs of the population. Federal support for dental education allowed dental schools to expand dramatically between 1960 and 1980; 13 new dental schools were built, and graduating classes grew from 3,775 in 1970–1971 to 5,756 in 1982–1983 (HRSA, 2005). Government support, however, has lagged recently. In 2005, HRSA released a report stating that “federal and state involvement in matters concerning the adequacy of the dental workforce has been intermittent, uncoordinated, and inconsistent” (HRSA, 2005).
Title VII Support for Training
Title VII training grants for dentistry currently take two forms: grants to increase the workforce that is prepared to care for vulnerable populations, and grants to diversify the workforce, though the public policy goals of the Title VII grants have varied over time. When the grants were established in the Health Professions Educational Assistance Act of 1963,26 Congress intended them to expand the supply and diversity of dentists and physicians due to concern over access to and maldistribution of practitioners (HRSA, 2005; Reynolds, 2008). This commitment to expanding and diversifying the health workforce continued through the mid-1970s with passage of the Health Professions Educational Assistance Amendments of 1965,27 the Health Manpower Act of 1968,28 and the Comprehensive Health Manpower Training Act of 197129 (Reynolds, 2008). Funding during this era was often tied to increasing class size: schools were given funds for construction, enhancing curriculum, and faculty support in exchange for a promise to enroll more students. Beginning in the mid-1970s, the focus of Title VII shifted to addressing the shortage of primary care providers, including dentists, especially in underserved areas (HRSA, 2005; Reynolds, 2008). The Health Professions Educational Assistance Act of 197630 required Title VII grant recipients to either require dental students
26 Health Professions Educational Assistance Act of 1963, Public Law 129, 88th Congress, 1st sess. (September 24, 1963).
27 Health Professions Educational Assistance Amendments of 1965, Public Law 290, 89th Cong., 1st sess. (October 22, 1965).
28 Health Manpower Act of 1968, Public Law 490, 90th Cong., 2d sess. (August 16, 1968).
29 Comprehensive Health Manpower Training Act of 1971, Public Law 157, 92d Cong., 1st sess. (November 18, 1971).
30 Health Professions Educational Assistance Act of 1976, Public Law 484, 94th Cong., 2d sess. (October 12, 1976).
to rotate in underserved and urban communities or dedicate a percentage of residency slots to general dentistry training, dramatically expanded the National Health Service Corps, and provided significant funding to train dental auxiliaries (Reynolds, 2008). This commitment to primary care continued throughout the 1980s, although it had limited success in encouraging practitioners to work in underserved areas (HRSA, 2005; Reynolds, 2008). Most recently, Title VII funding has focused on developing a workforce that is prepared to care for vulnerable populations and promoting diversity in the health professions (Reynolds, 2008). For example, all Title VII grants are now subject to grant scoring mechanisms that give preference to departments that train primary care practitioners or who provide most of their care to patients in medically underserved communities. Additionally, since 1998, all grant applications have had to propose curricula targeting vulnerable populations (Reynolds, 2008).
Title VII has been successful at expanding residencies in general and pediatric dentistry, which were, until recently, the only dental disciplines for which the grants were available. Between 72 and 75 percent of the growth in general dentistry residencies between 1977 and 1995 can be attributed to Title VII support (Duffy et al., 1997). Title VII–funded dental residencies have been successful at recruiting and training underrepresented minorities, and graduates of Title VII–funded medical residencies are more likely to provide care to underserved communities and populations and more prepared to provide culturally competent care (Edelstein et al., 2003; Green et al., 2008; HHS, 2003a).
The ACA significantly expanded the number of grants available for dental training. Title VII funds are now available for
• Dental public health residencies in addition to general and pediatric dentistry;
• Dental hygiene programs in general, pediatric, and public health dentistry;
• Predoctoral training programs in general, pediatric, and public health dentistry;
• Faculty development programs in general, pediatric, and public health dentistry;
• Technical assistance to pediatric dentistry training programs;
• Financial assistance to dentists who plan to teach or are teaching in general, pediatric, or public health dentistry; and
• Faculty loan repayment programs for general, pediatric, and public health dentists who agree to serve as full-time faculty.
Previously, training grants for dentistry were grouped together with grants for medicine in Title VII, section 747, of the Public Health Service
Act. The ACA removes dentistry from section 747 and creates a new section 748: Training in General, Pediatric, and Public Health Dentistry. As a result of the significant expansion of dental training grants, HRSA’s Advisory Committee on Training in Primary Care Medicine and Dentistry advised the Secretary of Health and Human Services to create a separate Advisory Committee in General, Pediatric, and Public Health Dentistry (HHS, 2010h).
Several Title VII grants are specifically targeted to increase the diversity of the health care workforce. Dental schools with significant enrollment of underrepresented minority students are eligible for Centers of Excellence grants to improve recruitment and training of minority students. Each center must agree to develop a competitive applicant pool; enhance academic performance; support faculty development to train, recruit, and retain underrepresented minority faculty; address minority health issues through clinical education and curriculum; facilitate research in minority health; and train students in community-based settings that provide a significant amount of care to underrepresented minorities.31 Health Careers Opportunity Program grants are available to dental and dental hygiene schools to establish or extend programs to identify, recruit, and support students from disadvantaged backgrounds.32 Scholarships for Disadvantaged Students grants provide funding to dental and dental hygiene schools for financial aid to disadvantaged students.33 Individuals from disadvantaged backgrounds who agree to serve as faculty for at least 2 years at dental and dental hygiene schools are eligible for the Faculty Loan Repayment Program.34
Grants to States for Training
HRSA also supports the training of the oral health workforce through grants to states for innovative programs to address the dental workforce needs of designated dental health professional shortage areas.35 States can use these grants a number of ways, including to recruit oral health professionals, to expand dental residencies, to support service expansion, and to establish faculty recruitment programs. In the past, states have increased the availability of school, community, and mobile-based oral health care; developed cultural competence curriculum for allied health professionals; and implemented school-based sealant programs, among many others (HRSA, 2011a).
31 42 U.S.C. §293.
32 42 U.S.C. §293c.
33 42 U.S.C. §293a.
34 42 U.S.C. §293b.
35 42 U.S.C. §256g.
GME Support for Training
GME payments are also available to train dental residents who train inside the hospital.36 Hospitals used to be able to receive GME for dental residents who trained at affiliated institutions outside the hospital, including dental school–based residency programs (HCFA, 1989).37 However, in 2003, CMS issued a regulation clarifying it would no longer make any GME payments for residents whose training had historically been paid for by dental schools (CMS, 2003). Dental schools could not substitute GME payments for alternative sources of funding.38 As a result of this rule, 26 dental schools lost funding for most or all of their residency programs, while the 6 additional schools that had GME agreements were not affected (Bresch, 2010).
A special type of GME funding is available for independent children’s teaching hospitals, which are generally not eligible for standard GME funding. In 2000, Congress established the Children’s Hospitals Graduate Medical Education Payment Program, which provides children’s teaching hospitals with funding to train health professionals who focus on children’s unique health care needs (HRSA, 2011c). This funding is available to train both dental and medical residents.39
Support from HHS Divisions
Both the NIH and the NIDCR support dental researchers through loan repayment, fellowships, and scholarships. NIH loan repayment programs include support for clinical researchers, pediatric researchers, health disparities researchers, and clinical researchers from disadvantaged backgrounds. The NIDCR also sponsors scholarships for students who are pursuing dual D.D.S./D.M.D.-Ph.D. programs. HRSA’s Bureau of Health Professions funds dental public health residency training grants to support approved residencies in dental public health (HRSA, 2010c). The CDC’s NCCDPHP sponsors a dental public health residency with the goal of producing dental public health specialists that can work in a variety of settings, such as in health agencies, research settings, or financing systems, to improve the oral health of populations (CDC, 2010a). In addition, the CDC trains health professionals, including dentists, in applied epidemiology through fellow-
36 Code of Federal Regulations, Centers for Medicare and Medicaid Services, Department of Health and Human Services, title 42, sec. 413.75 (2009).
37 Balanced Budget Act of 1997, Public Law 33, 105th Cong., 1st sess. (August 5, 1997):34621.
38 Code of Federal Regulations, Centers for Medicare and Medicaid Services, Department of Health and Human Services, title 42, sec. 413.81 (2009).
39 42 U.S.C. §256e.
ships and the Epidemic Intelligence Service (CDC, 2011). The IHS is also involved in training dentists and dental students. The IHS runs a comprehensive continuing dental education program for its staff, and it trains dental students through an externship program for second- and third-year students (Halliday, 2010).
The USPHS offers Commissioned Officer Student Training and Extern Programs (COSTEP) to a variety of students (including dental students) (USPHS, 2011). The junior version of the program is offered to students at the baccalaureate level and above to gain experience working in public health settings (usually during summer vacations). Students are compensated for their time. In the senior version of the program, students near graduation are given financial assistance toward their education in return for an obliged period of service to the USPHS after graduation.
The value of interdisciplinary care was discussed in Chapter 3, and HHS plays a role in promoting interdisciplinary team care through training grants. Some recent and ongoing examples of HHS’ efforts to promote interdisciplinary training include: $29.5 million from the ACA and the ARRA to fund interdisciplinary geriatric training (HHS, 2010e), and the Title VII interdisciplinary, community-based grant programs, which are designed to promote interdisciplinary care and increase access to care for underserved populations and in underserved areas.40 In its most recent report to the secretary and Congress, the Advisory Committee on Training in Primary Care and Dentistry recommended additional funding for training programs that promote interprofessional practice (HHS, 2010b).
While this report focuses on the role HHS alone has in improving the oral health of the nation, the committee notes that there are many opportunities for HHS to partner with multiple other stakeholders, such as those in the private sector (including consumers). The need for effective public-private partnerships has been a central theme across time as HHS has sought to improve oral health care. For example, the Meskin Commission in 1989 had predominately private-sector representation, along with collaborators from various federal agencies. In addition, the Meskin report called for greater interaction with national dental organizations within the department and more input from private dentistry (Interim Study Group on Dental Activities, 1989).
40 42 U.S.C. §§294 et seq.
Healthy People (discussed previously throughout this report) represents a successful collaboration between the public and private sectors to develop national goals and objectives. Another example of a public-private partnership is the Friends of the NIDCR, created in 1998 (upon the 50th anniversary of the NIDCR) to “educate the public and key decision makers about the importance of investing in the NIDCR” (FNIDCR, 2010a). As a non-for-profit 501(c)(3), the foundation brings together a coalition of key stakeholders, including advocacy groups, dental schools and societies, corporations, and individuals to educate Congress and the administration about the importance of oral health research. Another example is the partnership between the CDC and the Association of State and Territorial Dental Directors to establish the previously discussed National Oral Health Surveillance System. This system can track state-level data that can be used to monitor progress toward Healthy People goals, justify budget allocations, and guide state policy development (Crall, 2009; Malvitz et al., 2009).
As the professional organization representing about 70 percent of practicing dentists in the United States (Gist, 2010), the ADA is a key partner for HHS. The ADA is actively involved in lobbying the government regarding oral health issues. In 2010, the ADA spent $2.6 million on lobbying related to funding for community-based prevention, the recruitment of dentists, and improving the Medicaid dental program, especially for low-income adults, making it the fourth largest lobbying group among all health professional groups (Center for Responsive Politics, 2009, 2010a,b).
The ADA has convened several summits that included stakeholders from both the public and private sectors. For example, in 2007 they convened the American Indian/Alaskan Native Oral Health Access Summit (ADA, 2007). In 2009, they convened the Access to Dental Care Summit, which included representatives from state dental societies, the dental industry, dental specialty interest groups, federal programs, health care policy makers, other health care professions, dental education and research institutions, consumer advocacy groups, finance organizations, ADA leadership, volunteer dental leaders, and safety net dental providers (ADA, 2009). Overall, participants sought to identify common ground for the future in areas such as workforce development, financing, prevention, literacy, quality assessment, and better collaboration between professions. From 2001 to 2008, the Office of Head Start partnered with MCHB and the Association of State and Territorial Dental Directors to foster collaboration between Head Start programs and state oral health programs. During the course of the collaboration, state oral health programs reported becoming more actively involved in Head Start programs and all 50 states developed Head Start oral health action plans (Geurink and Isman, 2009). In 2007, the Office of Head Start began a collaborative effort with the American Academy
of Pediatric Dentistry on a Dental Home Initiative. The goal of the initiative was to establish dental homes for all Head Start children, to develop oral health leadership and infrastructure at the regional and state levels, and to expand oral education for Head Start children, families, and staff. However, in 2010, the Office of Head Start announced it would not exercise the two remaining option years for the American Academy of Pediatric Dentistry’s partnership on the project (AAPD, 2010).
Recently, two efforts have arisen to promote the sharing of health data and encourage innovation in the use of the data. First, HHS’ Community Health Data Initiative is an effort to provide the public with free access to “easily accessible, standardized, structured, downloadable data on health care, health, and determinants of health performance at the national, state, and county levels, as well as by age, gender, race/ethnicity, and income (where available)” (HHS, 2011a). This will include data from CMS and Healthy People, including data that have not been available to the public in the past. HHS hopes to use this effort to encourage all interested parties to use the data in innovative ways that will benefit the public as a whole. HHS compares this effort to that of the National Oceanic and Atmospheric Administration, which openly shares weather data that users can turn into websites, applications, and other useful tools for the public domain (HHS, 2011a). Similarly, the Blue Button Initiative, a partnership between CMS and the VA, will aim to promote public innovation related to improving the use of personal health information (CMS, 2010a).
Finally, there is a history of consumer involvement within HHS agencies as the department has sought to advance oral health for patients. For example, the National Institute for Dental Research and later the NIDCR sought (and continues to seek) the input of patient advocacy organizations in conducting its research work (NIDCR, 2008). Patient advocacy organizations also voluntarily partner with and participate through foundations such as the Friends of NIDCR (FNIDCR, 2010b). This reflects the recent movement toward patient-centeredness and shared decision making (IOM, 2001).
The committee also notes that other parts of the federal government are responsible for the delivery of oral health care as well as collection of oral health data for their relevant populations. The following sections highlight just some areas in which other federal departments are involved in oral health.
Department of Agriculture
The U.S. Department of Agriculture (USDA) is most notably involved in oral health through its Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) that “provides federal grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk” (USDA, 2010b). WIC is often the first contact with the health care system for low-income children and their mothers (Mitchell, 2010). WIC has been a tremendous source of education for young mothers about nutrition and immunization and could be a great setting to educate on oral health as well. WIC is administered by the Food and Nutrition Service of the USDA, providing grants to 90 state agencies who administer the program at more than 10,000 WIC clinics (Mitchell, 2010). In addition to the educational services they provide, WIC agencies work to improve the linkage between their clients and outside health care professionals—including dentists—through referrals to the provider networks they have developed. At a 2010 IOM workshop on planning a WIC research agenda, speakers addressed the research needed to ensure WIC’s continued effectiveness, including “how to include oral health screening, fluoride treatment, dental sealant application, and other basic oral-health examination and referrals as part of WIC services, considering that poor oral health is a silent epidemic, especially in the pediatric population” (IOM, 2010b).
The USDA’s Food and Nutrition Information Center also provides educational services to its clients. For example, one recent document provided information on toddler nutrition, including links to numerous resources (NAL, 2009). Among the educational materials included were links to a CDC website that detailed the steps to follow in caring for the teeth of a child. The USDA document included resources from the American Academy of Pediatrics (AAP) that described good oral health practices and strategies for keeping teeth healthy throughout childhood. The document also provided links to materials from the Kansas Head Start Association regarding appropriate containers (e.g., to avoid baby bottle tooth decay) and included advice on making better food and drink choices.
Every 5 years, the USDA and HHS work collaboratively to produce national Dietary Guidelines for Americans. In 2005, a key recommendation for carbohydrates was “[r]educe the incidence of dental caries by practicing good oral hygiene and consuming sugar- and starch-containing foods and beverages less frequently” (HHS and USDA, 2005). The USDA runs the National School Lunch Program; these meals must meet the relevant recommendations of the Dietary Guidelines for Americans (USDA, 2010a). However, the federal regulations for the program concentrate on fat con-
tent, caloric intake, and recommended daily allowances of certain nutrients, and not on the presence or frequency of cariogenic foods.
Department of Commerce
The National Institute of Standards and Technology (NIST), an agency of the U.S. Department of Commerce, and the ADA have a dental research collaboration that dates back many decades. This collaboration has led to the development of many instruments and materials that have been used daily in dental practice. Inventions resulting from the partnership include the panoramic X-ray machine, resin composite filling materials, and dental bonding systems (NIST, 2010b).
NIST currently operates the Dental Materials Project, funded by NIDCR, which seeks to facilitate a better approach to dental materials design (NIST, 2010a). While the materials used in dental restorations have been improving, many still must be replaced because the restoration materials degrade or secondary dental caries develop under the restoration. The goal of the Dental Materials Project is to develop methods to assess the performance of and improve the longevity of restorations in vitro, where bacteria and other environmental factors may affect the restoration materials in different ways (NIST, 2010a).
Department of Defense
Throughout the years, the prevalence of oral disease and dental emergencies emerged as a major concern in military recruitment, retention, and readiness for deployment. During the Civil War, many recruits had to be turned away because they didn’t have adequate dentition to bite off the end of the paper cartridges of gun powder (as was needed in order to load their weapons) (King and Hynson, 2007). During the Vietnam War, field commanders complained of loss of soldiers due to dental emergencies; this led to the development of programs to improve care on both a routine and an ad hoc basis (King and Hynson, 2007).
By the early 1990s, the army had developed a classification system for “dental readiness,” which defined an oral health standard (associated with a decreased risk of dental emergency) that was required for deployment of troops (King and Hynson, 2007). In 2005, about 33 percent of all military personnel needed dental work before they could be deployed (up from 16 percent in 1998), ranging from 22 percent of those serving in the Air Force to 46 percent of those serving in the Marine Corps (Bray et al., 2006).
In 2005, approximately 81 percent of all military personnel reported having a dental check within the previous year (down from 90 percent in 2002) (Bray et al., 2003, 2006). Among those who had not had a visit, the
most common reasons given were the inability to get time off at work, the inability to get an appointment with a military dentist, and personal aversion to visiting a dentist (Bray et al., 2006).
The Military Health System
The Military Health System (MHS) is a global network that provides health care services to the military, both in military and in civilian settings. Aside from health care services, the MHS fosters innovative research, education, and training programs (DOD, 2010). The MHS is also responsible for assuring the oral health of all uniformed DOD personnel, including determination of readiness for deployment based on oral health status (DOD, 2002). TRICARE, a major component of the MHS, is the health care program primarily for members of the uniformed services,41 retirees, their families, and some members of the National Guard and Reserve. The program includes dental care as part of the medical benefit for active duty service members (TRICARE, 2010).
TRICARE also offers two voluntary dental benefit programs. The TRICARE Dental Program offers benefits for family members of the active duty military, as well as National Guard and Reserve members and their eligible families (TRICARE, 2010). The TRICARE Retiree Dental Program offers benefits for military retirees and their eligible family members, National Guard and Reserve members and their eligible family members, and several other categories of personnel (e.g., Medal of Honor recipients) (Humana Military, 2010; TRICARE, 2010). Both are administered by private companies (United Concordia Companies Inc. and Delta Dental of California, respectively) and provide access to a nationwide network of dentists. Program benefits cover a range of diagnostic and preventive services, oral surgery, as well as endodontic, prosthodontic, and periodontic services. Approximately 1.9 million people are currently enrolled in the TRICARE Dental Program (United Concordia, 2010).
Department of Education
The U.S. Department of Education (DOE) is ultimately responsible for the quality of education of oral health care professionals. Institutional accreditation is used as one method to protect the public from poorly trained health professionals. IOM’s Dental Education at the Crossroads (1995) said “the accreditation of U.S. dental education programs is a private func-
41 The seven uniformed services of the U.S. government include the U.S. Army, U.S. Marine Corps, U.S. Navy, U.S. Air Force, U.S. Coast Guard, U.S. Public Health Service Commissioned Corps, and the National Oceanic and Atmospheric Administration Commissioned Corps.
tion with a public purpose” (IOM, 1995). The DOE currently delegates responsibility for accrediting dental schools and dental programs to the Commission on Dental Accreditation (CODA), which is housed in the ADA (DOE, 2010). (The role of the DOE in general public education was discussed earlier in this chapter; oral health education and training of the health care professions was reviewed in Chapter 3.)
Department of Homeland Security
The U.S. Department of Homeland Security is notably involved in the delivery of oral health care in that the U.S. Coast Guard (USCG) is located within the department. The USCG employs 58 dentists (USPHS dental officers detailed to the Department of Homeland Security) in their 30 clinics (USCG, 2009). USCG dentists provide a range of dental services primarily to active members of the USCG or other military services; therefore, very few clinics offer care for pediatric or geriatric patients. Commissioned dental officers are eligible for residency training as well as both sign-on bonuses and special pay bonuses.
In addition, the Department of Homeland Security provides and oversees the health care of detainees in custody of the U.S. Immigration and Customs Enforcement (ICE) or the U.S. Customs and Borders Protection through the ICE Health Service Corps (DHS, 2010). The ICE Health Service Corps (formerly the Division of Immigration Health Services) uses USPHS commissioned officers, federal civil servants, and contractors directly provide or oversee the health care (including dental care) for about 32,000 detainees (DHS, 2011b). In FY2010, the ICE Health Service Corps provided nearly 33,000 dental visits (DHS, 2011a).
Department of Justice
The Federal Bureau of Prisons (BOP) within the U.S. Department of Justice (DOJ) hires dentists and dental hygienists (or uses USPHS commissioned officers) to provide a range of dental services for the inmates of the nation’s federal prisons.42 As of August 2010, there were almost 210,000 individuals incarcerated in a variety of settings (BOP, 2010b). The BOP identifies a “constant need” for dental officers (BOP, 2010a). As of August 2010, there were eight vacancies listed for dental hygienists and 39 vacancies for dentists (USPHS, 2010b). BOP has made strides in advancing technology for the oral health care of its population. For example, in FY 2008, the BOP transitioned to the use of digital dental radiography and successfully developed an electronic medical record that integrated the am-
42 This section speaks only to the federal prison system.
bulatory medical record and the dental record (BOP, 2008). Overall, there is little recent peer-reviewed literature on the oral health and oral health care of prisoners across the United States, but it indicates poor oral health status among inmates, including racial and ethnic disparities (Treadwell and Formicola, 2005).
Department of Labor
The Bureau of Labor Statistics (BLS) within the U.S. Department of Labor provides detailed statistical measures of the nation’s employment and economic status. It is the principal fact-finding agency for the federal government in the broad field of labor economics (BLS, 2011a). BLS’ Occupational Outlook Handbook (BLS, 2011b) provides detailed information on specific types of employment, including working conditions, necessary training, advancement potential, job outlook and earnings for over 250 different occupations (approximately 9 out of 10 jobs in the economy). BLS also publishes a measure of the fastest-growing occupations in the United States.
BLS information was used in this report to document labor trends among dentists, dental hygienists, dental assistants, and laboratory technicians as well as other providers such as physician assistants and pharmacists. It also provided an assessment of the growth projections for various oral health job classifications. In addition, BLS provided information on the oral health care benefits provided by employers and consumer out-of-pocket expenditures.
Department of Veterans Affairs
The U.S. Department of Veterans Affairs arguably runs one of the nation’s largest health care systems. More than 8 million veterans are enrolled in the VA health care system, and in FY 2010, more than 5.6 million individuals received care in this system (National Center for Veterans Analysis and Statistics, 2011). The VA provides health care in over 1,400 sites, including 152 medical centers (VA, 2011a,b). Criteria of eligibility for outpatient dental care in the VA differ from the guidelines used for determining other health care benefits and have several different classifications through which the extent of benefits are determined. For inpatient care (veterans in hospital, nursing home, and domiciliary settings), veterans may receive dental services that are “professionally determined by a VA dentist, in consultation with the referring physician, to be essential to the management of the patient’s medical condition under active treatment” (VA, 2010). The VA has an integrated medical and dental electronic record system and requires the use of diagnostic codes for oral health care.
Environmental Protection Agency
The Environmental Protection Agency (EPA) regulates levels of fluoride in community drinking water. The EPA’s involvement in monitoring water quality dates back to 1974 with the enactment of the Safe Drinking Water Act (EPA, 2011a). The agency is required to determine safe levels of potential drinking water contaminants, or its maximum contaminant level goals. Fluoridation is not required by the EPA; in fact, it is prohibited by the Act from requiring the addition of any substance to drinking water for preventive health care purposes (EPA, 2011b). The decision to fluoridate a water supply is made by the state or local municipality. The CDC does provide recommendations about the optimal levels of fluoride in drinking water in order to prevent tooth decay.
In early 2011, the EPA released new fluoride risk and exposure assessments and announced its intent to review the national drinking water regulations for fluoride. The assessments addressed recommendations made by the National Research Council (NRC) of the National Academies of Science in a 2006 report titled, Fluoride in Drinking Water: A Scientific Review of EPA’s Standards (NRC, 2006). The NRC’s report recommended that EPA update its risk assessment to include new data on the health risks of fluoride and better estimates of total fluoride exposure.
A Revitalized Oral Health Coordinating Committee (2009)
In 2009, newly appointed Assistant Secretary for Health Dr. Howard Koh asked the OHCC, located in the USPHS, to “regroup” (Bailey, 2010). Membership to the OHCC occurs through nomination by HHS operating divisions, staff divisions, or agencies with oral health functions. Other entities will also be included in the OHCC, such as national dental organizations and other federal agencies (e.g., DOD, VA, BOP, DOE) (Bailey, 2010).
Overall, the purpose of the OHCC is to “assist the USPHS in meeting its responsibility to promote the oral health of the American public: through coordination of a broad spectrum of oral health policy, research, and programs; within the USPHS; across federal agencies; and between public and private sectors” (Bailey, 2010). The specific functions of the OHCC are quite broad, especially given that the OHCC itself has not been allocated any funding and its membership all serve in full-time positions elsewhere in the department. The new charter enumerates 16 functions for the OHCC (Bailey, 2010):
1. Provide policy direction for the USPHS through preparation, review, and evaluation of relevant USPHS and agency documents,
with particular attention to the Healthy People 2010/2020 National Oral Health Objectives; the 2000 surgeon general’s report and the National Call to Action; and recommendations from other relevant oral health workshops and reports.
2. Propose goals, objectives, and approaches for promoting oral health and preventing oral, dental, and craniofacial diseases throughout the life span.
3. Propose goals, objectives, and approaches for reducing and/or eliminating oral health disparities.
4. Promote oral health workforce development.
5. Coordinate planning, implementation, and evaluation of departmental oral health research, policy, surveillance, services, education, and health promotion activities.
6. Promote oral health initiatives and serve as liaison to relevant federal and nonfederal agencies.
7. Encourage relevant nonfederal organizations to participate with the OHCC in planning, implementing, and evaluating joint public- and private-sector initiatives to improve the oral health of the nation.
8. Provide consultation to the assistant secretary for health and the surgeon general on oral health matters.
9. Promote the integration of oral health care into primary care and encourage collaboration between primary care and oral health services providers.
10. Promote the translation of oral health research into practice.
11. Provide leadership in supporting a National Oral Health Agenda that focuses on continually improving oral health outcomes, workforce development, and enhancing access to oral health services.
12. Promote the application of science-based new technologies into oral health care and practice, including harnessing the full potential of health information technology.
13. Examine and make recommendations regarding the financing of oral health care, including federal payment policies for Medicaid, CHIPRA, and locations designated as being health professional shortage sites.
14. Collaborate with the nation’s leading quality experts on the development of performance and quality measures for use by federal programs.
15. Provide a written annual report to the assistant secretary for health as to OHCC activities and progress of oral health initiatives relative to national oral health.
16. Provide the HHS secretary with periodic updates on the state of oral health in the nation.
Part of the OHCC’s role is to coordinate agency activity, but with no dedicated staff, it will be very difficult for the OHCC to achieve all of the functions listed above.
The HHS Oral Health Initiative (2010)
In April 2010, HHS Assistant Secretary Koh announced the initiation of a department-wide effort within HHS to improve the nation’s oral health (HHS, 2010f). The HHS Oral Health Initiative 2010 (OHI 2010) is co-led by Koh and HRSA Administrator Dr. Mary Wakefield, and is supported both by the OHCC (which would help coordinate programs) and the HHS Office of Minority Health. The OHI 2010 once again calls on the department to “improve coordination and integration among programs to maximize outputs” (HHS, 2010g). In addition to realigning existing resources, it established nine new oral health activities (two of which are IOM reports—see Box 4-6). It is notable that AHRQ plays a large role in the collection of oral health data, and might have a role in advancing ef-
HHS Oral Health Initiative 2010
Administration for Children and Families (ACF)
Head Start Dental Home Initiative
Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH)
National Oral Health Surveillance Plan
Centers for Medicare and Medicaid Services (CMS)
Review of Innovative State Medicaid Dental Programs
Health Resources and Services Administration (HRSA)
National Study on an Oral Health Initiative (IOM)
National Study on Oral Health Access to Services (IOM)
Indian Health Service (IHS)
The Early Childhood Caries Initiative
National Institutes of Health (NIH)
Clinical and Translational Science Program
Office of Minority Health
A Cultural Competency E-Learning Continuing Education Program for Oral Health Professionals
The Office on Women’s Health
Oral Health as Part of Women’s Health Across the Life Span
SOURCE: HHS, 2010g.
forts toward quality assessment efforts in oral health, yet it is not explicitly involved in the OHI 2010.
Drawing upon the surgeon general’s report, the department has indicated that the key message of the OHI 2010 will be “Oral health is integral to overall health.” Once again, HHS voices a desire to work with national and state partners and continues building upon previous efforts. However, the department’s literature on OHI 2010 does not specify how the existing HHS programs will be coordinated or how the new activities will be integrated with the older ones. The specific goals (e.g., outcomes) and strategies are also not clear, aside from indicating that “the initiative utilizes a systems approach to create and finance programs to
• Emphasize oral health promotion/disease prevention,
• Increase access to care,
• Enhance the oral health workforce, and
• Eliminate oral health disparities” (HHS, 2010g).
American Recovery and Reinvestment Act (2009)
The American Recovery and Reinvestment Act of 2009 (ARRA) included provisions that affect delivery and access to oral health services, as well as investment in oral health research. ARRA investments that affect oral health fall into four major categories: training grants, health information technology, health centers, and research funding from the NIDCR. ARRA invested $500 million in training the health workforce, including dentistry (HRSA, 2009). The training grants included in excess of $800,000 for dental public health residencies and $50 million for equipment to enhance training for health professionals (HRSA, 2009, 2010b). ARRA also included $20 billion to develop health information technology infrastructure and incentive payments to practices that adopt information technology, including dental offices.
ARRA authorized $2 billion for investments in community health centers, including $1.5 billion for construction, renovation, and equipment, and $500 million for services (HHS, 2011b). Some of this money was used to build dental facilities and hire oral health personnel (Patrick, 2010). HRSA’s Bureau of Primary Health Care reported that ARRA funds supported 565 dental professionals between July and September 2010 (NACHC, 2011).
The NIDCR distributed $101 million of ARRA funds for dental and craniofacial research. The funds supported 141 new or competing 2-year research grants, 128 administrative supplements to existing NIDCR grants, and research projects in 33 states (NIDCR, 2010c). Nearly a quarter of the funds were used to support NIH Challenge Grants in Health and Science
Research. These grants were created in ARRA and were designed to support research in very specific areas where NIH identified knowledge gaps, scientific opportunities, new technologies, data generation, or research methods that would benefit from an influx of funds to quickly advance the area in significant ways. A number of oral health topics were identified, including validating dental caries risk assessment guidelines, treatment and outcomes for cleft palate/cleft lip, infrastructure for comparative effectiveness studies in oral health and craniofacial conditions, and novel self-healing smart dental and biorestorative materials (NIH, 2009a). ARRA funds also allowed the NIDCR to provide faculty recruitment grants to seven dental schools, allowing each to hire two new faculty members (NIDCR, 2010c).
Patient Protection and Affordable Care Act (2010)
On March 23, 2010, President Obama signed the ACA. The law contains many significant provisions for the oral health of the nation. However, most of these provisions are not yet funded. The provisions explicitly related to oral health are contained in Table 4-3. While the committee notes the significance of these provisions, they recognize the reality of the current economic situation and that not all of these provisions may ultimately receive the needed funding.
Strategic Plan (FY 2010–2015)
Every 3 years, HHS updates its strategic plan to address the department’s mission, which is “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” (HHS, 2010j). In the most recent iteration of this plan, the secretary identified five overarching goals (see Box 4-7).
Each of these goals has several objectives as well as strategies for achieving those objectives, including examples for oral health. For example, for Goal 1, the plan identifies one objective as ensuring access to quality, culturally competent care for vulnerable populations. A listed strategy is “Increase access to primary oral healthcare services and to oral disease preventive services by expanding access to health centers, school-based health centers, and Indian Health Service-funded health programs that have comprehensive primary oral health care services, and state and community-based programs that improve oral health, especially for children and pregnant women” (HHS, 2010j). For Goal 2, one strategy includes “Strengthen oral health research and use evidence-based oral health promotion and disease prevention to clarify the interrelationships between oral disease and other medical diseases” (HHS, 2010j). Finally, under Goal 5, the plan
Key Oral Health Provisions in the ACA
|Coverage and access||Oral health services for children—Sec. 1201, 1302||Requires health plans offered through state exchanges, and the individual or small group market to cover pediatric oral health care||n/a|
|Stand alone dental plans—Sec. 1311||Allows insurers to offer stand-alone dental plans through state exchanges, as long as the plans cover pediatric oral health care||Yes|
|Expanded Medicaid eligibility—Sec. 2001||Requires states to expand Medicaid eligibility to residents at or below 133% of the federal poverty level||No|
|Medicare Advantage—Sec. 3202||Requires Medicare Advantage plans to use rebates to pay for dental services, among other items||n/a|
|School based health centers—Sec. 4101||Establishes a grant program for school based health centers, and requires grantees to provide referrals to, and follow-up for, oral health services||Yes|
|Indian health care improvement—Sec. 10221||Allows Indian tribes or tribal organizations to use the dental health aide therapist program, if the state in which the tribe is located has authorized new and emerging oral health practitioners||n/a|
|Workforce||Health Care Workforce Commission—Sec. 5101||Establishes a National Health Care Workforce Commission to assess the adequacy of the health care workforce; the oral health workforce is identified as a high priority area.||No; the President's FY 2012 budget requests $3 million|
|Training in general, pediatric, and public health dentistry—Sec. 5303||Expands Title VII training grant programs for dentistry, including newly authorized funding for dental schools, financial assistance to dental and dental hygiene students, and pediatric dentistry residencies, among others||No; the President's FY 2012 budget requests an additional $19 million for oral health training|
|Alternative dental health care providers demonstration project—Sec. 5304||Authorizes the secretary to award grants for demonstration programs to train or employ alternative dental health care providers in order to increase access for rural and underserved populations||No|
|Primary care residency programs—Sec. 5508||Establishes grant program for newly established or expanded “teaching health centers,” which are community-based care centers that operate primary care residency programs, including general and pediatric dental residencies. Also describes payment mechanisms for residents working in teaching health centers||No; the President's FY 2012 budget requests $10 million|
|Prevention||Oral health care prevention campaign—Sec. 4102||Requires the CDC to establish a 5-year oral health campaign for prevention of oral diseases||No|
|Dental caries disease management—Sec. 4102||Requires the CDC to award demonstration grants to research the effectiveness of research-based dental caries disease management||No|
|School based sealant programs—Sec. 4102||Requires the CDC and HRSA to award grants to all states, territories, Indians, Indian tribes, tribal organizations, and urban Indian organizations to develop school-based sealant programs||No|
|Infrastructure and surveillance||Oral health infrastructure—Sec. 4102||Requires the CDC to enter into cooperative agreements with states, territories, and Indian tribes or tribal organizations to improve oral health infrastructure||No|
|Oral healthcare surveillance (PRAMS)—Sec. 4102||Requires the secretary to improve the Pregnancy Risk Assessment Monitoring System (PRAMS) for oral health and requires states to report oral health measures in PRAMS||NO|
|Oral healthcare surveillance (NHANES)—Sec. 4102||Requires the National Health and Nutritional Examination Survey (NHANES) to include tooth-level surveillance||No|
|Oral health care surveillance (MEPS)—Sec. 4102||Requires the Medical Expenditure Panel Survey (MEPS) to report on dental utilization, expenditure, and coverage||No; the President's FY 2012 budget requests $10 million|
|Oral healthcare surveillance (NOHSS)—Sec. 4102||Authorizes funding to increase the participation in the National Oral Health Surveillance System (NOHSS) from 16 states to all 50 states, territories, and the District of Columbia||No; the President's FY 2012 budget requests $10 million|
SOURCE: Patient Protection and Affordable Care Act, Public Law 148, 11th Cong., 2nd sess. (March 23, 2010).
identifies this strategy: “Expand the primary oral healthcare team and promote models that incorporate new providers, expanded scope of existing providers, and utilization of medical providers to provide evidence-based oral health preventive services” (HHS, 2010j). Many of the other goals, objectives, and strategies do not explicitly call out to oral health but are implicit to quality oral health care.
Healthy People 2020
Recently, HHS released the objectives for Healthy People 2020 (see Box 4-8). There will be four overarching goals for Healthy People 2020: eliminating health disparities; increasing life expectancy and the quality of life for people of all ages; eliminating preventable disease, disability, injury, and premature death; and creating social and physical environments that promote good health for all (Koh, 2010). The first two were retained from Healthy People 2010; the last two are new for 2020. In addition to the overarching goals, 17 objectives specific to oral health have been proposed. Many of these objectives were retained from Healthy People 2010, but two new objectives have also been added.
Goals of HHS Strategic Plan FY 2010–2015
Goal 1: Transform health care.
Goal 2: Advance scientific knowledge and innovation.
Goal 3: Advance the health, safety, and well-being of the American people.
Goal 4: Increase efficiency, transparency, and accountability of HHS programs.
Goal 5: Strengthen the nation’s health and human services infrastructure and workforce.
SOURCE: HHS, 2010j.
Healthy People 2020: Oral Health Proposed Objectives
Oral Health of Children and Adolescents
• Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth.
• Reduce the proportion of children and adolescents with untreated dental decay.
Oral Health of Adults
• Reduce the proportion of adults with untreated dental decay.
• Reduce the proportion of adults who have ever had a permanent tooth extracted because of dental caries or periodontal disease.
• Reduce the proportion of adults aged 45–74 with moderate or severe periodontitis.
• Increase the proportion of oral and pharyngeal cancers detected at the earliest stage.
Access to Preventive Services
• Increase the proportion of children, adolescents, and adults who used the oral health care system in the past year.
• Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year.
• Increase the proportion of school-based health centers with an oral health component.
• Increase the proportion of local health departments and Federally Qualified Health Centers that have an oral health component.
• Increase the proportion of patients that receive oral health services at Federally Qualified Health Centers each year.
Oral Health Interventions
• Increase the proportion of children and adolescents who have received dental sealants on their molar teeth.
• Increase the proportion of the U.S. population served by community water systems with optimally fluoridated water.
• Increase the proportion of adults who receive preventive interventions in dental offices.
Monitoring and Surveillance Systems
• Increase the number of states and the District of Columbia that have a system for recording and referring infants and children with cleft lips and cleft palates to craniofacial anomaly rehabilitative teams.
• Increase the number of states and the District of Columbia that have an oral and craniofacial health surveillance system.
Public Health Infrastructure
• Increase the number of health agencies that have a public dental health program directed by a dental professional with public health training.
SOURCE: HHS, 2010d.
The committee noted the following key findings and conclusions:
• Oral diseases can affect all Americans, and vulnerable and underserved populations are especially at risk. Therefore, the prioritization of oral health as a key issue for HHS falls in line with its basic mission.
• HHS has had some notable successes in improving oral health in the past, yet that prior work has not had the necessary transformative impact on oral health.
• HHS needs to capitalize on its prior efforts and then build on that work to elevate the priority and visibility of oral health in all relevant divisions of HHS.
• The oral health activities of HHS are spread throughout the agency with little communication and coordination between divisions.
• The failure of previous HHS initiatives to produce significant results resulted from a lack of coordination, a lack of clear goals, a lack of resources, and a lack of high-level accountability.
• HHS has many unique opportunities to influence the oral health system, particularly through education grants, fostering payment innovation, promoting research, coordinating with other agencies that collect oral health data, and developing quality measures.
• The ACA has many authorized provisions related to oral health, but most remain unfunded.
• HHS has many opportunities to partner with the private sector (e.g., professional societies) as well as other parts of the public sector (e.g., states, other federal agencies).
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