Improving Access to Oral Health Care for Vulnerable and Underserved Population
Committee on Oral Health Access to Services
Board on Children, Youth, and Families
Board on Health Care Services
INSTITUTE OG MEDICINE AND
NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. HHSH25034002T between the National Academy of Sciences and the U.S. Department of Health and Human Services and Contract No. 15328 between the National Academy of Sciences and the California HealthCare Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
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Suggested citation: IOM (Institute of Medicine) and NRC (National Research Council). 2011. Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
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COMMITTEE ON ORAL HEALTH ACCESS TO SERVICES
FREDERICK P. RIVARA (Chair), Seattle Children’s Guild Endowed Chair in Pediatrics; Professor of Pediatrics, School of Medicine, University of Washington
PAUL C. ERWIN, Professor and Chair, Department of Public Health, University of Tennessee, Knoxville
CASWELL A. EVANS, JR., Associate Dean for Prevention and Public Health Sciences, College of Dentistry, University of Illinois, Chicago
THEODORE G. GANIATS, Professor, Department of Family and Preventive Medicine, School of Medicine, University of California, San Diego
SHELLY GEHSHAN, Director, Pew Children’s Dental Campaign, Pew Center on the States
KATHY VOIGT GEURINK, Clinical Associate Professor, Department of Dental Hygiene, School of Health Professions, University of Texas Health Science Center
PAUL GLASSMAN, Professor of Dental Practice, Director of Community Oral Health, Arthur A. Dugoni School of Dentistry, University of the Pacific
DAVID M. KROL, Team Director, Senior Program Officer, Human Capital, Robert Wood Johnson Foundation
JANE PERKINS, Legal Director, National Health Law Program
MARGARET A. POTTER, Associate Dean; Director, Center for Public Health Practice; Associate Professor of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh
RENEE SAMELSON, Associate Professor of Obstetrics and Gynecology, Albany Medical College
PHYLLIS W. SHARPS, Professor and Associate Dean, Community and Global Programs, School of Nursing, Johns Hopkins University
LINDA H. SOUTHWARD, Research Fellow & Research Professor, Social Science Research Center, Mississippi State University
MARIA ROSA WATSON, Research Director, Primary Care Coalition of Montgomery County
BARBARA WOLFE, Professor of Economics and Population Health Sciences; Public Affairs and Faculty Affiliate, Institute for Research on Poverty, University of Wisconsin-Madison
TRACY A. HARRIS, Study Director
PATTI SIMON, Senior Program Officer
MEG BARRY, Associate Program Officer
ROSEMARY CHALK, Director, Board on Children, Youth, and Families
WENDY E. KEENAN, Program Associate
AMY ASHEROFF, Senior Program Assistant
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
BRUCE J. BAUM, National Institute of Dental and Craniofacial Research
PAUL CASAMASSIMO, Nationwide Children’s Hospital
DANIEL G. DAVIDSON, private practice
A. CONAN DAVIS, University of Alabama
R. BRUCE DONOFF, Harvard School of Dental Medicine
CHRISTINE M. FARRELL, Michigan Department of Community Health
JANE GILLETTE, Mint Dental Studio
JOHN S. GREENSPAN, University of California, San Francisco
MICHAEL J. HELGESON, Apple Tree Dental
CATHERINE HESS, National Academy for State Health Policy
CYNTHIA E. HODGE, National Dental Association Foundation
GENEVIEVE KENNEY, The Urban Institute
JULIA LEAR, The George Washington University
HUGH SILK, University of Massachusetts Medical School and Hahnemann Family Health Center
GEORGE W. TAYLOR, University of Michigan
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by DONALD M. STEINWACHS, Johns Hopkins University, and GEORGES C. BENJAMIN, American Public Health Association. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Oral health care is not uniformly attainable across the nation. Unfortunately, individuals who face the greatest barriers to care are often among the most vulnerable members of our society. Theimpact of unmet oral health care needs is magnified by the well-established connection between oral health and overall health. These problems led the Health Resources and Services Administration and the California Health-Care Foundation to ask the Institute of Medicine (IOM) to advise them on how to improve access to oral health care. The IOM committee, led by Frederick Rivara, was charged with assessing the current oral health care delivery system; exploring its strengths, limitations, and future challenges; and describing a vision for the delivery of oral health care to vulnerable and underserved populations. The committee worked in parallel with a second IOM committee that focused on the role of the U.S. Department of Health and Human Services in improving oral health. Together, they comprise an extensive examination of the status of oral health and oral health care in America.
In its examination of the evidence, the committee uncovered decades of efforts that have been insufficient in eliminating significant disparities in access to oral health care. However, this examination also revealed an array of groups committed to improving access and highlighted common goals and opportunities for collaboration and innovation. Examples appear throughout the report and inform the committee’s recommendations. The committee calls for a renewed commitment and a confluence of energies directed at tackling these familiar and persistent challenges.
This report presents a vision for oral health care in the United States
where everyone has access to quality oral health care throughout the life cycle. The committee acknowledges that realizing this vision will require numerous coordinated and sustained actions, with special attention to the distinct and varied needs of the nation’s vulnerable and underserved populations. Achieving this goal will require flexibility and ingenuity among leaders at the federal, state, local, and community levels acting in concert with oral health and other health care professionals. We hope this report will encourage these groups to act on behalf of the nation’s vulnerable and underserved populations and to take the important and necessary next steps to improve access to oral health care, reduce oral health disparities, and improve oral health.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
As Americans, we have become increasingly cognizant and, it is hoped, intolerant of the disparities in access to health care in this country. While our health care system has the capabilities for amazing treatment of a wide array of maladies, this care is not uniformly available to all. Disparities exist, however, not only in access to the latest in life-saving technology but also in access to the most basic of routine health care. The Patient Protection and Affordable Care Act of 2010 is intended to improve access to care for all and reduce these disparities in health care and health.
Oral health care is one of those dimensions of our health care delivery system in which striking disparities exist. More than half of the population does not visit a dentist each year. Poor and minority children are substantially less likely to have access to oral health care than are their nonpoor and nonminority peers. Americans living in rural areas have poorer oral health status and more unmet dental needs than their urban counterparts. Older adults, especially those living in long-term care facilities, have a high prevalence of oral health problems and difficulty accessing care by individuals trained in their special needs. Disabled individuals uniformly confront access barriers, regardless of their financial resources. The consequences of these disparities in access to oral health care have a strong influence not only on oral health but on overall health as well. Poor oral health can lead to malnutrition, childhood speech problems, and serious, and sometimes fatal, infections. Poor oral health is associated with diabetes, heart disease, and premature births. Oral disease in pregnant women and young mothers can be transmitted vertically to their offspring, perpetuating a cycle of disease.
In 2000, the surgeon general issued a report on oral health in this country calling for action to improve the oral health of the nation. The many efforts in both the public and private delivery systems to address these disparities have been important, but they have not been successful in eliminating them. Therefore, with support from the Health Resources and Services Administration and the California HealthCare Foundation, the National Research Council and the Institute of Medicine, through collaborative efforts between the Board on Children, Youth, and Families and the Board on Health Care Services, formed the Committee on Oral Health Access to Services. The charge was to assess current access to oral health care especially for vulnerable and underserved populations and to provide a vision of how oral health care should be addressed by public and private providers across the nation.
The committee held five meetings and one public workshop. We engaged in vigorous, thoughtful discussions regarding the causes of the current disparities in access to oral health care and the best approaches to addressing the problem both in the short and long term. We did so cognizant of the economic challenges facing the nation and individual states today, and with the awareness that oral health care is a part of our overall health care delivery system. It is our hope that the findings and recommendations of this report will help policy makers, service providers and their professional organizations, and funders and government agencies to address these access problems in new, meaningful, and innovative ways that will result in oral health for all.
The committee could not have done its work without the outstanding guidance and support provided by the NRC-IOM staff: Tracy Harris, study director; Patti Simon, senior program officer; and Meg Barry, associate program officer. Amy Asheroff provided skilled logistic support to the committee. Rosemary Chalk’s guidance and counsel were invaluable throughout our deliberations. The health professionals who participated in our workshop and provided information to the committee deserve special thanks for their time and effort.
All Americans deserve to enjoy good oral health. We hope this report will help the nation achieve that vision.
Frederick P. Rivara, Chair
Committee on Oral Health Access to Services
The Committee on Oral Health Access to Services benefited from the contributions of many individuals. The committee takes this opportunity to recognize those who so generously gave their time and expertise to inform its deliberations.
The committee benefited from presentations made by a number of experts outside the committee. The following individuals shared their experiences and perspectives during public meetings of the committee:
Ann Battrell, American Dental Hygienists’ Association
Marcia K. Brand, Health Resources and Services Administration
Gina Capra, Health Resources and Services Administration
James Crall, American Academy of Pediatric Dentistry
Terry Dickinson, Virginia Dental Association
Bruce Dye, Centers for Disease Control and Prevention
Steven Geiermann, American Dental Association
Michael Griffiths, Institutional Dental Care
David Grossman, Group Health Cooperative
David Halpern, Academy of General Dentistry
Lawrence Hill, Cincy Smiles Foundation
John McFarland, National Network for Oral Health Access
Peter Milgrom, University of Washington
Laurie Norris, Pew Children’s Dental Campaign
Greg Nycz, Family Health Center of Marshfield, Inc.
Edward O’Neil, University of California, San Francisco
Jesley Ruff, American Dental Partners
Bob Russell, Iowa Department of Public Health
Mary Kate Scott, Scott & Company, Inc.
Robert Shesser, George Washington University
Mark Siegal, Ohio State Department of Health
Kristen Simmons, Willamette Dental
Woosung Sohn, University of Michigan
Ron Tankersley, American Dental Association
Jessica Van Arsdale, Humboldt State University
Louise Veselicky, West Virginia University
The committee commissioned papers to provide background information for its deliberations and to synthesize the evidence on particular issues. We thank the following individuals for their contributions to these papers:
David Armstrong, Center for Health Workforce Studies, University at Albany
Howard Bailit, University of Connecticut
John D’Adamo, University of Connecticut
Burton Edelstein, Columbia University
Margaret Langelier, Center for Health Workforce Studies, University at Albany
Jean Moore, Center for Health Workforce Studies, University at Albany
We extend special thanks to the following individuals who were essential sources of information, generously giving their time and knowledge to further the committee’s efforts:
Kay Johnson, Johnson Group Consulting
Lew Lampiris, American Dental Association
Richard W. Valachovic, American Dental Education Association
Many within the Institute of Medicine were helpful to the study staff. The staff would like to thank Patrick Burke, Greta Gorman, Roger Herdman, William McLeod, Janice Mehler, Abbey Meltzer, Lauren Tobias, and Ben Wheatley for their time and support to further the committee’s efforts. We also thank Mark Goodin, copyeditor.
Finally, the committee gratefully acknowledges the assistance and support of individuals instrumental in developing this project: Marcia Brand, Health Resources and Services Administration; Len Finocchio, California HealthCare Foundation; and Mark Nehring, Health Resources and Services Administration.