Vulnerable and underserved populations face persistent and systemic barriers to accessing oral health care. These barriers are numerous and complex and include social, cultural, economic, structural, and geographic factors, among others. For example:
• In 2008, 4.6 million children did not obtain needed dental care because their families could not afford it.
• In 2011, there were approximately 33.3 million unserved individuals living in dental Health Professional Shortage Areas.1
• In 2006, only 38 percent of retired individuals had dental coverage.
In addition, endemic low levels of oral health literacy among the public and many in the health care professions may limit their ability to understand the importance of good oral health to overall health status. Furthermore, low oral health literacy creates additional obstacles to recognizing risk for oral diseases as well as seeking and receiving needed oral health care.
Lack of access to oral health care contributes to profound and enduring oral health disparities in the United States. For example, dental caries2—a chronic, infectious, and largely preventable disease commonly known as tooth decay—disproportionately affects vulnerable and underserved popu-
1 Dental Health Professional Shortage Areas are geographic areas, population groups, or facilities with shortages of dental providers.
2 The term dental caries is used in the singular and refers to the disease commonly known as tooth decay (Dorland’s Illustrated Medical Dictionary, 31st ed., s.v. “caries”).
lations, groups who commonly lack access to oral health care. Vulnerable and underserved populations include but are not limited to
• Racial and ethnic minorities, including immigrants and non-English speakers;
• Children, especially those who are very young;
• Pregnant women;
• People with special needs;
• Older adults;
• Individuals living in rural and urban underserved areas;
• Uninsured and publicly insured individuals;
• Homeless individuals; and
• Populations of lower socioeconomic status.
Because good overall health requires good oral health, the unmet oral health needs of millions of American cannot be neglected.
While the majority of the U.S. population is able to routinely obtain oral health care in traditional dental practice settings, a disproportionate number of vulnerable and underserved individuals cannot. An array of providers and population-based public health programs—collectively referred to as the safety net—has emerged through uncoordinated attempts to reach these individuals. However, access to oral health care continues to elude too many Americans. Fortunately, additional opportunities exist—in both the public and private sectors—to ameliorate the situation.
In the fall of 2009, with support from the Health Resources and Services Administration (HRSA) and the California HealthCare Foundation, the National Research Council and the Institute of Medicine (IOM) formed the Committee on Oral Health Access to Services to assess the current oral health care system with a focus on the delivery of oral health care to vulnerable and underserved populations (see Box S-1).
The committee’s vision is both aspirational and achievable (see Box S-2), but numerous coordinated and sustained actions will be needed to realize this vision.
GUIDING PRINCIPLES AND OVERALL CONCLUSIONS
To guide its deliberations, the committee began with two well-established and evidence-based principles:
1. Oral health is an integral part of overall health and, therefore, oral health care is an essential component of comprehensive health care.
2. Oral health promotion and disease prevention are essential to any strategies aimed at improving access to care.
The IOM-NRC Board on Children, Youth, and Families, in collaboration with the Board on Health Care Services, will undertake a study to
• Assess the current U.S. oral health system of care;
• Explore its strengths, weaknesses, and future challenges for the delivery of oral health care to vulnerable and underserved populations;
• Describe a desired vision for how oral health care for these populations should be addressed by public and private providers (including innovative programs) with a focus on safety net programs serving populations across the life cycle and Maternal and Child Health Bureau (MCHB) programs serving vulnerable women and children; and
• Recommend strategies to achieve that vision.
Vision for Oral Health Care in the United States
Everyone has access to quality oral health care across the life cycle.
To be successful with underserved and vulnerable populations, an evidence-based oral health system will
1. Eliminate barriers that contribute to oral health disparities;
2. Prioritize disease prevention and health promotion;
3. Provide oral health services in a variety of settings;
4. Rely on a diverse and expanded array of providers competent, compensated, and authorized to provide evidence-based care;
5. Include collaborative and multidisciplinary teams working across the health care system; and
6. Foster continuous improvement and innovation.
These principles are woven throughout the text of this report and are fundamental to the recommendations. In addition, after reviewing the evidence, the committee came to the following overall conclusions:
1. Improving access to oral health care is a critical and necessary first step to improving oral health outcomes and reducing disparities.
2. The continued separation of oral health care from overall health care contributes to limited access to oral health care for many Americans.
3. Sources of financing for oral health care for vulnerable and underserved populations are limited and tenuous.
4. Improving access to oral health care will necessarily require multiple solutions that use an array of providers in a variety of settings.
If the current approaches to oral health education, financing, and regulation continue unchanged, equitable access to oral health care cannot be achieved. This report, however, should not be perceived as simply a call for more spending. Investing additional money in a delivery system that is poorly designed to meet the oral health care needs of the nation’s underserved and vulnerable populations would produce limited results. Rather, the report calls for transformation through targeted investments in programs and policies that are most likely to yield the greatest impact. Therefore, the committee makes recommendations in key areas, suggests actions that various stakeholders can take, and identifies the relevant policy levers that are most likely to produce both short-term and long-term change.
Integrating Oral Health Care into Overall Health Care
Nondental health care professionals need to take a role in oral health care.3 Young children, for example, visit pediatricians and family physicians earlier and more frequently than they visit dentists. Similarly, for older adults living in institutions, nurses and nursing assistants often provide personal oral health care. With proper training, these and other primary care providers are well situated to educate individuals about how to prevent oral
3 In this report, the committee uses the term dental professionals to refer to dentists, dental hygienists, dental assistants, and dental laboratory technicians. The term nondental health care professionals includes all other types of health care professionals (e.g., nurses, pharmacists, physician assistants, physicians). Together, they are referred to as oral health care professionals.
diseases, to assess risk and screen for oral diseases, and to deliver preventive services (e.g., fluoride varnish).
Several nondental health care professions have made great strides in improving the oral health education and training of their students through development of oral health curricula and requirements for training in oral health care. The available evidence indicates that these efforts have been effective at increasing knowledge about oral health and integrating oral health care into primary care practices. However, these types of initiatives have not spread widely through the health professions.
Defining a core set of oral health competencies would describe essential skills that nondental health care professionals need in order to provide quality oral health care. Instead of having each profession develop their own set of competencies, one strategy is to develop a core set of competencies that would be broad and applicable to many nondental health professions. Once developed, this core set would need to be adopted by health professional schools and incorporated into the curricula. The committee concludes that the best way to encourage adoption is for professional accreditation and certification bodies to require these competencies for accreditation and maintenance of certification. Therefore, the committee recommends
RECOMMENDATION 1a: The Healthcare Resources and Services Administration (HRSA) should convene key stakeholders from both the public and private sectors to develop a core set of oral health competencies for nondental health care professionals.
RECOMMENDATION 1b: Following the development of a core set of oral health competencies
• Accrediting bodies for undergraduate and graduate-level nondental health professional education programs should integrate these core competencies into their requirements for accreditation; and
• All certification and maintenance of certification for health care professionals should include demonstration of competence in oral health care as a criterion.
The minimum core competencies will need to prepare graduates to
• Recognize risk for oral disease through competent oral examinations,
• Provide basic oral health information,
• Integrate oral health information with diet and lifestyle counseling, and
• Make and track referrals to dental professionals.
The committee suggests the following strategies:
• HRSA can require that Title VII-funded programs include interprofessional education on oral health.
• HRSA can support curriculum development and dissemination efforts for nondental health professional education programs.
Creating Optimal Laws and Regulations
A variety of regulations and policies determine how and by whom oral health care is provided. In spite of the existence of national accreditation standards on education and training of health care professionals, regulations defining supervision levels and scopes of practice vary widely from state to state and even by procedure. Some states have altered their scope-of-practice and supervision regulations to allow a broader range of competent oral health care professionals to treat patients, or for existing oral health care professionals to perform a wider range of procedures under various levels of supervision.
When expansions to existing scopes of practice are proposed, concerns inevitably arise about the quality of care provided when patients are treated by individuals with less training.4 However, many have called for state practice acts to be expanded in alignment with professional competence. Moreover, the Federal Trade Commission suggests that lawmakers consider whether overly restrictive regulations preclude a countervailing benefit, such as through increased access to care. Therefore, the committee recommends
RECOMMENDATION 2: State legislatures should amend existing state laws, including practice acts, to maximize access to oral health care.
At minimum, state dental practice acts should
• Allow allied dental professionals to practice to the full extent of their education and training,
• Allow allied dental professionals to work in a variety of settings under evidence-supported supervision levels, and
• Allow technology-supported remote collaboration and supervision.
This recommendation will enable members of a stratified workforce of professionals to work in community settings, change supervision require-
4 The IOM defines quality as being safe, timely, effective, efficient, equitable, and patient-centered.
ments to levels supported by evidence, and allow the appropriate use of telehealth technologies to reach underserved populations.
States can be supported in these efforts with strong evidence and clear guidance. This committee, therefore, proposes the following strategies:
• The Centers for Medicare and Medicaid Services (CMS) can disseminate rules and policies that promote Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries’ access to appropriate care, and ensure that these rules and policies reflect the practice abilities of current and new types of licensed professionals.
• The Office of the Assistant Secretary for Planning and Evaluation can examine and report on the impact of state practice acts on oral health care delivery to vulnerable and underserved populations. These reports would need to be conducted and published periodically to support sustained attention.
• Foundations, professional organizations, and public policy organizations can conduct and disseminate an initial review of state practice acts with a focus on access to services.
• Foundations, professional organizations, and public policy organizations can issue “best practices” briefs to highlight what each state is doing and what impact it is having on access.
Improving Dental Education and Training
An improved and responsive dental education system is needed to ensure that current and future generations of dental professionals can deliver quality care to diverse populations, in a variety of settings, using a variety of service-delivery mechanisms, and across the life cycle. Diversity in the health care workforce is associated with expanded access to care for racial and ethnic minority patients, greater patient choice and satisfaction, better patient-provider communication, and better educational experiences for all students. Furthermore, all dental professionals need to develop the necessary skills to work in a variety of community-based settings and with vulnerable and underserved populations, such as the ability to work in interprofessional teams with general health, education, and social service professionals; the ability to work in dental professional teams; and the ability to use new service-delivery mechanisms such as telehealth technologies for supervision, consultation, and collaboration.
Evidence points to limited training of dental students in community-based settings, thereby limiting their exposure to and practical experience with the broad range of patients cared for in these settings. This creates missed opportunities to improve cultural competence and to reinforce the professional and ethical role of caring for the vulnerable and underserved
populations. Providing students with clinical experiences in community-based settings helps them acquire skills that cannot be learned in academic settings, improves their comfort level with caring for vulnerable and underserved populations, and increases the likelihood that students may return to such settings in their future careers. Finally, schools will require more faculty members with experience and expertise in caring for vulnerable and underserved populations to adequately prepare students in this manner. Therefore, the committee recommends
RECOMMENDATION 3: Dental professional education programs should
• Increase recruitment and support for enrollment of students from underrepresented minority, lower-income, and rural populations;
• Require all students to participate in community-based education rotations with opportunities to work with interprofessional teams; and
• Recruit and retain faculty with experience and expertise in caring for underserved and vulnerable populations.
To support Recommendation 3, the committee further recommends
RECOMMENDATION 4: HRSA should dedicate Title VII funding to
• Support the development, implementation, and maintenance of substantial community-based education rotations, and
• Increase funding for recruitment and scholarships for underrepresented minority, lower-income, and rural populations to attend dental professional schools.
Continuation of proven strategies will help prepare—and ultimately promote—a greater desire among dental professionals to provide care to underserved and vulnerable populations. The committee suggests that private foundations and professional organizations can strengthen efforts of dental professional education programs to
• Increase enrollment of students from underrepresented minority, lower-income, and rural populations by funding bridge programs.
• Develop and evaluate innovative educational models to prepare students to work in diverse settings and with new delivery mechanisms.
Upon completion of dental school, students may have had limited opportunities to integrate their skills and knowledge with practical hands-on experience and may not feel adequately prepared for dental practice. In the
1995 IOM report Dental Education at the Crossroads (Crossroads) the committee noted:
A year of postgraduate or advanced education in general dentistry would allow students to gain speed and confidence in procedures, broaden their patient management skills to cover more complex problems, and mature in the nontechnical aspects of patient care.
Dentists who have completed general dentistry residency programs report feeling more comfortable caring for underserved patients and patients with complex health care needs, and tend to care for those patients more often, even after completing residency. Dental residencies are also a source of care for underserved and vulnerable populations, and some evidence shows that, with appropriate funding, requiring a year of residency training can expand the capacity of these programs to care for more individuals. Therefore, the committee recommends
RECOMMENDATION 5: HRSA should dedicate Title VII funding to support and expand opportunities for dental residencies in community-based settings.
• Subsequently, state legislatures should require a minimum of one year of dental residency before a dentist can be licensed to practice.
To be optimally effective, dental residency programs especially need to include clinical experiences with young children, individuals with special health care needs, and older adults. For this reason, these residency programs need to be located in settings where services to these and other vulnerable and underserved populations are most needed.
In alignment with the Crossroads report, this committee recommends increased opportunities rather than requirements for residencies as a short-term goal.
Since funding of residency programs has been tenuous, the committee recommends a continuous source of existing funding—Title VII of the Public Health Services Act—be directed to support dental residencies. This will require that Title VII receives priority within current and future funding levels. In the long term, the committee recommends that states should ultimately require a minimum of 1 year of dental residency before a dentist can be licensed to practice. This will involve, among other actions, the need for each state to revise its statutes and the need to increase the capacity of dental residency programs.
The committee suggests the following as potential strategies:
• HRSA can support care for underserved and vulnerable populations where they live, work, and learn by designating the types of clinical experiences and settings that would qualify for dental residencies.
• The public and private sectors can help identify and address barriers to having all states make postgraduate education a requirement for licensure.
• Hospitals and dental schools can increase the number of formal relationships with community-based care settings (e.g., Federally Qualified Health Centers [FQHCs], nursing homes, state and local health departments, and prisons) for dental residency programs.
Reducing Financial and Administrative Barriers
Dental coverage is a major determinant of access to and utilization of oral health care. In addition, a parent’s insurance status and utilization of oral health care is associated with whether his or her children receive oral health care. All states are required to provide comprehensive dental benefits for all children enrolled in Medicaid or CHIP. In contrast, states are not required to provide Medicaid benefits for adults. Among states that offer dental coverage for adult Medicaid recipients, the benefits are often limited to emergency coverage.
Recognizing that publicly funded programs are the primary source of coverage for underserved and vulnerable populations, the committee concludes that Medicaid cannot properly address access to oral health services if it excludes oral health benefits. However, in the absence of a comprehensive cost-benefit analysis and in a climate of significantly limited resources, the committee lacks the necessary evidence base and appropriate fiscal conditions to recommend that all states be required to cover essential dental benefits for all Medicaid beneficiaries. Nevertheless, the committee firmly concludes that including dental benefits for all Medicaid beneficiaries is a critical and necessary goal. Toward this end, the committee recommends
RECOMMENDATION 6: CMS should fund and evaluate state-based demonstration projects that cover essential oral health benefits for Medicaid beneficiaries.
State-based demonstration projects will help establish a basis for sound policy and fiscal decision making both for participating states and for future federal and state actions. Recognizing the different challenges faced by individual states, the committee suggests that CMS build in flexibility and encourage innovation in the demonstrations. For example, states may choose to focus on providing oral health benefits to specific populations
(e.g., “high-risk” enrollees) or to examine the effects of providing benefits to all enrolled populations. The committee suggests the following strategies:
• CMS can ensure that Medicaid beneficiaries receive the appropriate level of care by appointing and convening a committee of key stakeholders to establish an essential dental benefits package for Medicaid.
• CMS can provide technical assistance and oversight to state-based demonstration projects including guidance on program design elements that address the specialized needs of targeted beneficiaries and consultation on program evaluation and monitoring systems.
• CMS can develop a report at the culmination of the demonstration projects to review, translate, and disseminate evidence and guidance to all states.
• Private foundations can partner with CMS and participating states to support outreach for state-based demonstration projects including campaigns to raise awareness of changes in state oral health benefits available and to promote the use of newly covered services.
Financing also influences providers’ practice patterns. For example, low reimbursement by public programs is often cited as a disincentive to provider participation. Increases in reimbursement rates have shown promise in increasing dentists’ participation in these programs. However, increasing reimbursement rates alone is not sufficient. To that end, many states have taken measures to reduce the administrative burdens of publicly funded programs. These actions, in conjunction with rate increases and other supportive strategies (e.g., increased education and outreach to beneficiaries) can have a greater impact on increasing provider participation and patient utilization rates. Therefore, the committee recommends
RECOMMENDATION 7: To increase provider participation in publicly funded programs, states should
• Set Medicaid and CHIP reimbursement rates so that beneficiaries have equitable access to essential oral health services, as required by law;
• Provide case-management services; and
• Streamline administrative processes.
In a climate of limited resources and perennial demands on tight state budgets, states will need additional support in these efforts. Therefore, the committee suggests the following as strategies:
• Congress can provide enhanced federal matching funds to help offset the additional expense to the states. To be most effective, Congress can require that an enhanced match be tied to efforts of states to streamline administrative procedures related to provider participation and patient utilization in Medicaid.
• CMS can ensure that Medicaid beneficiaries have equitable access to essential oral health services by appointing and convening a committee of key stakeholders to establish an essential dental benefits package for Medicaid.
As noted above, simply increasing reimbursement rates, in the absence of other actions, will not be sufficient in improving access to care. Therefore, the committee proposes the following strategies:
• CMS can issue guidance to state Medicaid officers on strategies to reduce administrative burdens associated with provider participation in Medicaid.
• States can use Maternal and Child Health Services Block Grant (Title V) funds to evaluate and assess their case-management services to determine the most effective strategies to expand access to oral health care.
• Professional organizations and patient advocacy organizations can work with their constituencies to help identify populations in need of case management and the specific administrative barriers serving these populations.
Over the course of this study, the committee encountered considerable gaps in the evidence base. For example, little is known about the best ways to care for the distinct segments of the American public that are not well served by the traditional oral health care system. To this end, there are a number of programs currently under way designed to deliver oral health care through innovations in the workforce and in delivery of care in nontraditional settings.
First, as discussed earlier, research is needed on how to best include nondental health care professionals in oral health care. Further, several new models seek to develop new types of dental professionals or expand the role of existing dental professionals. For example, while limited, evaluations of the dental health aide therapist program in Alaska to date point to the quality and acceptability of dental therapists, but more research is needed to determine the broader impact and implementation of these types of programs. Similar research is also needed on the provision of oral health
care in nontraditional settings (e.g., school-based health centers, mobile equipment) and through innovative technologies (e.g., telehealth).
Quality assessment and improvement efforts in oral health are hampered by a deficiency in the collection, analysis, and use of data related to important aspects of oral health. Because of the limited infrastructure and the current paucity of measures in use to assess the technical competence, practice procedures, and quality of care and outcomes of care provided by any dental professionals, making comparisons of care rendered by different types of professionals is even more challenging.
Finally, little has been done to investigate better methods of financing and regulation that might lead to improvements in dental coverage, access to oral health care, and, again, improvements in oral health status.
Therefore, the committee recommends
RECOMMENDATION 8: Congress, the Department of Health and Human Services, federal agencies, and private foundations should fund oral health research and evaluation related to underserved and vulnerable populations, including
• New methods and technologies (e.g., nontraditional settings, nondental professionals, new types of dental professionals, and telehealth);
• Measures of access, quality, and outcomes; and
• Payment and regulatory systems.
Given the need for further research, the committee concludes that a variety of stakeholders will need to take additional actions to support this recommendation, including
• Federal agencies can increase funding for programs that successfully provide education and preventive and treatment services to vulnerable and underserved populations such as Head Start; the Women, Infants, and Children program; and school-based health centers.
• HRSA can provide new funding toward demonstration projects that promote innovations in oral health care delivery, such as new workforce models, nontraditional settings of care, and new ways to finance oral health care.
State oral health programs are essential to direct resources and monitor the impact of oral health efforts. One important aspect of state oral health programs is their ability to monitor and analyze the burden of oral health
disease, conditions, and personal behaviors over time. Other functions of state oral health programs (e.g., community water fluoridation, dental sealant programs, fluoride varnish programs, dental screening programs, and oral health programs specifically for pregnant women) also have a positive impact on oral health. According to the Association of State and Territorial Dental Directors,
with expanded infrastructure and capacity, state oral health programs are better able to monitor oral health status, address high-risk populations, increase population-based prevention activities, and extend resources to local health agencies and communities in order to implement oral health strategies.
In spite of this impact, funding for state and local dental public health services continues to be limited and often insufficient. In FY 2010, the Centers for Disease Control and Prevention (CDC) provided $6.8 million to 19 state oral health programs to support evidence-based prevention programs, surveillance of oral disease burden, and to develop plans to improve oral health and address disparities.
Recognizing the critical role of state-based programs, the committee recommends
RECOMMENDATION 9: The Centers for Disease Control and Prevention (CDC) and the Maternal and Child Health Bureau (MCHB) should collaborate with states to ensure that each state has the infrastructure and support necessary to perform core dental public health functions (e.g., assessment, policy development, and assurance).
The committee proposes the following strategies:
• The CDC can continue to increase the number of states that receive cooperative agreement funding for dental public health programs.
• The MCHB can support an oral health component under Title V through block grants (formulary grants to states), discretionary funds, and/or “set asides” (a percentage of funds) for oral health.
• Congress can fund the Oral Healthcare Prevention Education Campaign authorized by the Patient Protection and Affordable Care Act (ACA) [Public Law 111-148, Title IV, Sec. 4102] which calls for a national public education campaign focused on oral health and disease prevention targeted toward vulnerable and underserved populations.
• Private foundations can partner with public agencies to develop, implement, and evaluate public education and oral health literacy campaigns.
Expanding the capacity of FQHCs to deliver oral health care is also important to meet the needs of vulnerable and underserved populations. FQHCs are required to provide certain oral health services—including preventive, but not comprehensive, dental services—either in the clinic or by referral. In 2009, HRSA funded 1,131 FQHCs in all 50 states, the District of Columbia, and Puerto Rico. The American Recovery and Rehabilitation Act included $2 billion for FQHCs, and the ACA included $11 billion for a Community Health Centers Trust Fund that will allow FQHCs to expand access and make capital improvements, and also appropriated $1.5 billion to a new National Health Service Corps Trust Fund.
In 2009, over 3.4 million patients used dental services in the health center system. Still, this is only a small fraction of the underserved population. The committee concludes that with adequate support, FQHCs are well positioned to significantly expand the delivery of oral health care to vulnerable and underserved populations.
The committee, therefore, recommends
RECOMMENDATION 10: To expand the capacity of FQHCs to deliver essential oral health services, HRSA should
• Support the use of a variety of oral health care professionals;
• Enhance financial incentives to attract and retain more oral health care professionals;
• Provide guidance to implement best practices in management, operation, and efficiency; and
• Assist FQHCs in all states to operate programs outside their physical facilities and take advantage of new systems to improve the oral health of the population they serve.
Each of the specific actions outlined for FQHCs in this recommendation build upon the committee’s previous recommendations and the evidence that supports them.
The committee proposes the following strategies:
• Public-private partnerships can supplement educational loan repayment programs for oral health care professionals who are willing to serve a designated amount of time in medically underserved areas.
• HRSA can support dissemination and implementation of this recommendation by identifying FQHC “best practices” to highlight what states or individual clinics are doing and what impact these efforts are having on access.
• HRSA can support the demonstration and dissemination of models that extend the reach of FQHCs by operating programs out-
side their physical facilities and that use new delivery models and techniques.
• Other nonprofit community health centers can take the steps outlined in this recommendation to increase the delivery of essential oral health services to greater numbers of vulnerable and underserved individuals.
The release of this report coincides with a transformative moment in the nation’s health care system. As the nation struggles to address the larger systemic issues of access to health care, greater effort will be needed to ensure that oral health is included in this conversation.
The recommendations presented in this report are directed to national, state, and local governments; all types of health care professions; licensing and accreditation bodies; educational institutions; health care researchers; and philanthropic and advocacy organizations. Together, these groups have the power to transform the delivery of oral health care to vulnerable and underserved populations. This report envisions an integrated delivery system that provides quality oral health care to vulnerable and underserved people where they live, work, and learn through changes in the education, financing, and regulation of oral health care. The recommendations support the creation of a diverse workforce that is competent, compensated, and authorized to serve vulnerable and underserved populations across the life cycle. Implementation of these recommendations will be a critical next step in increasing access to oral health care, reducing persistent oral health disparities, and improving oral health outcomes among vulnerable and underserved populations.