Advancing Oral Health in America (2011) / Chapter Skim
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3 The Oral Health Care System
3 The Oral Health Care System
Pages 81-140
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In the United States, medical and dental education and practice have been separated since the establishment of the first dental school in Baltimore in 1840 (University of Maryland, 2010)
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In addition, some oral health care, especially for young children, has begun to be supplied by nondental providers in settings such as physicians' offices, which is discussed later in this chapter. This section gives a brief overview of the basic settings of oral health care by dental professionals -- namely, dentists, dental hygienists, and dental assistants.
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of their patients have private insurance; only about 7 percent receive publicly supported dental coverage, and the remaining 30 percent are not covered by any dental insurance (ADA, 2009b)
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The Oral Health Safety Net Some segments of the American population, namely socioeconomically disadvantaged groups, have difficulty accessing the private dental system due to geographic, financial, or other access barriers and must rely on the dental safety net (if they are seeking care) (Bailit et al., 2006; Brown, 2005; Wendling, 2010)
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PAYING FOR ORAL HEALTH CARE Multiple challenges exist in the financing of oral health care in the United States, including state budget crises, the relative lack of dental coverage, a payment system (like in general health care) that rewards treatment procedures rather than health promotion and disease prevention, and the high cost of dental services.
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, and "routine dental care" is specifically excluded from the traditional Medicare benefits package. Highincome older adults are more likely to have dental coverage than are other older adults (Manski et al., 2010c)
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. The availability of dental coverage through one's employer is associated with the size of the establishment; that is, the larger the number of employees overall, the higher the incidence of standalone dental plans available to employees (Barsky, 2004; Ford, 2009)
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and does not account for care provided in settings such as hospitals and nursing homes. While a much lower percentage of funds for dental services come from public sources as compared to the funding of many other services, the government may, in fact, have a very important role to play for those who cannot afford to pay for care.
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In contrast, Medicaid dental benefits are not required for adults, and even among those states that offer dental coverage for adult Medicaid recipients, the benefits are often limited to emergency care (ASTDD, 2011c)
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THE DENTAL WORKFORCE Traditionally, a combination of dentists, dental hygienists, and dental assistants directly provide oral health care. Dental laboratory technicians create bridges, dentures, and other dental prosthetics.
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The extent to which all of these professionals interact can vary greatly. The surgeon general's 2000 report expressed concerns about a declining dentist-to population ratio, an inequitable distribution of oral health care professionals, a low number of underrepresented minorities applying to dental school, the effects of the costs of dental education and graduation debt on decisions to pursue a career in dentistry, the type and location of practice upon graduation, current and expected shortages in personnel for dental school faculties and oral health research, and an evolving curriculum with an ever-expanding knowledge base.
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. Job growth during the next decade is projected to be above average for all the dental professions, particularly for dental hygienists and dental assistants (see Table 3-3)
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. As discussed previously, professionally active dentists overwhelmingly work in the private practice setting (92 percent)
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. TABLE 3-4 Top 15 Fastest-Growing Occupations, 2008 and Projected 2018 Percent Change, Occupation 2008–2018 Biomedical engineers 72.0 Network systems and data communications analysts 53.4 Home health aides 50.0 Personal and home care aides 46.0 Financial examiners 41.2 Medical scientists, except epidemiologists 40.4 Physician assistants 39.0 Skin care specialists 37.9 Biochemists and biophysicists 37.4 Athletic trainers 37.0 Physical therapist aides 36.3 Dental hygienists 36.1 Veterinary technologists and technicians 35.8 Dental assistants 35.8 Computer software engineers, applications 34.0 SOURCE: BLS, 2010c.
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SOURCES: ADA, 2009d, 2010a. Dental Hygienists The dental hygiene profession began almost a century ago when a dentist trained his assistant to assist in preventive dental services (University of Bridgeport, 1998)
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. Like dental hygienists, dental assistants are nearly all female (McDonough, 2007)
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The ADA's Commission on Dental Accreditation (CODA) accredits predoctoral dental education programs; programs for dental hygienists, dental assistants, and dental laboratory technicians; and advanced dental educational programs (i.e., residencies)
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In the early years of the profession, dental hygiene education programs were often colocated with dental education programs in schools of dentistry (Haden et al., 2001)
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However, a few have a 2-year curriculum resulting in an associate degree. About 14 percent of faculty in CODA-accredited programs are dentists, 70 percent are dental assistants, and 28 percent are dental hygienists (ADA, 2009a)
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. Health care professionals from underrepresented minority (URM)
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. Several factors complicate recruitment of underrepresented minorities into dentistry including lack of exposure to and knowledge of the dental profession, minimal opportunities for mentorship from dental professionals, and competition from other health professions for underrepresented minority students who are academically qualified (Haden et al., 2003)
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Kellogg Foundation, created the initiative Pipeline, Profession, and Practice: Community-Based Dental Education,11 which ended in July 2010. This project provided much insight into strategies for successful implementation (Lavizzo-Mourey, 2010; Leviton, 2009)
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. Dental therapists and dental nurses have been used internationally for decades (Ambrose et al., 1976; Gallagher and Wright, 2003; GAO, 2010; Nash and Nagel, 2005b; Nash et al., 2008; Pew Center on the States and National Academy for State Health Policy, 2009; Sun et al., 2010)
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, like many nonphysician health care professionals, are an important source of care in rural populations: CRNAs are the sole providers of anesthesia in more than two-thirds of 12 2009 Minn.
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There are many studies of the safety and quality of dental therapists and dental nurses around the world, but these models occur in different systems of care delivery and financing. Evaluations in the United States to date have been limited, and it is nearly impossible to compare their quality to that of existing dental professionals, since little evidence exists on the quality of care provided by traditional dental practitioners (see a discussion of quality of care later in this chapter)
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At the end of the section, the role of nondental health care professionals as a whole in the delivery of preventive services for oral health is discussed. Physicians The need for physicians to learn about oral health has been recognized for nearly a century (Gies, 1926)
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Foundation funded a 3-year grant to examine dental education, New Models of Dental Education (Formicola et al., 2005; Machen, 2008)
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noted that "oral health has not been a high nursing priority in the past" and urged the profession to "increase nursing's awareness, knowledge, and skill about the significance that oral health holds." However, as with other nondental health care professions, the training of nurses in oral health and hygiene is highly variable and often inadequate (Jablonski, 2010)
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do not delineate any specific competencies for oral health. In 2006, the Arizona School of Health Sciences and the Arizona School of Dentistry and Oral Health developed a set of proposed oral health competencies for nurse practitioners and physician assistants (PAs)
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. Pharmacists As health care professionals in community settings, the role of the pharmacist has expanded over time from merely dispensing medications to being an important partner with other health care professionals.
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In the past, nondental health care professionals could not be reimbursed for preventive care in oral health, but this is changing. As of 2010, 39 state Medicaid programs reimbursed primary medical care providers for preventive oral health services, 2 approved such reimbursement but did not have funding, and another 3 allowed reimbursement under certain circumstances (AAP, 2010)
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. Aside from lack of reimbursement, other barriers to engaging nondental health care professionals in preventive care (both for oral health as well as other health conditions)
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includes online training modules for child health professionals in oral health management and risk assessment. PUBLIC HEALTH WORKERS Public health workers include many of the professions previously mentioned, including both dental and nondental health care professionals.
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. In 1951, the American Dental Association (ADA)
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. The importance of interaction between dentists and other health care professionals is a not new finding.
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. This allows the pediatric nurse practitioner students to learn about caries risk assessment and how to apply fluoride varnish while the dental students can become more familiar with the role of the nurse in oral health.
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The Role of States While the education, training, and testing of most health care professionals and the accreditation of educational programs have national standards, the scope of practice for individual professions is established at the state level, often resulting in wide variability among states. As was briefly discussed earlier in this chapter, professional battles and controversy over expanding a profession's scope of practice are not new to the health care professions or unique to oral health care (Carson-Smith and Minarik, 2007; Daly, 2006; Dulisse and Cromwell, 2010; Huijbregts, 2007; RCHWS, 2003; Wing et al., 2004)
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The Dental Assisting National Board estimates that almost 12 percent of dental assistants in the United States are certified dental assistants (CDAs) by the Dental Assisting National Board (ADAA/DANB Alliance, 2005)
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One ongoing significant challenge for health care quality measurement has been developing and implementing measures of significant outcomes relevant to patients. Cost metrics have also been challenging to develop and implement.
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. Further, the most recent annual editions of the National Healthcare Quality Report and the National Healthcare Disparities Report only included information about access to dental services, and not about the state of quality in oral health care (AHRQ, 2010)
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In addition, there is no single source of oversight or reporting on any measures that are currently in use. Limitations to Expanding Quality Measurement in Oral Health Care The construction of quality measures depends on robust, timely, accurate, and reliable data sources.
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. Future Directions for Quality Measurement in Oral Health Care Quality improvement in oral health is hampered by an insufficient evidence base for interventions, insufficient data sources, and a lack of quality measures.
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KEY FINDINGS AND CONCLUSIONS The committee noted the following key findings and conclusions: Sites of Care • Oral health is provided in two separate systems -- private offices and the safety net -- neither of which function adequately for vul nerable populations. Financing Oral Health Care • Out-of-pocket payments account for 44 percent of dental expen ditures, and dental services account for 22 percent of all out-of pocket health care expenditures.
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• Interprofessional, team-based care has the potential to improve care-cooridination, patient outcomes, and produce cost savings, yet most health care professionals are not trained to work in either intra- or interdisciplinary teams. • While the regulation of health care professions occurs at the state level, HHS has a role to play in the demonstration and testing of new workforce models.
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2009a. 2008-09 survey of allied dental education.
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Assessing recruitment of underrepresented minority and low-income dental students to increase access to dental care. Journal of Dental Education 74(6)
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2010d. Occupational outlook handbook 2010-11 edition, dental assistants.
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Journal of Dental Education 74(10 Supp.)
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Journal of Dental Education 54(11)
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1999. Population-based primary care and dental education: A new role for dental schools.
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1926. Dental education in the United States and Canada.
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2001. Trends in allied dental education: An analysis of the past and a look to the future.
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1995. Dental education at the crossroads: Challenges and change.
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Journal of Dental Education 74(Supp.
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The role of cultural competency in health dispari ties: Training of primary care medical practitioners in children's oral health. Journal of Dental Education 67(8)
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2004. Trends in dental and allied dental education.
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Journal of Dental Education 74(9)
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2008. Re forming dental education: Faculty members' perceptions on the continuation of pipeline program changes.
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Jour nal of Dental Education.
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Journal of Dental Education 68(5)
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