+
Principles in Dental Public Health
© AAPHD
+
Course Created By
Vinodh Bhoopathi., BDS., MPH.,DScD
Course Contributors:
Dr. Woosung Sohn, Dr. Susan Reed, Diane Brunson, Robin Knowles,
Karen Yoder, Dr. Ana Karina Mascarenhas,
Dr. Kathryn Ann Atchison
+ This project is supported by the Health Resources and
Services Administration (HRSA) of the U.S. Department
of Health and Human Services (HHS) under grant
number D83HP19949 Predoctoral Training in General,
Pediatric, and Public Health Dentistry and Dental
Hygiene, grant amount $650,000. This information or
content and conclusions are those of the author and
should not be construed as the official position or
policy of, nor should any endorsements be inferred by
HRSA, HHS or the U.S. Government.
3
© AAPHD 3
+ Course Competencies
Describe social and health care systems and
determinants of health and their impact on the
oral health of the individual and population
Demonstrate the ability to access and describe
the use of population-based health data for
health promotion, patient care, and
quality improvement
4
© AAPHD 4
+ Course Objectives

Identify and describe the principles of public health as it relates to
oral health and the dental professional.

Describe the public health and dental public health achievements in
the US.

Describe the oral health status and needs of the US population,
including various age groups, underserved, and minority populations.

Describe the dental disease trends among various US populations.

Identify and explain determinants associated with heath care access
and utilization of dental care services.

Recognize the roles of public, private, professional and voluntary
organizations in promoting oral health, and the delivery of dental
health care services.

Describe and differentiate different oral health workforce models.
© AAPHD 5
+ Lecture 1
Introduction to Dental Public Health
6
© AAPHD 6
+
Learning Objectives

Define Public Health and Dental Public Health

Describe three core functions of public health

Describe the ten essential public health services

Identify the difference between the roles of a private dental
practitioner and a dental public health specialist

List and describe the roles of major federal agencies involved
in oral health and dental public health

Identify the roles of other
promoting oral health
professional organizations
© AAPHD 7
+
Mission of Public Health
“Fulfilling society’s interest in assuring conditions
in which people can be healthy”
The Future of the Public's Health in the 21st Century, 2002. Institute of Medicine
© AAPHD 8
+
*
Definition

Public Health: the science and art of preventing
disease, prolonging life, and promoting physical health
and efficiency through organized community efforts.

Dental Public Health*: the science and art of preventing
and controlling dental diseases and promoting dental
health through organized community efforts.
Competency Statements in Dental Public Health. J Public Health Dent, 1998; 58 (1): 119-22.
© AAPHD 9
+
Dental Public Health (DPH)
One of nine dental specialties recognized by the American
Dental Association (ADA)
 Recognized a specialty in 1950
 Sponsoring organization is the American Association of
Public Health Dentistry (AAPHD)
 Separate and distinct from any recognized dental specialty
 Contributes to new knowledge, research, education,
services that directly benefits different aspects of clinical
patient care
 Unique knowledge and skills (Masters in Public Health and
residency) that generally takes two years of education
beyond the pre-doctoral dental curriculum
© AAPHD 10
Core
Competencies
in
Dental
+
Public Health (DPH)
A specialist in DPH will
I.
Plan oral health programs for populations
II. Select interventions and strategies for the prevention and control of
oral diseases and promotion of oral health.
III. Develop resources, implement and manage oral health programs for
populations
IV. Incorporate ethical standards in oral health programs and activities
V. Evaluate and monitor dental care delivery systems
VI. Design and understand the use of surveillance systems to monitor
oral health
VII. Communicate and collaborate with groups and individuals on oral
health issues
VIII. Advocate for, implement and evaluate public health policy,
legislation, and regulations to protect and promote the public's oral
health
IX. Critique and synthesize scientific literature
X. Design and conduct population-based studies to answer oral and
public health questions
Dental Public Health Competencies. J Public Health Dent 1998, 58; 121-22
© AAPHD 11
+ Public Health
 The
concept of Public Health that emerged
in the beginning of the 20th century had
three core public health functions:
 Assessment
 Policy
Development
 Assurance
© AAPHD 12
+
Assessment
 “…is
the regular and systematic collection,
assemblage, analysis, and communication on the
health of the community.”
 Includes
statistics on:
 Health and oral health status
 Community health needs
 Resources to address needs
IOM: The Future of Public Health, 1988
© AAPHD 13
+ Policy Development
 “….is
the development of comprehensive public
health policies by promoting use of the scientific
knowledge base in decision-making about public
health….”
 Strategic approach
IOM: Future of Public Health, 1988
© AAPHD 16
+ Assurance
 Assure
that the public has access to necessary
health services through regulation, education or
direct provision of services
 Encouraging actions by other entities, public or
private
 Requiring such action through legislation
 Providing services directly
© AAPHD 18
+ Assurance
 “…involve
key policymakers and the general
public in determining a set of high-priority
personal and communitywide health services that
governments will guarantee to every member of
the community…..”
 Include subsidization or direct provision of highpriority personal health services for those
unable to afford them
IOM: The Future of Public Health, 1988
© AAPHD 19
The Ten
Essential
Services
© AAPHD 21
+ Ten Essential Public Health Services
From these core functions (Assessment, Policy Development, and Assurance)
ten essential public health services emanate
1.Monitor
health status to identify and solve community health problems.
2.Diagnose and investigate health problems and health hazards in the
community.
3.Inform, educate, and empower people about health issues.
4.Mobilize community partnerships and action to identify and solve health
problems.
5.Develop policies and plans that support individual and community health
efforts.
6.Enforce laws and regulations that protect health and ensure safety.
7.Link people to needed personal health services and assure the provision of
health care when otherwise unavailable.
8.Assure competent public and personal health care workforce.
9.Evaluate effectiveness, accessibility, and quality of personal and
population-based health services.
10.Research for new insights and innovative solutions to health problems.
© AAPHD 22
+
How can DDS/RDH use 3 core PH
functions compared to a DPH
specialist?
Private Practice
(DDS/RDH)
Public Health
(DPH Specialist)
Individual Patient
Community as Patient
Exam
Survey
Diagnosis/Assessment
Analysis
Treatment Plan
Program Planning
Treatment
Program Implementation
Fee/payment
Budget/Financing
Recall/pt. evaluation
Program Evaluation
© AAPHD 23
23
Dental
Public
Health
+
Infrastructure in the US
© AAPHD
+ Dental Public Health Infrastructure
 The
dental public health (DPH) infrastructure is the
foundation upon which public dental programs and
activities are assessed, planned, executed, and
evaluated.
 Federal, state, and
local or county governments have
the potential to make a significant impact on a
community’s oral health
 US
Department of Health and Human Services (HHS)
is the primary federal agency that administers
public health programs in the US
Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental
Public Health in the United States. Dent Clin N Am 2008, 52: 259-280
© AAPHD 25
HHS
Organization
Chart
+
The Executive Secretariat
Office of Health Reform
Secretary
---------------------Deputy
Secretary
----------------------Chief of Staff
Office of Intergovernmental
and External Affairs
Office of the Assistant
Secretary for Administration
(ASA)
Administration for Children and
Families (ACF)
Centers for Medicare and
Medicaid Services (CMS)
Program Support
Center (PSC)
Administration for Community
Living (ACL)
Food and Drug
Administration (FDA) *
Agency for Health Care
Research and Quality (AHRQ)*
Health Resources and
Services Administration
(HRSA) *
Office of the Assistant
Secretary for Financial
Resources (ASFR)
Office of the Assistant
Secretary for Health (OASH) *
Office of the Assistant
Secretary for Legislation (ASL)
Office of the Assistant
Secretary for Planning and
Evaluation (ASPE)
Agency for Toxic Substances
and Disease Registry (ATSDR)*
Indian Health Services (IHS) *
Centers for Disease Control
and Prevention (CDC) *
National Institute of Health
(NIH) *
Substance Abuse & Mental
Health Services
Administration (SAMHSA) *
Office of the Assistant
Secretary for Preparedness
and Response (ASPR) *
Office of the Assistant
Secretary for Public Affairs
(ASPA)
Center for Faith-based and
Neighborhood Partnerships
(CFBNP)
Office of Civil Rights (OCR)
Departmental Appeals Board
(DAB)
Office of the General
Counsel(OGC)
Office of Global Affairs
(OGA) *
Office of Inspector General
(OIG)
Office of Medicare Hearing
and Appeals (OMHA)
* Designates a component of U.S. Public Health Services
Office of National Coordinator
for Health Information
Technology (ONC)
http://www.hhs.gov/about/orgchart/
© AAPHD
26
+ HHS
 Office
of Surgeon General

Surgeon General - nation’s chief health educator,
appointed by the President and confirmed by the
Senate, and reports to the Secretary of Health and
Human Services.

In 2000, the first ever Surgeon General’s Report on
Oral Health describing the magnitude of oral diseases
in the United States population and the actions
necessary to address them was released
Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental
Public Health in the United States. Dent Clin N Am 2008, 52: 259-280
© AAPHD 27
+ HHS

Healthy People 2020
Healthy People - health objectives for the nation. Current one is
Health People 2020 to be achieved over the second decade of this
century
 Oral health Goal
“Prevent and control oral health diseases, conditions, and injuries, and
improve access to preventive services and dental care”
 Oral health objectives (OH 1 to 17)






OH1 to 6 - Oral health in children, adolescents and adults
 (dental caries, untreated tooth decay, tooth loss)
OH7 to 11- Access Preventive Services
 (school based centers, service utilization, FQHCs with oral health)
OH 12 to 14 - Oral health interventions
 (sealants, community water fluoridation)
OH 15 to 16 – Monitoring and surveillance systems
 (systems recording and referring cleft lip and palate, oral and
craniofacial systems)
OH 17 - Public health infrastructure
 (health agencies with a DPH professional directing programs)
© AAPHD 28
+ HHS
Healthy People 2020

The Oral Health Leading Health Indicator is:
“Persons aged 2 years and older who used the oral
health care system in the past 12 months (OH-7)”

HP2020 Baseline is 2007: 44.5% of persons aged 2 years
and over had a dental visit in the past 12 months (age
adjusted).

HP2020 Target: 49.0% (age adjusted), or 10 percent
improvement
http://www.healthypeople.gov/2020/LHI/oralHealth.aspx?tab=data
© AAPHD 29
+ HHS
30
United States Public Health
Services (USPHS)
Indian Health Services

Uniformed service of more
than 6,000 health professionals
who serve in the HHS and
other federal agencies

The Surgeon General heads
this uniformed commissioned
corps

In 2007 approximately 390
dental offices

Primary care provider and
advocate for Alaskan Native
and American Indians
Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental
Public Eealth in the United States. Dent Clin N Am 2008, 52: 259-280
© AAPHD 30
+ HHS

National Institute for Dental and Craniofacial Research
(NIDCR) – one of the 24 institutes under National
Institutes of Health

To
improve
oral,
dental
and
craniofacial
health through research, research training, and the
dissemination of health information.
 Performing and supporting basic and clinical research;
 Conducting and funding research training and career
development programs to ensure an adequate number of
talented, well-prepared and diverse investigators;
 Coordinating and assisting relevant research and
research-related activities among all sectors of the
research community;
 Promoting the timely transfer of knowledge gained from
research and its implications for health to the public,
health professionals, researchers, and policy-makers.
http://www.nidcr.nih.gov/AboutUs/MissionandStrategicPlan/MissionStatement/
© AAPHD 31
+ HHS

Centers for Disease Control and Prevention: Division of Oral
Health







Works to improve the oral health of the nation and reduce inequalities
in oral health by:
Helping states improve their oral health programs.
Extending the use of proven strategies to prevent oral disease by—
 Encouraging the effective use of fluoride products and community
water fluoridation.
 Promoting greater use of school-based and –linked dental sealant
programs.
Enhancing efforts to monitor oral diseases, such as dental caries and
periodontal infections.
Contributing to the scientific knowledge-base regarding oral health
and disease.
Guiding infection control in dentistry.
Helping states improve their oral health programs
Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental
Public Health in the United States. Dent Clin N Am 2008, 52: 259-280
© AAPHD 32
+ HHS
 Health
Resources and Services Administration
(HRSA)
Federal agency for improving access to health care
services for people who are uninsured, isolated or
medically vulnerable.
 HRSA grantees provide health care to uninsured
people, people living with HIV/AIDS, and pregnant
women, mothers and children
 Goal I: Improve Access to Quality Care and
Services.
 Goal II: Strengthen the Health Workforce.
 Goal III: Build Healthy Communities.
 Goal IV: Improve Health Equity.

© AAPHD 33
+ HHS
 Centers
for Medicare & Medicaid Services
(CMS)
 The
CMS is an agency within the HHS
responsible for administration of several key
federal health care programs - in addition to
Medicare (the federal health insurance program
for seniors) and Medicaid (the federal needsbased program), CMS oversees the Children’s
Health Insurance Program (CHIP), and the Health
Insurance Portability and Accountability Act
(HIPAA), among other services
© AAPHD 34
+ HHS
 U.S





Food and Drug Administration (FDA)
Protect the public health by assuring that foods are safe,
wholesome, sanitary and properly labeled; ensuring that
human and veterinary drugs, and vaccines and other
biological products and medical devices intended for
human use are safe and effective.
Protect public from electronic product radiation
Assure cosmetics and dietary supplements are safe and
properly labeled
Regulate tobacco products
Advance the public health by helping to speed product
© AAPHD 35
+ Professional Organizations
Supporting Dental Public Health
 Advocate
and promote optimal oral health care
for all
American Association of Public Health Dentistry
 American Board of Dental Public Health
 American Public Health Association, Oral Health
Section
 Association of State and Territorial Dental Directors
 American Association of Community Dental
Programs
 American Dental Education Association
 American Dental Association
 American Academy of Pediatric Dentistry

© AAPHD 36
+ American Association of Public
Health Dentistry (AAPHD)

Founded 1937

Sponsor of the American Board of Dental Public Health,

Publishes the Journal of Public Health Dentistry, and is

Co-sponsor of the yearly National Oral Health Conference

AAPHD is committed to:

“Promotion of effective efforts in disease prevention, health promotion
and service delivery”,

“Education of the public, health professionals and decision-makers
regarding the importance of oral health to total well-being”, and

“Expansion of the knowledge base of dental public health and fostering
competency in its practice”.
© AAPHD 37
+ American Board of Dental Public
Health

National examining and certifying agency for the
specialty of dental public health

Functions
 creation of standards for the practice of dental public
health;
 grant and issue dental public health certificates to
dentists who have successfully completed the
prescribed training and experience requisite for the
practice of dental public health; and
 ensure continuing competency of diplomates
© AAPHD 38
+ American Public Health
Association

Founded in 1872 – largest public health organization in
the world

Publishes the American Journal of Public Health.

Oral Health Section is one of many sections of APHA

Provides DPH members a forum to obtain support from nonDPH members/leaders and decision makers

Some public health issues that OH section investigates and
promotes

Community water fluoridation

Access to dental care for vulnerable groups

Reducing racial and ethnic oral health disparities

Domestic violence screening etc
© AAPHD 39
Association
of
State
and
Territorial
+
Dental Directors
 Non-profit
organization representing the directors
and staff of state public health agency programs for
oral health
 Promote
the leadership capacity of state dental
programs and the impact that their collective oral
disease prevention and health promotion activities
have on the nation's oral health
establishes national dental public health policies,
 assists in development and implementation of programs
and policies for the prevention of oral diseases;
 developing position papers and policy statements;
 provides information on oral health to health officials
and policy makers, and conducts conferences for the
dental public health community

© AAPHD 40
American
Association
of
+
Community Dental Programs
 Voluntary
membership organization - Supports
effort of those with an interest in serving the oral
health needs at the community level

Guides local public health agencies through the steps for
developing,
integrating,
expanding,
or
enhancing
community oral health programs
 Members
include local dental directors and staff of
city, county, and community-based health programs
© AAPHD 41
American Dental Education
+
Association

National organization representing academic dentistry - voice
of dental education.

ADEA members - 19,000 students, faculty, staff, and
administrators from all of the U.S. and Canadian dental schools,
many allied and advanced dental education programs, and
numerous corporations working in oral health education

ADEA has a section on community and preventive dentistry and
behavioral sciences.
 explores issues related to community and preventive
dentistry as they apply to dental and dental hygiene
education, research and practice

The ADEA publishes the Journal of Dental Education
© AAPHD 42
+ American Dental Association

Founded in 1859, the American Dental Association (ADA) is
the oldest and largest national dental society in the world over 157,000 ADA members

“professional association of dentists committed to the
public’s oral health, ethics, science and professional
advancement; leading a unified profession through
initiatives in advocacy, education, research and the
development of standards”

Works to advance the dental profession on the national,
state and local level
http://www.ada.org/6876.aspx
http://www.ada.org/sections/professionalResources/pdfs/dph_educational_module.pdf
© AAPHD 43
+ American Academy of
Pediatric Dentistry
 Membership
organization
representing
specialty of pediatric dentistry
the
 Mission
of the AAPD is to advocate policies,
guidelines and programs that promote optimal oral
health and oral health care for children.
 Serves
and represents its membership in the areas
of professional development and governmental
and legislative activities.
© AAPHD 44
+ Lecture 2
Population-Based Public Health
Strategies
45
© AAPHD 45
+ Learning Objectives

Define the approaches used by Public Health to improve
the health of the community

Describe the importance of various public health
achievements,
including
dental
public
health
achievements in the last century

Describe the population level impact of community level
water fluoridation
© AAPHD 46
+ Public Health Practice

Focuses on the health of groups, community, or the
nation.

Population-focused care is defined as interventions
aimed at disease prevention and health promotion that
shape a community’s overall health profile (DHHS,
1994a)

Key feature of public health practice is the
acknowledgment that health is greater than the
biological determinants of individual health;

It also embraces a host of behavioral, social, economic, and
environmental factors (including biological determinants
of individuals) that affect the health of a community.
Porsche DJ. Public & community health nursing practice : a population-based approach 2004. Available at
http://www.sagepub.com/upm-data/3989_Chapter_1.pdf
© AAPHD 47
+
20th
Century Public Health
Achievements U.S. 1900-1999
48

Vaccination

Healthier Mothers and Babies

Motor Vehicle Safety

Family Planning

Safer Workplaces

Community Water Fluoridation

Control of Infectious Disease


Decline in Deaths from CVD
and Stroke
Recognition of Tobacco Use as
a Health Hazard

Safer and Healthier Foods
http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm
© AAPHD 48
+ Vaccinations
 Polio
vaccinations

First outbreak described in US in
1843

1951-1954, an average of 16,316
paralytic polio cases and 1879 deaths

Polio vaccines introduced in US 1955

Following the introduction of vaccine,
polio cases declined sharply to less
than 1000 cases in 1962 and
remained below 100 cases after that
year
http://www.cdc.gov/vaccines/pubs/pinkbook/polio.html
© AAPHD 49
+ Vaccinations
ONLY
82% receive
vaccination
in 2011
Only 69%
received
vaccination
DTP, polio,
MMR, and Hib
vaccines
© AAPHD 50
DTP, polio, MMR, and
Hib vaccines
+ hepatitis B vaccine, and
the varicella vaccine
+ Vaccinations

51
Community or Herd immunity

Critical portion of a community is immunized against a contagious
disease, most members of the community are protected against
that disease because there is little opportunity for an outbreak.
The National Institute of Allergy and Infectious Diseases (NIAID)
http://www.vaccines.gov/basics/protection/index.html
© AAPHD 51
+ Vaccinations
52
 Community
or Herd immunity
 18% not immunized could increase the risk of outbreaks
The National Institute of Allergy and Infectious Diseases (NIAID)
http://www.vaccines.gov/basics/protection/index.html
© AAPHD 52
© AAPHD 53
+ Motor Vehicle Safety

1960 unintentional injuries caused 93,803 deaths –
41% related to motor vehicle crashes

1966- Highway Safety Act and Motor Vehicle Safety
Act
 Vehicles were built with new safety features
 head rests, energy-absorbing steering wheels,
shatter-resistant windshields, and safety belts
 Roads were improved – use of breakaway signs,
improved illuminations
 1970 – evidence decrease in deaths due to motor
vehicle crashes.
© AAPHD 54
+ Motor Vehicle Safety
Motor-vehicle related death rates per 100,000 population and per 100 million
vehicle miles traveled (VMT), by year – Unites States, 1966-1997
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.html
© AAPHD 55
+ Safer Workplaces

Beginning of this century – workers faced high health
and safety risk in their workplaces
© AAPHD 56
Safer
Workplaces
–
Example
Mining
+
related deaths
50% decrease in coal mining fatality
rates occurred from 1966-1970 to 19711975 following passage of the 1969
Federal Coal Mine Health and Safety
Act
Following the 1977 Federal Mine Safety and
Health Act, a 33% decrease in fatalities
occurred in metal and nonmetallic minerals
mining (1976-1980 compared with 1981-1985)
MMWR July 11, 1999 / 48(22);461-469
© AAPHD 57
+ Safer Workplaces – Dental office

Universal precautions

Infection control

Mercury and amalgam safety

Radiation safety

Ergonomics

Agency responsible to oversee
workplace safety: Occupational Safety
and Health Administration (OSHA)
© AAPHD 58
+ Control of Infectious Disease

The 19th century shift in



population from country to city
industrialization and immigration
 overcrowding in poor housing served by inadequate or
nonexistent public water supplies and waste-disposal
systems.
 These conditions resulted in repeated outbreaks of cholera,
dysentery, TB, typhoid fever, influenza, yellow fever, and
malaria
Discovery of microorganisms as the cause of diseases –
resulted in improvements in sanitation, hygiene,
discovery of antibiotics, vaccination programs etc





Tuberculosis
Typhoid Fever
Diphtheria
Cholera
HIV/AIDS
© AAPHD 59
+ Control of Infectious Diseases

60
Typhoid fever in US

Dramatic declines in incidence and mortality - after widespread
implementation of municipal water and sewage treatment systems


1920: 33.8 new cases per 100,000 population; 1930, 20 new cases, and 1960
less than 1 new case
Rare disease, with approximately 300 clinical cases reported per year
http://www.cdc.gov/healthywater/observances/dww-graph.html
© AAPHD 60
+ Control of Infectious Diseases
Reductions in diagnosis and deaths
attributed to active antiretroviral
therapies introduced in 1996
http://www.cdc.gov/hiv/topics/surveillance/resources/slides/trends/index.html
© AAPHD 61
+ Safer and Healthier Foods

Early 20th century – contaminated food, milk, water caused
foodborne infections

1906 – Pure food and drug act
 Food Safety:



Identification
of
handwashing,
sanitation,
refrigeration,
pasteurization, and pesticide application as methods to minimize
foodborne infections (TB, Typhoid fever, Cholera)
Healthier animal care, feeding and processing – improved food
supply
Nutrition:


Food fortification programs decreased nutritional deficiency
diseases like goiter, rickets
Pellagra elimination in 1940s – improved diet, enrichment of flour
with niacin
© AAPHD 62
+ Safer and Healthier Foods
Number of reported pellagra deaths, by sex of decedent and year – US, 1920-1960
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4840a1.html
© AAPHD 63
63
+ Decline in Deaths from CVD and
Stroke




1920s-30s: heart disease and stroke leading cause of death – together
40% of all deaths
Since 1950- death rates from cardiovascular disease (CVD) declined
60%
During 1970s-80s – public health interventions to reduce CVD have
benefitted from a “high risk” approach (target high risk people for
CVD), and “population-wide” approach (lower risk for the entire
community)
 National programs targeted health providers, patients and public
 National High Blood Pressure Education Program:1972
 National Cholesterol Education Program: 1985
Reduction due to combination of factors
 Decline cigarette smoking, mean blood pressure and cholesterol
levels, changes in diet (consumption of saturated fat and
cholesterol decreased), improvements in medical care and
availability of medications
© AAPHD 64
+ Decline in Deaths from CVD and
Stroke
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.html
© AAPHD 65
+ Family Planning

In 1900, 6 to 9 / 1000 women died in childbirth, and one in
five children died during the first 5 years of life.

Distributing information and counseling patients about
contraception and contraceptive devices was illegal under
federal and state laws

1912 – Modern Birth control movement began

Hallmark of family planning – the ability to achieve desired
birth spacing and family size - leading to decreased fertility
rates

Traditional methods of fertility control

Modern contraception and reproductive health systems

1972 - Publicly supported family planning services through
Medicaid funding prevented 1.3million unintended pregnancies
annually
© AAPHD 66
+ Family Planning
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.html
© AAPHD 67
+ Healthy Mothers and Healthy
Babies
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4838a2.html
© AAPHD 68
+ Healthy Mothers and Healthy
Babies

Infant mortality - Beginning of 20th
century – 100 infants/1000 live
births died before age 1


Improved sewage, refuse
disposal, safe drinking water –
key role in infant mortality

Decline fertility rate – longer
spacing of children, small family,
better nutritional status

Milk pasteurization – controlled
milk-borne diseases

Antibiotics, safe blood
transfusions, electrolyte
replacements

Vaccinations
Maternal Mortality – Beginning of
20th century, for every 1000 live
birth 6 to 9 women died of
pregnancy complications
 Maternal mortality highest
between 1900 to 1930 – due to
Poor obstetric education and
delivery practices
 1930s to 40s – White House
Conference Review
committees
 Home births shift to hospital
births
 Improved institutional
guidelines
 Antibiotics, asepsis,
management of
hypertension
© AAPHD 69
69
+ Tobacco Use

First decades of 20th century-lung cancer rare


Per capita cigarette consumption increased from 54 cigarettes in
1900 to 4345 cigarettes in 1963
Increased smoking lead to more lung cancer cases

1964 – advisory committee to US Surgeon general
identified – tobacco use as a serious health hazard

Various public health efforts followed suit







Health hazards of tobacco established – scientific evidence
Disseminating this evidence to public;
surveillance and evaluation of prevention and cessation
programs;
campaigns by advocates for nonsmokers' rights;
restrictions on cigarette advertising;
policy changes (i.e., enforcement of minors' access laws,
legislation restricting smoking in public places, and increased
taxation);
improvements in treatment and prevention programs;
© AAPHD 70
+ Tobacco Use
Trends in cigarette smoking* among persons aged ≥ 18 years, by
sex- United States, 1955-1997
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4843a2.html
© AAPHD 71
+
Community Water
Fluoridation
© AAPHD
+ History
Colorado Springs, Colorado

1901 Dr. F. McKay
investigates “Colorado
Brown Stain” (teeth stain)

1909 – Dr Robertson
observed brown stained
teeth of children drinking
from a locally dug well


Hypothesis that
something in the
water causes the stain
1930 Alcoa chemist H.V
Churchill identifies
fluoride by
spectrophotometry -- up
to 14 ppm
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.html
© AAPHD 73
+ History
•1931 -
Dentist H.Trendley Dean appointed to begin the Dental Hygiene
Unit of the newly established National Institute of Health to
investigate
•1934 -
Severity of dental fluorosis categorized as “Dean’s Index”
Compares fluorosis data from 26 states to tooth decay data –
identifies Caries lower in cities with more fluoride in their
community water supplies at concentrations > 1.0ppm
•1941 -
“21 Cities Study” - documented dental caries experience in
different communities dropped sharply as F concentration rose
toward 1.0 ppm, then leveled off
•1945 – Four pair city study – over 15 years, reduced caries in 50 -70%
children in communities with fluoridated water
•1950 – US Public Health Services issued a policy statement to American
Dental Association, supporting community water fluoridation
•1951-
Reaffirmed “community water fluoridation” - Official policy of
public health service in testimony before senate
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.html
McLure FJ. Water Fluoridation – the search and the victory. Bethesda (MD):US Dept of Education
and Welfare, NIH, NIDR: 1970. Chapter 14: 247-9
© AAPHD 74
+ What Is Community Water
Fluoridation?

The adjustment of the level of fluoride in the water supply
 Current (recommended level of fluoride: 0.7 parts per
million (ppm) or 0.7 mg/Liter of water
 Previous recommended level of fluoride in water: 0.7 to
1.2 ppm or 0.7 to 1.2 mgs/Liter of Water

Most water supplies contain trace amounts of fluoride.

Water systems are considered naturally fluoridated when
the natural level of fluoride is greater than 0.7 parts per
million (ppm).
http://wayback.archive-it.org/3926/20140108162323/http:/www.hhs.gov/news/press/2011pres/01/20110107a.html
© AAPHD 75
+ Facts about Fluoride

Fluorine [F] is a member of the halogen family –
naturally occurring

The most electronegative of all elements, F -2

Is extremely reactive

Occurs in minerals, e.g. fluorspar (CaF2), cryolite
(Na3AlF6), fluorosilicates (Na2SiF6)

Also found in mica, hornblende, pegmatites (coarse

Ranks 17th abundance in earth’s crust (0.06-0.09%)

Present in sea water (1.2 – 1.4 ppm)

Occurs in biological mineralized tissue, e.g. bones and
teeth as fluoridated hydroxyapatite
granite)
© AAPHD 76
+ 3 Mechanisms of Fluoride
Action
1.
Topical interaction with the enamel

2.
Interaction with the bacteria

3.
Remineralization with more acid-resistant apatite Conversion of hydroxyapatite into
calciumfluoroapatite which reduces the solubility
of tooth enamel in acid and makes it more resistant
to tooth decay – topical effect
Fluoride inhibits glycolysis, inhibits dextran
formation for dental plaque adherence, and direct
effect on bacteria
Developmental interaction with enamel

Reduction in enamel solubility
© AAPHD 77
Calciumfluoroapatite
crystals – reduced
solubility
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.html
© AAPHD 78
+ Benefits of Fluoridation
 Dental

caries most common disease
DMFT (Decayed, Missing, Filled Teeth due to dental
caries) 4.0 in 1966-1970 to 1.3 in 1988-1994
 Earlier
studies
suggest
caries
reduction
attributable to fluoridation ranged from 50% to
70%
 Studies
between 1979-1989 found that caries
reduction was 8%-37% among adolescents
© AAPHD 79
mean DMFT
among
persons
aged 12
years in the
United
States
declined
68%, from
4.0 in 19661970 to 1.3
in 1988-1994
Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental
Caries MMWR weekly, 1999/48 (41); 933-40.
© AAPHD 80
+ Benefits of Fluoridation

It does not require costly services of health care
professionals to deliver

There are no daily –dosage schedules to remember

No bad taste

Widespread community water fluoridation prevents
cavities even in neighboring communities that are
not fluoridated – Halo effect or the diffused effect –
eating food beverages processed from fluoride
water
© AAPHD 81
+ In United States (2010)
 Total
US population – 308, 745, 538
 U.S.
Population on Public Water Supply Systems 276,607,387
 Total
U.S. Population on Fluoridated Drinking Water
Systems -204,283,554
 Percentage
of U.S. Population receiving Fluoridated
Water -66.2%
http://www.cdc.gov/fluoridation/statistics/2010stats.html
© AAPHD 82
+ Dental Fluorosis
 Series
of conditions occurring in those teeth that
have been exposed to excessive sources of
fluoride ingested during enamel formation
 Older
children and adults are not at risk for
dental fluorosis
Mild -Photo by Elke Babiuk
Severe-Source of photo unknown
© AAPHD 83
+
Antifluoridation
© AAPHD
+ Lecture 3
Oral Health and
Oral Health Disparities
85
© AAPHD 85
+ Learning Objectives
 Describe
the current oral health status of the
US population
 Describe
what oral health disparities mean
 Describe
various factors associated to oral
health disparities among US population
© AAPHD 86
+
Why is Oral Health
Important?
© AAPHD
+
Background

Department of Health and
Human Services released first
ever Surgeon General’s report
on Oral Health (2000)

Oral health is essential to the
general health and well-being
of all Americans and can be
achieved by all Americans.

However, not all Americans are
achieving the same degree of
oral health

Substantial oral health
disparities exists among
different subgroups of US
population
U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.
Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health, 2000.
© AAPHD
+ Oral Health

In the first ever Surgeon General’s report on Oral Health (2000),
“In
spite of the safe and effective means of maintaining oral
health that have benefited the majority of Americans over the
past half century, many among us still experience needless pain
and suffering, complications that devastate overall health and
well-being, and financial and social costs that diminish the
quality of life and burden American society”
U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.
Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health, 2000.
© AAPHD 89
+ Oral Health Impact
Pain
Infection
Poor Feeding
Poor Speech
© AAPHD 90
Poor Self
Esteem
Poor School
Performance
+
© AAPHD 91
Oral
Health
Status
in
+
the US
© AAPHD
+
Distribution of Caries by age
Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status, United States, 1988-1994 and
1999-2004. National Center for Health Statistics. Vital Health Stat 11(248); 2007.
© AAPHD 93
+
Dye BA, Li X, Beltrán-Aguilar ED. Selected oral health indicators in the United States, 2005–2008. NCHS data brief, no 96.
Hyattsville, MD: National Center for Health Statistics. 2012.
© AAPHD
+ Distribution of Periodontitis in Adults:
Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status, United States, 1988-1994 and
1999-2004. National Center for Health Statistics. Vital Health Stat 11(248); 2007.
© AAPHD 95
+ Distribution of Periodontitis in Adults:
Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status, United States, 1988-1994 and
1999-2004. National Center for Health Statistics. Vital Health Stat 11(248); 2007.
© AAPHD 96
+ Distribution of Periodontitis in Adults:
Prevalence of moderate/severe periodontitis by age group: NHANES 2009-2010
Eke PI et al. Prevalence of Periodontitis in Adults in the United States: 2009 and 2010. J Dent Res 91(10):914-920, 2012
© AAPHD
+
© AAPHD 98
Disparities in Oral Health
+ status and in accessing dental
care services
© AAPHD
Health Disparities
+
 Health


Disparities –
Defined as “population-specific differences in the presence of
disease, health outcomes, or access to health care” (Health
Resources and Service Administration[HRSA])
If a health outcome is seen in a greater or lesser extent
between populations, there is disparity
(www.Healthypeople.gov)

Race or ethnicity, sex, sexual identity, age, disability, socioeconomic
status, and geographic location all contribute to an individual’s
ability to achieve good health.
© AAPHD 100
Differences
between
populations
+
in health

Key is that there are differences between populations in the
measures of health

A health disparity is believed to exist when (examples):
 Tooth decay more common in low–income children compared to
high-income children
 35.8% of children living below 100% Federal poverty level
(Low-income) had tooth decay compared to only 15.5% of
children living above 200% Federal poverty level (Highincome) [2005-2008 National Health and Nutrition Examination
Survey data]
 Black or African Americans have a lower survival rate due to
oral and pharyngeal cancer (OPC) compared to White
Americans
 62.9% of White men live up to 5 years after diagnosis
compared to only 37.2% of Black Americans – this low survival
rate is attributed due to late diagnosis of OPC in Black
Americans [2002-2008 Surveillance Epidemiology and End
http://www.cdc.gov/nchs/data/databriefs/db96.html
Results Data]
http://seer.cancer.gov/statfacts/html/oralcav.html
© AAPHD 101
+ Disparities in Caries in Children
Prevalence of dental caries in permanent teeth * among children and adolescents aged 6 - 19 years, by
selected characteristics –United States, National Health and Nutrition Examination Survey, 1988-1994, and
1999-2002
© AAPHD 102
+ Factors underlying health and
health care related disparities
 Disparities
in oral health status may arise due to:
 Differences (barriers) in access to health care

Timely use of personal health services to achieve
the best health outcomes




Lack of dental insurance, lack of adequate dental
coverage (entry level barriers),
Lack of transportation to reach dentist, living in a
remote/rural region (structural barriers),
Patient’s low oral health literacy, and health information
(patient barriers),
Dentists not accepting/treating low-income patients,
low cultural competence of dental professionals
(provider barriers)
© AAPHD 103
+ Oral Health Indicators

Measurable characteristics that describe the health of a
population:




Diseases
 Dental caries, gingivitis, tooth loss, oral cancer
Determinants of health
 Oral health behaviors, oral health risk factors, physical
environments, and socioeconomic environments
Access to dental care
 Use - dental visits, dental sealants, filling
 Cost - insurance
Depending on the measure, a oral health indicator may
be defined for a specific population, place, or
geographic area.
Modified from
http://healthindicators.gov/Resources/Glossary
© AAPHD 105
+ Healthy people 2020 Oral Health
Objectives

Healthy People 2020 Objectives - each objective related to an
oral health indicator is developed to be achieved over the
second decade of this century

Oral Health objectives (OH 1 to 17)





OH1 to 6, focuses on oral health in children, adolescents and adults
(dental caries, untreated tooth decay, tooth loss, dental
restorations/fillings)
OH7 to 11, focuses on access to preventive dental services (school
based centers, using oral health care system, health centers with
oral health component)
OH 12 to 14, focuses on oral health prevention interventions
(sealants, community water fluoridation)
OH 15 to 16, focuses on oral health surveillance systems (systems
recording cleft lip and palate, oral and craniofacial systems)
OH 17, public health infrastructure (health agencies with a dental
professional directing a program)
© AAPHD 106
+ Examples of Oral Health indicators
in HP2020
Dental Sealants
Untreated tooth decay

Denotes dental disease
experience / dental
treatment needs in a
population group

HP2020 Objective:

OH-1: Reduce the
proportion of children and
adolescents who have
dental caries experience in
their primary or permanent
teeth

Denotes utilization of
“preventive” services

HP2020 Objective:

© AAPHD 107
OH-12: Increase the
proportion of children
and adolescents who
have received dental
sealants on their molar
teeth
Disparities in untreated dental
+
caries and dental restorations
Prevalence of untreated dental caries and existing dental restorations in teeth, by sex,
race, and ethnicity, and poverty level: 2005-2008
Characteristic
Untreated dental
caries
Dental
restoration
Non-hispanic white1
17.8%
80.1%
Non-hispanic black
2 34.2%
2 62.6%
Mexican American
2 31.1%
2 61.8%
Below 100%
2 35.8%
2 62.7%
100 to less than 200%
2 30.5%
2 68.8%
15.5%
80.2%
2 24.6%
2 72.1%
18.6%
78.7%
Race/Ethnicity
Poverty level
200% or higher1
Gender
Male
Female1
Reference group, 2 p <0.05
Source: CDC/NCHS National Health and Nutrition Examination Survey
1
© AAPHD 108
+
Disparities in dental caries experience and
untreated dental caries
Prevalence of dental caries in primary teeth, by age and race and Hispanic origin among children aged
2–8 years: United States, 2011–2012
1
Includes untreated and treated (restored) dental caries.
Significantly different from those aged 6–8 years, p < 0.05.
3
Significantly different from non-Hispanic black children, p < 0.05.
4
Significantly different from Hispanic children, p < 0.05.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.
2
Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children
and adolescents in the United States, 2011–2012. NCHS data brief, no 191. Hyattsville, MD:
National Center for Health Statistics. 2015.
© AAPHD
+ Disparities in dental visits
Dental visits in the past year by selected characteristics among 2 years and older:
United States, selected years 1997-2010
Characteristic5
1997
2010
White Only
66.4%
65.6%
Black/African American
58.9%
58.8%
American Indian/Alaskan Indian
55.1%
57.4%
Asian Only
62.5%
66.5%
Hispanic or Latino
54.0%
56.5%
Non-Hispanic or Non-Latino
66.4%
66.2%
300-399% (Rich)
78.9%
79.3%
200%-299%
66.2%
63.5%
100%-199%
50.8%
51.6%
Below 100% (Poor)
50.5%
50.6%
RACE
ETHNICITY
PERCENT OF POVERT LEVEL
National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic
Status and Health. Hyattsville, MD. 2012.
© AAPHD 110
+ Utilization of Dental Service
Oral Health: Efforts Under Way to Improve Children’s Access to Dental Services, but Sustained Attention
Needed to Address Ongoing Concerns. GAO-11-96, Nor 2010. Government Accountability Office.
© AAPHD 111
111
Disparities
in
Dental
Sealants
+
prevalence
© AAPHD 112
+
Disparities in Dental Sealants prevalence
Prevalence of dental sealants in permanent teeth, by age and race and Hispanic origin among children
aged 6–11 years: United States, 2011–2012
1
Significantly different from those aged 9–11 years, p < 0.05.
Significantly different from non-Hispanic black children, p < 0.05.
3
Significantly different from non-Hispanic Asian children, p < 0.05..
SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.
2
Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children
and adolescents in the United States, 2011–2012. NCHS data brief, no 191. Hyattsville, MD:
National Center for Health Statistics. 2015.
© AAPHD 113
Disparities
in
edentulism
+
(complete tooth loss)
© AAPHD 114
One Example:
Dental workforce
shortage
+
as a factor related to oral
health disparities
© AAPHD
+ Health Professional Shortage
Areas (HPSA)

Designated by HRSA

Having shortages of primary medical care, dental or mental
health providers

Based on



Geography (a county or service area)
demographic (low income population)
institutional (comprehensive health center, federally qualified
health center or other public facility).
http://www.hrsa.gov/publichealth/clinical/oralhealth/workforce.html
http://www.hrsa.gov/shortage/
© AAPHD 116
+
Dental Health Professional
Shortage Areas (DHPSA)

Currently approximately 4,600 Dental HPSAs.

Dental HPSAs are based on a dentist to population ratio of
1:5,000.

Take approximately 6,600 additional dentists to eliminate the
current dental HPSA designations.

More than 49 million Americans live in dental Health
Professional Shortage Areas
http://www.hrsa.gov/publichealth/clinical/oralhealth/workforce.html
http://www.hrsa.gov/shortage/
© AAPHD 117
5,000
Number of U.S. Designated Dental Health Professions
Shortage Areas
+
U.S. Designated Dental Health
Professions Shortage Areas 1991- 2011
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
1991
2000
2001
2002
2003
2004
2005
2011
Year
Source: Shortage Designation Branch, Office of Workforce Evaluation and Quality Assurance, Bureau of Health
Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services
© AAPHD 118
+
SOURCE: U.S. Department of Health and Human Services, Health Resources and Services Administration, Designated HPSA Statistics Report, (as presented in)
The Pew Center of States. May 2011. The State of Children’s Dental Health: Making Coverage Matter. The Pew Charitable Trusts.
© AAPHD 119
+
Estimated Changes in Number of
Dentists in the Dental Workforce,
1995- 2040

From 2014 to
2027,
it
is
estimated that
more dentists
will leave the
workforce
than enter it
These data assume that the number of graduates remains at 4,850 after 2007 and retirement age is 65
Source: American Dental Education Association
© AAPHD 120
+
Distribution of
Dentists in
Illinois, 2006
© AAPHD 121
+ Review: factors related to oral health
disparities




Lack of dental insurance, lack of adequate dental
coverage (entry level barriers),
Lack of transportation to reach dentist, living in a
remote/rural region (structural barriers),
Patient’s low oral health literacy, and health
information (patient barriers),
Dentists not accepting/treating low-income
patients, low cultural competence of dental
professionals. Geographical location of dental
providers (provider barriers)
© AAPHD 122
+ Lecture 4
Access to Dental Care and
Utilization of Dental Care
Services
123
© AAPHD 123
+
Learning Objectives
1.
Define and describe concepts, and measures of access to
dental care and utilization of dental services
2.
Recognize the issues (problems) with access to dental care
in the US, especially among underserved and vulnerable
population groups
3.
Identify factors associated with access to dental care and
utilization of dental services and discuss ways to modify
them to improve access and utilization
© AAPHD 124
Access to dental care
+
Definition

The ability of a person to receive dental health care
services.

Access to dental care is a function of perceived need,
demand, utilization of care, availability of personnel
and supplies, and ability to pay for those services,
© AAPHD 125
+ Access to dental care
Perceived
need:
 A person’s self perceived need or want of dental
care
Demand
for dental care:
 A person expresses the need for dental care by
acting on it, and willingness to seek dental care.
Utilization
of dental care:
 A person’s actual use of dental care services that is
available to him/her
© AAPHD 126
Access to dental care
+
Regular care and regular dentist
 Ease to find a dentist when needed
 Numbers of providers
 Location
 Ability to afford dental care
 Insurance
 Out-of-pocket
 Low-cost or free access
 Access to any provider
 Alternative providers (therapists, independent
practicing hygienists)

© AAPHD 127
+
Access to dental care

Complex, multidimensional concept.
 Dentist available
 Financial resources
 Transportation
 Other barriers (job and free time)

A continuum, not a matter of presence or absence.

Access to care is important for prevention and for
prompt treatment of illness and injury.
© AAPHD 128
+ Surgeon General’s Report:
Oral Health in America (2000)
• “Fewer than 20% of Medicaidcovered children had a dental visit
in a given year”
• “The consequence of low dentalservice utilization by Medicaid
participants are poor oral health
and significant unmet dental needs”
• “A silent epidemic of oral diseases
is affecting our most vulnerable
citizens - poor children, the elderly,
and many members of racial and
ethnic minority groups”
© AAPHD 129
+ Surgeon General’s Report:
Oral Health in America (2000)
 25%
of poor children have not seen a dentist
before entering kindergarten.
 Uninsured
children are 2.5 times less likely to
receive dental care.
 Children
from families without dental insurance are
3 times more likely to have dental need.
 For
each child without medical insurance there are
2.6 without dental insurance.
© AAPHD 130
+ Disparities in dental visits
Dental visits in the past year by selected characteristics among 2 years and older:
United States, selected years 1997-2010
Characteristic5
1997
2010
White Only
66.4%
65.6%
Black/African American
58.9%
58.8%
American Indian/Alaskan Indian
55.1%
57.4%
Asian Only
62.5%
66.5%
Hispanic or Latino
54.0%
56.5%
Non-Hispanic or Non-Latino
66.4%
66.2%
Below 100% (Poor)
50.5%
50.6%
100%-199%
50.8%
51.6%
200%-299%
66.2%
63.5%
300-399% (Rich)
78.9%
79.3%
RACE
ETHNICITY
PERCENT OF POVERT LEVEL
National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic
Status and Health. Hyattsville, MD. 2012.
© AAPHD 131
+ Child Dies for Lack of Dental
Care
- Washington Post 2-28-2007

A twelve year old Maryland boy
died Sunday after the infection
from an abscessed tooth spread
to his brain.

The boy had not been receiving
routine dental care.

Mother had trouble finding a
dental provider who would
accept Medicaid
© AAPHD 132
+ Access to dental care: Status
 In
2010, 64.7% of US residents 2 years and older
reported that they had visited a dentist within the
previous year.¥
 Access problems are concentrated
 Low-income areas
 Rural areas
 Minority population groups
 Very young children
 Elderly
 Special needs patients
 Institutionalized
in
¥-National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic
Status and Health. Hyattsville, MD. 2012.
© AAPHD 133
+ Utilization of Dental Service
Oral Health: Efforts Under Way to Improve Children’s Access to Dental Services, but Sustained Attention
Needed to Address Ongoing Concerns. GAO-11-96, Nor 2010. Government Accountability Office.
© AAPHD 134
134
Measures of “access to dental
care”
+

Adequacy of dentist supply
 Dentist/population ratio
 “Need” vs. “Demand”

Percent of population who had:
 A dental visit last year
 Regular dental visit
 Regular dentist to go (dental home)
© AAPHD 135
+ Measures of “Utilization of dental
services”

CMS 416 (Centers for Medicare and Medicaid Services)
# children with a dental visit during the year (any point)
# children enrolled at any point during the year

HEDIS (Health plan Employer Data & Information Set)
# children enrolled for 11-12 mos with a dental visit
# children enrolled for 11-12 mos during the year
© AAPHD 136
+ Funding Problem in Dental Care

120 million Americans do not have dental insurance (43
million without medical insurance)

Upon retiring, 85% of Americans have no dental insurance

There are limited dental benefits for adults under Medicaid

Uninsured patients must pay out-of-pocket, and for low
income patients the expense of dental care is generally
prohibitive
© AAPHD 137
+ Federal Programs to Improve Access
(for children)

Medicaid

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment)

Children’s Health Insurance Program (CHIP)

Children’s Health Insurance Program Reauthorization Act
(CHIPRA, 2009)
© AAPHD 138
+ Federal Programs to Improve
Access: Medicaid
Health coverage program for low-income people and
working families who qualify, funded jointly by both
the Federal and State Government.
 Established in 1965 by Title XIX of Social Security Act.
 Medicaid Partnership:
 Federal oversight: Centers for Medicare & Medicaid
Services (CMS)
 State oversight: State Department of Health

© AAPHD 139
+ Federal Programs to Improve
Access: EPSDT

EPSDT (Early and Periodic Screening, Diagnostic, and
Treatment)

Child health component of Medicaid up to age 19.

Required in every state

Financing appropriate and necessary pediatric services.

Dental services for children must minimally include:
 Relief of pain and infections
 Restoration of teeth
 Maintenance of dental health
EPSDT benefit requires that all services must be provided
if determined medically necessary

© AAPHD 140
Children’s
Health
Insurance
+
Program (CHIP)

Provides health coverage to children in families with
incomes too high to qualify for Medicaid, but cannot
afford private coverage.

Jointly funded by the federal government and states.

Administered by the states

nearly 8 million children covered
© AAPHD 141
+
Surgeon General’s Report:
Access to Dental Care (2000)
 Medicaid
has not been able to fill
the gap in providing dental care
for poor children.

80% of Medicaid eligible kids did
not receive preventive services in a
given year
 Although
new programs such as
State Children’s Health Insurance
Program (SCHIP) may increase the
number of insured children, many
still be left without effective dental
coverage.
© AAPHD 142
+
Dental care through Medicaid
 Limited
access to dental care
 Declining # of dentists accepting Medicaid
 Inadequate funding
 Multi-level
reasons for problem with dental
Medicaid
 Medicaid reimbursement levels that are far
below dentists’ usual and customary fees
 Administrative difficulties
 Dental practice operations and productivity

Excessive number of broken appointments

Perceived undesirable behaviors (such as non-compliance)
 Social
stigma
© AAPHD 143
Affordable Care Act
+

The Affordable Care Act (ACA) requires Americans to purchase
health coverage in 2014 and thereafter or pay a fine

All individual and small group market plans - both inside and
outside the exchange - must be certified as “qualified health
plans” – Should include dental coverage for children <19 yrs

Children’s dental services are included as part of the Essential
Health Benefit (EHB) package. So, children in segments of the
population where the EHB package is required will have dental
coverage offered as part of that package

Additional 5.3 million children expected to get dental coverage
through ACA in 2014

Total 8.7 million in 2018

Dental coverage for adults is NOT required
http://www.nadp.org/Libraries/LMS/The_ACA_and_Dental_Coverage--The_Basics--Jan_2013.sflb.ashx
http://www.ada.org/en/home-ada/publications/ada-news/2013-archive/august/affordable-care-act-dental-benefits-examined
© AAPHD
+ Lecture 5
Dental Health Care
Delivery Systems
145
© AAPHD 145
+
Learning Objectives
 Understand
different dental care delivery sites
operated by federal, state and local governments
 Identify
the roles and scope of various dental and
non-dental care delivery models.
 Describe
different types of common payment
methods for dental services
146
© AAPHD
+ Dental Care Delivery System
A
system where providers of care, health care
organizations, insurance companies, employer
groups, and other government agencies come
together to provide optimal dental care to the
public to promote oral health
Vehicles: where dental care is provided
 Workforce: The supply of various types of health care
professionals to provide dental care
 Financing:
How is dental care paid for, common
payment services

147
© AAPHD
+ Where do we access dental care?
Vehicles of dental
health care delivery
PUBLIC
“PUBLIC”
Federal
Government
“PUBLIC”
State
Government
PRIVATE
“PUBLIC”
Local
Government
© AAPHD 148
“PRIVATE”
Non-Profit
“PRIVATE”
For-Profit
+
Structure of the Dental System:
Private For-Profit Delivery Sites
 Private
Dental Practices
 Solo Practice: principal form of dental practice in
US
 Group Practice
 For-profit
dental clinics: Clinic which may be
owned by one dentist who employs others to
perform care as employees or Independent
contractors.
© AAPHD 149
Structure of the Dental System:
Private For-Profit Delivery Sites
+

Almost 90% of all private practices are located in
metropolitan areas

<1% are located in rural areas

Between 1982-2004, 98 U.S. counties never had a dental
practice; 78% of these were rural.

Higher mean per capita income for a county is associated
with a higher number of dentists practicing in the county.
Nash KD. Geographic Distribution of Dentists in United States. Health Policy Analysis Series.
Chicago: American Dental Association,Health Policy Analysis Section, 2011.
© AAPHD 150
+ Where do we access dental care?
Vehicles of dental
health care delivery
PUBLIC
“PUBLIC”
Federal
Government
“PUBLIC”
State
Government
PRIVATE
“PUBLIC”
Local
Government
© AAPHD 151
“PRIVATE”
Non-Profit
“PRIVATE”
For-Profit
+

Federal Government
Mainly serves population groups who have low access
to health care
 Federally Qualified Health Centers (FQHCs)
 Migrant Health Centers
 Health Care Centers for Homeless
 Public Housing Primary Care Centers
 Native Hawaiians Health Centers
 Indian Health Service Programs
 Federal Prison
 Coast Guard
 Veterans Affairs Hospitals
 School Based Health Centers
152
© AAPHD 152
+ FQHC: Federally Qualified
Health Center
 Qualifies
for enhanced reimbursements from
Medicaid
 Must be in underserved area
 Must offer sliding fee scale – should provide
services to people irrespective of ability to pay
 Must provide comprehensive services
 Must have a governing Board of Directors
153
© AAPHD 153
+ Federally Qualified Health Centers

Migrant health programs



Migrant or seasonal farm workers and their families
More than 3 million estimated in US
 Eligibility: Principal employment for both migrant
and seasonal farmworkers must be in agriculture
 Served 862,808 workers in 2011
Health Centers for Homeless

930,589 people are homeless on a given night and 2
to 3 million are homeless over the course of a year

1 million homeless served in 2011

Mobile dental clinics in shelters, grant funded
programs
© AAPHD 154
+ Federally Qualified Health Centers

Public Housing Primary Care Centers
 Services are provided on the premises of
public housing developments or at other
locations
immediately
accessible
to
resident
 Estimated 1.2 million live in public housing
 FQHCs served 187,992 residents

Native Hawaiians
 1.2 million people estimated (2010 US
census)
 2011, approximately 8500 were served
© AAPHD 155
+ Indian Health Service Program

The Indian Health Service (IHS), an agency within the
Department of Health and Human Services, is responsible
for providing federal health services to native American
Indians and Alaska Natives

Approximately 2 million American Indians in the US
 Dental Services provided annually – approximately 3.7
million dental services provided
 310 dentists in the Indian Health Service system
© AAPHD 156
+ U. S Coast Guard

One of the five armed forces of the
United States and the only military
organization within the Department of
Homeland Security
 2011 – 43,000 active members

In 2012, 58 dentists in 30 clinics, which
are located mainly along the Atlantic,
Gulf, and Pacific Coasts, including
Alaska, Hawaii and Puerto Rico.
 All appropriate dental treatment
services are provided
© AAPHD 157
+ Veteran Affairs

Government-run military veteran benefit system – including
families of veterans - 22.7 million veterans

VA employs nearly 280,000 people at Veterans Affairs medical
facilities, clinics, and benefits offices

Dental benefits for veterans vary

Dental benefits include a full range of services for eligible
Veterans. Some of the many services offered by VA Dentistry:

Regularly scheduled cleaning and x-rays.

Restorative procedures such as fillings, crowns and bridges.

Comfortable, well-fitting dentures.

Oral surgery such as tooth extractions.

Oral and facial reconstruction surgery resulting from trauma or serious
illness.
© AAPHD 158
+ Federal Bureau of Prisons

Sub-division of Department of Justice

The BOP has over 3,000 health care
positions, including approximately 750
Public Health Service (PHS)
Commissioned Officers
 Estimated 160,000 inmates

All basic dental services are provided
© AAPHD 159
+ School Based Health Centers - Federal

Center of health in the schools where they are based.

partnership between the school and a community health
organization, such as a community health center, hospital, or
local health department

About 20 to 23% of school based health centers receive
funding from federal government

Rest by local (37%) and/or state government (78%)

In 2007-2008, 1900 SBHCs funded by Federal government

Provide broad range of preventive services – oral health
education, dental screening, fluoride varnish applications,
and sealants

Dental hygienists or school nurses provide most of the
services.

Dentists very rare.
SOURCE: Strozer, J., Juszczak, L., & Ammerman, A. (2010). 2007-2008 National School-Based Health Care Census.
Washington, DC: National Assembly on School-Based Health Care
© AAPHD 160
+ Structure of the Dental System:
State Delivery Sites

School Based Health Centers or Sealant Programs

Dept. of Corrections: Provides direct care to those
incarcerated in State Prisons

Dept. of Mental Health: Provides direct care to patients at
state mental hospitals

Mobile Community Based Programs

Community Health Centers
© AAPHD 161
+ Structure of the Dental System:
Local Delivery Sites

School Based Dental Programs

Oral Rinse Programs

Sealant Programs

Mouth Guard Programs

Local Health Dept. Clinics

Mobile Dental Health Programs
© AAPHD 162
New Dental Workforce
+ Models
© AAPHD
+ New Dental Workforce Models
 Expanded



dental workforce models
Expanded function dental hygienists
Expanded function dental assistants
Alternate dental workforce models
 Non
dental workforce models
© AAPHD 164
+ Expanded Dental Workforce
Models

Dental Hygienists
 Work with dentists in
traditional dental offices
 Scope of function varies
state to state
 Provide diagnosis (x-rays),
preventive services (apply
sealants and fluorides),
dental hygiene care
(remove plaque and
calculus), and educational
services (tooth brushing,
flossing, nutritional
counseling)

Expanded function dental
hygienists
 Eg. Registered Dental Hygienist
in Alternative Practice
 In 1998 the California
Legislature created a new
license category of Oral Health
Professionals, the Registered
Dental Hygienist in Alternative
Practice, abbreviated as
RDHAP.
 The purpose of this new
license category was to deliver
dental hygiene care and
preventive services, and
educational services to special
populations in alternative
settings where people live or
frequent, rather than the
traditional dental office or
clinic.
© AAPHD 165
165
Expanded Dental Workforce
Models
+
 Dental

Assistants
Help dentists with oral
care procedures and
typically complete onthe-job training, oneyear diploma programs
or two-year associate
degree programs.
 Expanded
assistants

function dental
Are legally able to perform a
wider scope of clinical duties
after completing continuing
education courses.
Employment of these
professionals is projected to
increase 36 percent through
2018, according to the U.S.
Department of Labor Bureau of
Labor Statistics.
© AAPHD 166
166
Alternate Dental Workforce
Models
+
Dental workforce models

Community Dental Health
Coordinator

Advanced Dental Hygiene
Practitioners

Dental Health Aide Therapist
Non-dental workforce models

Primary care physicians

Pediatricians

School nurses

Public health / social workers
(promotoras)
© AAPHD 167
+ Alternate Dental Workforce
Models

Community Dental Health Coordinator (CDHC)
 Dental team member connected to a responsible
supervising dentist
 Scope:
Extensive care coordination services,
screening, limited preventive and palliative care
 Settings: Health and community settings such as
clinics, schools, churches, senior citizen centers, Head
Start Programs and other public settings
 CDHC come from the community in which they will
serve
© AAPHD 168
+ Alternate Dental Workforce
Models

Advanced Dental Hygiene Practitioner (ADHP)
 Dental team member connected to a responsible
supervising dentist, possibly via teledentistry
 Scope:
diagnostic,
preventive,
restorative,
prophylaxis, and simple extractions
 Settings: Health and community settings such as
clinics, schools, churches, senior citizen centers, Head
Start Programs and other public settings, private
practice
© AAPHD 169
+ Alternate Dental Workforce
Models

Dental Health Aide Therapist (DHAT)
 Dental team member connected to a responsible
supervising dentist, possibly via teledentistry
 Scope: preventive, restorative, pulpotomy, prophylaxis,
and simple extractions
 Settings: Health and community settings such as clinics,
schools, churches, senior citizen centers, Head Start
Programs and other public settings
 DHAT come from the community in which they will
serve
© AAPHD 170
+
Edelstein BL. Training new dental health providers in the US.
2009, W.K. Kellog Foundation.
© AAPHD 171
Financing
dental
+
care
© AAPHD
Payment Sources
+
 Private Third
Party System:
Patient and dentist are the first and second parties
 Third party – defined as the party to a dental
prepayment contract that collects premiums, assume
financial risk, pay claims, and provide administrative
services
 To meet the costs of providing care and administrative
costs of the 3rd party – premiums are periodically
collected – this is called dental prepayment or dental
insurance

 Public Third

Party System:
Medicaid, CHIP, Medicare
173
© AAPHD 173
+ Reimbursement of third party plans
1)
Fee schedule
2)
Usual, customary and reasonable fee (UCR fee)
3)
Table of allowances
4)
Discounted fee (Preferred provider
organizations),
5)
Capitation
6)
Sliding Fee Schedule
174
© AAPHD 174
+ Reimbursement of third party plans
 Fee
Schedule
List of charges established or agreed to by a dentist
for specific dental services
 The payment is in full for each services – dentist must
accept the listed amount as payment in full and NOT
charge the patient at all
 For example if a dentist usually charges $250 for a
service, and the plan list a fee of only $200 to be
reimbursed, the dentist may not charge patient the
additional fee to make up the difference

Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W.B. Saunders Publications Inc., Philadelphia
© AAPHD 175
Reimbursement of third party plans
+

Usual, Customary, and
Reasonable Fee

For certain services
 Usual: Fee that is most often
charged by the provider
 Customary: Range of fees
charged
by
similar
providers in a specific
geographic
area
–
establishes a maximum
benefit
 Reasonable: fee charged by
a dentist for a specific
dental procedure that has
been
modified
by
complications or unusual
circumstances and that is
different from the Usual or
Customary fees

Example (Dentist
cleaning)
visit
and

Actual charge-250$

UCR allowable charge – 200$

Contractual write off-$50

80/20 Insurance plan paid $160 (80% of UCR allowable
charge paid by insurance
company)

Co-insurance - $40

Patient costs - $40
Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W.B. Saunders Publications Inc., Philadelphia
© AAPHD
+ Reimbursement of third party plans
 Table
of Allowances
Also known as: schedule of allowances or indemnity
schedule
 A list of covered services with an assigned dollar
amount that represents the total obligation of the plan
with respect to payment for such services, but does
not necessarily represent the dentist's full fee for that
service
 For example if a dentist usually charges $250 for a
service, and the plan list a fee of only $200 to be
reimbursed, the dentist will charge additional $50
from the patient to make up the difference

Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W.B. Saunders Publications Inc., Philadelphia
© AAPHD 177
+ Reimbursement of third party plans
 Discounted
Fee
The basis for Preferred Provider Organizations (PPO)
[a preferred provider organization (or "PPO",
sometimes referred to as a participating provider
organization or preferred provider option) is a
managed care organization of medical doctors,
hospitals, and other health care providers who have
an agreement with an insurer or a third-party
administrator to provide health care at reduced rates
to the insurer's or administrator's clients plans]
 Dentists agree to a fee that are usually lower than
charged by dentists in that area

Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W.B. Saunders Publications Inc., Philadelphia
© AAPHD 178
+ Reimbursement of third party plans
 Capitation
Dental benefit program in which a dentist or dentists
contract with the insurance companies to provide all
or most of the dental services covered under the
program to clients in return for a payment on a per
capita basis.
 Capitation fee is a fixed monthly payment paid by a
carrier to a dentist based on the number of patients
assigned to the dentist for a treatment
 Capitation requires that patients be assigned to
specific dentists or dental practices – this is
important because the dentist receives a fixed sum of
money per enrolled person per month, regardless of
whether the participant receives care during that
month or not

Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W.B. Saunders Publications Inc., Philadelphia
© AAPHD 179
+ Reimbursement of third party plans
 Sliding
Fee Scale
 Fee
is adjusted based on family size and
income
 must provide services to patients without
regard for a person's ability to pay.
 May be subsidized by grant funding
 Most often found in clinics or community
health centers, and Federally Qualified Health
Centers
180
© AAPHD 180
Public Third Party Payment
Public Financing of Care
+
 MEDICARE

It was established because there were twin problems of high health
care needs and low income among persons age 65 years and above

Funded only by Federal government

Currently, Medicare pays for dental services that are an integral part
either of a covered procedure (e.g., reconstruction of the jaw
following accidental injury), or for extractions done in preparation for
radiation treatment for neoplastic diseases involving the jaw.

Medicare will also make payment for oral examinations, but not
treatment, preceding kidney transplantation or heart valve
replacement, under certain circumstances.

Does not cover routine dental/dental hygiene tx

Does not cover dentures
181
© AAPHD 181
+
Public Third Party Payment
Public Financing of Care: Medicare
Section 1862 (a)(12) of the Social Security Act states that Medicare will not cover
dental care, ”…where such expenses are for services in connection with the care,
treatment, filling, removal, or replacement of teeth or structures directly supporting
teeth.”
Medicare coverage: Dental services that are an integral part of a procedure
covered by Medicare:
Extractions made in preparation for radiation treatment for neoplastic diseases
involving the jaw.
Oral examinations (but not treatment) preceding some kidney transplantation or
heart valve replacement.
Some hospital stays if needed for emergency or complicated dental procedures,
however the dental treatment is not covered.
Medically necessary dental services if the individual, because of his underlying
medical condition and clinical status or because of the severity of the dental
procedure, requires hospitalization in connection with the provision of such
services.
Surgical procedures for the reconstruction of a ridge as the result of and at the
same time as a tumor removal (for other than dental purposes).
Payment for the wiring of teeth if performed in connection with the reduction of a
jaw fracture.
© AAPHD 182
Public Third Party Payment
Public Financing of Care
+
 MEDICAID
Differs from Medicare - Medicaid funded by both
federal and state governments
 People eligible should have an income below 100%
federal poverty level
 Dental services are an optional service for adult
Medicaid eligible age 21 and older,
 However, for most individuals under the age of 21,
dental services are a mandatory benefit as part of the
Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) service.

183
© AAPHD 183
Public Third Party Payment
Public Financing of Care
+
 State
Children Health Insurance Program
Series of federal and state partnerships
 Children of families with income that are above those
for Medicaid but are too low to afford a conventional
health care insurance
 SCHIP covers families who have incomes up to at
least 200% of the federal poverty level
 SCHIP programs vary from state to state, and may
require patient copayments, monthly premiums, and
annual payment limits, none of which is permitted
under Medicaid

© AAPHD 184
+ Acknowledgement
 Dr. Vinodh
Bhoopathi
 Dr. Woosung
 Dr. Susan
Sohn
Reed
 Diane
Brunson
 Robin
Knowles
 Karen Yoder
 Dr. Ana
Karina Mascarenhas
 Dr. Kathryn
Ann Atchison
© AAPHD 185