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Introduction

Access to oral health services is a problem for all segments of the U.S. population, often related to geography, insurance status, sociodemographic characteristics, and income levels. For example, the 2000 surgeon general’s report Oral Health in America called tooth decay the single most common and chronic childhood disease (HHS, 2000). The Medicare Expenditure Panel Survey found more than one-third of the U.S. population lacks dental coverage (Manski and Brown, 2007). Finally, older adults often reside or receive health care services in alternative settings such as private homes, nursing homes, and assisted living facilities, many of which do not offer onsite oral health services.

Access to oral health services is especially problematic for vulnerable populations, such as rural and underserved populations. As a result, many new models of care have been proposed, including the development of new types of oral health practitioners and the expansion of roles for dental hygienists and dental assistants. Alternate types of practitioners, such as the dental therapist, have been used internationally for decades. However, these and other strategies have been controversial with proponents arguing for their ability to increase access, especially for vulnerable populations, and opponents voicing concerns for the quality of care provided by these practitioners. Other challenges to improving access to oral health services include the lack of coordination and integration among the oral health, public health, and medical health care systems; misaligned payment and education systems that focus on the treatment of dental disease rather than prevention; the lack of a robust evidence base for many dental procedures and workforce models; and regulatory barriers that prevent the exploration of alternative models of care.



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1 Introduction Access to oral health services is a problem for all segments of the U.S. population, often related to geography, insurance status, sociodemographic characteristics, and income levels. For example, the 2000 surgeon general’s report Oral Health in America called tooth decay the single most common and chronic childhood disease (HHS, 2000). The Medicare Expenditure Panel Survey found more than one-third of the U.S. population lacks dental coverage (Manski and Brown, 2007). Finally, older adults often reside or receive health care services in alternative settings such as private homes, nursing homes, and assisted living facilities, many of which do not offer onsite oral health services. Access to oral health services is especially problematic for vulnerable populations, such as rural and underserved populations. As a result, many new models of care have been proposed, including the development of new types of oral health practitioners and the expansion of roles for dental hygien- ists and dental assistants. Alternate types of practitioners, such as the dental therapist, have been used internationally for decades. However, these and other strategies have been controversial with proponents arguing for their ability to increase access, especially for vulnerable populations, and oppo- nents voicing concerns for the quality of care provided by these practitioners. Other challenges to improving access to oral health services include the lack of coordination and integration among the oral health, public health, and medi- cal health care systems; misaligned payment and education systems that focus on the treatment of dental disease rather than prevention; the lack of a robust evidence base for many dental procedures and workforce models; and regula- tory barriers that prevent the exploration of alternative models of care. 

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 THE U.S. ORAL HEALTH WORKFORCE ROLE OF THE INSTITUTE OF MEDICINE The Institute of Medicine (IOM) has previously addressed issues related to oral health. Most notably, a 1995 study, Dental Education at the Cross- roads: Challenges and Change (IOM, 1995), provided recommendations to improve the availability of dental care to underserved populations, integrate dental school education with medical school education, increase student exposure to alternative sites of care, increase diversity of the dental work- force, and eliminate barriers to improving working relationships among all oral health professionals. In July 2007 the IOM convened a 1-day planning meeting to consider challenges in access to oral health services. As a result, the Health Resources and Services Administration and the California HealthCare Foundation cosponsored a project on the sufficiency of the U.S. oral health workforce to consider three key questions: • What is the current status of access to oral health services for the U.S. population? • What workforce strategies hold promise to improve access to oral health services? • How can policy makers, state and federal governments, and oral health care providers and practitioners improve the regulations and structure of the oral health care system to improve access to oral health services? A planning committee1 organized the 3-day workshop, the U.S. Oral Health Workforce in the Coming Decade, which was held February 9–11, 2009. WORKSHOP CHARGE AND APPROACH Daid N. Sundwall, M.D. Chair, IOM Planning Committee Utah Department of Health At the end of the day, a high-quality oral health system includes access to adequate, affordable, and appropriate oral health services for all. How- ever, defining that is quite challenging. Discussions in the first day of the workshop focused on the current status of oral health care and the delivery of oral health services. For many people, oral health services are unavailable 1 The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteur as a factual summary of what occurred at the workshop.

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 INTRODUCTION or unaffordable, and care tends to focus on treatment rather than preven- tion. Panelists discussed the intimate relationship between oral health and overall health and well-being (Chapter 2). They also presented on the cur- rent needs along the life cycle as well as special needs due to geography and racial and ethnic disparities (Chapter 3). Then, later presentations focused on the demographics and trends of the workforce itself, including the use of nonoral health professionals (Chapter 4). Finally, panelists discussed the current delivery system, which is primarily a private practice model, but increased efforts by public health professionals have arisen to meet the needs of underserved populations (Chapter 5). The panels for the second day of the workshop focused on the major challenges of the current overall system of oral health care (Chapter 7), the ethical principles and obligations to increasing access (Chapter 8), and innovative workforce solutions being used around the world (Chapter 9). Panelists then described a wide variety of strategies for increasing access to oral health services in the United States through new types of professionals, changing the roles of current oral health professionals, or developing new systems of care (Chapter 10). Finally, the third day of the workshop engaged stakeholders to discuss who will provide the leadership to make the necessary changes happen. Representatives from states, federal government, payors, academics, legislators, advocates, and others discussed each of their roles in moving the oral health care system forward (Chapters 12–14). The following is a summary of the presentations and discussion of the workshop and, as such, is limited to the views presented and discussed dur- ing the workshop. The broader scope of issues pertaining to this subject area is recognized but could not be addressed in this summary. In addition, as a summary, this document is not a transcript of each panelist’s presenta- tion but rather, a distillation of the themes of the discussions. The workshop was designed to address the planning committee’s charge (see earlier in this chapter) and is presented here chronologically. Chapters 2–6 cover the first day of the workshop, focusing on the status of access to oral health services. Chapters 7–11 cover the second day of the workshop, focusing on strategies to improve access to oral health services. Chapters 12–14 cover the third day of the workshop, focusing on the roles and responsibilities of various stakeholders to improve access to oral health services. Appendix A is the workshop agenda, and Appendix B presents the biosketches of the members of the planning committee. Appendix C lists the workshop speakers and moderators, and Appendix D lists the workshop participants. For many of the workshop sessions, participants were invited to submit comments and questions on cards; however, not all the comments and questions were able to be addressed during the discussion periods. Appendix E provides a rep- resentation of the breadth of comments and questions submitted (although not necessarily answered) by workshop participants.

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