The U.S. Oral Health Workforce in the Coming Decade: Workshop Summary (2009)

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3 Current Oral Health Needs and the Status of Access to Care A panel of experts discussed the unique oral health needs, challenges, and status of access to oral health services for several specific patient popu- lations, including examples of approaches used by various stakeholders to address these issues. EARLY LIFE CYCLE Shelly Gehshan, M.P.P. Pew Center on the States Good oral health is critical for children, as it can affect their overall health, social adjustment, appearance, school performance, and ability to thrive. Two factors that increased the focus on the status of the nation’s oral health and the delivery of oral health services are the surgeon general’s 2000 report Oral Health in America (HHS, 2000) and the death of Deamonte Driver in 2007. Issues for Children’s Oral Health Several challenges face the oral health care of young children (ages 0–3). First, there is a prevalent cultural attitude that baby teeth are not im- portant since they will be replaced by permanent teeth. In fact, baby teeth    See Chapter 13 for more information about Deamonte Driver, a 12-year-old boy who died as a result of complications from an untreated oral infection.  

10 THE U.S. ORAL HEALTH WORKFORCE are important for nutrition and speech development. Both early counsel- ing of mothers and caregivers regarding risk factors and the need for oral hygiene with appropriate fluoride use and the professional application of fluoride varnish have been employed to prevent dental caries. The provision of dental services for women may include education about how their own oral health relates to their children’s oral health. However, in the Medicaid program, only about half the states currently reimburse for the dental care of pregnant women. Finally, there just are not enough pediatric dentists. Oral health is also critical for elementary school-aged children. At this age, children are forming their health habits and permanent teeth are com- ing in. School-based interventions, including the application of sealants, can help improve oral health, but such programs are fragmented and may not help those who are most in need of care. In this age group, public health dental hygienists and general dentists are the most important parts of the oral health workforce. Finally, adolescents have critical oral health needs as well. Among this age group, there is an elevation of behavioral risks such as tobacco use, sports-related injuries, mouth jewelry, and ultimately, for many of those at the highest risk, the loss of Medicaid eligibility. Utilization and Disease Burden Among all these age groups, not nearly enough children get dental ­visits: about 25 percent of children under age 6, about 59 percent of children ages 6–12, and about 48 percent of adolescent children ages 13–20 had a dental visit in 2004 (Manski and Brown, 2007). Dental insurance coverage and the source of this coverage make a difference in utilization of dental services. In 2006, nearly one-fifth of all children had no source of dental insurance (see Figure 3-1). As seen in Figure 3-2, the source of coverage is important to the use of dental services. More specifically, a higher percentage of children who have private dental insurance will receive dental services than children covered by public sources or without dental coverage. About 80 percent of dental caries occurs among only 25 percent of children (Kaste et al., 1996). The prevalence of tooth decay is also related to income; the highest-income children have the least decay and, con- versely, the lowest-income children have the highest rates of decay. Three times as many children who are on Medicaid have decay compared to the non-Medicaid population. In spite of this, dentist participation in Medicaid is very low, in large part due to the business model of dentistry. Overall, the prevalence of caries had been improving, but there has been a recent increase among very low-income children and young children. Racial and    Includes both decayed and filled teeth. 

CURRENT ORAL HEALTH NEEDS 11 No dental coverage 19% Private dental coverage 51% Public dental coverage only 30% FIGURE 3-1  Sources of children’s dental coverage, 2006. SOURCE: Manski and Brown, 2008. 70 58 60 Figure 3-1 editable 45.1 50 40 35.1 26.3 30 20 10 0 Overall Private Public No dental coverage FIGURE 3-2  Percent of children utilizing dental services by coverage source, 2006. SOURCE: Manski and Brown, 2008. Figure 3-2 editable, grey and border removed 

12 THE U.S. ORAL HEALTH WORKFORCE ethnic disparities are especially stark—Hispanic and black children have much higher burdens of dental decay than white children. Prevention is critically important among young children, especially through the use of dental sealants. The percentage of children ages 6–19 with dental sealants has been increasing across all ages, races, and incomes. However, the most progress is seen in the groups least in need of care—those in the highest-income groups and those with the lowest disease burden. Barriers to Improving Access Many barriers impede improvements in children’s access to oral health services. The delivery system is based on a private-practice model that works well for those who are healthy, ambulatory, insured, and motivated to seek dental care. To access existing services, some patients may need help with filling out applications, translation services, and transportation. The system of care also needs to become more patient centered, including making services available where the most vulnerable patients are found, such as schools and child care centers. In addition, for low-income work- ing families, services need to be available during nontraditional hours. The financing of the current system is also largely inadequate. A safety net does not exist for dental care as it does for medical care. Community health centers, hospitals, and professional schools provide some services. However, all together, the dental safety net only cares for about 7 or 8 million of the 82 million people who are dentally underserved (Bailit et al., 2006). Finally, there are legal and policy barriers to improving access. Dental practice acts were created at a time when dentists were the only providers of oral health services; difficulties ensue every time a new type of practitioner is created in order to define scope of practice. In addition, each state has laws concerning who can own a dental practice, stifling innovation and the development of new models of care for the underserved. older adults and PEOPLE WITH DIsabilities Michael J. Helgeson, D.D.S. Apple Tree Dental Older adults (adults aged 65 and older) and people with disabilities have unique challenges in regards to their oral health. First, they often have chronic diseases that may exacerbate their oral health, and vice versa. For example, aspiration pneumonia is a major cause of death among nurs- ing home residents. One survey of nursing home residents with hospital- a ­ cquired pneumonia showed that dental plaque was the source of infection 

CURRENT ORAL HEALTH NEEDS 13 for 10 of the 14 residents (El-Solh et al., 2004). Second, older adults and people with disabilities may have difficulty accessing services due to physi- cal and mobility limitations, as well as mental health problems that may make management difficult in a dental setting. Finally, these populations usually have a large number of caregivers, and so good care coordination among them can be very complex. For example, arranging a dental visit for a chronically ill older adult or a person with a disability in a nursing home may include (but not be limited to) physicians, nurses, dentists, medi- cal records clerks, family caregivers, nurse aides, personal care aides, and medical van drivers. Challenges of the Current System These populations are challenged because the oral health delivery sys- tem does not accommodate their needs. The current system expects patients who are not self-responsible to be active in seeking dental care and does not proactively deliver patient-centered, equitable care. Most oral health profes- sionals lack expertise in special care dentistry. Physically, dental offices are often inaccessible to these populations, or the practitioners are unwilling or ill-equipped to treat older adults with complex health care needs. Finally, all but a very few nursing facilities, group homes, and other settings where people with disabilities live lack onsite dental clinics. For example, accord- ing to a 1999 survey, only 13 percent of nursing home residents over age 65 receive dental services in the billing year of their discharge (Jones, 2002). Financing issues also challenge the care of these special populations. There are very few dental benefits after retirement; Medicare and Medicaid provide little to no dental benefits, and those benefits that do exist are usu- ally designed for children, not frail older adults. In the year 2000, about 77 percent of dental care for all older adults was paid by out-of-pocket expenditures, and less than 1 percent was covered by Medicaid (Brown and Manski, 2004). Nationally, there is even less insurance coverage for low-income older adults. Apple Tree Dental These challenges may be overcome by embracing the principles of spe- cial care dentistry in which the delivery of dental services is adapted to a wide variety of special needs using different patient-centered approaches. For example, Apple Tree Dental is a nonprofit, sustainable staff model group dental practice and is an innovator in delivery systems. Apple Tree Dental has been increasing the visits and services to at-risk populations over the last 20 years. Helgeson, one of the founders of Apple Tree Dental, stated that almost 60,000 visits were provided in 2008. The model involves an 

14 THE U.S. ORAL HEALTH WORKFORCE interdisciplinary board of directors and a large staff with a wide variety of roles in oral health care delivery, support, and administration. Oral health services are delivered in special care clinics as well as in the community using mobile equipment. Underserved populations often lack the knowledge to seek care before problems arise, have health problems that impede their ability to access services, and lack financial resources. The Apple Tree Dental model pro­ actively delivers early education and prevention in collaboration with other professionals, leveraging financial resources from the whole community, to create what is called a “community collaborative practice.” This is essen- tially an extension of the private practice model into the community with a formal three-way collaboration between a dental practice, a community partner, and an onsite team, which provides quality care to populations in need. rural populations Diane Brunson, M.P.H., RDH University of Colorado, School of Dental Medicine Identification of a rural population can be challenging. For example, examination of populations at the subcounty level demonstrates that even some urban counties can have parts that are rural. This is important when defining health professional shortage areas and also when considering v ­ aried workforce strategies. In addition, defining a population as rural does not necessarily imply that it is low income, and a high-income area does not necessarily translate into a high degree of access. Rural areas may even have varying degrees of both income and access within a single population. For example, in the resort areas of Colorado, many residents may have a high income and not necessarily have access issues; however, these areas are also home to a large service industry (e.g., hotels, restaurants) whose workers may have access issues. When looking at rural areas, many often identify the number of coun- ties without a dentist or primary care physician; however, in reality, many of these areas do not have sufficient patient populations to support a full- time practice. In addition, other demographics may be more important such as the number of counties that do not have an oral health provider that accepts Medicaid. Also, rural areas may not have third-party dental insurance in general due to a lack of large employers that would provide such a benefit. 

CURRENT ORAL HEALTH NEEDS 15 Workforce Solutions—The Colorado Experience In Colorado, some common strategies for improving access have been implemented, but with some unique twists. For example, a dental loan repay­ment program was implemented in 2002 as a recruitment strategy. The program focuses on underserved populations instead of health pro- fessional shortage areas. The criterion of geographic distribution with an emphasis on low-income populations helps to reach the urban Medicaid population. The program also attempts to address retention in that prac- titioners who have participated in the program have priority to reenroll in the program. The program is funded by tobacco dollars and is available to both dentists and dental hygienists. Another strategy to increase the oral health workforce is to establish educational programs within the state, under the colloquialism of “growing your own.” A 2008 survey of rural dentists in Colorado showed that over 50 percent of the dentists grew up in rural areas (Colorado Health Institute, 2008). The University of Colorado is currently establishing an interdisci- plinary rural track for students in dentistry, medicine, and pharmacy. The track will include rural grand rounds, seminars, and rotations with a focus on establishing the leadership skills needed to practice in rural areas. The Colorado survey of dentists also showed that dentists are drawn to practice in rural areas because of the quality and pace of life. However, a b ­ arrier commonly seen is the ability for spouses to also find work in those areas. Therefore, the Colorado STRIDES effort encourages communities to examine their attractiveness to rural health professionals and their spouses. In addition, the Colorado Workforce Collaborative is working to estab­ lish a strategic public policy framework, including the examination of health care workforce issues as an element of health care reform. One of the specific issues the group is examining is the issue of clinical placements. Simply increasing class sizes will not solve access issues. For example, in medicine and nursing, every student needs a clinical site and a preceptor, which is challenging to find in rural communities. Another major area for the group is scope of practice. Last year, the governor of Colorado cre- ated a commission to conduct an evidence-based review of the scopes of practice of advanced nurse practitioners and dental hygienists; however, the commission did not make strong recommendations for change in either profession. Specific alternative workforce strategies currently implemented in C ­ olorado include • the use of mobile and portable practices to provide preventive care and limited restorative care to children and some homebound older persons; 

16 THE U.S. ORAL HEALTH WORKFORCE • the placement of dental hygienists not supervised by dentists in primary care and pediatrics offices; • the training of medical and general dental practitioners in caries risk assessment, fluoride varnish, and self-management goal setting; and • the training of medical students by dental students in caries risk assessment, fluoride varnish, and head and neck examination. Conclusions While no single intervention will solve the problems of the oral health system, several overarching elements are needed. First is the inter­disciplinary training of all students in order to bridge the gap between medicine and dentistry. Second is the retraining of existing professionals to understand the relationship between oral health and systemic disease. Third is to im- prove reimbursement and the opportunities available in rural communities. Finally, to improve access to oral health services in rural areas, the scopes of practice of all health care professionals need to be maximized. indian health service Patrick Blahut, D.D.S., M.P.H. Indian Health Service, Division of Oral Health The Indian Health Service (IHS) defines access to dental care as the percentage of the user population (people who accessed any part of the IHS system within the previous 3 years) that underwent at least one procedure in a dental clinic within the previous year. The most recent data show that access to dental care in the IHS is around 23 percent. However, this is likely an underrepresentation in part due to the lack of data submission by a number of tribal programs. Since access data for the general U.S. popula- tion is based on self-reporting, comparison is challenging, but the access for Native Americans appears relatively comparable to other minority populations in the United States. The major challenges that affect the IHS system include an extremely high prevalence and severity of decay, a lack of sufficient numbers of practitioners, and a relative lack of total resources. While much attention is paid to increasing the number of practitioners to provide treatment, more consideration should be given to decreasing disease in the first place through prevention.    Data presented in this section belongs to the Indian Health Service. Personal communica- tion, P. Blahut, Indian Health Service, February 9, 2009. 

CURRENT ORAL HEALTH NEEDS 17 Challenges and Strategies The biggest discrepancy in oral health burden between the American Indian and Alaska Natives and the rest of the U.S. population is at the youngest age groups; these children have much higher rates of decay as compared to similar age groups in the general U.S. population (IHS, 1999). Many children miss school due to dental pain and avoid laughing or smiling because of the way their teeth look. Another challenge underlying the IHS system is the staff vacancy rate in spite of the ability of facilities to accommodate multiple professionals. When these facilities are understaffed, efforts invariably need to focus on treating acute problems and the ability of these professionals to implement wider-reaching public health strategies such as enhancing water fluori- dation on reservations or establishing school-based sealant programs is diminished. In spite of these challenges, the IHS has fared better than the general U.S. population in the application of sealants in children. The IHS applies approximately 250,000 sealants each year, and the prevalence of sealants among 8-year-olds and 14-year-olds in the IHS is more than double the prevalence of sealants among the same age groups in the U.S. population. Strategies for improving oral health care in the IHS include • optimizing the use of allied personnel, • customizing programs for specific patient populations, • promoting cultural competency, • expanding the perspective of organized dentistry to recognize the needs of and reach out to patients outside of the private practice model of care, and • establishing responsibility for improving the care of underserved populations beyond the efforts of individual patients and their caregivers. Finally, without adequate resources, access to oral health services will deteriorate. Conclusions The challenge of providing adequate care to Native Americans serves as a ­microcosm of providing adequate care to the most underserved popula- tions in this country. However, access to oral health services and the orga- nization of oral health care delivery should not be examined in isolation, but rather within the context of the general organization of society. 

18 THE U.S. ORAL HEALTH WORKFORCE african american populations Hazel J. Harper, D.D.S., M.P.H. National Dental Association Health risk factors in the African American community still include r ­ acism, lack of education, socioeconomics, cultural mores, stress, and health disparities. Barriers and facilitators (many of which can be both) include access, availability, cultural competency, health literacy, lifestyle, under- represented minorities in the workforce, health policies, health legislation, and the health education curriculum itself. The National Dental Association (NDA), founded in 1913, has a com- mitment to vulnerable and underserved populations and works under the philosophy that health care is a right, not a privilege. The NDA has deter- mined several needs in oral health including the following: • Include community practitioners and health leaders in policy deliberations. • Increase the number of underrepresented minorities applying to and graduating from dental programs. • Place more attention on funding, regulating, and enforcing existing federal programs. • Improve the image and rewards of dental careers. • Mandate cultural competency as a core course in health profes- sions’ curricula. In response to these needs, the NDA developed multiple efforts includ- ing the training of national, local, and student leaders in the skills needed to be community health leaders; spokesperson training with both media and legislative training; consumer messaging in popular publications; and the promotion of partnerships and alliances with corporations, federal agen- cies, and other professional associations. One specific effort is the Student National Dental Association’s Im- pressions Program, a student-to-student recruitment effort wherein dental students expose elementary and high school students to the dental schools. Another is the Deamonte Driver Dental Project, which was formed by the Robert T. Freeman Dental Society, a local component of the NDA. This project was designed to provide grassroots solutions to the children’s dental health crisis in Prince George’s County, Maryland. The goals of the project include the following: • Increase the number of practitioners in the dental safety net and the number of dental Medicaid providers. • Increase the number of children connected to a dental home. 

CURRENT ORAL HEALTH NEEDS 19 • Identify and enroll eligible children who are not enrolled in Medicaid. • Increase community awareness of the link between oral health and overall health. hispanic populations Francisco Ramos-Gomez, D.D.S., M.S., M.P.H. University of California, Los Angeles, School of Dentistry Even without counting illegal immigrants or the island of Puerto Rico, Hispanics now represent the largest ethnic minority in the United States. The U.S. Census defines Hispanic as people who originate from Spanish- speaking countries or regions; this origin may include the person’s heritage, nationality group, lineage, or country of the person’s ancestors before they arrived in the United States. People who identify themselves as of Hispanic or Latino origin may be of any race. As seen in Figure 3-3, the Hispanic population is growing rapidly, with projections that Hispanics will comprise one quarter of the population in the year 2050. About one-third of Hispanics in this country are under the age of 18 (U.S. Census Bureau, 2007b). In spite of the growth within this popu- lation, Hispanics only make up a very small percentage of all dentists. For example, even though one-third of the population of ­California is ­Hispanic, less than 5 percent of California’s dentists are ­ Hispanic. This is important because Hispanic dentists typically care for the majority of ­Hispanic patients, mostly because patients tend to be more comfortable with a practitioner who speaks their language and understands their culture. Hispanic children are much more likely to have a history of tooth d ­ ecay and are less likely to receive treatment than their white peers. About 31 percent of Mexican American 6- to 11-year-olds have dental caries, compared to 19 percent among their non-Hispanic peers (Dye et al., 2007). In the general population, children under the poverty level are more likely to be untreated than those above the poverty level. This is important since the poverty rate of Hispanics is about three times greater than the poverty rate for non-Hispanic Whites. REACTION AND discussion An open discussion followed the panelists’ presentations. For this ses- sion, workshop participants were asked to submit cards with comments and questions for the panelists. The following sections summarize the discussion session. (See Appendix E for a broader sampling of the submitted questions and comments.) 

20 THE U.S. ORAL HEALTH WORKFORCE 30 25 24.4 22.3 20 20.1 17.8 15 15.5 12.5 10 9.0 6.4 5 4.7 0 1970 1980 1990 2000 2010 2020 2030 2040 2050 FIGURE 3-3  Hispanic population as percentage of total U.S. population, 1970–2050. SOURCE: U.S. Census Bureau, 2008. Figure 3-3, editable, gray and border removed Moderator: Shelly Gehshan, M.P.P. Pew Center on the States Financing In response to a question about the financing of Apple Tree Dental, Helgeson said that the revenues received from the 30 percent of patients who pay out of pocket help cover the cost of the rest of the patients who receive coverage through public programs. He added that about 10 percent of Apple Tree Dental’s total income came from grants and gifts, but that these monies were generally used to fund items such as capital acquisitions, new projects, and educational collaborations. Replicating Successful Models Several participants asked how to replicate successful models of care and what the implications might be for state dental practice acts. Brunson said that Colorado’s dental practice acts have allowed for the indepen- 

CURRENT ORAL HEALTH NEEDS 21 dent practice of dental hygiene since the 1980s under the premise that it would increase access to oral health services. She said that increasing the independent practice of dental hygiene still has many challenges includ- ing significant overhead in setting up practice and the inability of dental hygienists to receive reimbursement from many publicly funded programs or third-party carriers (because they are not recognized as qualifying prac- titioners). ­Helgeson said the success of Apple Tree Dental can be attributed to the nonprofit corporate structure, the interdisciplinary governance, and the collaborative staff model. He acknowledged that some state dental practice acts do not permit that type of structure. Brunson added that the A ­ ssociation of State & Territorial Dental Directors has a best practices website that shares information about successful models and programs. Nomenclature One participant submitted a comment stating that the semantics and words used to describe the various types of practitioners need to be a ­ ddressed and modernized. For example, older terminology such as unsuper­ vised, auxiliary, and midlevel practitioner may be demeaning and imply that these professionals are unnecessary. Broadening the Framework of Workforce Planning Participants submitted several comments regarding the need to think more broadly in workforce planning, especially with the inclusion of a prevention focus (rather than a treatment focus). Harper said that the NDA strives for broad collaboration and integration of many different segments of the community, including the business community, dental prac- titioners, state and local health departments, schools, parents, and faith- based groups. Blahut said that for Native Americans, simply increasing the number of dentists will not solve the problem; instead, oral health will not change until the socioeconomic strata of the population changes. Ramos- Gomez said that several dimensions need to be considered: the child, the family, the environment, and the community. He agreed that efforts need to be community driven but that professionals need to bring the evidence base to guide patients as to what is most appropriate for that particular individual, community, and population.    See http://www.astdd.org/index.php?template=bestpractices.html.