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Committee on an Oral Health Initiative
Board on Health Care Services
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Govern-
ing Board of the National Research Council, whose members are drawn from the
councils of the National Academy of Sciences, the National Academy of Engineer-
ing, and the Institute of Medicine. The members of the committee responsible for
the report were chosen for their special competences and with regard for appropri-
ate balance.
This study was supported by Contract No. HHSH25034003T between the National
Academy of Sciences and the U.S. Department of Health and Human Services. Any
opinions, findings, conclusions, or recommendations expressed in this publication
are those of the author(s) and do not necessarily reflect the view of the organizations
or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-18630-8
International Standard Book Number-10: 0-309-18630-7
Additional copies of this report are available from the National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or
(202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.
edu.
For more information about the Institute of Medicine, visit the IOM home page
at: www.iom.edu.
Copyright 2011 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Cover art: Scientific micrograph of tooth enamel. Getty Images.
The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The serpent ad-
opted as a logotype by the Institute of Medicine is a relief carving from ancient
Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2011. Advancing Oral Health in
America. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated to
the furtherance of science and technology and to their use for the general welfare.
Upon the authority of the charter granted to it by the Congress in 1863, the Acad-
emy has a mandate that requires it to advise the federal government on scientific
and technical matters. Dr. Ralph J. Cicerone is president of the National Academy
of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding en-
gineers. It is autonomous in its administration and in the selection of its members,
sharing with the National Academy of Sciences the responsibility for advising the
federal government. The National Academy of Engineering also sponsors engineer-
ing programs aimed at meeting national needs, encourages education and research,
and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi-
dent of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions in
the examination of policy matters pertaining to the health of the public. The Insti-
tute acts under the responsibility given to the National Academy of Sciences by its
congressional charter to be an adviser to the federal government and, upon its own
initiative, to identify issues of medical care, research, and education. Dr. Harvey V.
Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sci-
ences in 1916 to associate the broad community of science and technology with the
Academy’s purposes of furthering knowledge and advising the federal government.
Functioning in accordance with general policies determined by the Academy, the
Council has become the principal operating agency of both the National Academy
of Sciences and the National Academy of Engineering in providing services to the
government, the public, and the scientific and engineering communities. The Coun-
cil is administered jointly by both Academies and the Institute of Medicine. Dr.
Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of
the National Research Council.
www.national-academies.org
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COMMITTEE ON AN ORAL HEALTH INITIATIVE
RICHARD D. KRUGMAN (Chair), Vice Chancellor for Health Affairs,
School of Medicine, University of Colorado at Denver
JOSÉ F. CORDERO, Dean, Graduate School of Public Health, University
of Puerto Rico
CLAUDE EARL FOX, Executive Director, Florida Public Health
Institute; Research Professor, Miller School of Medicine, University of
Miami
TERRY FULMER, Erline Perkins McGriff Professor and Dean, College
of Nursing, New York University
VANESSA NORTHINGTON GAMBLE, University Professor of Medical
Humanities, Professor of American Studies and Health Policy, The
George Washington University
PAUL E. GATES, Chair, Department of Dentistry, Bronx-Lebanon
Hospital Center; Chair, Department of Dentistry, Dr. Martin L. King,
Jr. Community Health Center; Associate Professor, Albert Einstein
College of Medicine
MARY C. GEORGE, Associate Professor Emeritus, Department of
Dental Ecology, School of Dentistry, University of North Carolina at
Chapel Hill
ALICE M. HOROWITZ, Research Associate Professor, School of Public
Health, University of Maryland, College Park
ELIZABETH MERTZ, Assistant Professor in Residence, Preventive
and Restorative Dental Sciences, School of Dentistry and Social and
Behavioral Sciences, School of Nursing; Research Faculty, Center for
the Health Professions, University of California, San Francisco
MATTHEW J. NEIDELL, Assistant Professor, Mailman School of Public
Health, Columbia University; Faculty Research Fellow, National
Bureau of Economic Research
MICHAEL PAINTER, Senior Program Officer, Robert Wood Johnson
Foundation
SARA ROSENBAUM, Chair, Department of Health Policy; Harold
and Jane Hirsh Professor of Health Law and Policy, The George
Washington University School of Public Health and Health Sciences
HAROLD C. SLAVKIN, Professor, School of Dentistry, University of
Southern California
CLEMENCIA M. VARGAS, Associate Professor, University of Maryland
Dental School
v
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ROBERT WEYANT, Associate Dean, Public Health and Outreach;
Professor and Chair, Department of Dental Public Health and
Information Management, School of Dental Medicine, University of
Pittsburgh
Study Staff
TRACY A. HARRIS, Study Director
BEN WHEATLEY, Program Officer
MEG BARRY, Associate Program Officer
AMY ASHEROFF, Senior Program Assistant
REDA URMANAVICIUTE, Administrative Assistant (through December
2010)
JILLIAN LAFFREY, Administrative Assistant (from January 2011)
ROGER C. HERDMAN, Director, Board on Health Care Services
vi
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Reviewers
This report has been reviewed in draft form by individuals chosen
for their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional
standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report:
SUZANNE BOULTER, Concord Hospital Family Health Centers
JAMES J. CRALL, University of California, Los Angeles, and
American Academy of Pediatric Dentistry
SUSAN J. CRIM, University of Tennessee Health Science Center
BURTON L. EDELSTEIN, Columbia University and Children’s
Dental Health Project
JOHN W. ERDMAN, JR., University of Illinois
ROBERT GENCO, University at Buffalo
HAROLD GOODMAN, Maryland Department of Health and
Mental Hygiene
CATHERINE HAYES, Independent Consultant
AMID ISMAIL, Temple University
PAULA S. JONES, Private Practice
DUSHANKA KLEINMAN, University of Maryland
vii
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viii REVIEWERS
WILLIAM R. MAAS, Pew Center on the States
DONALD WAYNE MARIANOS, Consultant
R. GARY ROZIER, University of North Carolina at Chapel Hill
LISA A. TEDESCO, Emory University
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions
or recommendations, nor did they see the final draft of the report before its
release. The review of this report was overseen by HAROLD C. SOX, Dart-
mouth Medical School (retired), and GEORGES C. BENJAMIN, American
Public Health Association. Appointed by the National Research Council
and the Institute of Medicine, they were responsible for making certain that
an independent examination of this report was carried out in accordance
with institutional procedures and that all review comments were carefully
considered. Responsibility for the final content of this report rests entirely
with the authoring committee and the institution.
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Foreword
Oral health care is often excluded from our thinking about health.
Taken together with vision care and mental health care, it seems that prob-
lems above the neck are commonly regarded as peripheral to health care
and health care policy. This division is reinforced by the fact that dentists,
dental hygienists, and dental assistants are separated from other health care
professionals in virtually every way: where they are educated and trained,
how their services are reimbursed, and where they provide oral health care.
This separation is at odds with the fact that good oral health has been
shown to directly affect a person’s overall health.
The U.S. Department of Health and Human Services (HHS) is involved
in oral health care in a variety of ways, from financing safety net care to
developing the oral health workforce to providing public health surveil-
lance. Previous efforts by HHS to improve oral health in America have
produced some benefit, but not enough. Many populations, especially the
most vulnerable and underserved populations, suffer significant oral health
problems. Major barriers to care include low rates of dental insurance, high
out-of-pocket payments (even for those with insurance), relative lack of
training of the general health care workforce in oral health, and a lack of
awareness about the importance of good oral health—both by health care
professionals and the public.
The Health Resources and Services Administration asked the Institute
of Medicine (IOM) to provide advice on where to focus its efforts in oral
health. After the IOM convened the Committee on an Oral Health Initia-
tive, HHS announced a broad Oral Health Initiative and expressed opti-
mism that the committee’s work would be able to inform this endeavor. The
ix
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x FOREWORD
IOM Committee on an Oral Health Initiative, led by Richard Krugman,
was charged with assessing the current oral health care system, reviewing
the elements of an HHS Oral Health Initiative and exploring ways to pro-
mote the use of preventive oral health interventions and improve oral health
literacy. The committee worked in parallel with a second IOM committee
that focused on issues of access to oral health care for underserved and
vulnerable populations. Both of these IOM projects are included as official
components of the HHS Oral Health Initiative.
The IOM’s work in the area of oral health dates back more than 30
years. In 1980, the IOM released Public Policy Options for Better Dental
Health, which argued that basic dental services should be broadly available
and emphasized that any national health insurance plan should include
dental services. The 1995 report Dental Education at the Crossroads called
for numerous reforms in the system of education and training for dentists
and other dental professionals. Most recently, in 2009, the IOM held a
3-day workshop on the Sufficiency of the U.S. Oral Health Workforce in
the Coming Decade. The workshop focused on the connection between
oral health and overall health, the challenges facing the current oral health
system, and the roles various stakeholders can play in improving oral health
care.
The Committee on an Oral Health Initiative reaffirms that oral health
is an integral part of overall health and points to many opportunities to
improve the nation’s oral health. We issue this report in the hope that it
will prove useful to responsible government agencies, informative to the
health professions and public, and helpful in attaining higher levels of
dental health.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
April 2011
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Preface
In 2009, the U.S. Department of Health and Human Services (HHS)
asked the Institute of Medicine (IOM) to convene a panel to recommend
strategic actions for HHS in oral health. Although HHS has been actively
involved in oral health care for decades, many Americans continue to ex-
perience poor oral health and cannot access the oral health care system. In
fact, like the overall health care system in many ways, the term oral health
care system is a misnomer, as the delivery of oral health care occurs in
multiple settings by various health care professionals without coordination
or integration. To the extent that there is a system, it is fragmented into
two tiers: one for those who can access traditional dental private practices
and one for those who cannot, most often the vulnerable and underserved
populations who are most in need of care.
HHS and others have documented the stark reality of the poor oral
health status of many Americans. More than 10 years ago, the surgeon
general called oral health disease a “silent epidemic.” Unfortunately, the
situation largely remains unchanged. Dental caries continues to be one of
the most prevalent diseases of childhood.
While researchers have identified the multiple connections between oral
health and overall health, oral health care remains artificially separated
from the larger system of general health care. Many health professionals
know little to nothing about oral health. Oral health is, for the most part,
missing from the education and training of health care professionals such
as nurses, pharmacists, physician assistants, physicians, and others. Instead
of “oral health,” many people continue to think about “dental health” as
if it were separate from a person’s general health.
xi
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xii PREFACE
HHS has sought to address many of these challenges and to fill some of
the gaps in care nationwide. Its agencies currently perform the following:
• F
inance oral health care services for millions of Americans through
state Medicaid programs and the Children’s Health Insurance Pro-
gram (CHIP).
• P
rovide and oversee services through settings such as the Federally
Qualified Health Centers (FQHCs).
• S
upport oral health workforce demonstration projects.
• C
onduct oral health research and surveillance.
• C
ontribute in many other ways to the day-to-day functioning of
the oral health care “system” in the United States.
However, HHS itself suffers from considerable fragmentation, given
the multiple responsibilities and frequent lack of coordination among HHS
agencies. In addition, while some notable progress has been made, previous
HHS efforts to improve oral health have suffered from a lack of sufficient
resources and high-level accountability.
In 2010, as this study was under way, HHS launched a cross-agency
reform effort known as the Oral Health Initiative 2010, which seeks to
improve coordination and integration among existing oral health-related
programs within the department, and it included the launch of nine new
initiatives, including this current study. The committee sought to frame and
guide this effort by providing specific recommendations on the administra-
tion of the initiative and focused on issues that are particularly important
for HHS to address. First is the need to focus on prevention. While effective
preventive measures are well established, the oral health system continues
to focus on the identification and treatment of existing disease. Second is
the need to enhance the oral health workforce. The oral health system still
largely depends on a traditional, isolated dental care model in the private
practice setting—a model that does not always serve significant portions of
the American population well. More needs to be done to support the edu-
cation and training of all health care professionals in oral health care and
to promote interdisciplinary, team-based approaches. HHS can also work
to increase the racial and ethnic diversity of the oral health workforce and
explore the use of new types of oral health professionals in nontraditional
settings of care. In addition, HHS needs to explore new payment models
that can help improve access and coverage. Finally, HHS needs to expand
both primary and secondary research in oral health with a focus on devel-
oping a robust primary evidence base and coordinating federal data so it
can be used for secondary research. In addition, because quality assessment
and improvement efforts lag significantly behind those in the rest of health
care, HHS can promote the development of oral health measures of quality.
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xiii
PREFACE
And in all of these efforts, information and processes should be transparent
and involve representation from multiple stakeholders.
This report calls upon HHS to capitalize on the work it has already
done to improve oral health care in America. Currently, there is a conflu-
ence of high-level interest and passionate leadership. However, the commit-
tee recognizes that while HHS has a significant role to play as a leader in
oral health care, it is just one part of a larger solution. HHS needs to work
with stakeholders across the oral health care spectrum to focus on promot-
ing oral health prevention, integrating oral health into overall health, and
increasing access to oral health care for all Americans, including those
who are not currently receiving the care they need. In essence, this report
calls upon HHS to be a leader in helping to change our nation’s way of
thinking—to help leaders, health care professionals, and individuals to bet-
ter understand that oral health and oral diseases are a health care problem,
and not just a dental problem.
Richard D. Krugman, Chair
Committee on an Oral Health Initiative
April 2011
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Acknowledgments
Many individuals and organizations contributed to this study. The
Committee on an Oral Health Initiative takes this opportunity to recog-
nize those who so generously gave their time and expertise to inform its
deliberations.
The committee benefited from presentations made by a number of ex-
perts. The following individuals shared their experiences and perspectives
during public meetings of the committee:
William Bailey, U.S. Public Health Service
Ann Battrell, American Dental Hygienists’ Association
Cynthia Baur, Centers for Disease Control and Prevention
Marcia Brand, Health Resources and Services Administration
Jack Bresch, American Dental Education Association
Robin Brocato, Administration for Children and Families
James J. Crall, American Academy of Pediatric Dentistry
A. Conan Davis, Centers for Medicare and Medicaid Services
Bruce Dye, Centers for Disease Control and Prevention
Burton L. Edelstein, Columbia University
Isabel Garcia, National Institute of Dental and Craniofacial Research
Raymond Gist, American Dental Association
Karen Glanz, University of Pennsylvania
Christopher G. Halliday, Indian Health Service
David Halpern, Academy of General Dentistry
Rita Jablonski, The Pennsylvania State University
Laura Joseph, Farmingdale State College of New York
xv
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xvi ACKNOWLEDGMENTS
Dushanka Kleinman, University of Maryland
William Kohn, Centers for Disease Control and Prevention
Ann LaBelle
Susan Levy, University of Illinois at Chicago
William R. Maas, Pew Children’s Dental Campaign
Richard J. Manski, Agency for Healthcare Research and Quality
Vincent C. Mayher, private practice
Marian Mehegan, Office on Women’s Health
Lynn Douglas Mouden, Arkansas Department of Health
Wendy Mouradian, University of Washington
Linda Neuhauser, University of California, Berkeley
Rochelle Rollins, Office of Minority Health
John P. Rossetti
Rima Rudd, Harvard University
Mary Wakefield, Health Resources and Services Administration
The committee also thanks Kenneth Thorpe, Emory University, for his
commissioned paper, Financing Oral Health Care.
We extend special thanks to the following individuals who generously
gave their time and knowledge to further the committee’s efforts:
Lewis N. Lampiris, American Dental Association
Scott L. Tomar, University of Florida
Richard W. Valachovic, American Dental Education Association
Many within the Institute of Medicine were helpful to the study staff.
The staff would like to thank Pamella Atayi, Patrick Burke, Rosemary
Chalk, Greta Gorman, Wendy Keenan, William McLeod, Janice Mehler,
Abbey Meltzer, Patti Simon, and Lauren Tobias for their time and support
to further the committee’s efforts. We also thank Mark Goodin, copyeditor.
Finally, the committee gratefully acknowledges the assistance and sup-
port of two individuals instrumental in developing this project: Marcia
Brand and Jeffrey Johnston, both of the Health Resources and Services
Administration.
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Contents
SUMMARY 1
1 INTRODUCTION 15
Oral Health and Overall Health, 16
Influences on Oral Health and the Oral Health Care System, 17
Study Charge and Approach, 21
Overview of the Report, 25
References, 26
2 ORAL HEALTH AND OVERALL HEALTH AND
WELL-BEING 31
The Link Between Oral Health and Overall Health, 32
Overall Oral Health Status, 34
Oral Health Status and Oral Health Care Utilization by
Specific Populations, 38
Prevention of Oral Diseases, 44
Oral Health Literacy, 51
Key Findings and Conclusions, 60
References, 61
3 THE ORAL HEALTH CARE SYSTEM 81
Sites of Oral Health Care, 82
Paying for Oral Health Care, 85
The Dental Workforce, 90
The Nondental Oral Health Workforce, 106
xvii
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xviii CONTENTS
Public Health Workers, 113
Interprofessional Team Care, 115
Regulating the Oral Health Workforce, 116
Oral Health and Quality Measurement, 118
Key Findings and Conclusions, 123
References, 124
4 HHS AND ORAL HEALTH: PAST AND PRESENT 141
The History of HHS and Oral Health, 141
Current Roles of Individual HHS Divisions, 153
Role of HHS in Prevention, 165
Role of HHS in Health Literacy, 167
Role of HHS in Education and Training, 172
HHS Collaborations with the Private Sector, 178
Roles of Other Federal Agencies, 180
Current Reform Efforts, 186
Key Findings and Conclusions, 196
References, 196
5 A NEW ORAL HEALTH INITIATIVE 207
Learning from the Past, 207
The New Oral Health Initiative, 208
Looking to the Future, 221
References, 225
APPENDIXES
A Acronyms 227
B Organizational Charts of the U.S. Department of Health and
Human Services 231
C Workshop Agendas 235
D Committee and Staff Biographies 239
