Advancing
Oral Health

in America




Committee on an Oral Health Initiative

Board on Health Care Services




INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Woshington, D.C.
http://www.nap.edu



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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