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Summary
V
ulnerable and underserved populations face persistent and systemic
barriers to accessing oral health care. These barriers are numerous
and complex and include social, cultural, economic, structural, and
geographic factors, among others. For example:
• In 2008, 4.6 million children did not obtain needed dental care
because their families could not afford it.
• In 2011, there were approximately 33.3 million unserved individu-
als living in dental Health Professional Shortage Areas.1
• In 2006, only 38 percent of retired individuals had dental coverage.
In addition, endemic low levels of oral health literacy among the public and
many in the health care professions may limit their ability to understand the
importance of good oral health to overall health status. Furthermore, low
oral health literacy creates additional obstacles to recognizing risk for oral
diseases as well as seeking and receiving needed oral health care.
Lack of access to oral health care contributes to profound and enduring
oral health disparities in the United States. For example, dental caries2—a
chronic, infectious, and largely preventable disease commonly known as
tooth decay—disproportionately affects vulnerable and underserved popu-
1 Dental Health Professional Shortage Areas are geographic areas, population groups, or
facilities with shortages of dental providers.
2 The term dental caries is used in the singular and refers to the disease commonly known
as tooth decay (Dorland’s Illustrated Medical Dictionary, 31st ed., s.v. “caries”).
1
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2 IMPROVING ACCESS TO ORAL HEALTH CARE
lations, groups who commonly lack access to oral health care. Vulnerable
and underserved populations include but are not limited to
• Racial and ethnic minorities, including immigrants and non-English
speakers;
• Children, especially those who are very young;
• Pregnant women;
• People with special needs;
• Older adults;
• Individuals living in rural and urban underserved areas;
• Uninsured and publicly insured individuals;
• Homeless individuals; and
• Populations of lower socioeconomic status.
Because good overall health requires good oral health, the unmet oral
health needs of millions of American cannot be neglected.
While the majority of the U.S. population is able to routinely obtain
oral health care in traditional dental practice settings, a disproportionate
number of vulnerable and underserved individuals cannot. An array of pro-
viders and population-based public health programs—collectively referred
to as the safety net—has emerged through uncoordinated attempts to reach
these individuals. However, access to oral health care continues to elude too
many Americans. Fortunately, additional opportunities exist—in both the
public and private sectors—to ameliorate the situation.
STUDY CHARGE
In the fall of 2009, with support from the Health Resources and Ser-
vices Administration (HRSA) and the California HealthCare Foundation,
the National Research Council and the Institute of Medicine (IOM) formed
the Committee on Oral Health Access to Services to assess the current oral
health care system with a focus on the delivery of oral health care to vulner-
able and underserved populations (see Box S-1).
The committee’s vision is both aspirational and achievable (see Box
S-2), but numerous coordinated and sustained actions will be needed to
realize this vision.
GUIDING PRINCIPLES AND OVERALL CONCLUSIONS
To guide its deliberations, the committee began with two well-
established and evidence-based principles:
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3
SUMMARY
1. Oral health is an integral part of overall health and, therefore, oral
health care is an essential component of comprehensive health care.
2. Oral health promotion and disease prevention are essential to any
strategies aimed at improving access to care.
B OX S-1
Committee Charge
The IOM-NRC Board on Children, Youth, and Families, in collabora-
tion with the Board on Health Care Services, will undertake a study to
• Assess the current U.S. oral health system of care;
• xplore its strengths, weaknesses, and future challenges for the de-
E
livery of oral health care to vulnerable and underserved populations;
• escribe a desired vision for how oral health care for these popula-
D
tions should be addressed by public and private providers (including
innovative programs) with a focus on safety net programs serving
populations across the life cycle and Maternal and Child Health Bu-
reau (MCHB) programs serving vulnerable women and children; and
• Recommend strategies to achieve that vision.
BOX S-2
Vision for Oral Health Care in the United States
Everyone has access to quality oral health care across the life cycle.
To be successful with underserved and vulnerable populations, an
evidence-based oral health system will
1. liminate barriers that contribute to oral health disparities;
E
2. Prioritize disease prevention and health promotion;
3. Provide oral health services in a variety of settings;
4. ely on a diverse and expanded array of providers competent, com-
R
pensated, and authorized to provide evidence-based care;
5. nclude collaborative and multidisciplinary teams working across the
I
health care system; and
6. Foster continuous improvement and innovation.
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4 IMPROVING ACCESS TO ORAL HEALTH CARE
These principles are woven throughout the text of this report and are
fundamental to the recommendations. In addition, after reviewing the evi-
dence, the committee came to the following overall conclusions:
1. Improving access to oral health care is a critical and necessary first
step to improving oral health outcomes and reducing disparities.
2. The continued separation of oral health care from overall health
care contributes to limited access to oral health care for many
Americans.
3. Sources of financing for oral health care for vulnerable and under-
served populations are limited and tenuous.
4. Improving access to oral health care will necessarily require mul-
tiple solutions that use an array of providers in a variety of settings.
If the current approaches to oral health education, financing, and
regulation continue unchanged, equitable access to oral health care cannot
be achieved. This report, however, should not be perceived as simply a call
for more spending. Investing additional money in a delivery system that is
poorly designed to meet the oral health care needs of the nation’s under-
served and vulnerable populations would produce limited results. Rather,
the report calls for transformation through targeted investments in pro-
grams and policies that are most likely to yield the greatest impact. There-
fore, the committee makes recommendations in key areas, suggests actions
that various stakeholders can take, and identifies the relevant policy levers
that are most likely to produce both short-term and long-term change.
RECOMMENDATIONS
Integrating Oral Health Care into Overall Health Care
Nondental health care professionals need to take a role in oral health
care.3 Young children, for example, visit pediatricians and family physicians
earlier and more frequently than they visit dentists. Similarly, for older
adults living in institutions, nurses and nursing assistants often provide per-
sonal oral health care. With proper training, these and other primary care
providers are well situated to educate individuals about how to prevent oral
3 In this report, the committee uses the term dental professionals to refer to dentists,
dental hygienists, dental assistants, and dental laboratory technicians. The term nondental
health care professionals includes all other types of health care professionals (e.g., nurses,
pharmacists, physician assistants, physicians). Together, they are referred to as oral health
care professionals.
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5
SUMMARY
diseases, to assess risk and screen for oral diseases, and to deliver preventive
services (e.g., fluoride varnish).
Several nondental health care professions have made great strides in
improving the oral health education and training of their students through
development of oral health curricula and requirements for training in oral
health care. The available evidence indicates that these efforts have been
effective at increasing knowledge about oral health and integrating oral
health care into primary care practices. However, these types of initiatives
have not spread widely through the health professions.
Defining a core set of oral health competencies would describe essential
skills that nondental health care professionals need in order to provide qual-
ity oral health care. Instead of having each profession develop their own set
of competencies, one strategy is to develop a core set of competencies that
would be broad and applicable to many nondental health professions. Once
developed, this core set would need to be adopted by health professional
schools and incorporated into the curricula. The committee concludes that
the best way to encourage adoption is for professional accreditation and
certification bodies to require these competencies for accreditation and
maintenance of certification. Therefore, the committee recommends
RECOMMENDATION 1a: The Healthcare Resources and Services
Administration (HRSA) should convene key stakeholders from both the
public and private sectors to develop a core set of oral health competen-
cies for nondental health care professionals.
RECOMMENDATION 1b: Following the development of a core set
of oral health competencies
• Accrediting bodies for undergraduate and graduate-level nondental
health professional education programs should integrate these core
competencies into their requirements for accreditation; and
• All certification and maintenance of certification for health care
professionals should include demonstration of competence in oral
health care as a criterion.
The minimum core competencies will need to prepare graduates to
• Recognize risk for oral disease through competent oral examinations,
• Provide basic oral health information,
• Integrate oral health information with diet and lifestyle counseling,
and
• Make and track referrals to dental professionals.
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6 IMPROVING ACCESS TO ORAL HEALTH CARE
The committee suggests the following strategies:
• HRSA can require that Title VII–funded programs include inter-
professional education on oral health.
• HRSA can support curriculum development and dissemination ef-
forts for nondental health professional education programs.
Creating Optimal Laws and Regulations
A variety of regulations and policies determine how and by whom
oral health care is provided. In spite of the existence of national accredi-
tation standards on education and training of health care professionals,
regulations defining supervision levels and scopes of practice vary widely
from state to state and even by procedure. Some states have altered their
scope-of-practice and supervision regulations to allow a broader range of
competent oral health care professionals to treat patients, or for existing
oral health care professionals to perform a wider range of procedures under
various levels of supervision.
When expansions to existing scopes of practice are proposed, con-
cerns inevitably arise about the quality of care provided when patients are
treated by individuals with less training.4 However, many have called for
state practice acts to be expanded in alignment with professional compe-
tence. Moreover, the Federal Trade Commission suggests that lawmakers
consider whether overly restrictive regulations preclude a countervailing
benefit, such as through increased access to care. Therefore, the committee
recommends
RECOMMENDATION 2: State legislatures should amend existing
state laws, including practice acts, to maximize access to oral health
care.
At minimum, state dental practice acts should
• Allow allied dental professionals to practice to the full extent of
their education and training,
• Allow allied dental professionals to work in a variety of settings
under evidence-supported supervision levels, and
• Allow technology-supported remote collaboration and supervision.
This recommendation will enable members of a stratified workforce of
professionals to work in community settings, change supervision require-
4The IOM defines quality as being safe, timely, effective, efficient, equitable, and
patient-centered.
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SUMMARY
ments to levels supported by evidence, and allow the appropriate use of
telehealth technologies to reach underserved populations.
States can be supported in these efforts with strong evidence and clear
guidance. This committee, therefore, proposes the following strategies:
• The Centers for Medicare and Medicaid Services (CMS) can dis-
seminate rules and policies that promote Medicaid and Children’s
Health Insurance Program (CHIP) beneficiaries’ access to appropri-
ate care, and ensure that these rules and policies reflect the practice
abilities of current and new types of licensed professionals.
• The Office of the Assistant Secretary for Planning and Evaluation
can examine and report on the impact of state practice acts on oral
health care delivery to vulnerable and underserved populations.
These reports would need to be conducted and published periodi-
cally to support sustained attention.
• Foundations, professional organizations, and public policy orga-
nizations can conduct and disseminate an initial review of state
practice acts with a focus on access to services.
• Foundations, professional organizations, and public policy orga-
nizations can issue “best practices” briefs to highlight what each
state is doing and what impact it is having on access.
Improving Dental Education and Training
An improved and responsive dental education system is needed to en-
sure that current and future generations of dental professionals can deliver
quality care to diverse populations, in a variety of settings, using a variety
of service-delivery mechanisms, and across the life cycle. Diversity in the
health care workforce is associated with expanded access to care for racial
and ethnic minority patients, greater patient choice and satisfaction, bet-
ter patient–provider communication, and better educational experiences
for all students. Furthermore, all dental professionals need to develop the
necessary skills to work in a variety of community-based settings and with
vulnerable and underserved populations, such as the ability to work in
interprofessional teams with general health, education, and social service
professionals; the ability to work in dental professional teams; and the abil-
ity to use new service-delivery mechanisms such as telehealth technologies
for supervision, consultation, and collaboration.
Evidence points to limited training of dental students in community-
based settings, thereby limiting their exposure to and practical experience
with the broad range of patients cared for in these settings. This creates
missed opportunities to improve cultural competence and to reinforce the
professional and ethical role of caring for the vulnerable and underserved
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8 IMPROVING ACCESS TO ORAL HEALTH CARE
populations. Providing students with clinical experiences in community-
based settings helps them acquire skills that cannot be learned in academic
settings, improves their comfort level with caring for vulnerable and under-
served populations, and increases the likelihood that students may return
to such settings in their future careers. Finally, schools will require more
faculty members with experience and expertise in caring for vulnerable and
underserved populations to adequately prepare students in this manner.
Therefore, the committee recommends
RECOMMENDATION 3: Dental professional education programs
should
• Increase recruitment and support for enrollment of students from
underrepresented minority, lower-income, and rural populations;
• Require all students to participate in community-based education
rotations with opportunities to work with interprofessional teams;
and
• Recruit and retain faculty with experience and expertise in caring
for underserved and vulnerable populations.
To support Recommendation 3, the committee further recommends
RECOMMENDATION 4: HRSA should dedicate Title VII funding to
• Support the development, implementation, and maintenance of
substantial community-based education rotations, and
• Increase funding for recruitment and scholarships for underrep-
resented minority, lower-income, and rural populations to attend
dental professional schools.
Continuation of proven strategies will help prepare—and ultimately
promote—a greater desire among dental professionals to provide care to
underserved and vulnerable populations. The committee suggests that pri-
vate foundations and professional organizations can strengthen efforts of
dental professional education programs to
• Increase enrollment of students from underrepresented minority,
lower-income, and rural populations by funding bridge programs.
• Develop and evaluate innovative educational models to prepare stu-
dents to work in diverse settings and with new delivery mechanisms.
Upon completion of dental school, students may have had limited op-
portunities to integrate their skills and knowledge with practical hands-on
experience and may not feel adequately prepared for dental practice. In the
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9
SUMMARY
1995 IOM report Dental Education at the Crossroads (Crossroads) the
committee noted:
A year of postgraduate or advanced education in general dentistry would
allow students to gain speed and confidence in procedures, broaden their
patient management skills to cover more complex problems, and mature
in the nontechnical aspects of patient care.
Dentists who have completed general dentistry residency programs re-
port feeling more comfortable caring for underserved patients and patients
with complex health care needs, and tend to care for those patients more
often, even after completing residency. Dental residencies are also a source
of care for underserved and vulnerable populations, and some evidence
shows that, with appropriate funding, requiring a year of residency training
can expand the capacity of these programs to care for more individuals.
Therefore, the committee recommends
RECOMMENDATION 5: HRSA should dedicate Title VII funding to
support and expand opportunities for dental residencies in community-
based settings.
• Subsequently, state legislatures should require a minimum of one
year of dental residency before a dentist can be licensed to practice.
To be optimally effective, dental residency programs especially need
to include clinical experiences with young children, individuals with spe-
cial health care needs, and older adults. For this reason, these residency
programs need to be located in settings where services to these and other
vulnerable and underserved populations are most needed.
In alignment with the Crossroads report, this committee recommends
increased opportunities rather than requirements for residencies as a short-
term goal.
Since funding of residency programs has been tenuous, the commit-
tee recommends a continuous source of existing funding—Title VII of the
Public Health Services Act—be directed to support dental residencies. This
will require that Title VII receives priority within current and future fund-
ing levels. In the long term, the committee recommends that states should
ultimately require a minimum of 1 year of dental residency before a dentist
can be licensed to practice. This will involve, among other actions, the need
for each state to revise its statutes and the need to increase the capacity of
dental residency programs.
The committee suggests the following as potential strategies:
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10 IMPROVING ACCESS TO ORAL HEALTH CARE
• HRSA can support care for underserved and vulnerable popula-
tions where they live, work, and learn by designating the types
of clinical experiences and settings that would qualify for dental
residencies.
• The public and private sectors can help identify and address barri-
ers to having all states make postgraduate education a requirement
for licensure.
• Hospitals and dental schools can increase the number of formal
relationships with community-based care settings (e.g., Federally
Qualified Health Centers [FQHCs], nursing homes, state and local
health departments, and prisons) for dental residency programs.
Reducing Financial and Administrative Barriers
Dental coverage is a major determinant of access to and utilization of
oral health care. In addition, a parent’s insurance status and utilization of
oral health care is associated with whether his or her children receive oral
health care. All states are required to provide comprehensive dental benefits
for all children enrolled in Medicaid or CHIP. In contrast, states are not
required to provide Medicaid benefits for adults. Among states that offer
dental coverage for adult Medicaid recipients, the benefits are often limited
to emergency coverage.
Recognizing that publicly funded programs are the primary source of
coverage for underserved and vulnerable populations, the committee con-
cludes that Medicaid cannot properly address access to oral health services
if it excludes oral health benefits. However, in the absence of a comprehen-
sive cost-benefit analysis and in a climate of significantly limited resources,
the committee lacks the necessary evidence base and appropriate fiscal
conditions to recommend that all states be required to cover essential dental
benefits for all Medicaid beneficiaries. Nevertheless, the committee firmly
concludes that including dental benefits for all Medicaid beneficiaries is a
critical and necessary goal. Toward this end, the committee recommends
RECOMMENDATION 6: CMS should fund and evaluate state-based
demonstration projects that cover essential oral health benefits for
Medicaid beneficiaries.
State-based demonstration projects will help establish a basis for sound
policy and fiscal decision making both for participating states and for fu-
ture federal and state actions. Recognizing the different challenges faced
by individual states, the committee suggests that CMS build in flexibility
and encourage innovation in the demonstrations. For example, states may
choose to focus on providing oral health benefits to specific populations
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SUMMARY
(e.g., “high-risk” enrollees) or to examine the effects of providing benefits
to all enrolled populations. The committee suggests the following strategies:
• CMS can ensure that Medicaid beneficiaries receive the appropri-
ate level of care by appointing and convening a committee of key
stakeholders to establish an essential dental benefits package for
Medicaid.
• CMS can provide technical assistance and oversight to state-based
demonstration projects including guidance on program design ele-
ments that address the specialized needs of targeted beneficiaries
and consultation on program evaluation and monitoring systems.
• CMS can develop a report at the culmination of the demonstration
projects to review, translate, and disseminate evidence and guid-
ance to all states.
• Private foundations can partner with CMS and participating states
to support outreach for state-based demonstration projects in-
cluding campaigns to raise awareness of changes in state oral
health benefits available and to promote the use of newly covered
services.
Financing also influences providers’ practice patterns. For example, low
reimbursement by public programs is often cited as a disincentive to pro-
vider participation. Increases in reimbursement rates have shown promise
in increasing dentists’ participation in these programs. However, increasing
reimbursement rates alone is not sufficient. To that end, many states have
taken measures to reduce the administrative burdens of publicly funded
programs. These actions, in conjunction with rate increases and other sup-
portive strategies (e.g., increased education and outreach to beneficiaries)
can have a greater impact on increasing provider participation and patient
utilization rates. Therefore, the committee recommends
RECOMMENDATION 7: To increase provider participation in pub-
licly funded programs, states should
• Set Medicaid and CHIP reimbursement rates so that beneficiaries
have equitable access to essential oral health services, as required
by law;
• Provide case-management services; and
• Streamline administrative processes.
In a climate of limited resources and perennial demands on tight state
budgets, states will need additional support in these efforts. Therefore, the
committee suggests the following as strategies:
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12 IMPROVING ACCESS TO ORAL HEALTH CARE
• Congress can provide enhanced federal matching funds to help
offset the additional expense to the states. To be most effective,
Congress can require that an enhanced match be tied to efforts of
states to streamline administrative procedures related to provider
participation and patient utilization in Medicaid.
• CMS can ensure that Medicaid beneficiaries have equitable ac-
cess to essential oral health services by appointing and convening
a committee of key stakeholders to establish an essential dental
benefits package for Medicaid.
As noted above, simply increasing reimbursement rates, in the absence
of other actions, will not be sufficient in improving access to care. There-
fore, the committee proposes the following strategies:
• CMS can issue guidance to state Medicaid officers on strategies to
reduce administrative burdens associated with provider participa-
tion in Medicaid.
• States can use Maternal and Child Health Services Block Grant
(Title V) funds to evaluate and assess their case-management ser-
vices to determine the most effective strategies to expand access to
oral health care.
• Professional organizations and patient advocacy organizations can
work with their constituencies to help identify populations in need
of case management and the specific administrative barriers serving
these populations.
Promoting Research
Over the course of this study, the committee encountered considerable
gaps in the evidence base. For example, little is known about the best ways
to care for the distinct segments of the American public that are not well
served by the traditional oral health care system. To this end, there are a
number of programs currently under way designed to deliver oral health
care through innovations in the workforce and in delivery of care in non-
traditional settings.
First, as discussed earlier, research is needed on how to best include
nondental health care professionals in oral health care. Further, several
new models seek to develop new types of dental professionals or expand
the role of existing dental professionals. For example, while limited, evalu-
ations of the dental health aide therapist program in Alaska to date point
to the quality and acceptability of dental therapists, but more research is
needed to determine the broader impact and implementation of these types
of programs. Similar research is also needed on the provision of oral health
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SUMMARY
care in nontraditional settings (e.g., school-based health centers, mobile
equipment) and through innovative technologies (e.g., telehealth).
Quality assessment and improvement efforts in oral health are ham-
pered by a deficiency in the collection, analysis, and use of data related to
important aspects of oral health. Because of the limited infrastructure and
the current paucity of measures in use to assess the technical competence,
practice procedures, and quality of care and outcomes of care provided by
any dental professionals, making comparisons of care rendered by different
types of professionals is even more challenging.
Finally, little has been done to investigate better methods of financing
and regulation that might lead to improvements in dental coverage, access
to oral health care, and, again, improvements in oral health status.
Therefore, the committee recommends
RECOMMENDATION 8: Congress, the Department of Health and
Human Services, federal agencies, and private foundations should fund
oral health research and evaluation related to underserved and vulner-
able populations, including
• New methods and technologies (e.g., nontraditional settings,
nondental professionals, new types of dental professionals, and
telehealth);
• Measures of access, quality, and outcomes; and
• Payment and regulatory systems.
Given the need for further research, the committee concludes that a
variety of stakeholders will need to take additional actions to support this
recommendation, including
• Federal agencies can increase funding for programs that success-
fully provide education and preventive and treatment services to
vulnerable and underserved populations such as Head Start; the
Women, Infants, and Children program; and school-based health
centers.
• HRSA can provide new funding toward demonstration projects
that promote innovations in oral health care delivery, such as new
workforce models, nontraditional settings of care, and new ways
to finance oral health care.
Expanding Capacity
State oral health programs are essential to direct resources and monitor
the impact of oral health efforts. One important aspect of state oral health
programs is their ability to monitor and analyze the burden of oral health
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14 IMPROVING ACCESS TO ORAL HEALTH CARE
disease, conditions, and personal behaviors over time. Other functions of
state oral health programs (e.g., community water fluoridation, dental seal-
ant programs, fluoride varnish programs, dental screening programs, and
oral health programs specifically for pregnant women) also have a positive
impact on oral health. According to the Association of State and Territorial
Dental Directors,
with expanded infrastructure and capacity, state oral health programs are
better able to monitor oral health status, address high-risk populations,
increase population-based prevention activities, and extend resources to
local health agencies and communities in order to implement oral health
strategies.
In spite of this impact, funding for state and local dental public health
services continues to be limited and often insufficient. In FY 2010, the Cen-
ters for Disease Control and Prevention (CDC) provided $6.8 million to 19
state oral health programs to support evidence-based prevention programs,
surveillance of oral disease burden, and to develop plans to improve oral
health and address disparities.
Recognizing the critical role of state-based programs, the committee
recommends
RECOMMENDATION 9: The Centers for Disease Control and Pre-
vention (CDC) and the Maternal and Child Health Bureau (MCHB)
should collaborate with states to ensure that each state has the infra-
structure and support necessary to perform core dental public health
functions (e.g., assessment, policy development, and assurance).
The committee proposes the following strategies:
• The CDC can continue to increase the number of states that receive
cooperative agreement funding for dental public health programs.
• The MCHB can support an oral health component under Title V
through block grants (formulary grants to states), discretionary
funds, and/or “set asides” (a percentage of funds) for oral health.
• Congress can fund the Oral Healthcare Prevention Education Cam-
paign authorized by the Patient Protection and Affordable Care Act
(ACA) [Public Law 111-148, Title IV, Sec. 4102] which calls for
a national public education campaign focused on oral health and
disease prevention targeted toward vulnerable and underserved
populations.
• Private foundations can partner with public agencies to develop,
implement, and evaluate public education and oral health literacy
campaigns.
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SUMMARY
Expanding the capacity of FQHCs to deliver oral health care is also
important to meet the needs of vulnerable and underserved populations.
FQHCs are required to provide certain oral health services—including pre-
ventive, but not comprehensive, dental services—either in the clinic or by
referral. In 2009, HRSA funded 1,131 FQHCs in all 50 states, the District
of Columbia, and Puerto Rico. The American Recovery and Rehabilitation
Act included $2 billion for FQHCs, and the ACA included $11 billion for
a Community Health Centers Trust Fund that will allow FQHCs to expand
access and make capital improvements, and also appropriated $1.5 billion
to a new National Health Service Corps Trust Fund.
In 2009, over 3.4 million patients used dental services in the health
center system. Still, this is only a small fraction of the underserved popu-
lation. The committee concludes that with adequate support, FQHCs are
well positioned to significantly expand the delivery of oral health care to
vulnerable and underserved populations.
The committee, therefore, recommends
RECOMMENDATION 10: To expand the capacity of FQHCs to de-
liver essential oral health services, HRSA should
• Support the use of a variety of oral health care professionals;
• Enhance financial incentives to attract and retain more oral health
care professionals;
• Provide guidance to implement best practices in management, op-
eration, and efficiency; and
• Assist FQHCs in all states to operate programs outside their physi-
cal facilities and take advantage of new systems to improve the oral
health of the population they serve.
Each of the specific actions outlined for FQHCs in this recommendation
build upon the committee’s previous recommendations and the evidence
that supports them.
The committee proposes the following strategies:
• Public–private partnerships can supplement educational loan re-
payment programs for oral health care professionals who are will-
ing to serve a designated amount of time in medically underserved
areas.
• HRSA can support dissemination and implementation of this rec-
ommendation by identifying FQHC “best practices” to highlight
what states or individual clinics are doing and what impact these
efforts are having on access.
• HRSA can support the demonstration and dissemination of mod-
els that extend the reach of FQHCs by operating programs out-
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16 IMPROVING ACCESS TO ORAL HEALTH CARE
side their physical facilities and that use new delivery models and
techniques.
• Other nonprofit community health centers can take the steps out-
lined in this recommendation to increase the delivery of essential
oral health services to greater numbers of vulnerable and under-
served individuals.
CONCLUSION
The release of this report coincides with a transformative moment in
the nation’s health care system. As the nation struggles to address the larger
systemic issues of access to health care, greater effort will be needed to
ensure that oral health is included in this conversation.
The recommendations presented in this report are directed to national,
state, and local governments; all types of health care professions; licensing
and accreditation bodies; educational institutions; health care research-
ers; and philanthropic and advocacy organizations. Together, these groups
have the power to transform the delivery of oral health care to vulnerable
and underserved populations. This report envisions an integrated delivery
system that provides quality oral health care to vulnerable and underserved
people where they live, work, and learn through changes in the education,
financing, and regulation of oral health care. The recommendations sup-
port the creation of a diverse workforce that is competent, compensated,
and authorized to serve vulnerable and underserved populations across the
life cycle. Implementation of these recommendations will be a critical next
step in increasing access to oral health care, reducing persistent oral health
disparities, and improving oral health outcomes among vulnerable and
underserved populations.
