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4
Settings of Oral Health Care
T
he oral health care system is bifurcated with its two parts functioning
in almost complete separation; in general, they use different financ-
ing systems, serve different population groups, and provide care in
different settings. In the private delivery system, care is typically provided
in small, private dental offices and financed primarily through employer-
based or privately purchased dental coverage and out-of-pocket payments.
The safety net, in contrast, is made up of a diverse and fragmented group
of providers in various settings. It is financed primarily through Medicaid
and the Children’s Health Insurance Program (CHIP), other government
programs, private grants, and out-of-pocket payments. (Financing will be
discussed more specifically in Chapter 5.) The safety net has an important
role providing care to the underserved, but it is limited in its capacity. As
discussed in Chapter 3, the nondental health care workforce is becoming
increasingly involved in the provision of oral health care. While primary
care settings (including private medical offices) should also be seen as set-
tings of care for oral health, this chapter will focus primarily on settings for
care provided by dental professionals.
This chapter gives an overview to the delivery of care in both private
practices and safety net settings, including descriptions of their patients,
staffing, challenges, and successes. The capacity of the system to care for
vulnerable and underserved populations will be addressed, as well as par-
ticular non-financial challenges. Finally, the chapter concludes with descrip-
tions of innovations occurring across the country to change how and where
oral health services are provided in order to meet the needs of vulnerable
and underserved populations.
157
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158 IMPROVING ACCESS TO ORAL HEALTH CARE
PRIVATE DELIVERY SYSTEMS
Most dental services are provided in private dental practices owned
and staffed by a single dentist. Approximately 92 percent of professionally
active dentists work in this private practice model (ADA, 2009a). (See Box
3-1 in Chapter 3 for a description of types of dentists.) About 60 percent
of private practice dentists are solo dentists (Wendling, 2010). Thirteen
percent of private practice dentists are employees, and 3 percent function
as independent contractors (ADA, 2009d). Private practices tend to be
located in areas that have the population to support them; thus, there are
more practices located in urban areas than rural areas, and more practices
are located in high-income than low-income areas (ADA, 2009a; Solomon,
2007; Wall and Brown, 2007).
Staffing
Independent dentists usually employ one or more individuals in the
private practice setting, with an average of 4.8 total staff members per
dentist (ADA, 2009b). On average, the independent dentist employs 1.3
dental hygienists per dentist and 1.8 chairside assistants per dentist. Nearly
90 percent of independent dentists employ at least one full-time person, and
68 percent employ at least one person who only works part-time. The ma-
jority of these dentists employ chairside assistants (94 percent of dentists),
secretaries/receptionists (91 percent), and dental hygienists (68 percent).
Some independent dentists employ office managers (31 percent), financial
coordinators (16 percent), and other personnel such as sterilization assis-
tants and laboratory technicians. However, dental assistants often perform
many of these duties.
Workload
Independent dentists work about 47.5 weeks annually and 35.9 hours
per week. These dentists spend about 90 percent of their work hours
treating patients (ADA, 2009a). In a survey by the American Dental As-
sociation (ADA) of the perceived workload of independent dentists, about
20 percent stated they were “not busy enough, could have treated more
patients” (ADA, 2009a). Independent general practitioners have an aver-
age of 1,871 active patients1 (for single dentist practices) (ADA, 2009a).
Independent general practitioners spend about 51 minutes per patient, and
their patients have about 3.3 visits per year. Independent specialists spend
slightly less time per patient (42 minutes), and the typical patient visits
1 Active patients are commonly defined as those treated within the previous 2 years.
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SETTINGS OF ORAL HEALTH CARE
40
36.5
30
20 17.3
13 12.5
10 6.9
5.3 4 3.2
1.4
0
Operative
Prosthodontics
Diagnostic
Preventive
Endodontics
Oral and
Maxillofacial
Surgery
Periodontics
General Services
Orthodontics
FIGURE 4-1
Percentage distribution of time spent by independent general
practitioners in private practice, 2007.
SOURCE: ADA, 2009a.
more frequently (five times per year). Independent general practitioners
only spend about one-quarter of their time on diagnosis or prevention (see
Figure 4-1). Both new and existing patients wait about a week for a new
appointment (a decrease of one full day from 2003). Independent dentists
see a little over five walk-in or emergency patients each week. In 2007, in-
dependent dentists had about 81 weekly scheduled visits (including dental
hygiene appointments).
In the private practices of independent dentists, dental hygienists work,
on average, almost 47 weeks per year and 24 hours per week (ADA,
2009b). Dental hygienists see about 25 patients per week. Chairside assis-
tants work almost 48 weeks per year and 32 hours per week.
Patient Population
The patients of independent general practitioners are spread relatively
evenly across the age spectrum (see Figure 4-2). Specialists see a signifi-
cantly greater proportion of patients aged 17 years or less, likely due to
the practice profiles of orthodontists and pediatric dentists (ADA, 2009a).
Slightly more than half (55 percent) of independent dentists’ patients
are female, and nearly two-thirds (63 percent) have private insurance
(ADA, 2009a). Only 7 percent of the patients of independent dentists re-
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160 IMPROVING ACCESS TO ORAL HEALTH CARE
< 5 years
4%
> 65 years
5 to 17 years
15%
13%
55 to 64 years 18 to 34 years
21% 19%
35 to 54 years
29%
FIGURE 4-2
Age breakdown for patients of independent general practitioners
in private practice, 2007.
NOTE: Does not total 100 percent due to rounding.
SOURCE: ADA, 2009a.
ceive public assistance for their dental coverage; the remaining 30 percent
of patients are not covered by any dental insurance. Nearly two-thirds of
all independent dentists (63.3 percent) and slightly more than half of all
new independent dentists (57.5 percent) do not have any patients covered
by public sources.
Expenses and Income
In 2007, the average gross billings per owner from the primary private
practice for all independent dentists was approximately $774,000 (or about
$656,000 per dentist in the practice and $500 per active patient), of which
approximately 94 percent was collected2 (ADA, 2009c). Independent den-
tists in incorporated practices tend to have higher gross billings per owner
than those in unincorporated practices. Independent dentists primarily
receive payment from private insurance and direct patient payment (see
Figure 4-3). Specialists tend to receive less payment from private insurance
and more from direct patient payment.
2 Gross billings are the total amount of fees charged. Calculations are made on a per
owner basis assuming equal contribution by all partners. Gross billings are only reported for
independent dentists who own their private practice.
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SETTINGS OF ORAL HEALTH CARE
Other, 1%
Managed
care, 10%
Direct patient
payment, 39%
Private
insurance, 44%
Government
programs, 6%
FIGURE 4-3
Sources of gross billings, all independent dentists, 2007.
SOURCE: ADA, 2009c.
In 2007, practice expenses (excluding the salaries of owners, but in-
cluding the salaries of other employees) accounted for 59 percent of gross
billings from the primary private practice of all independent dentists (ADA,
2009c). As discussed in Chapter 3, the salaries of private practice dentists
vary depending on employment situation and type of practice. For all inde-
pendent practitioners, net income does not vary greatly by number of years
since graduation. However, this does not take the number of hours worked
into account. Between 2003 and 2007, the net income of independent den-
tists increased about 1 percent annually (when adjusted for inflation) (ADA,
2009c). Between 1982 and 2000, dentists’ real income grew without change
to their workload (essentially, the number of patients seen per day and the
number of weeks worked per year remained relatively constant) (Guay,
2005). This increase in productivity is, in part, due to the increased use of
dental hygienists and dental assistants (Brown, 2005; Guay, 2005). (The
capacity and efficiency of the oral health care system is discussed further
later in this chapter.)
Demand for dental care may vary with the economic climate of the
country (Guay, 2005; Wendling, 2010). For example, the recent recession
was identified as a key factor contributing to 2009 having the slowest rate
of growth in health spending (4 percent) in the last 50 years (Martin et
al., 2011). Notably, expenditures on dental services had a negative rate of
growth (–0.1 percent) in 2009, down from a positive rate of growth of 5.1
percent in 2008.
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162 IMPROVING ACCESS TO ORAL HEALTH CARE
THE ORAL HEALTH SAFETY NET
Underserved and vulnerable populations often cannot access the private
dental system due to geographic, monetary, or other barriers, and so they
rely on the safety net. While the term safety net may give the impression
of an organized group of providers available to serve anyone who cannot
access the private system, the dental safety net is composed of unrelated
entities that both individually and collectively have very limited capacity.
Generally, the safety net is composed of an array of providers, including
(but not limited to) Federally Qualified Health Centers (FQHCs), FQHC
look-alikes, non-FQHC community health centers, dental schools, school-
based clinics, state and local health departments, and not-for-profit and
public hospitals. Each type of provider offers some type of dental care, but
the extent of the services provided and the number of patients served varies
widely. Even with this variety of options, the safety net still does not meet
the needs of all who are left out of the private system, often because of a
lack of capacity of these providers or a perceived lack of affordable options
by individuals (Bailit et al., 2006; Haley et al., 2008; Kenney et al., 2009;
Mertz and O’Neil, 2002). The following sections give brief overviews of
several types of providers and programs typically considered as part of the
safety net.
Federally Qualified Health Centers
An FQHC is any health center that receives a grant established by sec-
tion 330 of the Public Health Service Act.3 FQHCs must be located in or
serve a medically underserved area or medically underserved population,
provide both primary health care services as well as supportive services
(e.g., education, transportation, translation services), and see patients re-
gardless of their ability to pay for those services. FQHCs are governed
by community boards that have a fiduciary responsibility for the center,
and more than half of the board members must be patients of the health
center and represent the population served. The statute that established
FQHCs specifically identifies migratory and seasonal agricultural workers,
the homeless, and residents of public housing as underserved populations.
Thus, some FQHCs are referred to as Migrant Health Centers, Health
Care for the Homeless Programs, and Public Housing Primary Health Care
Centers. All of these programs fall under the umbrella term FQHC. FQHCs
receive a number of additional benefits in addition to section 330 grants,
including higher Medicare and Medicaid reimbursement rates, access to
3 42 U.S.C. §254b.
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SETTINGS OF ORAL HEALTH CARE
providers funded by the National Health Service Corps, and drug pricing
discounts (HRSA, 2010).
FQHCs primarily provide care to underserved and vulnerable individu-
als. In 2009, 71 percent of patients served by FQHCs had income at or
below 100 percent of the federal poverty level, 93 percent had income at or
below 200 percent of the federal poverty level, 38 percent were uninsured,
and 37 percent were insured by Medicaid. Table 4-1 illustrates the propor-
tion of FQHC patients who come from vulnerable and underserved popula-
tions, as compared to their representation in the U.S. population as a whole.
The FQHC program is growing steadily. In 2009, the Health Resources
and Services Administration (HRSA) funded 1,131 FQHCs, which are lo-
cated in all 50 states, the District of Columbia, and Puerto Rico (HRSA,
2011b). That number is up from 914 FQHCs in 2004. Funding for FQHCs
is also increasing. The American Recovery and Rehabilitation Act includes
$2 billion for FQHCs (HHS, 2010a), and the health care reform bills in-
cludes $11 billion for a Community Health Centers Trust Fund that will
allow FQHCs to expand access and make capital improvements, and $1.5
billion for a new National Health Service Corps Trust Fund.4
FQHCs are required to provide certain services—including preventive,
but not comprehensive, dental services—either in the clinic or by referral.
In 2008, 80 percent of the 1,080 FQHCs provided on-site dental services,
and 88 percent provided dental services on site or by referral (Anderson,
2010; Cottam, 2010). This reflects significant progress towards the Healthy
People 2020 goal of 83 percent of health centers including an oral health
component (HHS, 2010b). In 2009, FQHCs provided dental care to 3.4
million patients, in 8.4 million dental visits, which is nearly a three-fold
increase over the number of patients and visits in 2000 (HRSA, 2011c;
Ruddy, 2007). This care is not exclusively preventive; although FQHCs are
not required to provide comprehensive oral health services, over 75 percent
do so, and millions of patients received restorative and rehabilitative care
through FQHCs in 2009 (Anderson, 2010; HRSA, 2011b). The expansion
of dental services in FQHCs reflects a concerted commitment from HRSA.
Since 2001, HRSA has invested $55 million in oral health service expansion
grants (Anderson, 2010). In addition, a statutory change in the Children’s
Health Insurance Program Reauthorization Act allows FQHCs to expand
their reach outside of their physical facilities.5 FQHCs may now contract
with private practice dentists to provide oral health services to FQHC
4 Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess.
(March 23, 2010); Health Care and Education Reconciliation Act of 2010, Public Law 152,
111th Cong. 2nd sess. (March 30, 2010).
5 Children’s Health Insurance Program Reauthorization Act of 2009, Public Law 3, 111th
Cong., 1st sess. (February 4, 2009), §501.
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164 IMPROVING ACCESS TO ORAL HEALTH CARE
TABLE 4-1
Underserved and Vulnerable Populations Served in FQHCs as
Compared to Their Representation in the U.S. Population, 2009
Percentage of Percentage of U.S.
FQHC Population Population
Poverty
At or below 100% of poverty 71 14
Medical insurance status
Uninsured 38 17
Medicaid (Title XIX) 36 16
Private insurance 15 64
Race
Asian/Pacific Islander 5 5
American Indian/Alaska Native 2 1
African American 27 13
White 62 72
Ethnicity
Hispanic/Latino 16
35
NOTES: Percentages are of the FQHC population reporting a certain characteristic.
SOURCES: DeNavas-Walt et al., 2010; HRSA, 2011c; U.S. Census Bureau, 2010.
patients in the dentist’s office. Previously, some states required the dentist
to individually enroll in Medicaid before providing services for the FQHC
(CMS, 2011b).
FQHCs employ over 8,000 full-time equivalent dental staff, includ-
ing over 2,500 dentists and over 1,000 dental hygienists (HRSA, 2011e).
FQHC executive directors report that they most commonly recruit dentists
through the National Health Service Corps, although only 10.2 percent of
FQHC dentists report receiving a NHSC scholarship, and an additional
19.4 percent report receiving NHSC loan repayment (Bolin, 2010). Even
fewer dental hygienists report receiving funding from the NHSC. A large
number of FQHC dentists previously worked in the private sector; 31.9
percent reported previously working as a private practice owner, partner,
or associate, and 18.5 percent reported previously working as an employee
dentist in a private practice (Bolin, 2010). Dentists and dental hygienists
working at FQHCs report being generally satisfied with their work: 80.2
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SETTINGS OF ORAL HEALTH CARE
percent of dentists and 93.3 percent of dental hygienists intend to remain
employed in a health center practice (Bolin, 2010). But more than 39
percent of health centers reported at least one dentist vacancy, and over
50 percent of those positions were vacant for more than 6 months (Bolin,
2010; Cottam, 2010).
With the rapid expansion of dental programs in FQHCs, there appears
to be a lack of training and guidance for FQHC dentists. FQHC dental pro-
grams are unique within dentistry because they generally function within
a general health clinic, may not be ultimately overseen by a dental profes-
sional, and charge per encounter, rather than per procedure. Therefore,
specialized guidance may be necessary for the dental programs to thrive
(Geiermann, 2010). Previously, HRSA offered training and technical as-
sistance to FQHC dentists through its regional dental consultant program.
That program has essentially been eliminated, with the retirement of the
last consultant in 2009 (Geiermann, 2010). The number of dental public
health professionals employed by HRSA has dwindled from a high of over
100 to under 20, most of whom are not able to provide technical assistance
to FQHCs. Anecdotal reports indicate that current FQHC dentists do not
have a reliable source of assistance (Geiermann, 2010). Indeed, the last oral
health guidance to FQHCs was issued in March 1987 (Geiermann, 2010).
FQHC Look-Alikes
FQHC look-alikes were established by Congress to extend the con-
cept of FQHCs (HRSA, 2003). Look-alikes must meet all of the statutory
requirements of FQHCs—for example, they provide services to the medi-
cally underserved, operate as nonprofits, and be governed by a community
board—but they do not receive grant funding under section 330 (HRSA,
2003). FQHCs look-alikes are eligible for many, but not all, of the benefits
extended to FQHCs, such as increased Medicaid and Medicare payments
and drug pricing discounts (HRSA, 2003). Very little data are available
about the dental care provided at FQHC look-alikes because they are not
required to submit detailed information to the Department of Health and
Human Services about visits.
Community Health Centers
Many community health centers (CHCs) do not receive federal funding
or subsidies and operate completely outside of the FQHC system. Some of
those health centers are nonprofits, while some are supported or operated
by state and local governments. There is no national database of CHCs, so
very little information is available about the types of services they provide
or the numbers of patients they serve. One study roughly estimated that
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166 IMPROVING ACCESS TO ORAL HEALTH CARE
they serve about 2.2 million dental patients each year (Bailit et al., 2006).
CHCs generally have very limited funding. In 2001, for example, Illinois
CHCs had an average annual budget of $182,000 (Byck et al., 2005).
Dental Schools and Residency Programs
Dental students gain experience treating patients in dental school-based
clinics. The patients served in those clinics are generally low-income, so
dental school clinics are considered part of the dental safety net (Bailit
et al., 2006). Dental students provided about 2.9 million patient visits in
2001–2002, with an average of 13 visits per patient, meaning that dental
students treated about 224,000 patients during the year (Bailit et al., 2006).
The number of patient visits has remained relatively constant; in 2009,
dental students had 2.9 million patient visits in dental school clinics and in
community-based rotations (ADA, 2010).
The care provided in dental school clinics is affordable but time con-
suming for patients because clinics are organized as student teaching labo-
ratories rather than patient-centered delivery systems (Bailit et al., 2007).
Dental Education at the Crossroads recognized that the mixed missions
of educating students and caring for patients lead to trade-offs in both ef-
ficiency and quality of care:
Dental students must gain sufficient clinical experience in a variety of
technical procedures to become competent entry-level practitioners, quali-
fied to graduate and become licensed. A procedure-driven learning pro-
cess does not necessarily translate into efficient, high-quality patient care,
particularly when student care is further constrained by low budgets for
clinical and administrative support. (IOM, 1995)
Some progress has been made toward increasing the efficiency and pa-
tient-centeredness of dental school clinics, but more can be done (Formicola
et al., 2008).
In addition to on-site clinics at dental schools, dental students also pro-
vide care through community rotations in FQHCs and community health
centers (ADA, 2010). Of the 2.9 million dental visits provided by dental
students in 2009, approximately 450,000 were provided in the community
(ADA, 2010), and a large proportion of those visits were in underserved
communities (Atchison et al., 2009).
Residencies in dentistry, as in medicine, are an important source of care
for underserved populations, including economically and socially disadvan-
taged populations and medically compromised patients (Mito et al., 2002).
One recent study concluded that requiring 1 year of residency training
would significantly expand the capacity of community hospitals (or dental
schools) to care for the underserved (Bailit et al., 2006). By their estimates,
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SETTINGS OF ORAL HEALTH CARE
approximately 1,800 additional dental school graduates would participate
in a 1-year general dentistry residency program and an additional 887,000
patients would receive care each year.
School-Based Dental Clinics
School-based health centers (SBHCs) were developed to provide basic
health care services, including dental care, in elementary and secondary
schools. SBHCs are perhaps the most convenient care location for both
children and parents because they eliminate the need for transportation,
parent time off, and missed school. Children with access to a SBHC are
more likely to have seen a dentist in the past year than similar students
without access to a SBHC (Kaplan et al., 1999). In addition, children at
high risk for dental caries who have access to a school-based dental seal-
ant program are more than twice as likely to have sealants than children
without access (Siegal and Detty, 2010). SBHCs are also associated with
improved academic performance, increased use of primary care, reduced
use of emergency rooms, and increased use of vaccines (Allison et al., 2007;
Walker et al., 2010; Young et al., 2001).
While SBHCs offer significant potential to increase access to oral health
care, only a small number of schools have SBHCs, and only a small per-
centage of those SBHCs offer dental services. Approximately 1,900 school-
based health centers operate throughout the country (NASBHC, 2010).
Table 4-2 summarizes the oral health services provided by SBHCs during
the 2007–2008 school year. Many SBHCs offer simple preventive oral
health care, such as oral health education and dental screenings, both on
site and by referral, but fewer clinics offer more complex procedures. For
example, 84 percent of SBHCs provide oral health education both on site
and by referral, but that number drops to 57 percent for dental screenings,
20 percent for dental examinations by a dentist, and the ability of an SBHC
to provide oral health services is limited by the number staff qualified to
provide oral health services. Only 12.4 percent of SBHCs have a dental
provider on staff (NASBHC, 2010). The dental capacity could potentially
be expanded by using the new and emerging providers discussed in Chap-
ter 3, as is now done with nurse practitioners and physician assistants in
providing medical care in SBHCs. SBHCs have successfully worked in
collaboration with public health departments (discussed below) to provide
both screening and treatment services. Recognizing the potential for SBHCs
to expand access to oral health care to underserved populations, HRSA re-
cently announced a grant program to fund comprehensive oral health care
services in SBHCs (HRSA, 2011d).
Although some concern has been raised about whether SBHCs have
an adequate funding source (Silberberg and Cantor, 2008), the Patient
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182 IMPROVING ACCESS TO ORAL HEALTH CARE
make arrangements for the child to receive it.10 Appropriate care is deter-
mined by the state’s Early and Periodic Screening, Diagnosis, and Treatment
program and periodicity schedule. Head Start programs must also obtain
or arrange for testing, examination, and treatment for children with known
or suspected dental problems, and develop and implement a follow-up plan
for any problems identified.
To foster access to oral health for children enrolled in Head Start, in
2006, the Office of Head Start invested $2 million in grants to 52 Head
Start, Early Head Start, and Migrant/Seasonal Head Start programs for the
Head Start Oral Health Initiative; grantees received supplemental funding
for 4 additional years. While grantees reported successfully developing
partnerships with community organizations and providers who would serve
Head Start children, educating staff about the importance of oral health,
and incorporating oral health education into the curriculum, they reported
that they likely could not sustain much of the oral health programming
when the grant funding ended (Del Grosso et al., 2008).
Requirements Tied to Public Education
Several states have introduced programs requiring a dental examina-
tion or oral health assessment prior to school entry, though the provisions
of these programs differ across states. Even though the requirements have
been legislated, many of the plans do not have enforcement or follow-up
mechanisms in place. In addition, little data exist on the impact of these
types of requirements. Examples include the following:
• Illinois will withhold student report cards if the requirement is
unfulfilled (Conis, 2009).
• In 2008, Kentucky passed a law effective in the 2010–2011 school
year requiring children to have a dental examination prior to en-
rolling in public school (Conis, 2009).
• New York requests parents to provide a dental certificate docu-
menting an oral health exam at certain points during a child’s
school career (Conis, 2009).
Alternative Sites of Care
Portable Equipment
Patient-centered approaches to caring for vulnerable and underserved
populations may require consideration for bringing oral health care to the
10 Ibid.
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SETTINGS OF ORAL HEALTH CARE
sites that are more convenient for those populations. In particular, older
adults and disabled individuals may be unable to travel to travel to dentists’
offices. In these cases, portable equipment is increasingly being used to
provide on-site, community-based care in settings such as nursing homes,
group homes, schools, and Head Start centers.
For example, Apple Tree Dental (Apple Tree) is a private, nonprofit
organization in Minnesota that has provided care to individuals with spe-
cial health care needs across the life span in a variety of settings for over
25 years (Silow-Carroll and Alteras, 2004). The program has two dental
clinic “hubs,” but it provides most of its care through community-based
mobile programs. Apple Tree contends advantages to mobile care include
reduced anxiety for patients (due to the familiar environment), interdisci-
plinary care, and improved efficiency (e.g., reduction in transportation costs
for each patient) (Silow-Carroll and Alteras, 2004). Apple Tree has been a
source of community-based educational experiences for dental hygienists
and dental assistants through partnerships with dental hygiene and dental
assisting programs. Apple Tree also collects data on its patient population,
which facilitates research on special care populations. In 2008, Apple Tree
reported almost 60,000 patient encounters (Helgeson, 2009).
In another example, Dr. Greg Folse made a presentation to this commit-
tee regarding his work providing mobile oral health services for residents in
23 nursing facilities (Folse, 2010). Dr. Folse estimated that 61 percent of the
dentate nursing home residents (or 45 percent of the total resident popu-
lation) needed surgical interventions due to abscesses and/or severe gum
disease. He further estimated that this meant that 1,062 existing patients
were in need of surgical interventions and that an additional 371 new resi-
dents would need such care each year. In 2009, working part-time in these
nursing homes and using portable equipment, Dr. Folse reported being able
to treat 392 surgical cases, manage 3 cases of oral cancer, direct between
1 and 5 dental emergencies weekly (many of which were life threatening),
and treat 262 denture patients. He also noted one death occurring as a
result of oral disease. Dr. Folse also noted using portable dental equipment
to care for children in Louisiana schools. He reported using 15 dentists
and 18 expanded duty dental assistants to provide care in 275 schools. He
stated that the benefits of using portable equipment included decrease in
“no-show” patients, no late appointments, and no loss of time from work
for parents. Disadvantages include difficulty with scheduling time during
the school hours and obtaining parental consent. Dr. Folse noted that since
2001, his Louisiana school-based model had treated over 20,000 children
in the school setting and included over 30,000 patient visits.
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184 IMPROVING ACCESS TO ORAL HEALTH CARE
Retail Health Clinics
Retail health clinics have been rapidly developing as a new site of care
for general health care (Hunter et al., 2009; Laws and Scott, 2008; Mullin,
2009; Pollack and Armstrong, 2009; Pollack et al., 2010; Rudavsky et al.,
2009; Thygeson et al., 2008; Wang et al., 2010). Recently, retail dental
clinics have been proposed as an alternative site of dental care (Scott, 2009,
2010). Much like retail health clinics, retail dental clinics would be located
in pharmacies, grocery stores, and large retailers. The clinics would offer
a limited menu of services at set prices, focus primarily on preventive and
diagnostic care, and refer patients with more complex needs to dentists. Al-
though no retail dental clinics currently exist, an economic model suggests
that they could be viable if dental professionals could provide care without
the presence of a dentist (Scott, 2009).
Dental Homes
While not a physical site of care, the dental home is an emerging strat-
egy to increase access to consistent oral health care. A dental home is an
ongoing relationship between a patient and a dentist (AAPD, 2010a). The
dentist provides, among other things, regular comprehensive oral health
assessment and care, individualized preventive care based on caries- and
periodontal-risk assessments, education on proper nutrition and home
care, and referrals to specialists when necessary (AAPD, 2010b). To date,
dental homes have centered on providing care to children. However, the
medical home model, on which dental homes are based, has been used with
all populations to provide acute, chronic, and preventive medical services
(Martin et al., 2004). Thus, there may be an opportunity to expand the
dental home beyond the pediatric population.
One example of a dental home program is the Access to Baby and Child
Dentistry (ABCD) program, operated across Washington state through a
variety of public–private partnerships (ABCD, 2011; Donahue et al., 2005).
Partners include local health departments, the Washington State Dental Soci-
ety, local dental societies, the Washington Department of Health (WDOH),
the Washington Department of Social and Health Services (WDSHS), the
University of Washington School of Dentistry, the Washington Dental Ser-
vice Foundation, private dentists, and other community partners. Local
health departments typically manage the daily functions of ABCD pro-
grams. They work with the state and local dental professional organizations
to encourage dentist participation. Dentists who participate in the program
receive training and are paid an enhanced reimbursement rate. The health
departments also actively recruit Medicaid-eligible children to the program
through partnerships with community organizations such as WIC, Head
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SETTINGS OF ORAL HEALTH CARE
Start, and Early Head Start. In addition, the health departments provide
case management services to ABCD families. The WDSHS, WDOH, Uni-
versity of Washington School of Dentistry, and Washington Dental Service
Foundation oversee the program at the state level. The WDSHS oversees
Medicaid financing in the state, and thus provides reimbursement to ABCD-
certified dentists, and provides billing assistance, among other things. The
WDSHS also contracts with the University of Washington Dental School to
provide training and ongoing education to ABCD providers. The WDOH
provides technical assistance and grants to local health departments. The
Washington Dental Service Foundation provides start-up grants and ongo-
ing technical assistance to local ABCD programs.
ABCD programs have significantly increased the rate of dental visits
among children enrolled in Medicaid (Grembowski and Milgrom, 2000;
Lewis et al., 2009; Milgrom et al., 1999), particularly among the youngest
children (Kaakko et al., 2002). However, the evidence indicates that the
programs may be more successful at encouraging parents to make a single
dental appointment than develop an ongoing relationship with a dentist,
which is a key component of a dental home (Kaakko et al., 2002; Milgrom
et al., 1999). More long-term evaluations of the program need to be done
to assess the program’s ability to establish dental homes.
FINDINGS AND CONCLUSIONS
The committee noted the following findings and conclusions:
• Most oral health care in the United States is provided in the pri-
vate practice setting by dentists, who employ dental hygienists and
dental assistants.
• Most patients seen in the private practice setting either have dental
insurance or pay out of pocket.
• Only a small portion of private-sector oral health care is supported
by publicly funded programs such as Medicaid.
• An array of programs provides oral health care to underserved
and vulnerable populations, including FQHCs, dental schools, and
health departments.
• An oral health safety net exists in concept, but the components of
this safety net are not necessarily connected or coordinated.
• No single setting of care will meet the various needs or over-
come the multitude of barriers for vulnerable and underserved
populations.
• More research is needed on the impact of individual site of care
models in improving access to care.
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186 IMPROVING ACCESS TO ORAL HEALTH CARE
• More research is needed on best practices for individual sites of
care.
• There is room for building the capacity of the safety net to care for
vulnerable and underserved populations, but it will not be enough
to care for all patients in need. Strategies to improve access to care
for these populations will require the participation of dentists in
the private practice setting.
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