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Committee on Oral Health Access to Services
Board on Children, Youth, and Families
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. HHSH25034002T between the National
Academy of Sciences and the U.S. Department of Health and Human Services and
Contract No. 15328 between the National Academy of Sciences and the California
HealthCare Foundation. 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: 978-0-309-20946-5
International Standard Book Number-10: 0-309-20946-3
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
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) and NRC (National Research
Council). 2011. Improving access to oral health care for vulnerable and underserved
populations. Washington, DC: The National Academies Press.
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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 ORAL HEALTH ACCESS TO SERVICES
FREDERICK P. RIVARA (Chair), Seattle Children’s Guild Endowed
Chair in Pediatrics; Professor of Pediatrics, School of Medicine,
University of Washington
PAUL C. ERWIN, Professor and Chair, Department of Public Health,
University of Tennessee, Knoxville
CASWELL A. EVANS, JR., Associate Dean for Prevention and Public
Health Sciences, College of Dentistry, University of Illinois, Chicago
THEODORE G. GANIATS, Professor, Department of Family and
Preventive Medicine, School of Medicine, University of California,
San Diego
SHELLY GEHSHAN, Director, Pew Children’s Dental Campaign, Pew
Center on the States
KATHY VOIGT GEURINK, Clinical Associate Professor, Department
of Dental Hygiene, School of Health Professions, University of Texas
Health Science Center
PAUL GLASSMAN, Professor of Dental Practice, Director of Community
Oral Health, Arthur A. Dugoni School of Dentistry, University of the
Pacific
DAVID M. KROL, Team Director, Senior Program Officer, Human
Capital, Robert Wood Johnson Foundation
JANE PERKINS, Legal Director, National Health Law Program
MARGARET A. POTTER, Associate Dean; Director, Center for Public
Health Practice; Associate Professor of Health Policy & Management,
Graduate School of Public Health, University of Pittsburgh
RENEE SAMELSON, Associate Professor of Obstetrics and Gynecology,
Albany Medical College
PHYLLIS W. SHARPS, Professor and Associate Dean, Community and
Global Programs, School of Nursing, Johns Hopkins University
LINDA H. SOUTHWARD, Research Fellow & Research Professor, Social
Science Research Center, Mississippi State University
MARIA ROSA WATSON, Research Director, Primary Care Coalition of
Montgomery County
BARBARA WOLFE, Professor of Economics and Population Health
Sciences; Public Affairs and Faculty Affiliate, Institute for Research
on Poverty, University of Wisconsin-Madison
v
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Study Staff
TRACY A. HARRIS, Study Director
PATTI SIMON, Senior Program Officer
MEG BARRY, Associate Program Officer
ROSEMARY CHALK, Director, Board on Children, Youth, and Families
WENDY E. KEENAN, Program Associate
AMY ASHEROFF, Senior Program Assistant
vi
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Reviewers
T
his 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 confiden-
tial to protect the integrity of the deliberative process. We wish to thank the
following individuals for their review of this report:
BRUCE J. BAUM, National Institute of Dental and Craniofacial
Research
PAUL CASAMASSIMO, Nationwide Children’s Hospital
DANIEL G. DAVIDSON, private practice
A. CONAN DAVIS, University of Alabama
R. BRUCE DONOFF, Harvard School of Dental Medicine
CHRISTINE M. FARRELL, Michigan Department of Community
Health
JANE GILLETTE, Mint Dental Studio
JOHN S. GREENSPAN, University of California, San Francisco
MICHAEL J. HELGESON, Apple Tree Dental
CATHERINE HESS, National Academy for State Health Policy
CYNTHIA E. HODGE, National Dental Association Foundation
GENEVIEVE KENNEY, The Urban Institute
vii
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viii REVIEWERS
JULIA LEAR, The George Washington University
HUGH SILK, University of Massachusetts Medical School and
Hahnemann Family Health Center
GEORGE W. TAYLOR, University of Michigan
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclu-
sions or recommendations nor did they see the final draft of the report
before its release. The review of this report was overseen by DONALD M.
STEINWACHS, Johns Hopkins University, 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
O
ral health care is not uniformly attainable across the nation. Un-
fortunately, individuals who face the greatest barriers to care are
often among the most vulnerable members of our society. The
impact of unmet oral health care needs is magnified by the well-established
connection between oral health and overall health. These problems led the
Health Resources and Services Administration and the California Health-
Care Foundation to ask the Institute of Medicine (IOM) to advise them
on how to improve access to oral health care. The IOM committee, led by
Frederick Rivara, was charged with assessing the current oral health care
delivery system; exploring its strengths, limitations, and future challenges;
and describing a vision for the delivery of oral health care to vulnerable and
underserved populations. The committee worked in parallel with a second
IOM committee that focused on the role of the U.S. Department of Health
and Human Services in improving oral health. Together, they comprise an
extensive examination of the status of oral health and oral health care in
America.
In its examination of the evidence, the committee uncovered decades
of efforts that have been insufficient in eliminating significant disparities
in access to oral health care. However, this examination also revealed an
array of groups committed to improving access and highlighted common
goals and opportunities for collaboration and innovation. Examples appear
throughout the report and inform the committee’s recommendations. The
committee calls for a renewed commitment and a confluence of energies
directed at tackling these familiar and persistent challenges.
This report presents a vision for oral health care in the United States
ix
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x FOREWORD
where everyone has access to quality oral health care throughout the life
cycle. The committee acknowledges that realizing this vision will require
numerous coordinated and sustained actions, with special attention to the
distinct and varied needs of the nation’s vulnerable and underserved popu-
lations. Achieving this goal will require flexibility and ingenuity among
leaders at the federal, state, local, and community levels acting in concert
with oral health and other health care professionals. We hope this report
will encourage these groups to act on behalf of the nation’s vulnerable and
underserved populations and to take the important and necessary next steps
to improve access to oral health care, reduce oral health disparities, and
improve oral health.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
July 2011
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Preface
A
s Americans, we have become increasingly cognizant and, it is hoped,
intolerant of the disparities in access to health care in this country.
While our health care system has the capabilities for amazing treat-
ment of a wide array of maladies, this care is not uniformly available to
all. Disparities exist, however, not only in access to the latest in life-saving
technology but also in access to the most basic of routine health care. The
Patient Protection and Affordable Care Act of 2010 is intended to improve
access to care for all and reduce these disparities in health care and health.
Oral health care is one of those dimensions of our health care delivery
system in which striking disparities exist. More than half of the population
does not visit a dentist each year. Poor and minority children are substan-
tially less likely to have access to oral health care than are their nonpoor
and nonminority peers. Americans living in rural areas have poorer oral
health status and more unmet dental needs than their urban counterparts.
Older adults, especially those living in long-term care facilities, have a high
prevalence of oral health problems and difficulty accessing care by individu-
als trained in their special needs. Disabled individuals uniformly confront
access barriers, regardless of their financial resources. The consequences of
these disparities in access to oral health care have a strong influence not
only on oral health but on overall health as well. Poor oral health can lead
to malnutrition, childhood speech problems, and serious, and sometimes
fatal, infections. Poor oral health is associated with diabetes, heart disease,
and premature births. Oral disease in pregnant women and young moth-
ers can be transmitted vertically to their offspring, perpetuating a cycle of
disease.
xi
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xii PREFACE
In 2000, the surgeon general issued a report on oral health in this
country calling for action to improve the oral health of the nation. The
many efforts in both the public and private delivery systems to address
these disparities have been important, but they have not been successful
in eliminating them. Therefore, with support from the Health Resources
and Services Administration and the California HealthCare Foundation,
the National Research Council and the Institute of Medicine, through col-
laborative efforts between the Board on Children, Youth, and Families and
the Board on Health Care Services, formed the Committee on Oral Health
Access to Services. The charge was to assess current access to oral health
care especially for vulnerable and underserved populations and to provide
a vision of how oral health care should be addressed by public and private
providers across the nation.
The committee held five meetings and one public workshop. We en-
gaged in vigorous, thoughtful discussions regarding the causes of the cur-
rent disparities in access to oral health care and the best approaches to
addressing the problem both in the short and long term. We did so cog-
nizant of the economic challenges facing the nation and individual states
today, and with the awareness that oral health care is a part of our overall
health care delivery system. It is our hope that the findings and recommen-
dations of this report will help policy makers, service providers and their
professional organizations, and funders and government agencies to address
these access problems in new, meaningful, and innovative ways that will
result in oral health for all.
The committee could not have done its work without the outstand-
ing guidance and support provided by the NRC-IOM staff: Tracy Harris,
study director; Patti Simon, senior program officer; and Meg Barry, as-
sociate program officer. Amy Asheroff provided skilled logistic support to
the committee. Rosemary Chalk’s guidance and counsel were invaluable
throughout our deliberations. The health professionals who participated in
our workshop and provided information to the committee deserve special
thanks for their time and effort.
All Americans deserve to enjoy good oral health. We hope this report
will help the nation achieve that vision.
Frederick P. Rivara, Chair
Committee on Oral Health Access to Services
July 2011
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Acknowledgments
T
he Committee on Oral Health Access to Services benefited from the
contributions of many individuals. The committee takes this op-
portunity to recognize 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 outside the committee. The following individuals shared their experi-
ences and perspectives during public meetings of the committee:
Ann Battrell, American Dental Hygienists’ Association
Marcia K. Brand, Health Resources and Services Administration
Gina Capra, Health Resources and Services Administration
James Crall, American Academy of Pediatric Dentistry
Terry Dickinson, Virginia Dental Association
Bruce Dye, Centers for Disease Control and Prevention
Greg Folse
Steven Geiermann, American Dental Association
Michael Griffiths, Institutional Dental Care
David Grossman, GroupHealth Cooperative
David Halpern, Academy of General Dentistry
Lawrence Hill, CincySmiles Foundation
John McFarland, National Network for Oral Health Access
Peter Milgrom, University of Washington
Laurie Norris, Pew Children’s Dental Campaign
Greg Nycz, Family Health Center of Marshfield, Inc.
Edward O’Neil, University of California, San Francisco
xiii
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xiv ACKNOWLEDGMENTS
Jesley Ruff, American Dental Partners
Bob Russell, Iowa Department of Public Health
Mary Kate Scott, Scott & Company, Inc.
Robert Shesser, George Washington University
Mark Siegal, Ohio State Department of Health
Kristen Simmons, Willamette Dental
Woosung Sohn, University of Michigan
Ron Tankersley, American Dental Association
Jessica Van Arsdale, Humboldt State University
Louise Veselicky, West Virginia University
The committee commissioned papers to provide background informa-
tion for its deliberations and to synthesize the evidence on particular issues.
We thank the following individuals for their contributions to these papers:
David Armstrong, Center for Health Workforce Studies, University at
Albany
Howard Bailit, University of Connecticut
John D’Adamo, University of Connecticut
Burton Edelstein, Columbia University
Margaret Langelier, Center for Health Workforce Studies, University
at Albany
Jean Moore, Center for Health Workforce Studies, University at Albany
We extend special thanks to the following individuals who were essen-
tial sources of information, generously giving their time and knowledge to
further the committee’s efforts:
Kay Johnson, Johnson Group Consulting
Lew Lampiris, American Dental Association
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 Patrick Burke, Greta Gorman, Roger
Herdman, William McLeod, Janice Mehler, Abbey Meltzer, Lauren Tobias,
and Ben Wheatley 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 individuals instrumental in developing this project: Marcia Brand,
Health Resources and Services Administration; Len Finocchio, California
HealthCare Foundation; and Mark Nehring, Health Resources and Services
Administration.
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Contents
SUMMARY 1
1 INTRODUCTION 17
Barriers to Oral Health Care Access, 18
The Consequences of Poor Oral Health, 19
Efforts to Improve Access to Oral Health Care, 19
Study Charge, Scope, and Approach, 21
Guiding Principles, 24
Definitions of Key Terms, 25
Notable Past Work, 27
Organization of the Report, 34
References, 35
2 ORAL HEALTH STATUS AND UTILIZATION 41
The Connection Between Oral Health and Overall Health, 41
Overview of Oral Health Status and Access to Oral Health Care
in the United States, 43
Oral Health Status and Access to Oral Health Care for
Vulnerable and Underserved Populations, 47
Factors That Contribute to Poor Oral Health and Lack of Access
to Oral Health Care, 60
Findings and Conclusions, 67
References, 67
xv
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xvi CONTENTS
3 THE ORAL HEALTH CARE WORKFORCE 83
The Dental Workforce, 83
Education and Training of the Dental Workforce, 94
The Nondental Workforce, 105
Public Health Workers, 112
Interprofessional Education, Training, and Care, 113
Regulating the Dental Workforce, 115
Innovations in the Oral Health Care Workforce, 121
Findings and Conclusions, 134
References, 137
4 SETTINGS OF ORAL HEALTH CARE 157
Private Delivery Systems, 158
The Oral Health Safety Net, 162
Capacity and Efficiency of the Current System, 173
Innovations in Settings of Care, 178
Findings and Conclusions, 185
References, 186
5 EXPENDITURES AND FINANCING FOR ORAL
HEALTH CARE 193
Overview of Expenditures, 194
Overview of Coverage, 197
Private Sources of Financing, 200
Publicly Subsidized Coverage, 202
Additional Sources of Federal and State Funding for
Oral Health Services, Infrastructure, and Research, 211
The Patient Protection and Affordable Care Act, 215
Innovations in Financing and Coverage, 216
Limitations, 221
Findings and Conclusions, 221
References, 222
6 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE
TO VULNERABLE AND UNDERSERVED POPULATIONS 229
Overall Conclusions, 230
A Vision for Improving Access to Oral Health Care, 230
Recommendations, 231
Closing Thoughts, 252
References, 253
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xvii
CONTENTS
APPENDIXES
A Acronyms 255
B Commissioned Papers 259
C Workshop Agendas 261
D Summary of Advancing Oral Health in America: A Report of the
IOM Committee on an Oral Health Initiative 265
E Committee and Staff Biographies 271
