+ Principles in Dental Public Health © AAPHD
+ Course Created By Vinodh Bhoopathi. , BDS. , MPH. , DSc. D Course Contributors: Dr. Woosung Sohn, Dr. Susan Reed, Diane Brunson, Robin Knowles, Karen Yoder, Dr. Ana Karina Mascarenhas, Dr. Kathryn Ann Atchison
+ This project is supported by the Health Resources and Services Administration (HRSA) of the U. S. Department of Health and Human Services (HHS) under grant number D 83 HP 19949 Predoctoral Training in General, Pediatric, and Public Health Dentistry and Dental Hygiene, grant amount $650, 000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U. S. Government. 3 © AAPHD 3
+ Course Competencies Describe social and health care systems and determinants of health and their impact on the oral health of the individual and population Demonstrate the ability to access and describe the use of population-based health data for health promotion, patient care, and quality improvement 4 © AAPHD 4
+ Course Objectives n Identify and describe the principles of public health as it relates to oral health and the dental professional. n Describe the public health and dental public health achievements in the US. n Describe the oral health status and needs of the US population, including various age groups, underserved, and minority populations. n Describe the dental disease trends among various US populations. n Identify and explain determinants associated with heath care access and utilization of dental care services. n Recognize the roles of public, private, professional and voluntary organizations in promoting oral health, and the delivery of dental health care services. n Describe and differentiate different oral health workforce models. © AAPHD 5
+ Lecture 1 Introduction to Dental Public Health 6 © AAPHD 6
+ Learning Objectives n Define Public Health and Dental Public Health n Describe three core functions of public health n Describe the ten essential public health services n Identify the difference between the roles of a private dental practitioner and a dental public health specialist n List and describe the roles of major federal agencies involved in oral health and dental public health n Identify the roles of other professional organizations promoting oral health © AAPHD 7
+ Mission of Public Health “Fulfilling society’s interest in assuring conditions in which people can be healthy” The Future of the Public's Health in the 21 st Century, 2002. Institute of Medicine © AAPHD 8
+ Definition n n * Public Health: the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts. Dental Public Health*: the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. Competency Statements in Dental Public Health. J Public Health Dent, 1998; 58 (1): 119 -22. © AAPHD 9
Dental Public Health (DPH) + One of nine dental specialties recognized by the American Dental Association (ADA) n Recognized a specialty in 1950 n Sponsoring organization is the American Association of Public Health Dentistry (AAPHD) n Separate and distinct from any recognized dental specialty n Contributes to new knowledge, research, education, services that directly benefits different aspects of clinical patient care n Unique knowledge and skills (Masters in Public Health and residency) that generally takes two years of education beyond the pre-doctoral dental curriculum © AAPHD 10
Core Competencies in Dental + Public Health (DPH) A specialist in DPH will I. Plan oral health programs for populations II. Select interventions and strategies for the prevention and control of oral diseases and promotion of oral health. III. Develop resources, implement and manage oral health programs for populations IV. Incorporate ethical standards in oral health programs and activities V. Evaluate and monitor dental care delivery systems VI. Design and understand the use of surveillance systems to monitor oral health VII. Communicate and collaborate with groups and individuals on oral health issues VIII. Advocate for, implement and evaluate public health policy, legislation, and regulations to protect and promote the public's oral health IX. Critique and synthesize scientific literature X. Design and conduct population-based studies to answer oral and public health questions Dental Public Health Competencies. J Public Health Dent 1998, 58; 121 -22 © AAPHD 11
+ Public Health n The concept of Public Health that emerged in the beginning of the 20 th century had three core public health functions: n Assessment n Policy Development n Assurance © AAPHD 12
+ Assessment n “…is the regular and systematic collection, assemblage, analysis, and communication on the health of the community. ” n Includes statistics on: n Health and oral health status n Community health needs n Resources to address needs IOM: The Future of Public Health, 1988 © AAPHD 13
+ Policy Development n “…. is the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision-making about public health…. ” n Strategic approach IOM: Future of Public Health, 1988 © AAPHD 16
+ Assurance n Assure that the public has access to necessary health services through regulation, education or direct provision of services n Encouraging actions by other entities, public or private n Requiring such action through legislation n Providing services directly © AAPHD 18
+ Assurance n “…involve key policymakers and the general public in determining a set of high-priority personal and communitywide health services that governments will guarantee to every member of the community…. . ” n Include subsidization or direct provision of highpriority personal health services for those unable to afford them IOM: The Future of Public Health, 1988 © AAPHD 19
The Ten Essential Services © AAPHD 21
+ Ten Essential Public Health Services From these core functions (Assessment, Policy Development, and Assurance) ten essential public health services emanate 1. Monitor health status to identify and solve community health problems. 2. Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships and action to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Assure competent public and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems. © AAPHD 22
+ How can DDS/RDH use 3 core PH functions compared to a DPH specialist? Private Practice (DDS/RDH) Public Health (DPH Specialist) Individual Patient Community as Patient Exam Survey Diagnosis/Assessment Analysis Treatment Plan Program Planning Treatment Program Implementation Fee/payment Budget/Financing Recall/pt. evaluation Program Evaluation © AAPHD 23 23
Dental Public Health + Infrastructure in the US © AAPHD
+ Dental Public Health Infrastructure n The dental public health (DPH) infrastructure is the foundation upon which public dental programs and activities are assessed, planned, executed, and evaluated. n Federal, state, and local or county governments have the potential to make a significant impact on a community’s oral health n US Department of Health and Human Services (HHS) is the primary federal agency that administers public health programs in the US Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental Public Health in the United States. Dent Clin N Am 2008, 52: 259 -280 © AAPHD 25
HHS Organization Chart + The Executive Secretariat Office of Health Reform Secretary -----------Deputy Secretary -----------Chief of Staff Office of Intergovernmental and External Affairs Office of the Assistant Secretary for Administration (ASA) Administration for Children and Families (ACF) Centers for Medicare and Medicaid Services (CMS) Program Support Center (PSC) Administration for Community Living (ACL) Food and Drug Administration (FDA) * Agency for Health Care Research and Quality (AHRQ)* Health Resources and Services Administration (HRSA) * Office of the Assistant Secretary for Financial Resources (ASFR) Office of the Assistant Secretary for Health (OASH) * Office of the Assistant Secretary for Legislation (ASL) Office of the Assistant Secretary for Planning and Evaluation (ASPE) Agency for Toxic Substances and Disease Registry (ATSDR)* Indian Health Services (IHS) * Centers for Disease Control and Prevention (CDC) * National Institute of Health (NIH) * Substance Abuse & Mental Health Services Administration (SAMHSA) * Office of the Assistant Secretary for Preparedness and Response (ASPR) * Office of the Assistant Secretary for Public Affairs (ASPA) Center for Faith-based and Neighborhood Partnerships (CFBNP) Office of Civil Rights (OCR) Departmental Appeals Board (DAB) Office of the General Counsel(OGC) Office of Global Affairs (OGA) * Office of Inspector General (OIG) Office of Medicare Hearing and Appeals (OMHA) * Designates a component of U. S. Public Health Services Office of National Coordinator for Health Information Technology (ONC) http: //www. hhs. gov/about/orgchart/ © AAPHD 26
+ HHS n Office of Surgeon General n Surgeon General - nation’s chief health educator, appointed by the President and confirmed by the Senate, and reports to the Secretary of Health and Human Services. n In 2000, the first ever Surgeon General’s Report on Oral Health describing the magnitude of oral diseases in the United States population and the actions necessary to address them was released Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental Public Health in the United States. Dent Clin N Am 2008, 52: 259 -280 © AAPHD 27
+ HHS n Healthy People 2020 Healthy People - health objectives for the nation. Current one is Health People 2020 to be achieved over the second decade of this century n Oral health Goal “Prevent and control oral health diseases, conditions, and injuries, and improve access to preventive services and dental care” n Oral health objectives (OH 1 to 17) n n n OH 1 to 6 - Oral health in children, adolescents and adults n (dental caries, untreated tooth decay, tooth loss) OH 7 to 11 - Access Preventive Services n (school based centers, service utilization, FQHCs with oral health) OH 12 to 14 - Oral health interventions n (sealants, community water fluoridation) OH 15 to 16 – Monitoring and surveillance systems n (systems recording and referring cleft lip and palate, oral and craniofacial systems) OH 17 - Public health infrastructure n (health agencies with a DPH professional directing programs) © AAPHD 28
+ HHS Healthy People 2020 n The Oral Health Leading Health Indicator is: “Persons aged 2 years and older who used the oral health care system in the past 12 months (OH-7)” n HP 2020 Baseline is 2007: 44. 5% of persons aged 2 years and over had a dental visit in the past 12 months (age adjusted). n HP 2020 Target: 49. 0% (age adjusted), or 10 percent improvement http: //www. healthypeople. gov/2020/LHI/oral. Health. aspx? tab=data © AAPHD 29
+ HHS 30 United States Public Health Services (USPHS) n Uniformed service of more than 6, 000 health professionals who serve in the HHS and other federal agencies n Primary care provider and advocate for Alaskan Native and American Indians The Surgeon General heads this uniformed commissioned corps n Indian Health Services In 2007 approximately 390 dental offices n Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental Public Eealth in the United States. Dent Clin N Am 2008, 52: 259 -280 © AAPHD 30
+ HHS n National Institute for Dental and Craniofacial Research (NIDCR) – one of the 24 institutes under National Institutes of Health n To improve oral, dental and craniofacial health through research, research training, and the dissemination of health information. n Performing and supporting basic and clinical research; n Conducting and funding research training and career development programs to ensure an adequate number of talented, well-prepared and diverse investigators; n Coordinating and assisting relevant research and research-related activities among all sectors of the research community; n Promoting the timely transfer of knowledge gained from research and its implications for health to the public, health professionals, researchers, and policy-makers. http: //www. nidcr. nih. gov/About. Us/Missionand. Strategic. Plan/Mission. Statement/ © AAPHD 31
+ HHS n Centers for Disease Control and Prevention: Division of Oral Health n n n n Works to improve the oral health of the nation and reduce inequalities in oral health by: Helping states improve their oral health programs. Extending the use of proven strategies to prevent oral disease by— n Encouraging the effective use of fluoride products and community water fluoridation. n Promoting greater use of school-based and –linked dental sealant programs. Enhancing efforts to monitor oral diseases, such as dental caries and periodontal infections. Contributing to the scientific knowledge-base regarding oral health and disease. Guiding infection control in dentistry. Helping states improve their oral health programs Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental Public Health in the United States. Dent Clin N Am 2008, 52: 259 -280 © AAPHD 32
+ HHS n Health Resources and Services Administration (HRSA) Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. n HRSA grantees provide health care to uninsured people, people living with HIV/AIDS, and pregnant women, mothers and children n Goal I: Improve Access to Quality Care and Services. n Goal II: Strengthen the Health Workforce. n Goal III: Build Healthy Communities. n Goal IV: Improve Health Equity. n © AAPHD 33
+ HHS n Centers for Medicare & Medicaid Services (CMS) n The CMS is an agency within the HHS responsible for administration of several key federal health care programs - in addition to Medicare (the federal health insurance program for seniors) and Medicaid (the federal needsbased program), CMS oversees the Children’s Health Insurance Program (CHIP), and the Health Insurance Portability and Accountability Act (HIPAA), among other services © AAPHD 34
+ HHS n U. S n n n Food and Drug Administration (FDA) Protect the public health by assuring that foods are safe, wholesome, sanitary and properly labeled; ensuring that human and veterinary drugs, and vaccines and other biological products and medical devices intended for human use are safe and effective. Protect public from electronic product radiation Assure cosmetics and dietary supplements are safe and properly labeled Regulate tobacco products Advance the public health by helping to speed product © AAPHD 35
+ Professional Organizations Supporting Dental Public Health n Advocate and promote optimal oral health care for all American Association of Public Health Dentistry n American Board of Dental Public Health n American Public Health Association, Oral Health Section n Association of State and Territorial Dental Directors n American Association of Community Dental Programs n American Dental Education Association n American Dental Association n American Academy of Pediatric Dentistry n © AAPHD 36
+ American Association of Public Health Dentistry (AAPHD) n Founded 1937 n Sponsor of the American Board of Dental Public Health, n Publishes the Journal of Public Health Dentistry, and is n Co-sponsor of the yearly National Oral Health Conference n AAPHD is committed to: n “Promotion of effective efforts in disease prevention, health promotion and service delivery”, n “Education of the public, health professionals and decision-makers regarding the importance of oral health to total well-being”, and n “Expansion of the knowledge base of dental public health and fostering competency in its practice”. © AAPHD 37
+ American Board of Dental Public Health n National examining and certifying agency for the specialty of dental public health n Functions n creation of standards for the practice of dental public health; n grant and issue dental public health certificates to dentists who have successfully completed the prescribed training and experience requisite for the practice of dental public health; and n ensure continuing competency of diplomates © AAPHD 38
+ American Public Health Association n Founded in 1872 – largest public health organization in the world n Publishes the American Journal of Public Health. n Oral Health Section is one of many sections of APHA n Provides DPH members a forum to obtain support from non. DPH members/leaders and decision makers n Some public health issues that OH section investigates and promotes n Community water fluoridation n Access to dental care for vulnerable groups n Reducing racial and ethnic oral health disparities n Domestic violence screening etc © AAPHD 39
Association of State and Territorial + Dental Directors n Non-profit organization representing the directors and staff of state public health agency programs for oral health n Promote the leadership capacity of state dental programs and the impact that their collective oral disease prevention and health promotion activities have on the nation's oral health establishes national dental public health policies, n assists in development and implementation of programs and policies for the prevention of oral diseases; n developing position papers and policy statements; n provides information on oral health to health officials and policy makers, and conducts conferences for the dental public health community n © AAPHD 40
American Association of + Community Dental Programs n Voluntary membership organization - Supports effort of those with an interest in serving the oral health needs at the community level n Guides local public health agencies through the steps for developing, integrating, expanding, or enhancing community oral health programs n Members include local dental directors and staff of city, county, and community-based health programs © AAPHD 41
American Dental Education + Association n National organization representing academic dentistry - voice of dental education. n ADEA members - 19, 000 students, faculty, staff, and administrators from all of the U. S. and Canadian dental schools, many allied and advanced dental education programs, and numerous corporations working in oral health education n ADEA has a section on community and preventive dentistry and behavioral sciences. n explores issues related to community and preventive dentistry as they apply to dental and dental hygiene education, research and practice n The ADEA publishes the Journal of Dental Education © AAPHD 42
+ American Dental Association n Founded in 1859, the American Dental Association (ADA) is the oldest and largest national dental society in the world over 157, 000 ADA members n “professional association of dentists committed to the public’s oral health, ethics, science and professional advancement; leading a unified profession through initiatives in advocacy, education, research and the development of standards” n Works to advance the dental profession on the national, state and local level http: //www. ada. org/6876. aspx http: //www. ada. org/sections/professional. Resources/pdfs/dph_educational_module. pdf © AAPHD 43
+ American Academy of Pediatric Dentistry n Membership organization representing specialty of pediatric dentistry the n Mission of the AAPD is to advocate policies, guidelines and programs that promote optimal oral health and oral health care for children. n Serves and represents its membership in the areas of professional development and governmental and legislative activities. © AAPHD 44
+ Lecture 2 Population-Based Public Health Strategies 45 © AAPHD 45
+ Learning Objectives n Define the approaches used by Public Health to improve the health of the community n Describe the importance of various public health achievements, including dental public health achievements in the last century n Describe the population level impact of community level water fluoridation © AAPHD 46
+ Public Health Practice n Focuses on the health of groups, community, or the nation. n Population-focused care is defined as interventions aimed at disease prevention and health promotion that shape a community’s overall health profile (DHHS, 1994 a) n Key feature of public health practice is the acknowledgment that health is greater than the biological determinants of individual health; n It also embraces a host of behavioral, social, economic, and environmental factors (including biological determinants of individuals) that affect the health of a community health nursing practice : a population-based approach 2004. Available at Porsche DJ. Public & http: //www. sagepub. com/upm-data/3989_Chapter_1. pdf © AAPHD 47
+ 20 th Century Public Health Achievements U. S. 1900 -1999 48 n Vaccination n Healthier Mothers and Babies n Motor Vehicle Safety n Family Planning n Safer Workplaces n Community Water Fluoridation n Control of Infectious Disease n n Decline in Deaths from CVD and Stroke Recognition of Tobacco Use as a Health Hazard n Safer and Healthier Foods http: //www. cdc. gov/mmwr/preview/mmwrhtml/00056796. htm © AAPHD 48
+ Vaccinations n Polio vaccinations n First outbreak described in US in 1843 n 1951 -1954, an average of 16, 316 paralytic polio cases and 1879 deaths n Polio vaccines introduced in US 1955 n Following the introduction of vaccine, polio cases declined sharply to less than 1000 cases in 1962 and remained below 100 cases after that year http: //www. cdc. gov/vaccines/pubs/pinkbook/polio. html © AAPHD 49
+ Vaccinations ONLY 82% receive vaccination in 2011 Only 69% received vaccination DTP, polio, MMR, and Hib vaccines © AAPHD 50 DTP, polio, MMR, and Hib vaccines + hepatitis B vaccine, and the varicella vaccine
+ Vaccinations n 51 Community or Herd immunity n Critical portion of a community is immunized against a contagious disease, most members of the community are protected against that disease because there is little opportunity for an outbreak. The National Institute of Allergy and Infectious Diseases (NIAID) http: //www. vaccines. gov/basics/protection/index. html © AAPHD 51
+ Vaccinations 52 n Community or Herd immunity n 18% not immunized could increase the risk of outbreaks The National Institute of Allergy and Infectious Diseases (NIAID) http: //www. vaccines. gov/basics/protection/index. html © AAPHD 52
© AAPHD 53
+ Motor Vehicle Safety n 1960 unintentional injuries caused 93, 803 deaths – 41% related to motor vehicle crashes n 1966 - Highway Safety Act and Motor Vehicle Safety Act n Vehicles were built with new safety features n head rests, energy-absorbing steering wheels, shatter-resistant windshields, and safety belts n Roads were improved – use of breakaway signs, improved illuminations n 1970 – evidence decrease in deaths due to motor vehicle crashes. © AAPHD 54
+ Motor Vehicle Safety Motor-vehicle related death rates per 100, 000 population and per 100 million vehicle miles traveled (VMT), by year – Unites States, 1966 -1997 http: //www. cdc. gov/mmwr/preview/mmwrhtml/mm 4818 a 1. html © AAPHD 55
+ Safer Workplaces n Beginning of this century – workers faced high health and safety risk in their workplaces © AAPHD 56
Safer Workplaces – Example Mining + related deaths 50% decrease in coal mining fatality rates occurred from 1966 -1970 to 19711975 following passage of the 1969 Federal Coal Mine Health and Safety Act Following the 1977 Federal Mine Safety and Health Act, a 33% decrease in fatalities occurred in metal and nonmetallic minerals mining (1976 -1980 compared with 1981 -1985) MMWR July 11, 1999 / 48(22); 461 -469 © AAPHD 57
+ Safer Workplaces – Dental office n Universal precautions n Infection control n Mercury and amalgam safety n Radiation safety n Ergonomics n Agency responsible to oversee workplace safety: Occupational Safety and Health Administration (OSHA) © AAPHD 58
+ Control of Infectious Disease n The 19 th century shift in n population from country to city industrialization and immigration n overcrowding in poor housing served by inadequate or nonexistent public water supplies and waste-disposal systems. n These conditions resulted in repeated outbreaks of cholera, dysentery, TB, typhoid fever, influenza, yellow fever, and malaria Discovery of microorganisms as the cause of diseases – resulted in improvements in sanitation, hygiene, discovery of antibiotics, vaccination programs etc n n n Tuberculosis Typhoid Fever Diphtheria Cholera HIV/AIDS © AAPHD 59
+ Control of Infectious Diseases n 60 Typhoid fever in US n Dramatic declines in incidence and mortality - after widespread implementation of municipal water and sewage treatment systems n n 1920: 33. 8 new cases per 100, 000 population; 1930, 20 new cases, and 1960 less than 1 new case Rare disease, with approximately 300 clinical cases reported per year http: //www. cdc. gov/healthywater/observances/dww-graph. html © AAPHD 60
+ Control of Infectious Diseases Reductions in diagnosis and deaths attributed to active antiretroviral therapies introduced in 1996 http: //www. cdc. gov/hiv/topics/surveillance/resources/slides/trends/index. html © AAPHD 61
+ Safer and Healthier Foods n Early 20 th century – contaminated food, milk, water caused foodborne infections n 1906 – Pure food and drug act n Food Safety: n n n Identification of handwashing, sanitation, refrigeration, pasteurization, and pesticide application as methods to minimize foodborne infections (TB, Typhoid fever, Cholera) Healthier animal care, feeding and processing – improved food supply Nutrition: n n Food fortification programs decreased nutritional deficiency diseases like goiter, rickets Pellagra elimination in 1940 s – improved diet, enrichment of flour with niacin © AAPHD 62
+ Safer and Healthier Foods Number of reported pellagra deaths, by sex of decedent and year – US, 1920 -1960 http: //www. cdc. gov/mmwr/preview/mmwrhtml/mm 4840 a 1. html © AAPHD 63 63
+ Decline in Deaths from CVD and Stroke n n 1920 s-30 s: heart disease and stroke leading cause of death – together 40% of all deaths Since 1950 - death rates from cardiovascular disease (CVD) declined 60% During 1970 s-80 s – public health interventions to reduce CVD have benefitted from a “high risk” approach (target high risk people for CVD), and “population-wide” approach (lower risk for the entire community) n National programs targeted health providers, patients and public n National High Blood Pressure Education Program: 1972 n National Cholesterol Education Program: 1985 Reduction due to combination of factors n Decline cigarette smoking, mean blood pressure and cholesterol levels, changes in diet (consumption of saturated fat and cholesterol decreased), improvements in medical care and availability of medications © AAPHD 64
+ Decline in Deaths from CVD and Stroke http: //www. cdc. gov/mmwr/preview/mmwrhtml/mm 4830 a 1. html © AAPHD 65
+ Family Planning n In 1900, 6 to 9 / 1000 women died in childbirth, and one in five children died during the first 5 years of life. n Distributing information and counseling patients about contraception and contraceptive devices was illegal under federal and state laws n 1912 – Modern Birth control movement began n Hallmark of family planning – the ability to achieve desired birth spacing and family size - leading to decreased fertility rates n Traditional methods of fertility control n Modern contraception and reproductive health systems n 1972 - Publicly supported family planning services through Medicaid funding prevented 1. 3 million unintended pregnancies annually © AAPHD 66
+ Family Planning http: //www. cdc. gov/mmwr/preview/mmwrhtml/mm 4847 a 1. html © AAPHD 67
+ Healthy Mothers and Healthy Babies http: //www. cdc. gov/mmwr/preview/mmwrhtml/mm 4838 a 2. html © AAPHD 68
+ Healthy Mothers and Healthy Babies n Infant mortality - Beginning of 20 th century – 100 infants/1000 live births died before age 1 n n Improved sewage, refuse disposal, safe drinking water – key role in infant mortality n Decline fertility rate – longer spacing of children, small family, better nutritional status n Milk pasteurization – controlled milk-borne diseases n Antibiotics, safe blood transfusions, electrolyte replacements n Vaccinations Maternal Mortality – Beginning of 20 th century, for every 1000 live birth 6 to 9 women died of pregnancy complications n Maternal mortality highest between 1900 to 1930 – due to Poor obstetric education and delivery practices n 1930 s to 40 s – White House Conference Review committees n Home births shift to hospital births n Improved institutional guidelines n Antibiotics, asepsis, management of hypertension © AAPHD 69 69
+ Tobacco Use n First decades of 20 th century-lung cancer rare n n Per capita cigarette consumption increased from 54 cigarettes in 1900 to 4345 cigarettes in 1963 Increased smoking lead to more lung cancer cases n 1964 – advisory committee to US Surgeon general identified – tobacco use as a serious health hazard n Various public health efforts followed suit n n n n Health hazards of tobacco established – scientific evidence Disseminating this evidence to public; surveillance and evaluation of prevention and cessation programs; campaigns by advocates for nonsmokers' rights; restrictions on cigarette advertising; policy changes (i. e. , enforcement of minors' access laws, legislation restricting smoking in public places, and increased taxation); improvements in treatment and prevention programs; © AAPHD 70
+ Tobacco Use Trends in cigarette smoking* among persons aged ≥ 18 years, by sex- United States, 1955 -1997 http: //www. cdc. gov/mmwr/preview/mmwrhtml/mm 4843 a 2. html © AAPHD 71
+ Community Water Fluoridation © AAPHD
+ History Colorado Springs, Colorado n 1901 Dr. F. Mc. Kay investigates “Colorado Brown Stain” (teeth stain) n 1909 – Dr Robertson observed brown stained teeth of children drinking from a locally dug well n n Hypothesis that something in the water causes the stain 1930 Alcoa chemist H. V Churchill identifies fluoride by spectrophotometry -- up to 14 ppm http: //www. cdc. gov/mmwr/preview/mmwrhtml/mm 4841 a 1. html © AAPHD 73
+ History ndley • 1931 - • 1934 - Dentist Unit of the newly established National Institute of Health to investigate Severity of dental fluorosis categorized as “Dean’s Index” Compares fluorosis data from 26 states to tooth decay data – identifies Caries lower in cities with more fluoride in their community water supplies at concentrations > 1. 0 ppm • http: //www. cdc. gov/mmwr/preview/mmwrhtml/mm 4841 a 1. html Mc. Lure FJ. Water Fluoridation – the search and the victory. Bethesda (MD): US Dept of Education and Welfare, NIH, NIDR: 1970. Chapter 14: 247 -9 © AAPHD 74
+ What Is Community Water Fluoridation? n The adjustment of the level of fluoride in the water supply n Current (recommended level of fluoride: 0. 7 parts per million (ppm) or 0. 7 mg/Liter of water n Previous recommended level of fluoride in water: 0. 7 to 1. 2 ppm or 0. 7 to 1. 2 mgs/Liter of Water n Most water supplies contain trace amounts of fluoride. n Water systems are considered naturally fluoridated when the natural level of fluoride is greater than 0. 7 parts per million (ppm). http: //wayback. archive-it. org/3926/20140108162323/http: /www. hhs. gov/news/press/2011 pres/01/20110107 a. html © AAPHD 75
![+ Facts about Fluoride n Fluorine [F] is a member of the halogen family](https://present5.com/presentation/2789b34680aadb5ef3bd782263cd9a0d/image-72.jpg "+ Facts about Fluoride n Fluorine [F] is a member of the halogen family")
+ Facts about Fluoride n Fluorine [F] is a member of the halogen family – naturally occurring n The most electronegative of all elements, F -2 n Is extremely reactive n Occurs in minerals, e. g. fluorspar (Ca. F 2), cryolite (Na 3 Al. F 6), fluorosilicates (Na 2 Si. F 6) n Also found in mica, hornblende, pegmatites (coarse n Ranks 17 th abundance in earth’s crust (0. 06 -0. 09%) n Present in sea water (1. 2 – 1. 4 ppm) n Occurs in biological mineralized tissue, e. g. bones and teeth as fluoridated hydroxyapatite granite) © AAPHD 76
+ 3 Mechanisms of Fluoride Action 1. Topical interaction with the enamel n 2. Interaction with the bacteria n 3. Remineralization with more acid-resistant apatite Conversion of hydroxyapatite into calciumfluoroapatite which reduces the solubility of tooth enamel in acid and makes it more resistant to tooth decay – topical effect Fluoride inhibits glycolysis, inhibits dextran formation for dental plaque adherence, and direct effect on bacteria Developmental interaction with enamel n Reduction in enamel solubility © AAPHD 77
Calciumfluoroapatite crystals – reduced solubility http: //www. cdc. gov/mmwr/preview/mmwrhtml/rr 5014 a 1. html © AAPHD 78
+ Benefits of Fluoridation n Dental n caries most common disease DMFT (Decayed, Missing, Filled Teeth due to dental caries) 4. 0 in 1966 -1970 to 1. 3 in 1988 -1994 n Earlier studies suggest caries reduction attributable to fluoridation ranged from 50% to 70% n Studies between 1979 -1989 found that caries reduction was 8%-37% among adolescents © AAPHD 79
mean DMFT among persons aged 12 years in the United States declined 68%, from 4. 0 in 19661970 to 1. 3 in 1988 -1994 Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent Dental Caries MMWR weekly, 1999/48 (41); 933 -40. © AAPHD 80
+ Benefits of Fluoridation n It does not require costly services of health care professionals to deliver n There are no daily –dosage schedules to remember n No bad taste n Widespread community water fluoridation prevents cavities even in neighboring communities that are not fluoridated – Halo effect or the diffused effect – eating food beverages processed from fluoride water © AAPHD 81
+ In United States (2010) n Total US population – 308, 745, 538 n U. S. Population on Public Water Supply Systems 276, 607, 387 n Total U. S. Population on Fluoridated Drinking Water Systems -204, 283, 554 n Percentage of U. S. Population receiving Fluoridated Water -66. 2% http: //www. cdc. gov/fluoridation/statistics/2010 stats. html © AAPHD 82
+ Dental Fluorosis n Series of conditions occurring in those teeth that have been exposed to excessive sources of fluoride ingested during enamel formation n Older children and adults are not at risk for dental fluorosis Mild -Photo by Elke Babiuk Severe-Source of photo unknown © AAPHD 83
+ Antifluoridation © AAPHD
+ Lecture 3 Oral Health and Oral Health Disparities 85 © AAPHD 85
+ Learning Objectives n Describe the current oral health status of the US population n Describe what oral health disparities mean n Describe various factors associated to oral health disparities among US population © AAPHD 86
+ Why is Oral Health Important? © AAPHD
+ Background n Department of Health and Human Services released first ever Surgeon General’s report on Oral Health (2000) n Oral health is essential to the general health and well-being of all Americans and can be achieved by all Americans. n However, not all Americans are achieving the same degree of oral health n Substantial oral health disparities exists among different subgroups of US population U. S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U. S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. © AAPHD
+ Oral Health n In the first ever Surgeon General’s report on Oral Health (2000), n“In spite of the safe and effective means of maintaining oral health that have benefited the majority of Americans over the past half century, many among us still experience needless pain and suffering, complications that devastate overall health and well-being, and financial and social costs that diminish the quality of life and burden American society” U. S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U. S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. © AAPHD 89
+ Oral Health Impact Pain Infection Poor Feeding Poor Speech © AAPHD 90 Poor Self Esteem Poor School Performance
+ © AAPHD 91
Oral Health Status in + the US © AAPHD
+ Distribution of Caries by age Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status, United States, 1988 -1994 and 1999 -2004. National Center for Health Statistics. Vital Health Stat 11(248); 2007. © AAPHD 93
+ Dye BA, Li X, Beltrán-Aguilar ED. Selected oral health indicators in the United States, 2005– 2008. NCHS data brief, no 96. Hyattsville, MD: National Center for Health Statistics. 2012. © AAPHD
+ Distribution of Periodontitis in Adults: ye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status, United States, 1988 -1994 and 1999 -2004. National Center for Health Statistics. Vital Health Stat 11(248); 2007. © AAPHD 95
+ Distribution of Periodontitis in Adults: Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status, United States, 1988 -1994 and 1999 -2004. National Center for Health Statistics. Vital Health Stat 11(248); 2007. © AAPHD 96
+ Distribution of Periodontitis in Adults: Prevalence of moderate/severe periodontitis by age group: NHANES 2009 -2010 Eke PI et al. Prevalence of Periodontitis in Adults in the United States: 2009 and 2010. J Dent Res 91(10): 914 -920, 2012 © AAPHD
+ Distribution of edentulism (loss of all teeth) © AAPHD 98
Disparities in Oral Health + status and in accessing dental care services © AAPHD
Health Disparities + n Health n n Disparities – Defined as “population-specific differences in the presence of disease, health outcomes, or access to health care” (Health Resources and Service Administration[HRSA]) If a health outcome is seen in a greater or lesser extent between populations, there is disparity (www. healthypeople. gov) n Race or ethnicity, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health. © AAPHD 100
Differences between populations + in health n Key is that there are differences between populations in the measures of health n A health disparity is believed to exist when (examples): n Tooth decay more common in low–income children compared to high-income children n 35. 8% of children living below 100% Federal poverty level (Low-income) had tooth decay compared to only 15. 5% of children living above 200% Federal poverty level (Highincome) [2005 -2008 National Health and Nutrition Examination Survey data] n Black or African Americans have a lower survival rate due to oral and pharyngeal cancer (OPC) compared to White Americans n 62. 9% of White men live up to 5 years after diagnosis compared to only 37. 2% of Black Americans – this low survival rate is attributed due to late diagnosis of OPC in Black Americans [2002 -2008 Surveillance Epidemiology and End http: //www. cdc. gov/nchs/databriefs/db 96. html Results Data] http: //seer. cancer. gov/statfacts/html/oralcav. html © AAPHD 101
+ Disparities in Caries in Children Prevalence of dental caries in permanent teeth * among children and adolescents aged 6 - 19 years, by selected characteristics –United States, National Health and Nutrition Examination Survey, 1988 -1994, and 1999 -2002 © AAPHD 102
+ Factors underlying health and health care related disparities n Disparities in oral health status may arise due to: n Differences (barriers) in access to health care n Timely use of personal health services to achieve the best health outcomes n n Lack of dental insurance, lack of adequate dental coverage (entry level barriers), Lack of transportation to reach dentist, living in a remote/rural region (structural barriers), Patient’s low oral health literacy, and health information (patient barriers), Dentists not accepting/treating low-income patients, low cultural competence of dental professionals (provider barriers) © AAPHD 103
+ Oral Health Indicators n Measurable characteristics that describe the health of a population: n n Diseases n Dental caries, gingivitis, tooth loss, oral cancer Determinants of health n Oral health behaviors, oral health risk factors, physical environments, and socioeconomic environments Access to dental care n Use - dental visits, dental sealants, filling n Cost - insurance Depending on the measure, a oral health indicator may be defined for a specific population, place, or geographic area. Modified from http: //healthindicators. gov/Resources/Glossary © AAPHD 105
+ Healthy people 2020 Oral Health Objectives n Healthy People 2020 Objectives - each objective related to an oral health indicator is developed to be achieved over the second decade of this century n Oral Health objectives (OH 1 to 17) n n n OH 1 to 6, focuses on oral health in children, adolescents and adults (dental caries, untreated tooth decay, tooth loss, dental restorations/fillings) OH 7 to 11, focuses on access to preventive dental services (school based centers, using oral health care system, health centers with oral health component) OH 12 to 14, focuses on oral health prevention interventions (sealants, community water fluoridation) OH 15 to 16, focuses on oral health surveillance systems (systems recording cleft lip and palate, oral and craniofacial systems) OH 17, public health infrastructure (health agencies with a dental professional directing a program) © AAPHD 106
+ Examples of Oral Health indicators in HP 2020 Dental Sealants Untreated tooth decay n Denotes dental disease experience / dental treatment needs in a population group n HP 2020 Objective: n n n OH-1: Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth Denotes utilization of “preventive” services HP 2020 Objective: n © AAPHD 107 OH-12: Increase the proportion of children and adolescents who have received dental sealants on their molar teeth
Disparities in untreated dental + caries and dental restorations Prevalence of untreated dental caries and existing dental restorations in teeth, by sex, race, and ethnicity, and poverty level: 2005 -2008 Characteristic Untreated dental caries Dental restoration Non-hispanic white 1 17. 8% 80. 1% Non-hispanic black 2 34. 2% 2 62. 6% Mexican American 2 31. 1% 2 61. 8% Below 100% 2 35. 8% 2 62. 7% 100 to less than 200% 2 30. 5% 2 68. 8% 15. 5% 80. 2% 2 24. 6% 2 72. 1% 18. 6% 78. 7% Race/Ethnicity Poverty level 200% or higher 1 Gender Male Female 1 Reference group, 2 p <0. 05 Source: CDC/NCHS National Health and Nutrition Examination Survey 1 © AAPHD 108
+ Disparities in dental caries experience and untreated dental caries Prevalence of dental caries in primary teeth, by age and race and Hispanic origin among children aged 2 – 8 years: United States, 2011– 2012 1 Includes untreated and treated (restored) dental caries. different from those aged 6– 8 years, p < 0. 05. 3 Significantly different from non-Hispanic black children, p < 0. 05. 4 Significantly different from Hispanic children, p < 0. 05. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011– 2012. 2 Significantly Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011– 2012. NCHS data brief, no 191. Hyattsville, MD: National Center for Health Statistics. 2015. © AAPHD
+ Disparities in dental visits Dental visits in the past year by selected characteristics among 2 years and older: United States, selected years 1997 -2010 Characteristic 5 1997 2010 White Only 66. 4% 65. 6% Black/African American 58. 9% 58. 8% American Indian/Alaskan Indian 55. 1% 57. 4% Asian Only 62. 5% 66. 5% Hispanic or Latino 54. 0% 56. 5% Non-Hispanic or Non-Latino 66. 4% 66. 2% 300 -399% (Rich) 78. 9% 79. 3% 200%-299% 66. 2% 63. 5% 100%-199% 50. 8% 51. 6% Below 100% (Poor) 50. 5% 50. 6% RACE ETHNICITY PERCENT OF POVERT LEVEL National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012. © AAPHD 110
+ Utilization of Dental Service Oral Health: Efforts Under Way to Improve Children’s Access to Dental Services, but Sustained Attention Needed to Address Ongoing Concerns. GAO-11 -96, Nor 2010. Government Accountability Office. © AAPHD 111
Disparities in Dental Sealants + prevalence © AAPHD 112
+ Disparities in Dental Sealants prevalence Prevalence of dental sealants in permanent teeth, by age and race and Hispanic origin among children aged 6– 11 years: United States, 2011– 2012 1 Significantly different from those aged 9– 11 years, p < 0. 05. different from non-Hispanic black children, p < 0. 05. 3 Significantly different from non-Hispanic Asian children, p < 0. 05. . SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011– 2012. 2 Significantly Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011– 2012. NCHS data brief, no 191. Hyattsville, MD: National Center for Health Statistics. 2015. © AAPHD 113
Disparities in edentulism + (complete tooth loss) © AAPHD 114
One Example: Dental workforce shortage + as a factor related to oral health disparities © AAPHD
+ Health Professional Shortage Areas (HPSA) n Designated by HRSA n Having shortages of primary medical care, dental or mental health providers n Based on n Geography (a county or service area) demographic (low income population) institutional (comprehensive health center, federally qualified health center or other public facility). http: //www. hrsa. gov/publichealth/clinical/oralhealth/workforce. html http: //www. hrsa. gov/shortage/ © AAPHD 116
+ Dental Health Professional Shortage Areas (DHPSA) n Currently approximately 4, 600 Dental HPSAs. n Dental HPSAs are based on a dentist to population ratio of 1: 5, 000. n Take approximately 6, 600 additional dentists to eliminate the current dental HPSA designations. n More than 49 million Americans live in dental Health Professional Shortage Areas http: //www. hrsa. gov/publichealth/clinical/oralhealth/workforce. html http: //www. hrsa. gov/shortage/ © AAPHD 117
+ U. S. Designated Dental Health Professions Shortage Areas 1991 - 2011 Source: Shortage Designation Branch, Office of Workforce Evaluation and Quality Assurance, Bureau of Health Professions, Health Resources and Services Administration, U. S. Department of Health and Human Services © AAPHD 118
+ SOURCE: U. S. Department of Health and Human Services, Health Resources and Services Administration, Designated HPSA Statistics Report, (as presented in) The Pew Center of States. May 2011. The State of Children’s Dental Health: Making Coverage Matter. The Pew Charitable Trusts. © AAPHD 119
+ Estimated Changes in Number of Dentists in the Dental Workforce, 1995 - 2040 n From 2014 to 2027, it is estimated that more dentists will leave the workforce than enter it These data assume that the number of graduates remains at 4, 850 after 2007 and retirement age is 65 Source: American Dental Education Association © AAPHD 120
+ Distribution of Dentists in Illinois, 2006 © AAPHD 121
+ Review: factors related to oral health disparities n n Lack of dental insurance, lack of adequate dental coverage (entry level barriers), Lack of transportation to reach dentist, living in a remote/rural region (structural barriers), Patient’s low oral health literacy, and health information (patient barriers), Dentists not accepting/treating low-income patients, low cultural competence of dental professionals. Geographical location of dental providers (provider barriers) © AAPHD 122
+ Lecture 4 Access to Dental Care and Utilization of Dental Care Services 123 © AAPHD 123
+ Learning Objectives 1. Define and describe concepts, and measures of access to dental care and utilization of dental services 2. Recognize the issues (problems) with access to dental care in the US, especially among underserved and vulnerable population groups 3. Identify factors associated with access to dental care and utilization of dental services and discuss ways to modify them to improve access and utilization © AAPHD 124
Access to dental care + Definition n The ability of a person to receive dental health care services. n Access to dental care is a function of perceived need, demand, utilization of care, availability of personnel and supplies, and ability to pay for those services, © AAPHD 125
+ Access to dental care n. Perceived need: n A person’s self perceived need or want of dental care n. Demand for dental care: n A person expresses the need for dental care by acting on it, and willingness to seek dental care. n. Utilization of dental care: n A person’s actual use of dental care services that is available to him/her © AAPHD 126
Access to dental care + Regular care and regular dentist n Ease to find a dentist when needed n Numbers of providers n Location n Ability to afford dental care n Insurance n Out-of-pocket n Low-cost or free access n Access to any provider n Alternative providers (therapists, independent practicing hygienists) n © AAPHD 127
+ Access to dental care n Complex, multidimensional concept. n Dentist available n Financial resources n Transportation n Other barriers (job and free time) n A continuum, not a matter of presence or absence. n Access to care is important for prevention and for prompt treatment of illness and injury. © AAPHD 128
+ Surgeon General’s Report: Oral Health in America (2000) • “Fewer than 20% of Medicaidcovered children had a dental visit in a given year” • “The consequence of low dentalservice utilization by Medicaid participants are poor oral health and significant unmet dental needs” • “A silent epidemic of oral diseases is affecting our most vulnerable citizens - poor children, the elderly, and many members of racial and ethnic minority groups” © AAPHD 129
+ Surgeon General’s Report: Oral Health in America (2000) n 25% of poor children have not seen a dentist before entering kindergarten. n Uninsured children are 2. 5 times less likely to receive dental care. n Children from families without dental insurance are 3 times more likely to have dental need. n For each child without medical insurance there are 2. 6 without dental insurance. © AAPHD 130
+ Disparities in dental visits Dental visits in the past year by selected characteristics among 2 years and older: United States, selected years 1997 -2010 Characteristic 5 1997 2010 White Only 66. 4% 65. 6% Black/African American 58. 9% 58. 8% American Indian/Alaskan Indian 55. 1% 57. 4% Asian Only 62. 5% 66. 5% Hispanic or Latino 54. 0% 56. 5% Non-Hispanic or Non-Latino 66. 4% 66. 2% Below 100% (Poor) 50. 5% 50. 6% 100%-199% 50. 8% 51. 6% 200%-299% 66. 2% 63. 5% 300 -399% (Rich) 78. 9% 79. 3% RACE ETHNICITY PERCENT OF POVERT LEVEL National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012. © AAPHD 131
+ Child Dies for Lack of Dental Care - Washington Post 2 -28 -2007 n A twelve year old Maryland boy died Sunday after the infection from an abscessed tooth spread to his brain. n The boy had not been receiving routine dental care. n Mother had trouble finding a dental provider who would accept Medicaid © AAPHD 132
+ Access to dental care: Status n In 2010, 64. 7% of US residents 2 years and older reported that they had visited a dentist within the previous year. ¥ n Access problems are concentrated n Low-income areas n Rural areas n Minority population groups n Very young children n Elderly n Special needs patients n Institutionalized in ¥-National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012. © AAPHD 133
+ Utilization of Dental Service Oral Health: Efforts Under Way to Improve Children’s Access to Dental Services, but Sustained Attention Needed to Address Ongoing Concerns. GAO-11 -96, Nor 2010. Government Accountability Office. © AAPHD 134
Measures of “access to dental care” + n Adequacy of dentist supply n Dentist/population ratio n “Need” vs. “Demand” n Percent of population who had: n A dental visit last year n Regular dental visit n Regular dentist to go (dental home) © AAPHD 135
+ Measures of “Utilization of dental services” n CMS 416 (Centers for Medicare and Medicaid Services) # children with a dental visit during the year (any point) # children enrolled at any point during the year n HEDIS (Health plan Employer Data & Information Set) # children enrolled for 11 -12 mos with a dental visit # children enrolled for 11 -12 mos during the year © AAPHD 136
+ Funding Problem in Dental Care n 120 million Americans do not have dental insurance (43 million without medical insurance) n Upon retiring, 85% of Americans have no dental insurance n There are limited dental benefits for adults under Medicaid n Uninsured patients must pay out-of-pocket, and for low income patients the expense of dental care is generally prohibitive © AAPHD 137
+ Federal Programs to Improve Access (for children) n Medicaid n EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) n Children’s Health Insurance Program (CHIP) n Children’s Health Insurance Program Reauthorization Act (CHIPRA, 2009) © AAPHD 138
+ Federal Programs to Improve Access: Medicaid Health coverage program for low-income people and working families who qualify, funded jointly by both the Federal and State Government. n Established in 1965 by Title XIX of Social Security Act. n Medicaid Partnership: n Federal oversight: Centers for Medicare & Medicaid Services (CMS) n State oversight: State Department of Health n © AAPHD 139
+ Federal Programs to Improve Access: EPSDT n EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) n Child health component of Medicaid up to age 19. n Required in every state n Financing appropriate and necessary pediatric services. n Dental services for children must minimally include: n Relief of pain and infections n Restoration of teeth n Maintenance of dental health EPSDT benefit requires that all services must be provided if determined medically necessary n © AAPHD 140
Children’s Health Insurance + Program (CHIP) n Provides health coverage to children in families with incomes too high to qualify for Medicaid, but cannot afford private coverage. n Jointly funded by the federal government and states. n Administered by the states n nearly 8 million children covered © AAPHD 141
+ Surgeon General’s Report: Access to Dental Care (2000) n Medicaid has not been able to fill the gap in providing dental care for poor children. n 80% of Medicaid eligible kids did not receive preventive services in a given year n Although new programs such as State Children’s Health Insurance Program (SCHIP) may increase the number of insured children, many still be left without effective dental coverage. © AAPHD 142
+ Dental care through Medicaid n Limited access to dental care n Declining # of dentists accepting Medicaid n Inadequate funding n Multi-level reasons for problem with dental Medicaid n Medicaid reimbursement levels that are far below dentists’ usual and customary fees n Administrative difficulties n Dental practice operations and productivity n Excessive number of broken appointments n Perceived undesirable behaviors (such as non-compliance) n Social stigma © AAPHD 143
Affordable Care Act + n The Affordable Care Act (ACA) requires Americans to purchase health coverage in 2014 and thereafter or pay a fine n All individual and small group market plans - both inside and outside the exchange - must be certified as “qualified health plans” – Should include dental coverage for children <19 yrs n Children’s dental services are included as part of the Essential Health Benefit (EHB) package. So, children in segments of the population where the EHB package is required will have dental coverage offered as part of that package n Additional 5. 3 million children expected to get dental coverage through ACA in 2014 n Total 8. 7 million in 2018 n Dental coverage for adults is NOT required http: //www. nadp. org/Libraries/LMS/The_ACA_and_Dental_Coverage--The_Basics--Jan_2013. sflb. ashx http: //www. ada. org/en/home-ada/publications/ada-news/2013 -archive/august/affordable-care-act-dental-benefits-examined © AAPHD
+ Lecture 5 Dental Health Care Delivery Systems 145 © AAPHD 145
+ Learning Objectives n Understand different dental care delivery sites operated by federal, state and local governments n Identify the roles and scope of various dental and non-dental care delivery models. n Describe different types of common payment methods for dental services 146 © AAPHD
+ Dental Care Delivery System n. A system where providers of care, health care organizations, insurance companies, employer groups, and other government agencies come together to provide optimal dental care to the public to promote oral health Vehicles: where dental care is provided n Workforce: The supply of various types of health care professionals to provide dental care n Financing: How is dental care paid for, common payment services n 147 © AAPHD
+ Where do we access dental care? Vehicles of dental health care delivery PUBLIC “PUBLIC” Federal Government “PUBLIC” State Government PRIVATE “PUBLIC” Local Government © AAPHD 148 “PRIVATE” Non-Profit “PRIVATE” For-Profit
+ Structure of the Dental System: Private For-Profit Delivery Sites n Private Dental Practices n Solo Practice: principal form of dental practice in US n Group Practice n For-profit dental clinics: Clinic which may be owned by one dentist who employs others to perform care as employees or Independent contractors. © AAPHD 149
Structure of the Dental System: Private For-Profit Delivery Sites + n Almost 90% of all private practices are located in metropolitan areas n <1% are located in rural areas n Between 1982 -2004, 98 U. S. counties never had a dental practice; 78% of these were rural. n Higher mean per capita income for a county is associated with a higher number of dentists practicing in the county. Nash KD. Geographic Distribution of Dentists in United States. Health Policy Analysis Series. Chicago: American Dental Association, Health Policy Analysis Section, 2011. © AAPHD 150
+ Where do we access dental care? Vehicles of dental health care delivery PUBLIC “PUBLIC” Federal Government “PUBLIC” State Government PRIVATE “PUBLIC” Local Government © AAPHD 151 “PRIVATE” Non-Profit “PRIVATE” For-Profit
+ n Federal Government Mainly serves population groups who have low access to health care n Federally Qualified Health Centers (FQHCs) n Migrant Health Centers n Health Care Centers for Homeless n Public Housing Primary Care Centers n Native Hawaiians Health Centers n Indian Health Service Programs n Federal Prison n Coast Guard n Veterans Affairs Hospitals n School Based Health Centers 152 © AAPHD 152
+ FQHC: Federally Qualified Health Center n Qualifies for enhanced reimbursements from Medicaid n Must be in underserved area n Must offer sliding fee scale – should provide services to people irrespective of ability to pay n Must provide comprehensive services n Must have a governing Board of Directors 153 © AAPHD 153
+ Federally Qualified Health Centers n Migrant health programs n n n Migrant or seasonal farm workers and their families More than 3 million estimated in US n Eligibility: Principal employment for both migrant and seasonal farmworkers must be in agriculture n Served 862, 808 workers in 2011 Health Centers for Homeless n 930, 589 people are homeless on a given night and 2 to 3 million are homeless over the course of a year n 1 million homeless served in 2011 n Mobile dental clinics in shelters, grant funded programs © AAPHD 154
+ Federally Qualified Health Centers n Public Housing Primary Care Centers n Services are provided on the premises of public housing developments or at other locations immediately accessible to resident n Estimated 1. 2 million live in public housing n FQHCs served 187, 992 residents n Native Hawaiians n 1. 2 million people estimated (2010 US census) n 2011, approximately 8500 were served © AAPHD 155
+ Indian Health Service Program n The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to native American Indians and Alaska Natives n Approximately 2 million American Indians in the US n Dental Services provided annually – approximately 3. 7 million dental services provided n 310 dentists in the Indian Health Service system © AAPHD 156
+ U. S Coast Guard n One of the five armed forces of the United States and the only military organization within the Department of Homeland Security n 2011 – 43, 000 active members n In 2012, 58 dentists in 30 clinics, which are located mainly along the Atlantic, Gulf, and Pacific Coasts, including Alaska, Hawaii and Puerto Rico. n All appropriate dental treatment services are provided © AAPHD 157
+ Veteran Affairs n Government-run military veteran benefit system – including families of veterans - 22. 7 million veterans n VA employs nearly 280, 000 people at Veterans Affairs medical facilities, clinics, and benefits offices n Dental benefits for veterans vary n Dental benefits include a full range of services for eligible Veterans. Some of the many services offered by VA Dentistry: n Regularly scheduled cleaning and x-rays. n Restorative procedures such as fillings, crowns and bridges. n Comfortable, well-fitting dentures. n Oral surgery such as tooth extractions. n Oral and facial reconstruction surgery resulting from trauma or serious illness. © AAPHD 158
+ Federal Bureau of Prisons n Sub-division of Department of Justice n The BOP has over 3, 000 health care positions, including approximately 750 Public Health Service (PHS) Commissioned Officers n Estimated 160, 000 inmates n All basic dental services are provided © AAPHD 159
+ School Based Health Centers - Federal n Center of health in the schools where they are based. n partnership between the school and a community health organization, such as a community health center, hospital, or local health department n About 20 to 23% of school based health centers receive funding from federal government n Rest by local (37%) and/or state government (78%) n In 2007 -2008, 1900 SBHCs funded by Federal government n Provide broad range of preventive services – oral health education, dental screening, fluoride varnish applications, and sealants n Dental hygienists or school nurses provide most of the services. n Dentists very rare. SOURCE: Strozer, J. , Juszczak, L. , & Ammerman, A. (2010). 2007 -2008 National School-Based Health Care Census. Washington, DC: National Assembly on School-Based Health Care © AAPHD 160
+ Structure of the Dental System: State Delivery Sites n School Based Health Centers or Sealant Programs n Dept. of Corrections: Provides direct care to those incarcerated in State Prisons n Dept. of Mental Health: Provides direct care to patients at state mental hospitals n Mobile Community Based Programs n Community Health Centers © AAPHD 161
+ Structure of the Dental System: Local Delivery Sites n School Based Dental Programs n Oral Rinse Programs n Sealant Programs n Mouth Guard Programs n Local Health Dept. Clinics n Mobile Dental Health Programs © AAPHD 162
New Dental Workforce + Models © AAPHD
+ New Dental Workforce Models n Expanded n n n dental workforce models Expanded function dental hygienists Expanded function dental assistants Alternate dental workforce models n Non dental workforce models © AAPHD 164
+ Expanded Dental Workforce Models n Dental Hygienists n Work with dentists in traditional dental offices n Scope of function varies state to state n Provide diagnosis (x-rays), preventive services (apply sealants and fluorides), dental hygiene care (remove plaque and calculus), and educational services (tooth brushing, flossing, nutritional counseling) n Expanded function dental hygienists n Eg. Registered Dental Hygienist in Alternative Practice n In 1998 the California Legislature created a new license category of Oral Health Professionals, the Registered Dental Hygienist in Alternative Practice, abbreviated as RDHAP. n The purpose of this new license category was to deliver dental hygiene care and preventive services, and educational services to special populations in alternative settings where people live or frequent, rather than the traditional dental office or clinic. © AAPHD 165
Expanded Dental Workforce Models + n Dental n Assistants Help dentists with oral care procedures and typically complete onthe-job training, oneyear diploma programs or two-year associate degree programs. n Expanded assistants n function dental Are legally able to perform a wider scope of clinical duties after completing continuing education courses. Employment of these professionals is projected to increase 36 percent through 2018, according to the U. S. Department of Labor Bureau of Labor Statistics. © AAPHD 166
Alternate Dental Workforce Models + Dental workforce models Community Dental Health Coordinator Non-dental workforce models Dental Health Aide Therapist Pediatricians School nurses n Public health / social workers (promotoras) Advanced Dental Hygiene Practitioners n Primary care physicians n n n © AAPHD 167
+ Alternate Dental Workforce Models n Community Dental Health Coordinator (CDHC) n Dental team member connected to a responsible supervising dentist n Scope: Extensive care coordination services, screening, limited preventive and palliative care n Settings: Health and community settings such as clinics, schools, churches, senior citizen centers, Head Start Programs and other public settings n CDHC come from the community in which they will serve © AAPHD 168
+ Alternate Dental Workforce Models n Advanced Dental Hygiene Practitioner (ADHP) n Dental team member connected to a responsible supervising dentist, possibly via teledentistry n Scope: diagnostic, preventive, restorative, prophylaxis, and simple extractions n Settings: Health and community settings such as clinics, schools, churches, senior citizen centers, Head Start Programs and other public settings, private practice © AAPHD 169
+ Alternate Dental Workforce Models n Dental Health Aide Therapist (DHAT) n Dental team member connected to a responsible supervising dentist, possibly via teledentistry n Scope: preventive, restorative, pulpotomy, prophylaxis, and simple extractions n Settings: Health and community settings such as clinics, schools, churches, senior citizen centers, Head Start Programs and other public settings n DHAT come from the community in which they will serve © AAPHD 170
+ Edelstein BL. Training new dental health providers in the US. 2009, W. K. Kellog Foundation. © AAPHD 171
+ Financing dental care © AAPHD
Payment Sources + n Private Third Party System: Patient and dentist are the first and second parties n Third party – defined as the party to a dental prepayment contract that collects premiums, assume financial risk, pay claims, and provide administrative services n To meet the costs of providing care and administrative costs of the 3 rd party – premiums are periodically collected – this is called dental prepayment or dental insurance n n Public n Third Party System: Medicaid, CHIP, Medicare 173 © AAPHD 173
+ Reimbursement of third party plans 1) Fee schedule 2) Usual, customary and reasonable fee (UCR fee) 3) Table of allowances 4) Discounted fee (Preferred provider organizations), 5) Capitation 6) Sliding Fee Schedule 174 © AAPHD 174
+ Reimbursement of third party plans n Fee Schedule List of charges established or agreed to by a dentist for specific dental services n The payment is in full for each services – dentist must accept the listed amount as payment in full and NOT charge the patient at all n For example if a dentist usually charges $250 for a service, and the plan list a fee of only $200 to be reimbursed, the dentist may not charge patient the additional fee to make up the difference n Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W. B. Saunders Publications Inc. , Philadelphia © AAPHD 175
Reimbursement of third party plans + n Usual, Customary, and Reasonable Fee n For certain services n Usual: Fee that is most often charged by the provider n Customary: Range of fees charged by similar providers in a specific geographic area – establishes a maximum benefit n Reasonable: fee charged by a dentist for a specific dental procedure that has been modified by complications or unusual circumstances and that is different from the Usual or Customary fees n Example (Dentist cleaning) visit and n Actual charge-250$ n UCR allowable charge – 200$ n Contractual write off-$50 n 80/20 Insurance plan paid $160 (80% of UCR allowable charge paid by insurance company) n Co-insurance - $40 n Patient costs - $40 Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W. B. Saunders Publications Inc. , Philadelphia © AAPHD
+ Reimbursement of third party plans n Table of Allowances Also known as: schedule of allowances or indemnity schedule n A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentist's full fee for that service n For example if a dentist usually charges $250 for a service, and the plan list a fee of only $200 to be reimbursed, the dentist will charge additional $50 from the patient to make up the difference n Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W. B. Saunders Publications Inc. , Philadelphia © AAPHD 177
+ Reimbursement of third party plans n Discounted Fee The basis for Preferred Provider Organizations (PPO) [a preferred provider organization (or "PPO", sometimes referred to as a participating provider organization or preferred provider option) is a managed care organization of medical doctors, hospitals, and other health care providers who have an agreement with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients plans] n Dentists agree to a fee that are usually lower than charged by dentists in that area n Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W. B. Saunders Publications Inc. , Philadelphia © AAPHD 178
+ Reimbursement of third party plans n Capitation Dental benefit program in which a dentist or dentists contract with the insurance companies to provide all or most of the dental services covered under the program to clients in return for a payment on a per capita basis. n Capitation fee is a fixed monthly payment paid by a carrier to a dentist based on the number of patients assigned to the dentist for a treatment n Capitation requires that patients be assigned to specific dentists or dental practices – this is important because the dentist receives a fixed sum of money per enrolled person per month, regardless of whether the participant receives care during that month or not n Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6 th Edition 2005, W. B. Saunders Publications Inc. , Philadelphia © AAPHD 179
+ Reimbursement of third party plans n Sliding Fee Scale n Fee is adjusted based on family size and income n must provide services to patients without regard for a person's ability to pay. n May be subsidized by grant funding n Most often found in clinics or community health centers, and Federally Qualified Health Centers 180 © AAPHD 180
Public Third Party Payment Public Financing of Care + n MEDICARE n It was established because there were twin problems of high health care needs and low income among persons age 65 years and above n Funded only by Federal government n Currently, Medicare pays for dental services that are an integral part either of a covered procedure (e. g. , reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. n Medicare will also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. n Does not cover routine dental/dental hygiene tx n Does not cover dentures 181 © AAPHD 181
+ Public Third Party Payment Public Financing of Care: Medicare Section 1862 (a)(12) of the Social Security Act states that Medicare will not cover dental care, ”…where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth. ” Medicare coverage: Dental services that are an integral part of a procedure covered by Medicare: n. Extractions made in preparation for radiation treatment for neoplastic diseases involving the jaw. n. Oral examinations (but not treatment) preceding some kidney transplantation or heart valve replacement. n. Some hospital stays if needed for emergency or complicated dental procedures, however the dental treatment is not covered. n. Medically necessary dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services. n. Surgical procedures for the reconstruction of a ridge as the result of and at the same time as a tumor removal (for other than dental purposes). n. Payment for the wiring of teeth if performed in connection with the reduction of a jaw fracture. © AAPHD 182
Public Third Party Payment Public Financing of Care + n MEDICAID Differs from Medicare - Medicaid funded by both federal and state governments n People eligible should have an income below 100% federal poverty level n Dental services are an optional service for adult Medicaid eligible age 21 and older, n However, for most individuals under the age of 21, dental services are a mandatory benefit as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service. n 183 © AAPHD 183
Public Third Party Payment Public Financing of Care + n State Children Health Insurance Program Series of federal and state partnerships n Children of families with income that are above those for Medicaid but are too low to afford a conventional health care insurance n SCHIP covers families who have incomes up to at least 200% of the federal poverty level n SCHIP programs vary from state to state, and may require patient copayments, monthly premiums, and annual payment limits, none of which is permitted under Medicaid n © AAPHD 184
+ Acknowledgement n Dr. Vinodh Bhoopathi n Dr. Woosung Sohn n Dr. Susan Reed n Diane Brunson n Robin Knowles n Karen Yoder n Dr. Ana Karina Mascarenhas n Dr. Kathryn Ann Atchison © AAPHD 185
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