Access to Dental Care in the US

– Time for Change??– Time for Change??

Dr. Ana Karina MascarenhasDr. Ana Karina MascarenhasDr. Ana Karina MascarenhasDr. Ana Karina Mascarenhas

Immediate Past President, AAPHD Immediate Past President, AAPHD Immediate Past President, AAPHD Immediate Past President, AAPHD

Associate Dean of Research, Chief of Primary Care,Associate Dean of Research, Chief of Primary Care,Associate Dean of Research, Chief of Primary Care,Associate Dean of Research, Chief of Primary Care,

Nova Southeastern University College of Dental MedicineNova Southeastern University College of Dental MedicineNova Southeastern University College of Dental MedicineNova Southeastern University College of Dental Medicine

What is all the fuss about?What is all the fuss about?

Have you met this Child?

Deamonte Driver

Have you met this Child?

Dylan Stewart

Age 5

4 filling and 8 crowns

The Need

Distribution of Dentists in Ohio

Susi and Mascarenhas, 2002

Ohio Population to Dentist Ratio

Susi and Mascarenhas, 2002

Mississippi Population to Dentist Ratio

Krause et al, 2005

Dental Health Professional Shortage Areas in Mississippi by County, 2000.

Krause et al, 2005

Distribution of Dentist in Illinois, 2006

Iowa

Kuthy et al. Dentist Workforce Trends in a Primarily Rural State: Iowa: 1997-2007. JADA 2009, 140: 1527-1534

Iowa

Kuthy et al. Dentist Workforce Trends in a Primarily Rural State: Iowa: 1997-2007. JADA 2009, 140: 1527-1534

Florida Dentist to Population Ratios 2009-2010

Bamashmous and Mascarenhas, 2011

What are these numbers?

• 4622

• 6997

• 9900

• 50,813,326

Dental Health Profession Shortage

Areas (DHPSA)

These 9,900 dentists would employ an additional

� 15,228 dental assistants

� 11,016 dental hygienists

Or the equivalent of

� Two graduating dental school classes

� Nearly three graduating dental hygiene classes

� More than two graduating dental assisting classes

Source: American Dental Education Association, “Unleashing the Potential.”

U.S. Designated Dental Health Professions

Shortage Areas 1991, 2000 - 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

U.S. Population Living in D-HPSAs* and

Estimated Underserved Population Living in

DHPSAs, 1991 and 2000 - 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 * Designated Health Professions Shortage Areas

Dentists Needed to Achieve Target Ratio

and Remove Designation in D-HPSAs*,

1991 and 2000 – 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 * Designated Health Professions Shortage Areas

THE MATH!

STUDENTS

• EACH STUDENT SAW 7PATIENTS PER DAY AT EXTERNSHIP

RESIDENTS

• EACH RESIDENT SAW 14 PATIENTS PER DAY

• 4,700 STUDENTS WOULD SEE 32,900 PATIENTS/VISITS

• 240 DAYS IN SCHOOL DURING THE YEAR

• 7,896,000 PATIENTS/VISITS

• 4,700 RESIDENTS WOULD SEE 65,800 PATIENTS/VISITS

• 240 DAYS IN SCHOOL DURING THE YEAR

• 15,792,000 PATIENTS/VISITS

THE MATH!

IF 20 NEW SCHOOLS OPEN WITH AN

AVERAGE CLASS SIZE OF 100,

RESULT IN ADDING 2,000 GRADUATES TO

THE 4,700 WE NOW GRADUATE. THE 4,700 WE NOW GRADUATE.

THE 6,700 TOTAL GRADUATES PER YEAR IS

IN THE BALLPARK OF THE 1980s GRADUATES

WHILE THE POPULATION IS GROWING VERY

FAST AND ACCESS IS GETTING WORSE.

Estimated Changes in Number of Dentists in

the Dental Workforce, 1995- 2040

• 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

Dental School Graduates through 2030

Source: American Dental Association, February 22, 2011

New Dental Providers

• Community Dental Health Coordinator

• Oral Preventive Assistant • Oral Preventive Assistant

• Advanced Dental Hygiene Practitioners

• Dental Health Aide Therapist

Community Dental Health Coordinator (CDHC)

• Dental team member connected to a responsible supervising dentist.

• Scope: Extensive care coordination services, screening, limited preventive and palliative carescreening, limited preventive and palliative care

• Settings: Health and community settings such as clinics, schools, churches, senior citizen centers, Head Start Programs and other public settings

• CDHC come from the community in which they will serve

Oral Preventive Assistant (OPA)

• Dental team member connected to a responsible supervising dentist.

• Scope: Collecting diagnostic data, preventive care including prophylaxisincluding prophylaxis

• Settings: Health and community settings such as clinics, schools, churches, senior citizen centers, Head Start Programs and other public settings, private practice

Advanced Dental Hygiene Practitioner (ADHP)

• Dental team member connected to a responsible supervising dentist, possibly via teledentistry

• Scope: diagnostic, preventive, restorative, prophylaxis, • Scope: diagnostic, preventive, restorative, prophylaxis,

and simple extractions

• Settings: Health and community settings such as clinics, schools, churches, senior citizen centers, Head Start Programs and other public settings, private practice

Dental Health Aide Therapist (DHAT)

• Dental team member connected to a responsible supervising dentist, possibly via teledentistry

• Scope: preventive, restorative, pulpotomy, prophylaxis,

and simple extractions

• Settings: Health and community settings such as clinics, schools, churches, senior citizen centers, Head Start Programs and other public settings

• DHAT come from the community in which they will serve

Edelstein BL. Training new dental health providers in the US. 2009, W.K. Kellog Foundation.

• Alaska

– Dental Health Aide Therapist

• Minnesota• Minnesota

– Dental Therapist

– Advanced Dental Therapist

(Advanced Dental Hygiene Practitioners)

• Alaska

• Minnesota

Other states considering:

• Maine

The writing is on the Wall

• Maine

• Connecticut

• California

• Washington

• ………………33 other states have demonstrated interest

The horse if out of the barn!!

And Sprinting

Away………

OROR

AAPHD’s Vision

Optimal Oral Health for All

AAPHD Policy on Access to Dental Care

AAPHD recognizes a number of current best practices and promising new strategies that have

the potential to improve access to oral health services for all communities:

• Community-based prevention programs, e.g., community water fluoridation

• School-based and school-linked programs, e.g., sealant and fluoride varnish programs

• Expanded use of non-dental personnel, e.g., medical care providers providing oral health

assessments and fluoride varnish applications

• Reform of publicly-financed health care programs, e.g., establishing market-based reimbursement

policies in Medicaidpolicies in Medicaid

• Expanded use of new and emerging types of dental personnel, e.g., Alaska Dental Health Aide

Therapist

• Strengthening the dental public health infrastructure, e.g., statutory authority for a state dental

director

• Involvement of multiple partners, e.g., oral health coalitions in many states.

• Assuring that any efforts to increase access to health care through reforms to

insurance programs include dental benefits commensurate with medical benefits.

AAPHD recognizes that health care providers have a moral obligation to heal the sick and

infirm regardless of financial inequities. All individuals should have access to needed oral

health prevention and treatment services as a basic moral right.

Resolution on the Need for Formal Demonstration Programs to Improve Access to Preventive and Therapeutic Oral Health Services

Whereas, The American Association of Public Health Dentistry views access to preventive and therapeutic oral health services as vitally important for all Americans,

Whereas, the AAPHD desires to foster broad-based policies and programs to help alleviate oral diseases,

Whereas, many populations, such as the Alaska Native population living in remote and isolated villages, have overwhelming unmet oral health needs,

Whereas, access to preventive and therapeutic oral health care for these populations is not readily available,

Whereas, in compliance with federal law, the Alaska Native Tribal Health Consortium has Whereas, in compliance with federal law, the Alaska Native Tribal Health Consortium has initiated a pilot program based on a long-standing training model to begin to address Native Alaskans’ unmet needs with their Dental Health Aide Program, and

Whereas, other model programs may now exist or be created that could provide effective and novel ways to improve access for high need populations, then

Be it resolved, the American Association of Public Health Dentistry strongly supports innovative demonstration programs aimed at improving access to preventive and therapeutic oral health services for underserved populations and commits to working with the communities of interest to assure an independent and formal evaluation and dissemination of accurate information to the public and the profession about such model programs.

WK Kellogg and Macy Foundations

Charge

1. Outline a proposed curriculum for 2-year post-secondary school education and training for dental therapists

2. Outline considerations concerning location and2. Outline considerations concerning location and

placement of such educational programs

3. Assess career path implications of the curriculum

4. Assess issues and opportunities regarding

4. accreditation of such programs

Competencies

1. Assessment and judgment

2. Preventive care, per protocol

3. Therapeutic care, per protocol

4. Pharmacological and emergency management, 4. Pharmacological and emergency management,

per protocol

5. Professional and community responsibility

The dental therapist curriculum is The dental therapist curriculum is

designed to be completed in 24 designed to be completed in 24

months (6 trimesters/8 quarters) months (6 trimesters/8 quarters)

and to serve as a template for a and to serve as a template for a and to serve as a template for a and to serve as a template for a

“suggested core curriculum”. “suggested core curriculum”.

Questions

1. Is this provider a "safe" provider?

2. Would this provider improve access to dental care in the US?dental care in the US?

3. Cost-effectiveness of this provider?

4. What are other solutions to the access problem?

“The various indicators …….five therapists who were “The various indicators …….five therapists who were

included in this study are performing well and

operating safely and appropriately within their

defined scope of practice. The data indicate that

the therapists who were observed are technically

competent to perform these procedures within their

scope of practice. The patients who were surveyed

were generally very satisfied with the care they

received from the therapists.”

Solo Pediatric Dentist

Solo General Dentist

Small group practice

“Almost ten years after the Surgeon

General’s report designating dental

disease as the "silent epidemic", the

nation continues to struggle with

adequate access to and utilization of adequate access to and utilization of

dental services.”

National Health Policy Forum - George Washington

University, March 29, 2010 - Issue Brief No. 836

(http://www.nhpf.org/library/details.cfm/2779)

FOR WANT OF A DENTIST

Have you met this Child?

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