A Call to Action

In 2000, Surgeon General David Satcher, MD, PhD, released “Oral Health in America: a Report of the Surgeon General,” which identified the “silent epidemic” of dental
diseases that burden some populations.¹ The report stated inexorably that oral health is intimately related to overall health. The Surgeon General called for collaboration
between agencies, health professions, individuals, and communities to work toward removing barriers to care, reducing the burden of disease, recognizing disparities in access to
care, and promoting disease prevention and not only disease elimination. Table 1 lists the report’s recommended five actions to advance oral health within a national agenda.

Now, 12 years later, the Institute of Medicine (IOM) has released two reports relative to oral health (see sidebar on page 68 for more information on IOM). The reports were separate in
their commission, yet they are complementary in many ways. “Advancing Oral Health In America” and “Improving Access to Oral Health Care for Vulnerable and Underserved Populations” are significant in their implications for the dental hygiene profession.^2,3

STATE OF AFFAIRS

It is clear that the issues identified in the 2000 Surgeon General’s Report still exist. It was hoped that the directive from the Surgeon General would facilitate solutions to the oral health crisis and promote coordination between federal agencies. Today, however, oral disease remains largely preventable but still prevalent; the most vulnerable populations
continue to suffer the highest burden of disease, yet have the least access to care; the current delivery system still fails to meet the oral health needs of many Americans; practitioners remain hindered by regulatory bodies that restrict their ability to provide services they’ve been trained to deliver; and barriers to care still exist.

ADDITIONAL INITIATIVE

In response to the Surgeon General’s call to action in 2000, the United States Department of Health and Human Services (HHS) issued its own Oral Health Initiative in 2010.⁴ The purpose of this initiative was to promote the idea that “oral health is integral to overall health.” It included the following four goals: emphasize oral health promotion/disease prevention, increase access to care, enhance the oral health workforce, and eliminate oral health disparities.

ADVANCING ORAL HEALTH

In 2009, the US Health Resources and Services Administration (HRSA) asked that the IOM convene a panel to develop recommendations on an oral health initiative. The goal was to
assess “the current oral health care system, reviewing the elements of the HHS Oral Health Initiative, and explore ways to promote the use of preventive oral health interventions
and improve oral health literacy.” The IOM panel faced the task of bridging the gap between oral health and general health.

The IOM committee chose to focus on the following components of oral health care delivery: settings of care, workforce, financing, quality assessment, access, and education. Although the 2000 Surgeon General’s Report was significant in its focus on oral health, it did not call for a different approach. While modest improvements in access were
achieved, America’s most vulnerable populations still cannot access necessary services.

Also, because funding did not follow the recommendations made by the Surgeon General, many were not implemented. The IOM committee proposed seven recommendations that comprise the New Oral
Health Initiative (NOHI) in its “Advancing Oral Health in America” report published in April 2011. The recommendations state:

1. The Secretary of HHS should give the leader(s) of the NOHI the authority and resources to successfully integrate oral health into the planning, programming, policies, and research that occur across all HHS programs and agencies. Accountability and measurable outcomes are important indicators for oral health status and access.
2. All relevant HHS agencies should promote and monitor the use of evidence-based preventive services in oral health (both clinical and community-based) across the life span. The committee agrees that ample evidence exists to support prevention as the key to promoting oral health, as opposed to just treating dental disease.
3. All relevant HHS agencies should undertake oral health literacy and education efforts aimed at individuals, communities, and health care professionals. This is important because the factors contributing to disease prevention are not well-understood, nor is the connection between oral health and systemic health. One problem is the lack of evidence within health literacy to formulate specific strategies to achieve this goal. The committee, however, recognizes that the current delivery system is not adequate. Nondental health care workers must be trained in the principles of oral health disease prevention and management as well as in the delivery of services.
4. HHS should invest in workforce innovations to improve oral health. To accomplish this, nondental health care professionals need education and training, and links to care
   need to be created to improve access. In addition, existing and new types of dental workers with training to perform expanded functions should be considered.
5. The federal Center for Medicare and Medicaid Services (CMS) should explore new delivery and payment models for Medicare, Medicaid, and the Children’s Health Insurance Program to improve access, quality, and coverage of oral health care across the life span. Financial barriers must be reviewed and alternative financing systems may need to be developed.
6. HHS should place a high priority on efforts to improve open, actionable, and timely information to advance science and improve oral health through research.
7. The leaders of the NOHI should convene an annual public meeting of the agency heads to report on progress of the initiative.

 

SYSTEM OF DELIVERY

The framework of the oral health care system has many implications for the dental hygiene profession. Traditionally, the delivery of oral health care is provided either within a private practice setting or a health safety net. These systems differ in many aspects, including financing and patients served. There is also a traditional model of the dental workforce, but new types of dental professionals are in practice or have been proposed. For example, the Indian Health Service developed the dental therapist role to improve access on Indian reservations.

The advanced dental therapist is another new addition. Alternative practice settings and expanding the scope of services that dental hygienists are licensed to provide are all ideas under consideration. The current system cannot support the demand for care and must be revisited. The most important assertion made in the

IOM’s “Advancing Oral Health in America” report is that oral diseases place a grave burden on the health and well-being of Americans that cannot be ignored.

IMPROVING ACCESS TO CARE

The second report, “Improving Access to Oral Health Care for Vulnerable and Underserved Populations” was released on July 13, 2011. This report examined the barriers to care and proposed 10 recommendations based on the IOM’s vision that all Americans should have access to oral health care throughout their lives. The committee was charged with designing a better oral health care delivery system to improve access to the millions of individuals who have little or no ability to receive professional dental care.

This includes racial and ethnic minorities, older adults, pregnant women, people with special needs, those of low socioeconomic status, and rural populations. The report’s guiding principles were that oral health is integral to health and therefore essential, and that oral health promotion and disease prevention are critical within any proposed strategy. The report named the following factors as critical to the success of the proposed evidence-based system: eliminate barriers that contribute to oral health disparities; prioritize disease prevention and health promotion; provide oral health services in a variety of settings; rely on a diverse and expanded array of providers who are competent, compensated, and authorized to provide evidence-based care; include collaborative and multidisciplinary teams working across the health care system; and foster continuous improvement and innovation.⁴

The report included 10 recommendations in six key areas: integrating oral health into overall health care, creating optimal laws and regulations, improving dental education and training, reducing financial and administrative barriers, promoting research, and expanding capacity.

The 10 recommendations include:

1. HRSA should convene key stakeholders from the private and public sector to develop a core set of oral health competencies for health care professions and a set for nondental health care professions.
2. State legislatures should amend existing state laws—including practice acts—to optimize access to oral health care. This would enable dental health care workers to practice to the full extent of their education and training, allow them to work in a variety of settings with appropriate supervision, and use telehealth technologies.
3. Dental professional education programs should increase recruitment of minority students, require participation in community-based programs, and hire faculty with knowledge and experience in delivery of care to underserved and vulnerable populations. Access will improve with a more diverse workforce and exposure to populations who traditionally have barriers accessing oral health care.
4. HRSA should dedicate funding to facilitate community-based experiences and provide financial assistance for minorities to participate in dental education programs.
5. HRSA should dedicate funding to support and expand opportunities for dental residencies in community-based settings. Clinical experience outside the walls of an educational institution and nontraditional opportunities may increase the likelihood of students choosing to practice in underserved areas.
6. CMS should fund and evaluate state-based projects that cover essential oral health benefits for Medicaid beneficiaries. Financial barriers affect access and many publicly funded programs are currently limited in their coverage for oral health services.
7. States should increase provider participation in publicly-funded programs by offering equitable reimbursement rates, providing case-management, and streamlining administrative processes. Non-participation in publicly funded programs is often due to low reimbursement rates and the burden of additional paperwork.
8. Congress, HHS, federal agencies, and private foundations should fund oral health research and evaluation related to underserved and vulnerable populations. There is not enough evidence-based research for best practices to increase access for those not receiving oral health care. This is particularly important for new models of care, emerging types of dental providers, and methods of financing and regulation.
9. The US Centers for Disease Control and Prevention and the Maternal and Child Health Bureau should collaborate with states to ensure that each state has the infrastructure and support necessary to perform core dental public health functions (eg, assessment, policy development, and assurance). The premise is that state oral health programs are capable of resource management and evaluation of oral health initiatives, but are limited by the funding they receive.
10. The capacity of Federally Qualified Health Centers (FQHCs) should be expanded to deliver essential oral health services through the following: using a variety of oral health care professionals, providing financial incentives to retain professionals, offering assistance in best practices to improve efficiency, and broadening their service provision outside of the clinic. FQHCs are the safety net for many individuals who cannot access oral health care in traditional systems.

 

DENTAL HYGIENE PROFESSION

The oral health care workforce is critically linked to access issues. Most dental hygienists are employed in traditional dental settings, while some work in public health, education, or alternative practices. Dental hygiene practice is also influenced by the distribution of dental providers and where they can find employment. Dental hygiene students also may not be prepared—educationally or clinically—to work with underserved or vulnerable populations.

A critical issue for dental hygienists is the ability to use the full extent of their education and training in the provision of services. Many states limit dental hygienists’ scope of practice so they can’t utilize their complete skill set. This confounds access problems by restricting the range of services that could otherwise be offered. The settings and supervision may be restricted as well. According to the American Dental Hygienists’ Association, only 44% of dental hygienists have the ability to perform some level of expanded function. There is no guarantee, however, that expanded functions or alternative setting/supervision changes will increase access where oral health care is not available. This is one of the topics where more research is needed. Further, it may be necessary to revise current dental hygiene curricula or provide advanced training and/or education to ensure clinical knowledge and provide the ability for expanded roles within dental hygiene. This is an area where strong advocacy efforts are indicated.

Dental hygiene professionals need to be cognizant of the fact that millions of Americans do not have access to professional oral health care services. We play an important role in solving these problems. There are many opportunities for dental hygienists to practice in safety net programs (eg FQHCs) and in alternative delivery sites (eg school-based clinics). By increasing exposure to community-based programs in dental hygiene education, hopefully, more providers will be comfortable working in nontraditional settings. Alternative settings can also provide additional avenues of employment in areas saturated with too many dental hygienists and too few private practice opportunities.

As a profession, dental hygiene must be adequately represented on state dental boards and intimately involved in the legislative quest to increase access to care. The current oral health care delivery system is not adequate to meet the demand for care. Our challenge is to do something about it.

The authors note that the recommendations are taken directly from the IOM reports so as not to misinterpret the intent.

REFERENCES

1. 1. National Institute of Dental and Craniofacial Research. Oral Health in America: A Report of theSurgeon General. Available at: www.nidcr.nih.gov/datastatistics/surgeongeneral/report/executivesummary.htm. Accessed May 29, 2012.
   2. Institute of Medicine. Advancing Oral Health in America. Available at: www.nap.edu/openbook.php?record_id=13086&page=R1. Accessed May 23, 2012.
   3. Institute of Medicine. Improving Access to Oral Health Care for Vulnerable Populations. Availableat: www.nap.edu/openbook.php?record_id=13116. Accessed May 23, 2012.
   4. HHS Oral Health Initiative 2010. Available at: www.hrsa.gov/publichealth/clinical/oralhealth/hhsinitiative.html. Accessed May 29, 2012.

From Dimensions of Dental Hygiene. June 2012; 10(6): 66-69.