+ principles in dental public health © aaphd. + vinodh bhoopathi., bds., mph.,dscd course created...

+

Principles in Dental Public Health

© AAPHD

+

Vinodh Bhoopathi., BDS., MPH.,DScD

Course Created By

Course Contributors:Dr. Woosung Sohn, Dr. Susan Reed, Diane Brunson, Robin

Knowles, Karen Yoder, Dr. Ana Karina Mascarenhas, Dr. Kathryn Ann Atchison

© AAPHD

+

3

3

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 D83HP19949 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.

© AAPHD

+

4

Course Competencies

4

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

© AAPHD

+ Course Objectives Identify and describe the principles of public health as it relates to

oral health and the dental professional.

Describe the public health and dental public health achievements in the US.

Describe the oral health status and needs of the US population, including various age groups, underserved, and minority populations.

Describe the dental disease trends among various US populations.

Identify and explain determinants associated with heath care access and utilization of dental care services.

Recognize the roles of public, private, professional and voluntary organizations in promoting oral health, and the delivery of dental health care services.

Describe and differentiate different oral health workforce models.

5

© AAPHD

+

6

Lecture 1Introduction to Dental Public Health

6

© AAPHD

+ Learning Objectives Define Public Health and Dental Public Health

Describe three core functions of public health

Describe the ten essential public health services

Identify the difference between the roles of a private dental practitioner and a dental public health specialist

List and describe the roles of major federal agencies involved in oral health and dental public health

Identify the roles of other professional organizations promoting oral health

7

© AAPHD

+ Mission of Public Health

“Fulfilling society’s interest in assuring conditions in which people can be healthy”

8

The Future of the Public's Health in the 21st Century, 2002. Institute of Medicine

© AAPHD

+ Definition

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.

9

* Competency Statements in Dental Public Health. J Public Health Dent, 1998; 58 (1): 119-22.

© AAPHD

+ Dental Public Health (DPH)

One of nine dental specialties recognized by the American Dental Association (ADA) Recognized a specialty in 1950 Sponsoring organization is the American Association of

Public Health Dentistry (AAPHD) Separate and distinct from any recognized dental

specialty Contributes to new knowledge, research, education,

services that directly benefits different aspects of clinical patient care

Unique knowledge and skills (Masters in Public Health and residency) that generally takes two years of education beyond the pre-doctoral dental curriculum

10

© AAPHD

+Core Competencies in Dental Public Health (DPH)

11

A specialist in DPH willI. Plan oral health programs for populationsII. 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 populationsIV. Incorporate ethical standards in oral health programs and

activities V. Evaluate and monitor dental care delivery systemsVI. 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

+ Public Health

The concept of Public Health that emerged in the beginning of the 20th century had three core public health functions: AssessmentPolicy DevelopmentAssurance

12

© AAPHD

+ Assessment

“…is the regular and systematic collection, assemblage, analysis, and communication on the health of the community.”

Includes statistics on: Health and oral health status Community health needs Resources to address needs

IOM: The Future of Public Health, 1988

13

© AAPHD

+Policy Development

“….is the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision-making about public health….” Strategic approach

IOM: Future of Public Health, 1988

16

© AAPHD

+Assurance

Assure that the public has access to necessary health services through regulation, education or direct provision of services Encouraging actions by other entities, public

or private Requiring such action through legislation Providing services directly

18

© AAPHD

+Assurance

“…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…..” Include subsidization or direct provision of

high-priority personal health services for those unable to afford them

IOM: The Future of Public Health, 1988

19

© AAPHD

The Ten Essential Services

21

© AAPHD

+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.

22

© AAPHD

+ How can DDS/RDH use 3 core PH functions compared to a DPH specialist?

23

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

23

© AAPHD

+

Dental Public Health Dental Public Health Infrastructure in the Infrastructure in the USUS

© AAPHD

+Dental Public Health Infrastructure

The dental public health (DPH) infrastructure is the foundation upon which public dental programs and activities are assessed, planned, executed, and evaluated.

Federal, state, and local or county governments have the potential to make a significant impact on a community’s oral health

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

25

© AAPHD

+Secretary

----------------------

Deputy Secretary

-----------------------

Chief of Staff

The Executive Secretariat

Office of Health Reform

HHS Organization ChartOffice of Intergovernmental

and External Affairs

Centers for Medicare and Medicaid Services (CMS)

Administration for Children and Families (ACF)

Food and Drug Administration (FDA) *

Health Resources and Services Administration

(HRSA) *

Indian Health Services (IHS) *

National Institute of Health (NIH) *

Administration for Community Living (ACL)

Agency for Health Care Research and Quality

(AHRQ)*

Agency for Toxic Substances and Disease Registry

(ATSDR)*

Centers for Disease Control and Prevention (CDC) *

Substance Abuse & Mental Health Services

Administration (SAMHSA) *

Office of the Assistant Secretary for Administration

(ASA)

Program Support Center (PSC)

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)

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)

Office of National Coordinator for Health Information Technology

(ONC)

* Designates a component of U.S. Public Health Services

http://www.hhs.gov/about/orgchart/

26

© AAPHD

+ HHS

Office of Surgeon General 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.

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


27

© AAPHD

+HHS

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

Oral health Goal“Prevent and control oral health diseases, conditions, and

injuries, and improve access to preventive services and dental care”

Oral health objectives (OH 1 to 17) OH1 to 6 - Oral health in children, adolescents and adults

(dental caries, untreated tooth decay, tooth loss) OH7 to 11- Access Preventive Services

(school based centers, service utilization, FQHCs with oral health)

OH 12 to 14 - Oral health interventions (sealants, community water fluoridation)

OH 15 to 16 – Monitoring and surveillance systems (systems recording and referring cleft lip and palate, oral and

craniofacial systems) OH 17 - Public health infrastructure

(health agencies with a DPH professional directing programs)

28

© AAPHD

+

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)”

HP2020 Baseline is 2007: 44.5% of persons aged 2 years and over had a dental visit in the past 12 months (age adjusted).

HP2020 Target: 49.0% (age adjusted), or 10 percent improvement

HHS

http://www.healthypeople.gov/2020/LHI/oralHealth.aspx?tab=data

Healthy People 2020

29

© AAPHD

+ HHS

Uniformed service of more than 6,000 health professionals who serve in the HHS and other federal agencies

The Surgeon General heads this uniformed commissioned corps

In 2007 approximately 390 dental offices

Primary care provider and advocate for Alaskan Native and American Indians

30

United States Public Health Services (USPHS)

Indian Health Services

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

30

© AAPHD

+HHS National Institute for Dental and Craniofacial

Research (NIDCR) – one of the 24 institutes under National Institutes of Health To improve oral, dental and craniofacial

health through research, research training, and the dissemination of health information. Performing and supporting basic and clinical research; Conducting and funding research training and career

development programs to ensure an adequate number of talented, well-prepared and diverse investigators;

Coordinating and assisting relevant research and research-related activities among all sectors of the research community;

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/AboutUs/MissionandStrategicPlan/MissionStatement/

31

© AAPHD

+HHS

Centers for Disease Control and Prevention: Division of Oral Health 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— Encouraging the effective use of fluoride products and

community water fluoridation. 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


32

© AAPHD

+HHS Health Resources and Services Administration

(HRSA) Federal agency for improving access to health

care services for people who are uninsured, isolated or medically vulnerable.

HRSA grantees provide health care to uninsured people, people living with HIV/AIDS, and pregnant women, mothers and children Goal I: Improve Access to Quality Care and

Services. Goal II: Strengthen the Health Workforce. Goal III: Build Healthy Communities. Goal IV: Improve Health Equity.

33

© AAPHD

+ HHSCenters for Medicare & Medicaid Services

(CMS)

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 needs-based program), CMS oversees the Children’s Health Insurance Program (CHIP), and the Health Insurance Portability and Accountability Act (HIPAA), among other services

34

© AAPHD

+ HHS

U.S 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

35

© AAPHD

+ Professional Organizations Supporting Dental Public Health Advocate and promote optimal oral health

care for all American Association of Public Health Dentistry American Board of Dental Public Health American Public Health Association, Oral Health

Section Association of State and Territorial Dental

Directors American Association of Community Dental

Programs American Dental Education Association American Dental Association American Academy of Pediatric Dentistry

36

© AAPHD

+American Association of Public Health Dentistry (AAPHD) Founded 1937

Sponsor of the American Board of Dental Public Health,

Publishes the Journal of Public Health Dentistry, and is

Co-sponsor of the yearly National Oral Health Conference

AAPHD is committed to: “Promotion of effective efforts in disease prevention, health

promotion and service delivery”, “Education of the public, health professionals and decision-makers

regarding the importance of oral health to total well-being”, and “Expansion of the knowledge base of dental public health and

fostering competency in its practice”.

37

© AAPHD

+American Board of Dental Public Health

National examining and certifying agency for the specialty of dental public health

Functions creation of standards for the practice of dental

public health; 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

ensure continuing competency of diplomates

38

© AAPHD

+American Public Health Association

Founded in 1872 – largest public health organization in the world

Publishes the American Journal of Public Health.

Oral Health Section is one of many sections of APHA Provides DPH members a forum to obtain support from

non-DPH members/leaders and decision makers Some public health issues that OH section investigates

and promotes Community water fluoridation Access to dental care for vulnerable groups Reducing racial and ethnic oral health disparities Domestic violence screening etc

39

© AAPHD

+Association of State and Territorial Dental Directors

Non-profit organization representing the directors and staff of state public health agency programs for oral health

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, assists in development and implementation of

programs and policies for the prevention of oral diseases;

developing position papers and policy statements; provides information on oral health to health

officials and policy makers, and conducts conferences for the dental public health community

40

© AAPHD

+American Association of Community Dental Programs

Voluntary membership organization - Supports effort of those with an interest in serving the oral health needs at the community level Guides local public health agencies through the steps

for developing, integrating, expanding, or enhancing community oral health programs

Members include local dental directors and staff of city, county, and community-based health programs

41

© AAPHD

+

National organization representing academic dentistry - voice of dental education.

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

ADEA has a section on community and preventive dentistry and behavioral sciences. explores issues related to community and preventive

dentistry as they apply to dental and dental hygiene education, research and practice

The ADEA publishes the Journal of Dental Education

American Dental Education Association

42

© AAPHD

+American Dental Association

Founded in 1859, the American Dental Association (ADA) is the oldest and largest national dental society in the world - over 157,000 ADA members

“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”

Works to advance the dental profession on the national, state and local level

http://www.ada.org/6876.aspx http://www.ada.org/sections/professionalResources/pdfs/dph_educational_module.pdf

43

© AAPHD

+American Academy of Pediatric Dentistry

Membership organization representing the specialty of pediatric dentistry

Mission of the AAPD is to advocate policies, guidelines and programs that promote optimal oral health and oral health care for children.

Serves and represents its membership in the areas of professional development and governmental and legislative activities.

44

© AAPHD

+

45

Lecture 2Population-Based Public Health Strategies

45

© AAPHD

+ Learning Objectives

Define the approaches used by Public Health to improve the health of the community

Describe the importance of various public health achievements, including dental public health achievements in the last century

Describe the population level impact of community level water fluoridation

46

© AAPHD

+ Public Health Practice

Focuses on the health of groups, community, or the nation.

Population-focused care is defined as interventions aimed at disease prevention and health promotion that shape a community’s overall health profile (DHHS, 1994a)

Key feature of public health practice is the acknowledgment that health is greater than the biological determinants of individual health; It also embraces a host of behavioral, social,

economic, and environmental factors (including biological determinants of individuals) that affect the health of a community.

47

Porsche DJ. Public & community health nursing practice : a population-based approach 2004. Available at http://www.sagepub.com/upm-data/3989_Chapter_1.pdf

© AAPHD

+ 20th Century Public Health Achievements U.S. 1900-1999

Vaccination

Motor Vehicle Safety

Safer Workplaces

Control of Infectious Disease

Decline in Deaths from CVD and Stroke

Safer and Healthier Foods

Healthier Mothers and Babies

Family Planning

Community Water Fluoridation

Recognition of Tobacco Use as a Health Hazard

48

48

http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm

© AAPHD

+VaccinationsPolio vaccinations

First outbreak described in US in 1843

1951-1954, an average of 16,316 paralytic polio cases and 1879 deaths

Polio vaccines introduced in US 1955

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

49

© AAPHD

+ Vaccinations

Only 69% received vaccinati

on

ONLY 82%

receive vaccinati

on in 2011

DTP, polio, MMR, and

Hib vaccines

DTP, polio, MMR, and Hib vaccines

+ hepatitis B vaccine, and the varicella vaccine

50

© AAPHD

+ Vaccinations

Community or Herd immunity 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.

51

http://www.vaccines.gov/basics/protection/index.html The National Institute of Allergy and Infectious Diseases

(NIAID)

51

© AAPHD

+Vaccinations

Community or Herd immunity 18% not immunized could increase the risk of outbreaks

52

http://www.vaccines.gov/basics/protection/index.html The National Institute of Allergy and Infectious Diseases (NIAID)

52

© AAPHD

+Motor Vehicle Safety

1960 unintentional injuries caused 93,803 deaths – 41% related to motor vehicle crashes

1966- Highway Safety Act and Motor Vehicle Safety Act Vehicles were built with new safety features

head rests, energy-absorbing steering wheels, shatter-resistant windshields, and safety belts

Roads were improved – use of breakaway signs, improved illuminations

1970 – evidence decrease in deaths due to motor vehicle crashes.

54

© AAPHD

+

55

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.html

Motor-vehicle related death rates per 100,000 population and per 100 million vehicle miles traveled (VMT), by year – Unites States, 1966-1997

Motor Vehicle Safety

© AAPHD

+ Safer Workplaces

Beginning of this century – workers faced high health and safety risk in their workplaces

56

© AAPHD

+

57

50% decrease in coal mining fatality rates occurred from

1966-1970 to 1971-1975 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

Safer Workplaces – Example Mining related deaths

© AAPHD

+ Safer Workplaces – Dental office

Universal precautions

Infection control

Mercury and amalgam safety

Radiation safety

Ergonomics

Agency responsible to oversee workplace safety: Occupational Safety and Health Administration (OSHA)

58

© AAPHD

+ Control of Infectious Disease The 19th century shift in

population from country to city industrialization and immigration

overcrowding in poor housing served by inadequate or nonexistent public water supplies and waste-disposal systems.

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 Tuberculosis Typhoid Fever Diphtheria Cholera HIV/AIDS

59

© AAPHD

+Control of Infectious Diseases Typhoid fever in US

Dramatic declines in incidence and mortality - after widespread implementation of municipal water and sewage treatment systems 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

60

http://www.cdc.gov/healthywater/observances/dww-graph.html

60

© AAPHD

+

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

Control of Infectious Diseases

61

© AAPHD

+ Safer and Healthier Foods

Early 20th century – contaminated food, milk, water caused foodborne infections

1906 – Pure food and drug act Food Safety:

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: Food fortification programs decreased nutritional deficiency

diseases like goiter, rickets Pellagra elimination in 1940s – improved diet, enrichment of

flour with niacin

62

© AAPHD

+ 63


Number of reported pellagra deaths, by sex of decedent and year – US, 1920-1960

Safer and Healthier Foods

63

© AAPHD

+Decline in Deaths from CVD and Stroke

1920s-30s: heart disease and stroke leading cause of death – together 40% of all deaths

Since 1950- death rates from cardiovascular disease (CVD) declined 60%

During 1970s-80s – 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) National programs targeted health providers, patients and

public National High Blood Pressure Education Program:1972 National Cholesterol Education Program: 1985

Reduction due to combination of factors 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

64

© AAPHD

+Decline in Deaths from CVD and Stroke


65

© AAPHD

+ Family Planning

In 1900, 6 to 9 / 1000 women died in childbirth, and one in five children died during the first 5 years of life. Distributing information and counseling patients about

contraception and contraceptive devices was illegal under federal and state laws

1912 – Modern Birth control movement began

Hallmark of family planning – the ability to achieve desired birth spacing and family size - leading to decreased fertility rates Traditional methods of fertility control Modern contraception and reproductive health systems 1972 - Publicly supported family planning services through

Medicaid funding prevented 1.3million unintended pregnancies annually

66

© AAPHD

+


Family Planning

67

© AAPHD

+

68


Healthy Mothers and Healthy Babies

© AAPHD

+Healthy Mothers and Healthy Babies

Infant mortality - Beginning of 20th century – 100 infants/1000 live births died before age 1 Improved sewage, refuse

disposal, safe drinking water – key role in infant mortality

Decline fertility rate – longer spacing of children, small family, better nutritional status

Milk pasteurization – controlled milk-borne diseases

Antibiotics, safe blood transfusions, electrolyte replacements

Vaccinations

Maternal Mortality – Beginning of 20th century, for every 1000 live birth 6 to 9 women died of pregnancy complications Maternal mortality highest

between 1900 to 1930 – due to Poor obstetric education and delivery practices

1930s to 40s – White House Conference Review committees Home births shift to

hospital births Improved institutional

guidelines Antibiotics, asepsis,

management of hypertension

69

69

© AAPHD

+Tobacco Use First decades of 20th century-lung cancer rare

Per capita cigarette consumption increased from 54 cigarettes in 1900 to 4345 cigarettes in 1963

Increased smoking lead to more lung cancer cases

1964 – advisory committee to US Surgeon general identified – tobacco use as a serious health hazard

Various public health efforts followed suit 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;

70

© AAPHD

+Trends in cigarette smoking* among persons aged ≥ 18

years, by sex- United States, 1955-1997


Tobacco Use

71

© AAPHD

+

Community Water Community Water FluoridationFluoridation

© AAPHD

+Colorado Springs, Colorado

History

1901 Dr. F. McKay investigates “Colorado Brown Stain” (teeth stain)

1909 – Dr Robertson observed brown stained teeth of children drinking from a locally dug well

Hypothesis that something in the water causes the stain

1930 Alcoa chemist H.V Churchill identifies fluoride by spectrophotometry -- up to 14 ppm


73

© AAPHD

+•1931 - Dentist H.Trendley Dean appointed to begin the Dental Hygiene Unit of the newly established National Institute of Health to investigate

•1934 - 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 > 1.0ppm

•1941 - “21 Cities Study” - documented dental caries experience in different communities dropped sharply as F concentration rose toward 1.0 ppm, then leveled off

•1945 – Four pair city study – over 15 years, reduced caries in 50 -70% children in communities with fluoridated water

•1950 – US Public Health Services issued a policy statement to American Dental Association, supporting community water fluoridation

•1951- Reaffirmed “community water fluoridation” - Official policy of public health service in testimony before senate

History

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.html McLure FJ. Water Fluoridation – the search and the victory. Bethesda (MD):US Dept of Education

and Welfare, NIH, NIDR: 1970. Chapter 14: 247-9

74

© AAPHD

+What Is Community Water Fluoridation?

The adjustment of the level of fluoride in the water supply Current (recommended level of fluoride: 0.7 parts

per million (ppm) or 0.7 mg/Liter of water Previous recommended level of fluoride in water: 0.7

to 1.2 ppm or 0.7 to 1.2 mgs/Liter of Water

Most water supplies contain trace amounts of fluoride.

Water systems are considered naturally fluoridated when the natural level of fluoride is greater than 0.7 parts per million (ppm).

75

http://wayback.archive-it.org/3926/20140108162323/http:/www.hhs.gov/news/press/2011pres/01/20110107a.html

© AAPHD

+ Facts about Fluoride

Fluorine [F] is a member of the halogen family – naturally occurring

The most electronegative of all elements, F -2

Is extremely reactive

Occurs in minerals, e.g. fluorspar (CaF2), cryolite (Na3AlF6), fluorosilicates (Na2SiF6)

Also found in mica, hornblende, pegmatites (coarse granite)

Ranks 17th abundance in earth’s crust (0.06-0.09%)

Present in sea water (1.2 – 1.4 ppm)

Occurs in biological mineralized tissue, e.g. bones and teeth as fluoridated hydroxyapatite

76

© AAPHD

+ 3 Mechanisms of Fluoride Action

1. Topical interaction with the enamel 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

2. Interaction with the bacteria Fluoride inhibits glycolysis, inhibits dextran

formation for dental plaque adherence, and direct effect on bacteria

3. Developmental interaction with enamel Reduction in enamel solubility

77

© AAPHD

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.html

Calciumfluoroapatite crystals –

reduced solubility

78

© AAPHD

+ Benefits of Fluoridation

Dental caries most common disease DMFT (Decayed, Missing, Filled Teeth due to dental

caries) 4.0 in 1966-1970 to 1.3 in 1988-1994

Earlier studies suggest caries reduction attributable to fluoridation ranged from 50% to 70%

Studies between 1979-1989 found that caries reduction was 8%-37% among adolescents

79

© AAPHD

Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries MMWR weekly, 1999/48 (41); 933-40.

mean DMFT among persons aged 12 years in

the United States

declined 68%, from

4.0 in 1966-1970 to 1.3 in

1988-1994

80

© AAPHD

+Benefits of Fluoridation It does not require costly services of health care

professionals to deliver

There are no daily –dosage schedules to remember

No bad taste

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

81

© AAPHD

+ In United States (2010)

Total US population – 308, 745, 538

U.S. Population on Public Water Supply Systems -276,607,387

Total U.S. Population on Fluoridated Drinking Water Systems -204,283,554

Percentage of U.S. Population receiving Fluoridated Water -66.2%

http://www.cdc.gov/fluoridation/statistics/2010stats.html

82

© AAPHD

+ Dental Fluorosis

Series of conditions occurring in those teeth that have been exposed to excessive sources of fluoride ingested during enamel formation

Older children and adults are not at risk for dental fluorosis

Severe-Source of photo

unknown Mild -Photo by Elke Babiuk

83

© AAPHD

+ Antifluoridation

© AAPHD

+

85

Lecture 3

Oral Health andOral Health Disparities

85

© AAPHD

+Learning Objectives

Describe the current oral health status of the US population

Describe what oral health disparities mean

Describe various factors associated to oral health disparities among US population

86

© AAPHD

+

Why is Oral Why is Oral Health Health Important?Important?

© AAPHD

+ Background Department of Health and

Human Services released first ever Surgeon General’s report on Oral Health (2000)

Oral health is essential to the general health and well-being of all Americans and can be achieved by all Americans.

However, not all Americans are achieving the same degree of oral health

Substantial oral health disparities exists among different subgroups of US populationU.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 CraniofacialResearch, National Institutes of Health, 2000.

© AAPHD

+

In the first ever Surgeon General’s report on Oral Health (2000),

“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”

Oral Health

89

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 CraniofacialResearch, National Institutes of Health, 2000.

© AAPHD

+Oral Health Impact

90

© AAPHD

+

91

© AAPHD

+

Oral Health Status Oral Health Status in the USin the US

© AAPHD

+

93

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.

Distribution of Caries by age

© AAPHD

+

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:


95

© AAPHD

+Distribution of Periodontitis in Adults:


96

© AAPHD

+ 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

+

98

© AAPHD

+

Disparities in Oral Health Disparities in Oral Health status and in accessing status and in accessing dental care servicesdental care services

© AAPHD

+

Health 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) Race or ethnicity, sex, sexual identity, age, disability,

socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health.

Health Disparities

100

© AAPHD

+

101

Key is that there are differences between populations in the measures of health A health disparity is believed to exist when (examples):

Tooth decay more common in low–income children compared to high-income children 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 (High-income) [2005-2008 National Health and Nutrition Examination Survey data]

Black or African Americans have a lower survival rate due to oral and pharyngeal cancer (OPC) compared to White Americans 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 Results Data]http://www.cdc.gov/nchs/data/databriefs/db96.html

http://seer.cancer.gov/statfacts/html/oralcav.html

Differences between populations in health

© AAPHD

+ 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

102

© AAPHD

+

103

Disparities in oral health status may arise due to: Differences (barriers) in access to health

care Timely use of personal health services to achieve

the best health outcomes 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)

Factors underlying health and health care related disparities

© AAPHD

+

105

Measurable characteristics that describe the health of a population:

Diseases Dental caries, gingivitis, tooth loss, oral cancer

Determinants of health Oral health behaviors, oral health risk factors,

physical environments, and socioeconomic environments

Access to dental care Use - dental visits, dental sealants, filling Cost - insurance

Depending on the measure, a oral health indicator may be defined for a specific population, place, or geographic area.

Oral Health Indicators

Modified fromhttp://healthindicators.gov/Resources/Glossary

© AAPHD

+

106

Healthy people 2020 Oral Health Objectives

Healthy People 2020 Objectives - each objective related to an oral health indicator is developed to be achieved over the second decade of this century

Oral Health objectives (OH 1 to 17) OH1 to 6, focuses on oral health in children, adolescents and

adults (dental caries, untreated tooth decay, tooth loss, dental restorations/fillings)

OH7 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

+

107

Untreated tooth decay Denotes dental disease

experience / dental treatment needs in a population group

HP2020 Objective: 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

HP2020 Objective: OH-12: Increase the

proportion of children and adolescents who have received dental sealants on their molar teeth

Dental Sealants

Examples of Oral Health indicators in HP2020

© AAPHD

+ 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

Race/Ethnicity

Non-hispanic white1 17.8% 80.1%

Non-hispanic black 2 34.2% 2 62.6%

Mexican American 2 31.1% 2 61.8%

Poverty level

Below 100% 2 35.8% 2 62.7%

100 to less than 200% 2 30.5% 2 68.8%

200% or higher1 15.5% 80.2%

Gender

Male 2 24.6% 2 72.1%

Female1 18.6% 78.7%1 Reference group, 2 p <0.05

Source: CDC/NCHS National Health and Nutrition Examination Survey

108

© AAPHD

+

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.

1Includes untreated and treated (restored) dental caries. 2Significantly different from those aged 6–8 years, p < 0.05.3Significantly different from non-Hispanic black children, p < 0.05.4Significantly different from Hispanic children, p < 0.05.SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.

Prevalence of dental caries in primary teeth, by age and race and Hispanic origin among children aged 2–8 years: United States, 2011–2012

Disparities in dental caries experience and untreated dental caries

© AAPHD

+Disparities in dental visits

National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012.

Dental visits in the past year by selected characteristics among 2 years and older: United States, selected years 1997-2010

110

Characteristic5 1997 2010

RACE

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%

ETHNICITY

Hispanic or Latino 54.0% 56.5%

Non-Hispanic or Non-Latino 66.4% 66.2%

PERCENT OF POVERT LEVEL

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%

© AAPHD

+ Utilization of Dental Service 111

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.

111

© AAPHD

+ Disparities in Dental Sealants prevalence

112

© AAPHD

+Disparities in Dental Sealants prevalence

113

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.

1Significantly different from those aged 9–11 years, p < 0.05.2Significantly different from non-Hispanic black children, p < 0.05.3Significantly different from non-Hispanic Asian children, p < 0.05..SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.

Prevalence of dental sealants in permanent teeth, by age and race and Hispanic origin among children aged 6–11 years: United States, 2011–2012

© AAPHD

+

114

Disparities in edentulism (complete tooth loss)

© AAPHD

+

One Example: Dental workforce shortageas a factor related to oral health disparities

© AAPHD

+ Health Professional Shortage Areas (HPSA)

Designated by HRSA

Having shortages of primary medical care, dental or mental health providers

Based on 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.htmlhttp://www.hrsa.gov/shortage/

116

© AAPHD

+ Dental Health Professional Shortage Areas (DHPSA)

Currently approximately 4,600 Dental HPSAs.

Dental HPSAs are based on a dentist to population ratio of 1:5,000.

Take approximately 6,600 additional dentists to eliminate the current dental HPSA designations.

More than 49 million Americans live in dental Health Professional Shortage Areas

http://www.hrsa.gov/publichealth/clinical/oralhealth/workforce.htmlhttp://www.hrsa.gov/shortage/

117

© AAPHD

+

118

U.S. Designated Dental Health Professions Shortage Areas 1991- 2011

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

1991 2000 2001 2002 2003 2004 2005 2011

Num

ber o

f U.S

. Des

igna

ted

Den

tal H

ealt

h Pr

ofes

sion

s Sh

orta

ge A

reas

Year

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

+

119

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

+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 65Source: American Dental Education Association

120

© AAPHD

+

Distribution of Dentists in Illinois, 2006

121

© AAPHD

+ Review: factors related to oral health disparities

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)

122

© AAPHD

+

123

Lecture 4Access to Dental Care and Utilization of Dental Care Services

123

© AAPHD

+ 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

124

© AAPHD

+ Access to dental care

Definition

The ability of a person to receive dental health care services.

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,

125

© AAPHD

+ Access to dental care

Perceived need: A person’s self perceived need or want of

dental care

Demand for dental care: A person expresses the need for dental care by

acting on it, and willingness to seek dental care.

Utilization of dental care: A person’s actual use of dental care services

that is available to him/her

126

© AAPHD

+ Regular care and regular dentist Ease to find a dentist when needed

Numbers of providers Location

Ability to afford dental care Insurance

Out-of-pocket Low-cost or free access

Access to any provider Alternative providers (therapists,

independent practicing hygienists)

127

Access to dental care

© AAPHD

+

Complex, multidimensional concept. Dentist available Financial resources Transportation Other barriers (job and free time)

A continuum, not a matter of presence or absence.

Access to care is important for prevention and for prompt treatment of illness and injury.

128

Access to dental care

© AAPHD

+

129

Surgeon General’s Report: Oral Health in America (2000)

• “Fewer than 20% of Medicaid-covered children had a dental visit in a given year”

• “The consequence of low dental-service 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

+

25% of poor children have not seen a dentist before entering kindergarten.

Uninsured children are 2.5 times less likely to receive dental care.

Children from families without dental insurance are 3 times more likely to have dental need.

For each child without medical insurance there are 2.6 without dental insurance.

Surgeon General’s Report: Oral Health in America (2000)

130

© AAPHD

+Disparities in dental visits

National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012.

Dental visits in the past year by selected characteristics among 2 years and older: United States, selected years 1997-2010

131

Characteristic5 1997 2010

RACE

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%

ETHNICITY

Hispanic or Latino 54.0% 56.5%

Non-Hispanic or Non-Latino 66.4% 66.2%

PERCENT OF POVERT LEVEL

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%

© AAPHD

+ Child Dies for Lack of Dental Care - Washington Post 2-28-2007

A twelve year old Maryland boy died Sunday after the infection from an abscessed tooth spread to his brain.

The boy had not been receiving routine dental care.

Mother had trouble finding a dental provider who would accept Medicaid

132

© AAPHD

+

In 2010, 64.7% of US residents 2 years and older reported that they had visited a dentist within the previous year.¥

Access problems are concentrated in Low-income areas Rural areas Minority population groups Very young children Elderly Special needs patients Institutionalized

Access to dental care: Status

133

¥-National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012.

© AAPHD

+ Utilization of Dental Service134

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.

134

© AAPHD

+ Measures of “access to dental care”

Adequacy of dentist supply Dentist/population ratio “Need” vs. “Demand”

Percent of population who had: A dental visit last year Regular dental visit Regular dentist to go (dental home)

135

© AAPHD

+ Measures of “Utilization of dental services”

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

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

136

© AAPHD

+ Funding Problem in Dental Care 120 million Americans do not have dental insurance

(43 million without medical insurance)

Upon retiring, 85% of Americans have no dental insurance

There are limited dental benefits for adults under Medicaid

Uninsured patients must pay out-of-pocket, and for low income patients the expense of dental care is generally prohibitive

137

© AAPHD

+ Federal Programs to Improve Access (for children)

Medicaid EPSDT (Early and Periodic Screening, Diagnostic, and

Treatment)

Children’s Health Insurance Program (CHIP)

Children’s Health Insurance Program Reauthorization Act (CHIPRA, 2009)

138

© AAPHD

+ 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.

Established in 1965 by Title XIX of Social Security Act.

Medicaid Partnership: Federal oversight: Centers for Medicare &

Medicaid Services (CMS) State oversight: State Department of Health

139

© AAPHD

+ Federal Programs to Improve Access: EPSDT

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) Child health component of Medicaid up to age 19. Required in every state Financing appropriate and necessary pediatric services. Dental services for children must minimally include:

Relief of pain and infections Restoration of teeth Maintenance of dental health

EPSDT benefit requires that all services must be provided if determined medically necessary

140

© AAPHD

+ Children’s Health Insurance Program (CHIP)

Provides health coverage to children in families with incomes too high to qualify for Medicaid, but cannot afford private coverage.

Jointly funded by the federal government and states.

Administered by the states

nearly 8 million children covered

141

© AAPHD

+ Surgeon General’s Report: Access to Dental Care (2000) Medicaid has not been able to

fill the gap in providing dental care for poor children. 80% of Medicaid eligible kids did

not receive preventive services in a given year

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.

142

© AAPHD

+ Dental care through Medicaid

Limited access to dental care Declining # of dentists accepting Medicaid Inadequate funding

Multi-level reasons for problem with dental Medicaid Medicaid reimbursement levels that are far

below dentists’ usual and customary fees Administrative difficulties Dental practice operations and productivity

Excessive number of broken appointments Perceived undesirable behaviors (such as non-

compliance) Social stigma

143

© AAPHD

+ Affordable Care Act The Affordable Care Act (ACA) requires Americans to

purchase health coverage in 2014 and thereafter or pay a fine

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 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

Additional 5.3 million children expected to get dental coverage through ACA in 2014

Total 8.7 million in 2018 Dental coverage for adults is NOT required

http://www.nadp.org/Libraries/LMS/The_ACA_and_Dental_Coverage--The_Basics--Jan_2013.sflb.ashxhttp://www.ada.org/en/home-ada/publications/ada-news/2013-archive/august/affordable-care-act-dental-benefits-examined

© AAPHD

+ Understand different dental care delivery sites

operated by federal, state and local governments

Identify the roles and scope of various dental and non-dental care delivery models.

Describe different types of common payment methods for dental services

146

Learning Objectives

© AAPHD

+

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 Workforce: The supply of various types of health

care professionals to provide dental care Financing: How is dental care paid for, common

payment services

147

Dental Care Delivery System

© AAPHD

+ Structure of the Dental System:Private For-Profit Delivery Sites

Private Dental Practices Solo Practice: principal form of dental

practice in US Group Practice

For-profit dental clinics: Clinic which may be owned by one dentist who employs others to perform care as employees or Independent contractors.

149

© AAPHD

+ Structure of the Dental System:Private For-Profit Delivery Sites Almost 90% of all private practices are located in

metropolitan areas

<1% are located in rural areas

Between 1982-2004, 98 U.S. counties never had a dental practice; 78% of these were rural.

Higher mean per capita income for a county is associated with a higher number of dentists practicing in the county.

150

Nash KD. Geographic Distribution of Dentists in United States. Health Policy Analysis Series. Chicago: American Dental Association,Health Policy Analysis Section, 2011.

© AAPHD

+ Mainly serves population groups who have low

access to health care Federally Qualified Health Centers (FQHCs)

Migrant Health Centers Health Care Centers for Homeless Public Housing Primary Care Centers Native Hawaiians Health Centers

Indian Health Service Programs Federal Prison Coast Guard Veterans Affairs Hospitals School Based Health Centers

152

Federal Government

152

© AAPHD

+

Qualifies for enhanced reimbursements from Medicaid

Must be in underserved area Must offer sliding fee scale – should provide

services to people irrespective of ability to pay

Must provide comprehensive services Must have a governing Board of Directors

153

FQHC: Federally Qualified Health Center

153

© AAPHD

+ Migrant health programs

Migrant or seasonal farm workers and their families

More than 3 million estimated in US Eligibility: Principal employment for both

migrant and seasonal farmworkers must be in agriculture

Served 862,808 workers in 2011

Health Centers for Homeless 930,589 people are homeless on a given night

and 2 to 3 million are homeless over the course of a year

1 million homeless served in 2011 Mobile dental clinics in shelters, grant funded

programs

Federally Qualified Health Centers

154

© AAPHD

+

Public Housing Primary Care Centers Services are provided on the premises

of public housing developments or at other locations immediately accessible to resident

Estimated 1.2 million live in public housing

FQHCs served 187,992 residents

Native Hawaiians 1.2 million people estimated (2010 US

census) 2011, approximately 8500 were served

Federally Qualified Health Centers

155

© AAPHD

+ 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

Approximately 2 million American Indians in the US Dental Services provided annually – approximately

3.7 million dental services provided 310 dentists in the Indian Health Service system

Indian Health Service Program

156

© AAPHD

+

One of the five armed forces of the United States and the only military organization within the Department of Homeland Security 2011 – 43,000 active members

In 2012, 58 dentists in 30 clinics, which are located mainly along the Atlantic, Gulf, and Pacific Coasts, including Alaska, Hawaii and Puerto Rico. All appropriate dental treatment

services are provided

U. S Coast Guard

157

© AAPHD

+

Government-run military veteran benefit system – including families of veterans - 22.7 million veterans

VA employs nearly 280,000 people at Veterans Affairs medical facilities, clinics, and benefits offices

Dental benefits for veterans vary

Dental benefits include a full range of services for eligible Veterans. Some of the many services offered by VA Dentistry: Regularly scheduled cleaning and x-rays. Restorative procedures such as fillings, crowns and bridges. Comfortable, well-fitting dentures. Oral surgery such as tooth extractions. Oral and facial reconstruction surgery resulting from trauma or

serious illness.

Veteran Affairs

158

© AAPHD

+

Sub-division of Department of Justice

The BOP has over 3,000 health care positions, including approximately 750 Public Health Service (PHS) Commissioned Officers Estimated 160,000 inmates

All basic dental services are provided

Federal Bureau of Prisons

159

© AAPHD

+ Center of health in the schools where they are based.

partnership between the school and a community health organization, such as a community health center, hospital, or local health department

About 20 to 23% of school based health centers receive funding from federal government Rest by local (37%) and/or state government (78%)

In 2007-2008, 1900 SBHCs funded by Federal government

Provide broad range of preventive services – oral health education, dental screening, fluoride varnish applications, and sealants

Dental hygienists or school nurses provide most of the services. Dentists very rare.

School Based Health Centers - Federal

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

160

© AAPHD

+ Structure of the Dental System:State Delivery Sites

School Based Health Centers or Sealant Programs

Dept. of Corrections: Provides direct care to those incarcerated in State Prisons

Dept. of Mental Health: Provides direct care to patients at state mental hospitals

Mobile Community Based Programs

Community Health Centers

161

© AAPHD

+ Structure of the Dental System:Local Delivery Sites

School Based Dental Programs

Oral Rinse Programs

Sealant Programs

Mouth Guard Programs

Local Health Dept. Clinics

Mobile Dental Health Programs

162

© AAPHD

+ New Dental Workforce Models

Expanded dental workforce models Expanded function dental hygienists Expanded function dental assistants

Alternate dental workforce models

Non dental workforce models

164

© AAPHD

+ Expanded Dental Workforce Models

Expanded function dental hygienists Eg. Registered Dental

Hygienist in Alternative Practice In 1998 the California

Legislature created a new license category of Oral Health Professionals, the Registered Dental Hygienist in Alternative Practice, abbreviated as RDHAP.

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.

Dental Hygienists Work with dentists in

traditional dental offices Scope of function varies

state to state 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)

165

165

© AAPHD

+ Expanded Dental Workforce Models

Expanded function dental assistants 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.

Dental Assistants

Help dentists with oral care procedures and typically complete on-the-job training, one-year diploma programs or two-year associate degree programs.

166

166

© AAPHD

+ Alternate Dental Workforce Models

Community Dental Health Coordinator

Advanced Dental Hygiene Practitioners

Dental Health Aide Therapist

Primary care physicians

Pediatricians

School nurses

Public health / social workers (promotoras)

Dental workforce models Non-dental workforce models

167

© AAPHD

+

Community Dental Health Coordinator (CDHC) Dental team member connected to a responsible

supervising dentist Scope: Extensive care coordination services,

screening, 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

Alternate Dental Workforce Models

168

© AAPHD

+

Advanced Dental Hygiene Practitioner (ADHP) Dental team member connected to a responsible

supervising dentist, possibly via teledentistry 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


169

© AAPHD

+

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


170

© AAPHD

+

Private Third Party System: Patient and dentist are the first and second parties Third party – defined as the party to a dental

prepayment contract that collects premiums, assume financial risk, pay claims, and provide administrative services

To meet the costs of providing care and administrative costs of the 3rd party – premiums are periodically collected – this is called dental prepayment or dental insurance

Public Third Party System: Medicaid, CHIP, Medicare

173

Payment Sources

173

© AAPHD

+

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

Reimbursement of third party plans

174

© AAPHD

+

Fee Schedule List of charges established or agreed to by a

dentist for specific dental services 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 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


175

Burt BA, Eklund SA. Dentistry, Dental Practice and the Community. 6th Edition 2005, W.B. Saunders Publications Inc., Philadelphia

© AAPHD

+ Reimbursement of third party plans Usual, Customary, and

Reasonable Fee For certain services

Usual: Fee that is most often charged by the provider

Customary: Range of fees charged by similar providers in a specific geographic area – establishes a maximum benefit

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

Example (Dentist visit and cleaning) Actual charge-250$ UCR allowable charge –

200$ Contractual write off-$50

80/20 Insurance plan paid - $160 (80% of UCR allowable charge paid by insurance company)

Co-insurance - $40

Patient costs - $40


© AAPHD

+

Table of Allowances Also known as: schedule of allowances or

indemnity schedule 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 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


177


© AAPHD

+ 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]

Dentists agree to a fee that are usually lower than charged by dentists in that area


178


© AAPHD

+ 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.

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

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


179


© AAPHD

+

Sliding Fee Scale Fee is adjusted based on family size and

income must provide services to patients without

regard for a person's ability to pay. May be subsidized by grant funding Most often found in clinics or community

health centers, and Federally Qualified Health Centers

180


180

© AAPHD

+

MEDICARE It was established because there were twin problems of high

health care needs and low income among persons age 65 years and above

Funded only by Federal government 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.

Medicare will also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances.

Does not cover routine dental/dental hygiene tx Does not cover dentures

181

Public Third Party PaymentPublic Financing of Care

181

© AAPHD

+ Public Third Party PaymentPublic Financing of Care: MedicareSection 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:Extractions made in preparation for radiation treatment for neoplastic diseases involving the jaw.Oral examinations (but not treatment) preceding some kidney transplantation or heart valve replacement. Some hospital stays if needed for emergency or complicated dental procedures, however the dental treatment is not covered. 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.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).Payment for the wiring of teeth if performed in connection with the reduction of a jaw fracture.

182

© AAPHD

+

MEDICAID Differs from Medicare - Medicaid funded by both

federal and state governments People eligible should have an income below

100% federal poverty level Dental services are an optional service for adult

Medicaid eligible age 21 and older, 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.

183


183

© AAPHD

+

State Children Health Insurance Program Series of federal and state partnerships Children of families with income that are above

those for Medicaid but are too low to afford a conventional health care insurance

SCHIP covers families who have incomes up to at least 200% of the federal poverty level

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


184

© AAPHD

+ Acknowledgement

Dr. Vinodh Bhoopathi

Dr. Woosung Sohn

Dr. Susan Reed

Diane Brunson

Robin Knowles

Karen Yoder

Dr. Ana Karina Mascarenhas

Dr. Kathryn Ann Atchison

185

+ principles in dental public health © aaphd. + vinodh bhoopathi., bds., mph.,dscd course created...

Documents

principles of public

determinants of health

public health dentistry

health promotion

department of health

physical health

health resources

publics health