Millions of Americans Lack Access to Essential Oral Health Care

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Millions of Americans are not receiving needed dental care services because of "persistent and systemic" barriers that limit their access to oral health care, says a new report by the Institute of Medicine and National Research Council. To remove these barriers -- which disproportionately affect children, seniors, minorities, and other vulnerable populations -- the report recommends changing funding and reimbursement for dental care; expanding the oral health work force by training doctors, nurses, and other nondental professionals to recognize risk for oral diseases; and revamping regulatory, educational, and administrative practices.

"The consequences of insufficient access to oral health care and resultant poor oral health -- at both the individual and population levels -- are far-reaching," said Frederick Rivara, Seattle Children's Guild Endowed Chair in Pediatrics at the University of Washington School of Medicine, Seattle, and chair of the committee that wrote the report. "As the nation struggles to address the larger systemic issues of access to health care, we need to ensure that oral health is recognized as a basic component of overall health."

The report says that economic, structural, geographic, and cultural factors contribute to this problem. For example, approximately 33.3 million people live in areas with shortages of dental health professionals. In 2008, 4.6 million children did not obtain needed dental care because their families could not afford it. And in 2006, only 38 percent of retirees had dental coverage, which is not covered by Medicare.

Lack of regular oral health care has serious consequences, the report says, including increased risk of respiratory disease, cardiovascular disease, and diabetes, as well as inappropriate use of hospital emergency departments for preventable dental diseases. The report offers a vision of oral health care in which prevention of oral diseases and promotion of oral health are a priority and a facet of overall health.

Although all states must provide comprehensive dental benefits for children enrolled in Medicaid or the Children’s Health Insurance Program (CHIP), they are not required to provide such benefits for adults. Because publicly funded programs are the primary source of health coverage for underserved populations, including dental benefits for all Medicaid beneficiaries is a critical and necessary goal, the report says. Toward that end, the committee recommended that the Centers for Medicare and Medicaid Services fund and evaluate state-based demonstration projects that cover essential oral health benefits for adult Medicaid beneficiaries. In addition, Medicaid and CHIP reimbursement rates for providers should be increased and administrative practices need to be streamlined to increase use by both dental providers and patients.

To maximize access to oral health care, state legislatures should amend existing laws so that hygienists, assistants, and other dental professionals can practice to the full extent of their training and can work in a variety of settings under appropriate evidence-based levels of supervision. In spite of national accreditation standards for education and training of oral health professionals, regulations defining supervision and scope-of-practice parameters vary widely from state to state and even by procedure. Legislation should also allow dental professionals to collaborate and supervise remotely via conferencing technology.

The uneven distribution of the dental work force, both in geographic dispersion as well as in specialization, is a long-recognized challenge, the report notes. In addition, graduating dental students report that they feel unprepared to care for older patients and those with special needs.

The report says that efforts should be made to increase recruitment and support for dental students from minority, lower-income, and rural populations, as well as to boost the number of dental faculty with expertise caring for underserved and vulnerable populations. In addition, the Health Resources and Services Administration should dedicate Title VII funding to aid and expand opportunities for dental residencies in community-based settings. These residencies should take place in geographically underserved areas and include clinical experiences with young children, individuals with special health care needs, and older adults.