1. The USPHS and Access to Oral Health Chester W. Douglass, DMD, PhD Professor Emeritus Harvard University May 25, 2010 San Diego, CA

2. Access to Oral Health - Outline 1.The U.S. PHS –Mission and Goals –Careers in Dental Public Health 2.What is Access to Oral Health? 3.Trends in the Market –Population Trends –Disease Trends –Financing –Delivery Systems 4.Improving Oral Health (53 ways…) 5.30 Prevention Technologies 6.USPHS Leadership

3. Mission The mission of the U.S. Public Health Service Commissioned Corps is to protect, promote, and advance the health and safety of our Nation. As Americas uniformed service of public health professionals, the Commissioned Corps achieves its mission through: Rapid and effective response to public health needs Leadership and excellence in public health practices Advancement of public health science

4. The Commissioned Core 1.Provide essential public health care services to underserved and disadvantaged populations 2.Prevent and control injury and the spread of disease 3.Conduct and support cutting-edge research for the prevention, treatment, and elimination of disease, health disparities, and injury

5. Forces for Change 1.Demographic 2.Disease distributions 3.Scientific forces New technologies 4.Market forces New delivery systems Economic forces 5.Policy

6. U.S. Resident Population Projection: 2000-2050 Resident population projection assumes middle levels of fertility, life expectancy, and net immigration. Source: U.S. Bureau of the Census, Current Population Reports. 281.4 400 + 20002010202020302050

7. Projected Elderly Population by Age:1990-2050 Source: U.S. Census Bureau

8. Race / Ethnicity Composition of the Resident Population of the United States: 1997-2050 Source: U.S. Census Bureau

9. Think Cohorts Life experience with dental disease and dental care tends to determine each cohorts oral health expectations and behavior

10. Patient Expectations By Age Cohort World War II Generation 1900-1925 Pepsi Generation 1926-1945 Baby Boomers 1946-1964 Atari Generation 1965-1985 New Age Generation Since 1986

11. Trends in Dentistry: Opportunities for Business Growth Demand Side Trends Disease Trends

12. Dispelling the Myth that 50 Percent of U.S. Schoolchildren Have Never Had a Cavity Burton L. Edelstein, DDS, MPH Chester W. Douglass, DDS, PhD Public Health Reports, Sept/Oct 1995: Vol 111

13. Percent of Schoolchildren with Caries

15. US Adult Population and Number of Teeth at Risk, 1972 Source: Reinhardt/Douglass: Future Need for Dentistry

16. Cohort-specific Projections of Adult Teeth at Risk in the US, 1990 Source: Reinhardt/Douglass: Future Need for Dentistry (middle series population projections)

17. Cohort-specific Projections of Adult Teeth at Risk in the US, 2030 Source: Reinhardt/Douglass: Future Need for Dentistry (middle series population projections)

18. Trends in Percent Edentulism in Adults Aged 18 to 74: 1971-1994 Age Groups 14.7 7.7 1.0 0.0 3.2 9.0 16.0 0.7 2.8 33.4 9.30 20.1 45.6 28.6 Source: U.S. Dept. of Health and Human Services, National Center for Health Statistics and National Institute of Dental Research

19. Mean number of Restored Coronal Surfaces, by Number of Teeth* (Adjusted for Age and Sex) Number of Teeth (Toothgrp) MeanSEF StatisticP-valueGroup comparison P-value 1-10 (1)7.51.37178.06.00011 vs 2.001 11-24 (2)31.81.171 vs 3.001 25-32 (3)50.01.952 vs 3.001 *ANOVA model with number of restored coronal surfaces as dependent variable and age, sex, and tooth group as main effects and possible interaction terms.

20. Mean number Sites with Pocket Depth 4mm, by Number of Teeth* (Adjusted for Age and Sex) Number of Teeth (Toothgrp) MeanSEF StatisticP-valueGroup comparison P-value 1-10 (1)2.480.6132.41.0011 vs 2.001 11-24 (2)6.960.471 vs 3.001 25-32 (3)10.500.842 vs 3.001 *ANOVA model with number of sites with pocket depth 4mm as dependent variable and age, sex, and tooth group as main effects and possible interaction effects.

21. Validity of Prevalence of Pocketing Method< 4 mm4-6 mm>6 mm All Sites Full Mouth12.6%65.9%21.5% Three Sites Full Mouth 17.3%64.8%17.9% Two Sites Full Mouth 35.0%55.8%9.2% Two Sites Half Mouth 49.8%44.9%5.2% All pairwise comparisons on maximum pocket depth p < 0.0001 – Wilcoxin Signed Rank Test

22. Trends in Dentistry: Opportunities for Business Demand Side Trends Need for Dental Care

23. Formula for Calculation of Hours of Treatment for Operative Dentistry TN = Σ[ t i · c i · 0.5 ] + Σ[ f i · 0.1 · 0.5 ] TN = total hours of treatment needed t i = age-specific number of teeth c i = age-specific proportion of carious teeth 0.5 = one-half hour of service time needed per restoration f i = age-specific proportion of teeth filled 0.1 = the proportion of restorations needing replacement in a given year

24. Future Operative Needs

25. Formula for Calculating Unmet Need for Fixed and Removable Partial Dentures Total Need TN = n(%N)(pt) where TN = Total Need n = Number of People %N = Percentage of people who need an FPR or RPD Pt = Procedure time

26. Projected Amount of Need for FPDs and RPDs (in Millions of Hours) by Year

27. Formula for Estimating the Current and Future Market for Complete Dentures Denture Market =Total amount of demand for dentures in any specific year Age-specific Population =Number of men and women in each age group in any specific year Age-specific percent edentulism =Percentage of men and women with 1 or 2 edentulous arches in any specific year 10-year trends in edentulism =Percent decline in edentulism over each 10-year period since 1960 Percent utilization of dentures = Percentage of persons who not only need but also acquire and use dentures Denture Market = Age-specific population x Age-specific percent edentulism x 10-year declining trends in edentulism x Percent utilization of dentures (demand)

28. Number US adults (in thousands) who need one or two dentures

29. Distribution of Public and Private U.S. Dental Schools as of 2001 Public Dental Schools Private Dental Schools Puerto Rico x x xx x x X New Dental Schools

30. U.S. Dental School Graduates 1956-2008 Source: American Dental Association, Survey Center, Surveys of Dental Education 5,878 3,253 4,976 3,875

31. Estimated Additions of Dentists to the Dental Workforce: 1995-2040 Assumptions: number of graduates remains at 4050 retirement age of 65 year 2014 year 2023-1706 year 1995 year 2040 year 2031 Source: American Association of Dental Schools

32. Net Change in Dentists Compared to Population Growth

33. Inflation Rates Physicians Fees Dentists Fees

34. % Annual Increase Annual Inflation Rates of Medical Care, Dental Care, and All Goods & Services

35. Current Delivery System Limited access to care to most adults Insufficient number of dentists Increase in cost of services Privatization of dental services

36. So what can we do? Preventive services, products, and programs Examples of successful prevention programs Prevention as a public policy measure

37. Market Forces

38. Improving Access to Oral Health

39. Improve Supply With More Appropriate Delivery System 1.Establish school-based dental clinic 2.Use mobile dental equipment for services in outreach sites 3.Allow foreign dental graduates credentialing 4.Train more dentists and dental hygienists 5.Require continuing education on access to care 6.Increase salaries of safety net providers 7.Require PGY-1 8.Have practitioners work in satellite clinics one or two days a week 9.Require payback programs for public service 10.Expand duties of allied dental personnel

40. Improve Supply (cont.) 11.Have existing home visitors do oral health assessments 12.Train midlevel providers- ex. Alaska Dental Nurse- and midlevel prevention specialists 13.Remove supervision restrictions on dental hygiene practice 14.Improve diversity of provider supply 15.Integrate dental care into primary medical care 16.Train MDs to do oral exams 17.Establish dental clinic in nursing homes 18.Link oral health with smoking cessation program 19.Provide advanced training in management of special needs patients 20.Develop case management programs 21.Improve practice management 22.Adopt Electronic Records and Billing system

41. Increase Demand By Improving Awareness and Dental Insurance 1.Develop media public awareness campaigns, such as Watch Your Mouth 2.Lobby for oral health funding 3.Encourage provider participation in the Medicaid program 4.Improve Medicaid claims processing speed 5.Improve Medicaid program by allowing case load limitations 6.Improve Medicaid program by increasing reimbursement rates 7.Promote oral health screenings and referrals through children health and welfare programs

42. Increase Demand (cont.) 8.Have states mandate dental screenings for school-aged children 9.Include oral hygiene education and practice in pre-natal visits for pregnant women 10.Include primary dental care services into Medicare 11.Include medically necessary dental care into Medicare 12.Change insurance regulations to encourage enrollment 13.Develop private insurance for lower income population 14.Encourage foundation support for oral health programs 15.Establish new foundations focused on oral health

43. Decrease Need By Preventing the Disease 1.Include oral health education in school health curriculum 2.Establish school-based sealant programs 3.Establish fluoride varnish programs 4.Create outreach programs in Head Start and Early Head Start 5.Create outreach programs in schools which incorporate education, screening, and referral to dental services 6.Implement salt fluoridation if no community fluoridated water systems 7.Promote self-care 8.Create outreach programs in nursing homes

44. Decrease Need (cont.) 9.Fluoridate and label bottled water 10.Promote early detection and referral by pediatricians 11.Have pediatricians apply fluoride varnish 12.Link oral health to systemic health through: a) Patient education b) Patient care from MDs and RNs 13.Provide nutritional counseling 14.Establish dental homes for all children 15.Promote preventive services by private dental practices 16.Fluoridate community water systems

45. Thirty Prevention Technologies by Mode of Delivery

46. Conclusion An ounce of prevention….. ……is worth a pound of cure!

47. Dont mop the floor……. Turn the spigot off….. Conclusion The Imperative of Prevention

48. Rapid and effective response to public health needs Leadership and excellence in public health practices Advancement of public health science