Principles in Dental Public Health

Principles in Dental Public Health
© AAPHD

Vinodh Bhoopathi., BDS., MPH.,DScD
Through Garcia case Course Created By Vinodh Bhoopathi., BDS., MPH.,DScD Course Contributors: Dr. Woosung Sohn, Dr. Susan Reed, Diane Brunson, Robin Knowles, Karen Yoder, Dr. Ana Karina Mascarenhas, Dr. Kathryn Ann Atchison

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.

Course Competencies 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

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.

Lecture 1 Introduction to Dental Public Health

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

Mission of Public Health
“Fulfilling society’s interest in assuring conditions in which people can be healthy” The Future of the Public's Health in the 21st Century, Institute of Medicine

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

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

Core Competencies in Dental Public Health (DPH)
A specialist in DPH will Plan oral health programs for populations Select interventions and strategies for the prevention and control of oral diseases and promotion of oral health. Develop resources, implement and manage oral health programs for populations Incorporate ethical standards in oral health programs and activities Evaluate and monitor dental care delivery systems Design and understand the use of surveillance systems to monitor oral health Communicate and collaborate with groups and individuals on oral health issues Advocate for, implement and evaluate public health policy, legislation, and regulations to protect and promote the public's oral health Critique and synthesize scientific literature Design and conduct population-based studies to answer oral and public health questions Dental Public Health Competencies. J Public Health Dent 1998, 58;

Public Health The concept of Public Health that emerged in the beginning of the 20th century had three core public health functions: Assessment Policy Development Assurance

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

Example of Assessment: The Case for Water Fluoridation How community water fluoridation was adopted in the US? 14

The Case for Water Fluoridation
Assessment: 1901 – Dr. McFay – investigates “Colorado Brown stain” 1909 – Dr. Robertson observes similar symptoms Belief something in water caused stains 1930 – Churchill identifies Fluoride in water supplies 1930s to 40s - identifies Caries lower in cities with more fluoride in their community water supplies at concentrations > 1.0ppm Subsequent long term studies – found that caries reduced in 50 to 70% of children from fluoridated communities. 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 Dentist H.Trendley Dean appointed to begin the Dental Hygiene Unit of the newly established National Institute of Health to investigate 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 “21 Cities Study” - documented dental caries experience in different communities dropped sharply as F concentration rose toward 1.0 ppm, then leveled off

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

Example for Policy Development: The Case for Water Fluoridation
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 McLure FJ. Water Fluoridation – The search and the victory. Bethesda (MD):US Dept of Education and Welfare, NIH, NIDR: Chapter 14: 247-9

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

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

Example of Assurance: The Case for Water Fluoridation
Effectiveness of water fluoridation and policy statement from US Public Health Service promoted rapid adoption of water fluoridation Professional scientific organizations endorsed water fluoridation More other modalities for delivery fluoride such as tooth pastes, gels, rinses, tablets and drops were developed The effectiveness of community water fluoridation in preventing dental caries prompted rapid adoption of this public health measure in cities throughout the United States. As a result, dental caries declined precipitously during the second half of the 20th century. For example, the mean DMFT among persons aged 12 years in the United States declined 68%, from 4.0 in The American Dental Association, the American Medical Association, the World Health Organization, and other professional and scientific organizations quickly endorsed water fluoridation. Knowledge about the benefits of water fluoridation led to the development of other modalities for delivery of fluoride, such as toothpastes, gels, mouth rinses, tablets, and drops. Several countries in Europe and Latin America have added fluoride to table salt. McLure FJ. Water Fluoridation – the search and the victory. Bethesda (MD):US Dept of Education and Welfare, NIH, NIDR: Chapter 14: 247-9

The Ten Essential Services

Ten Essential Public Health Services
From these core functions (Assessment, Policy Development, and Assurance) ten essential public health services emanate Monitor health status to identify and solve community health problems. Diagnose and investigate health problems and health hazards in the community. Inform, educate, and empower people about health issues. Mobilize community partnerships and action to identify and solve health problems. Develop policies and plans that support individual and community health efforts. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Assure competent public and personal health care workforce. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Research for new insights and innovative solutions to health problems.

How can DDS/RDH use 3 core PH functions compared to a DPH specialist?
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 This slide shows or compares how clinician and a DPH specialist use three core public health funcitions in their area of work. 23

Dental Public Health Infrastructure in the US

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:

HHS Organization Chart
Secretary Deputy Secretary Chief of Staff The Executive Secretariat Office of Intergovernmental and External Affairs Office of Health Reform Office of the Assistant Secretary for Administration (ASA) Administration for Children and Families (ACF) Centers for Medicare and Medicaid Services (CMS) Center for Faith-based and Neighborhood Partnerships (CFBNP) Program Support Center (PSC) Administration for Community Living (ACL) Food and Drug Administration (FDA) * Office of Civil Rights (OCR) Office of the Assistant Secretary for Financial Resources (ASFR) Agency for Health Care Research and Quality (AHRQ)* Health Resources and Services Administration (HRSA) * Departmental Appeals Board (DAB) Office of the Assistant Secretary for Health (OASH) * Agency for Toxic Substances and Disease Registry (ATSDR)* Indian Health Services (IHS) * Office of the General Counsel(OGC) Centers for Disease Control and Prevention (CDC) * National Institute of Health (NIH) * Office of the Assistant Secretary for Legislation (ASL) Office of Global Affairs (OGA) * Office of the Assistant Secretary for Planning and Evaluation (ASPE) Office of Inspector General (OIG) Substance Abuse & Mental Health Services Administration (SAMHSA) * Office of the Assistant Secretary for Preparedness and Response (ASPR) * Office of Medicare Hearing and Appeals (OMHA) * Designates a component of U.S. Public Health Services Office of the Assistant Secretary for Public Affairs (ASPA) Office of National Coordinator for Health Information Technology (ONC)

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 Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental Public Health in the United States. Dent Clin N Am 2008, 52:

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)

HHS Healthy People 2020 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 United States Public Health Services (USPHS)
Indian Health Services 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 Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental Public Eealth in the United States. Dent Clin N Am 2008, 52: 30

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.

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 Allukian M J, Adekugbe O. The Practice and Infrastructure of Dental Public Health in the United States. Dent Clin N Am 2008, 52:

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.

HHS Centers 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

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 Responsible for Protecting the public health by assuring that foods (except for meat from livestock, poultry and some egg products which are regulated by the U.S. Department of Agriculture) 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. Protecting the public from electronic product radiation. Assuring cosmetics and dietary supplements are safe and properly labeled. Regulating tobacco products. Advancing the public health by helping to speed product innovations. FDA's responsibilities extend to the 50 United States, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, American Samoa, and other U.S. territories and possessions

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

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”.

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

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

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 ASTDD is a national non-profit organization representing the directors and staff of state public health agency programs for oral health Promoting 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 formulates and promotes the establishment of national dental public health policy, assists state dental programs in the development and implementation of programs and policies for the prevention of oral diseases; builds awareness and strengthens dental public health professionals' knowledge and skills by 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

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

American Dental Education Association
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 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

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.

Lecture 2 Population-Based Public Health Strategies

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

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. Porsche DJ. Public & community health nursing practice : a population-based approach Available at

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

Vaccinations Polio vaccinations First outbreak described in US in 1843
, 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

Vaccinations ONLY 82% receive vaccination in 2011
Only 69% received vaccination DTP, polio, MMR, and Hib vaccines + hepatitis B vaccine, and the varicella vaccine DTP, polio, MMR, and Hib vaccines In this slide you see a comparison of percentage of children aged 19 to 35 months receiving two different vaccine regimens between in the US. In 1994 only 69% of children received vaccination compared to in 2011, where 82% of the children received vaccination. This also suggests that 18% of the children did not receive any vaccination in 2011.

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. So what may happen when 18% of a community is not vaccinated? The National Institute of Allergy and Infectious Diseases (NIAID) 51

Vaccinations Community or Herd immunity
18% not immunized could increase the risk of outbreaks The National Institute of Allergy and Infectious Diseases (NIAID) 52

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. In 1960, unintentional injuries caused 93,803 deaths; 41% were associated with motor-vehicle crashes. in 1966, passage of the Highway Safety Act and the National Traffic and Motor Vehicle Safety Act authorized the federal government to set and regulate standards for motor vehicles and highways, a mechanism necessary for effective prevention. Many changes in both vehicle and highway design followed this mandate. Vehicles (agent of injury) were built with new safety features, including head rests, energy-absorbing steering wheels, shatter-resistant windshields, and safety belts . Roads (environment) were improved by better delineation of curves (edge and center line stripes and reflectors), use of breakaway sign and utility poles, improved illumination, addition of barriers separating oncoming traffic lanes, and guardrails. The results were rapid.

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

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

Safer Workplaces – Example Mining related deaths
50% decrease in coal mining fatality rates occurred from to 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 ( compared with ) MMWR July 11, 1999 / 48(22);

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) After OSHA, which is the agency responsible to oversee workforce safety was established, safer workplaces have to be, including the dental offices. The mission of the Occupational Safety and Health Administration (OSHA) is to save lives, prevent injuries, and protect the health of America’s workers.

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 Public health action to control infectious diseases in the 20th century is based on the 19th century discovery of microorganisms as the cause of many serious diseases (e.g., cholera and TB). Disease control resulted from improvements in sanitation and hygiene, the discovery of antibiotics, and the implementation of universal childhood vaccination programs. Scientific and technologic advances played a major role in each of these areas.

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 less than 1 new case Rare disease, with approximately 300 clinical cases reported per year 60

Control of Infectious Diseases
Reductions in diagnosis and deaths attributed to active antiretroviral therapies introduced in 1996 This slide presents trends from 1985 through 2009 in the estimated numbers of AIDS diagnoses, deaths of persons with AIDS, and persons living with an AIDS diagnosis (prevalence) in the 50 states, the District of Columbia, and 6 U.S. dependent areas. AIDS diagnoses and deaths increased during the beginning of the epidemic. The peak in AIDS diagnoses during 1993 can be associated with the expansion of the AIDS surveillance case definition implemented in January The overall declines in AIDS diagnoses and deaths of persons with AIDS are due in part to the success of highly active antiretroviral therapies, introduced in The estimated numbers of persons living with an AIDS diagnosis has steadily increased throughout All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Deaths of persons with an AIDS diagnosis may be due to any cause (may not be HIV-related).

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 During the early 20th century, contaminated food, milk, and water caused many foodborne infections, including typhoid fever, tuberculosis, botulism, and scarlet fever. In 1906, Upton Sinclair described in his novel The Jungle the unwholesome working environment in the Chicago meat-packing industry and the unsanitary conditions under which food was produced. Public awareness dramatically increased and led to the passage of the Pure Food and Drug Act (1). Once the sources and characteristics of foodborne diseases were identified--long before vaccines or antibiotics--they could be controlled by handwashing, sanitation, refrigeration, pasteurization, and pesticide application. Healthier animal care, feeding, and processing also improved food supply safety. The discovery of essential nutrients and their roles in disease prevention has been instrumental in almost eliminating nutritional deficiency diseases such as goiter, rickets, and pellagra in the United States. The near elimination of pellagra by the end of the 1940s has been attributed to improved diet and health associated with economic recovery during the 1940s and to the enrichment of flour with niacin.

Safer and Healthier Foods
Number of reported pellagra deaths, by sex of decedent and year – US, 63

Decline in Deaths from CVD and Stroke
1920s-30s: heart disease and stroke leading cause of death – together 40% of all deaths Since 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 Heart disease has been the leading cause of death in the United States since 1921, and stroke has been the third leading cause since 1938; together they account for approximately 40% of all deaths. Since 1950, age-adjusted death rates from cardiovascular disease (CVD) have declined 60%, representing one of the most important public health achievements of the 20th century. During the 1970s and 1980s, along with numerous clinical trials demonstrating the efficacy of antihypertensive and lipid-lowering drugs, community trials sought to reduce risk at the community level. Public health interventions to reduce CVD have benefitted from a combination of the "high risk" approach--aimed at persons with increased risk for CVD--and the population-wide approach--aimed at lowering risk for the entire community. National programs that combine these complementary approaches and that are aimed at health-care providers, patients, and the general public include the National High Blood Pressure Education Program, initiated in 1972, and the National Cholesterol Education Program, initiated in Although earlier CDC community demonstration projects focused on cardiovascular health, CDC established its National Center for Chronic Disease Prevention and Health Promotion in 1989, with a high priority of promoting cardiovascular health. Reasons for the declines in heart disease and stroke may vary by period and across region or socioeconomic groups (e.g., age, sex, and racial/ethnic groups). Prevention efforts and improvements in early detection, treatment, and care have resulted in a number of beneficial trends, which may have contributed to declines in heart disease and stroke. These trends include 1) a decline in cigarette smoking among adults aged greater than or equal to 18 years from approximately 42% in 1965 to 25% in Substantial public health efforts to reduce tobacco use began soon after recognition of the association between smoking and CVD and between smoking and cancer and the first Surgeon General's report on smoking and health published in 1964. 2) a decrease in mean blood pressure levels in the U.S. population. 3) an increase in the percentage of persons with hypertension who have the condition treated and controlled. 4) a decrease in mean blood cholesterol levels. 5) changes in the U.S. diet. Data based on surveys of food supply suggest that consumption of saturated fat and cholesterol has decreased since Data from the National Health and Nutrition Examination surveys suggest that decreases in the percentage of calories from dietary fat and the levels of dietary cholesterol coincide with decreases in blood cholesterol levels. 6) improvements in medical care, including advances in diagnosing and treating heart disease and stroke, development of effective medications for treatment of hypertension and hypercholesterolemia, greater numbers of specialists and health-care providers focusing on CVD, an increase in emergency medical services for heart attack and stroke, and an increase in coronary-care units. These developments have contributed to lower case-fatality rates, lengthened survival times, and shorter hospital stays for persons with CVD.

Decline in Deaths from CVD and Stroke

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 Publicly supported family planning services through Medicaid funding prevented 1.3million unintended pregnancies annually During the 20th century, the hallmark of family planning in the United States was the ability to achieve desired birth spacing and family size. Fertility decreased as couples chose to have fewer children; concurrently, child mortality declined, people moved from farms to cities, and the age at marriage increased. Smaller families and longer birth intervals have contributed to the better health of infants, children, and women, and have improved the social and economic role of women (2,3). Despite high failure rates, traditional methods of fertility control contributed to the decline in family size (4). Modern contraception and reproductive health-care systems that became available later in the century further improved couples' ability to plan their families. Publicly supported family planning services prevent an estimated 1.3 million unintended pregnancies annually (5). This report reviews the history of family planning during the past century; summarizes social, legal, and technologic developments and the impact of family planning services; and discusses the need to ensure continued technologic improvements and access to care.

Family Planning

Healthy Mothers and Healthy Babies

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 At the beginning of the 20th century, for every 1000 live births, six to nine women in the United States died of pregnancy-related complications, and approximately 100 infants died before age 1 year. Urban environmental interventions (e.g., sewage and refuse disposal and safe drinking water) played key roles in reducing infant mortality. Rising standards of living, including improvements in economic and education levels of families, helped to promote health. Declining fertility rates also contributed to reductions in infant mortality through longer spacing of children, smaller family size, and better nutritional status of mothers and infants (1). Milk pasteurization, first adopted in Chicago in 1908, contributed to the control of milkborne diseases (e.g., gastrointestinal infections) from contaminated milk supplies. The discovery and widespread use of antimicrobial agents and the development of fluid and electrolyte replacement therapy and safe blood transfusions accelerated the declines in infant mortality; from 1930 through 1949, mortality rates declined 52% 69

Tobacco Use First decades of 20th century-lung cancer rare
Per capita cigarette consumption increased from 54 cigarettes in 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; During the first decades of the 20th century, lung cancer was rare; however, as cigarette smoking became increasingly popular, first among men and later among women, the incidence of lung cancer became epidemic. In 1930, the lung cancer death rate for men was 4.9 per 100,000; in 1990, the rate had increased to 75.6 per 100,000. Annual per capita cigarette consumption increased from 54 cigarettes in 1900 to 4345 cigarettes in 1963.

Tobacco Use Trends in cigarette smoking* among persons aged ≥ 18 years, by sex- United States,

Community Water Fluoridation

History Colorado Springs, Colorado 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

History Dentist H.Trendley Dean appointed to begin the Dental Hygiene Unit of the newly established National Institute of Health to investigate 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 “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 % children in communities with fluoridated water 1950 – US Public Health Services issued a policy statement to American Dental Association, supporting community water fluoridation Reaffirmed “community water fluoridation” - Official policy of public health service in testimony before senate Dentist H.Trendley Dean was appointed to begin the Dental Hygiene Unit of the newly established National Institute of Health to investigate severity of dental fluorosis categorized as “Dean’s Index” Compares fluorosis data from 26 states to tooth decay data – identifies Caries among children was lower in cities with more fluoride in their community water supplies at concentrations > 1.0ppm “21 Cities Study” the landmark study that documented dental caries experience in different communities dropped sharply as F concentration rose toward 1.0 ppm, then leveled off In the hypothesis that dental caries could be prevented by adjusting the fluoride level of community water supplies from negligible levels to ppm was tested in a prospective field study conducted in four pairs of cities (intervention and control) starting in 1945: Grand Rapids and Muskegon, Michigan; Newburgh and Kingston, New York; Evanston and Oak Park, Illinois; and Brantford and Sarnia, Ontario, Canada. After conducting sequential cross-sectional surveys in these communities over years, caries was reduced 50%-70% among children in the communities with fluoridated water McLure FJ. Water Fluoridation – the search and the victory. Bethesda (MD):US Dept of Education and Welfare, NIH, NIDR: Chapter 14: 247-9

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).

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 ( %) Present in sea water (1.2 – 1.4 ppm) Occurs in biological mineralized tissue, e.g. bones and teeth as fluoridated hydroxyapatite

3 Mechanisms of Fluoride Action
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 Interaction with the bacteria Fluoride inhibits glycolysis, inhibits dextran formation for dental plaque adherence, and direct effect on bacteria Developmental interaction with enamel Reduction in enamel solubility

Calciumfluoroapatite crystals – reduced solubility

Benefits of Fluoridation
Dental caries most common disease DMFT (Decayed, Missing, Filled Teeth due to dental caries) 4.0 in to 1.3 in Earlier studies suggest caries reduction attributable to fluoridation ranged from 50% to 70% Studies between found that caries reduction was 8%-37% among adolescents

mean DMFT among persons aged 12 years in the United States declined 68%, from 4.0 in to 1.3 in Achievements in Public Health, : Fluoridation of Drinking Water to Prevent Dental Caries MMWR weekly, 1999/48 (41);

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

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%

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 Mild -Photo by Elke Babiuk Severe-Source of photo unknown

Antifluoridation Many groups have organized together to act against water fluoridation in the last few years, despite the best available evidence. Some of these groups are presented here.

Oral Health Disparities
Lecture 3 Oral Health and Oral Health Disparities

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

Why is Oral Health Important?

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 population 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 Craniofacial Research, National Institutes of Health, 2000.

Oral Health 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” 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 Craniofacial Research, National Institutes of Health, 2000.

Poor School Performance
Oral Health Impact Pain Infection Poor Feeding Poor Speech Poor Self Esteem Poor School Performance

Oral Health Status in the US

Distribution of Caries by age
This slide indicates how caries experience increases as age increases. Data from and shows that people in the cohort experienced less caries compared to those in cohort. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status, United States, and National Center for Health Statistics. Vital Health Stat 11(248); 2007.

Between 2005 and 2008, 21.5% or 1 in every 5 people aged 5 and above living in the US had an untreated dental caries in one or more tooth. Greater proportion (25%) of people aged 20 to 44 years had untreated dental caries compared to all other age groups. 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

Distribution of Periodontitis in Adults:
The distribution of moderate or severe periodontitis is seen in this slide in adults. Here we describe the differences by age. Only 5% of adult Americans had moderate or severe periodontitis in NHANES IV. A substantial decrease from NHANES III. 10% versus 5%. Also seen is distribution by age and income. As expected as age increased the percentage with moderate or severe periodontitis increased. With income, as income increased the percentage with moderate or severe periodontitis decreased. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status, United States, and National Center for Health Statistics. Vital Health Stat 11(248); 2007.

The distribution of moderate or severe periodontitis is seen in this slide in adults. Only 5% of adult Americans had moderate or severe periodontitis in NHANES IV. A substantial decrease from NHANES III. 10% versus 5%. Also seen is distribution by age and income. As expected as age increased the percentage with moderate or severe periodontitis increased. With income, as income increased the percentage with moderate or severe periodontitis decreased. For example as income increased, the moderate to severe periodontitis decreased both in NHANES III and IV for those aged 50 to 64. Likewise for other age groups Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in Oral Health Status, United States, and National Center for Health Statistics. Vital Health Stat 11(248); 2007.

Prevalence of moderate/severe periodontitis by age group: NHANES Eke PI et al. Prevalence of Periodontitis in Adults in the United States: 2009 and J Dent Res 91(10): , 2012

Distribution of edentulism (loss of all teeth)

Disparities in Oral Health status and in accessing dental care services

Health Disparities 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 ( Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health.

Differences between populations in health
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) [ 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 [ Surveillance Epidemiology and End Results Data]

Disparities in Caries in Children
Prevalence of dental caries in permanent teeth * among children and adolescents aged years, by selected characteristics –United States, National Health and Nutrition Examination Survey, , and Disparities in caries see by race and income. Mexican American children have higher caries prevalence than White or Black children. Children from lower income families have higher caries prevalence than children from higher income families. 102

Factors underlying health and health care related disparities
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
Disparities in oral health status may arise due to: Differences in the quality of health care received Timeliness: care that reduces delays in the use of care. Patient Centeredness: care that is respectful and responsive to the individual needs, preferences and values of patients. Equity: care that encompasses the need for health care systems to provide care that does not vary in quality because of personal characteristics (such as gender, ethnicity, geographic location and socioeconomic status).

Oral Health Indicators
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. Modified from

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)

Examples of Oral Health indicators in HP2020
Untreated tooth decay Dental Sealants 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

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: 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% This slide shows disparities in untreated dental caries, and having dental restorations by racial/ethnicity, poverty level and gender. Compared to whites, non-hispanic blacks and Mexican Americans have higher untreated dental caries, meaning have a poor oral health, while there is a disparity in having dental restorations, in that, higher percentage of whites seem to have their teeth filled compared to non-hispanic blacks or Mexican Americans. Despite having a higher unmet dental caries, the non-hispanic black and Mexican Americans don’t get treated as much as whites do. Likewise based on poverty, as income increases, the percent with untreated dental caries decreases, and percentage of people with dental fillings increases. Based on gender, higher percentage of males seem to have untreated caries compared to females, the vice-versa for dental restorations 1 Reference group, 2 p <0.05 Source: CDC/NCHS National Health and Nutrition Examination Survey

Disparities in dental caries experience and untreated dental caries
Prevalence of dental caries in primary teeth, by age and race and Hispanic origin among children aged 2–8 years: United States, 2011–2012 More recent data from the CDC shows that there are significant disparities in dental caries experience and untreated dental caries based on age and gender. Children aged 6 to 8 years had significantly higher dental caries experience and untreated dental caries compared to those aged 2 to 5 years. And significantly lower proportion of non-Hispanic white children experienced carried and had untreated dental caries compared to Non-Hispanic black and Hispanic children. 1Includes untreated and treated (restored) dental caries. 2Significantly different from those aged 6–8 years, p < Significantly different from non-Hispanic black children, p < Significantly different from Hispanic children, p < SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012. 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

PERCENT OF POVERT LEVEL
Disparities in dental visits Dental visits in the past year by selected characteristics among 2 years and older: United States, selected years 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 66.2% PERCENT OF POVERT LEVEL % (Rich) 78.9% 79.3% 200%-299% 63.5% 100%-199% 50.8% 51.6% Below 100% (Poor) 50.5% 50.6% This slide shows disparities in dental visits based on race, ethnicity and poverty level. For example for the year 1997, Whites and Asians had a higher dental visit rate compared to african americans and american indians. Almost 66% of non-Hispanics visited dentists compared to ONLY 54% of hispanics, indicating that there is a disparity in dental visit based on ethnicity. Likewise, there is a disparity in dentist visit based on income or poverty level. As the income increases, dental visit utilization, with almost 80% of people at 400% or more poverty level visiting the dentists compared to only 51% of those at below 100% poverty level. Similar disparities were observed for the year 2010, which means that substantial disparities in dental visits by race, ethnicity and poverty level still exist. National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD

Utilization of Dental Service
This slide shows data of utilization of dental services, both preventive and dental treatment services for children in the years 2001 and In 2008, Only 36% of the children received any dental services, which means that 64% of the children did not receive any dental services. Likewise in 2008, only 32% received any preventive dental services, and only 18% received any dental treatment service. 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 Government Accountability Office. 111

Disparities in Dental Sealants prevalence
Disparities in dental sealant prevalence among those aged 5 to 19 years is observed in the US, by race/ethnicity and income. Compared to non-hispanic whites, a significantly lower percentage of non-hispanic blacks aged mexican americans had sealants on their permanent teeth. Likewise, compared to high income group or those living at 200% of FPL, a significantly lower percentage of those living below 100% FPL and between 100% to 200% FPL have sealants placed on their permanent teeth.

Disparities in Dental Sealants prevalence
Prevalence of dental sealants in permanent teeth, by age and race and Hispanic origin among children aged 6–11 years: United States, 2011–2012 Nearly one-half of children aged 9–11 had at least one dental sealant on a permanent tooth, whereas 31% of children aged 6–8 had a dental sealant. Non-Hispanic black and non-Hispanic Asian children aged 6–11 (31%) had lower dental sealant prevalence compared with non-Hispanic white children (44%). Hispanic children (40%) had higher dental sealant prevalence compared with non-Hispanic black children aged 6–11 (31%). 1Significantly different from those aged 9–11 years, p < Significantly different from non-Hispanic black children, p < Significantly different from non-Hispanic Asian children, p < SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012. 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

Disparities in edentulism (complete tooth loss)
This slide clearly shows disparities based on ethncity and income level. Among those aged 65 and above, black americans are more likely to have lost all their teeth compared to whites and Mexican Americans. Those with higher income, that is above 200% of poverty level, only 16% have had lost all their teeth compared to more than 30% of low income people who have had lost all their teeth.

One Example: Dental workforce shortage as a factor related to oral health disparities
Though differences in oral health status is influenced by many factors as reviewed in the last slide, the next set of slides highlights how lack of sufficient dentists (dental workforce shortage) may leave many people, especially the underserved to not have easy access to dental care.

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).

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 When there are 5,000 or more people per dentist, an area is eligible to be designated as a dental HPSA.

U.S. Designated Dental Health Professions Shortage Areas 1991- 2011
Source: Shortage Designation Branch, Office of Workforce Evaluation and Quality Assurance, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services

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 The State of Children’s Dental Health: Making Coverage Matter. The Pew Charitable Trusts.

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 Nationally there is going to be a shortage of dentists, as estimated by ADEA. These data assume that the number of graduates remains at 4,850 after 2007 and retirement age is 65 Source: American Dental Education Association

Distribution of Dentists in Illinois, 2006
In this slide what you see is the distribution of dentists, and federally qualified health care centers in the State of Illinois. Each dot either yellow or green represents dentists. A higher concentration of dentists in one region, which is Chicago indicates that most of the dentists practicing in State of Illinois are around the Chicago area.

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)

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

Learning Objectives Define and describe concepts, and measures of access to dental care and utilization of dental services Recognize the issues (problems) with access to dental care in the US, especially among underserved and vulnerable population groups Identify factors associated with access to dental care and utilization of dental services and discuss ways to modify them to improve access and utilization

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,

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

Access to dental care 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)

Access to dental care 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.

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”

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

PERCENT OF POVERT LEVEL
Disparities in dental visits Dental visits in the past year by selected characteristics among 2 years and older: United States, selected years 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 66.2% PERCENT OF POVERT LEVEL Below 100% (Poor) 50.5% 50.6% 100%-199% 50.8% 51.6% 200%-299% 63.5% % (Rich) 78.9% 79.3% This slide shows disparities in dental visits based on race, ethnicity and poverty level. For example for the year 1997, Whites and Asians had a higher dental visit rate compared to african americans and american indians. Almost 66% of non-Hispanics visited dentists compared to ONLY 54% of hispanics, indicating that there is a disparity in dental visit based on ethnicity. Likewise, there is a disparity in dentist visit based on income or poverty level. As the income increases, dental visit utilization, with almost 80% of people at 400% or more poverty level visiting the dentists compared to only 51% of those at below 100% poverty level. Similar disparities were observed for the year 2010, which means that substantial disparities in dental visits by race, ethnicity and poverty level still exist. National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD

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

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

Utilization of Dental Service
This slide shows data of utilization of dental services, both preventive and dental treatment services for children in the years 2001 and In 2008, Only 36% of the children received any dental services, which means that 64% of the children did not receive any dental services. Likewise in 2008, only 32% received any preventive dental services, and only 18% received any dental treatment service. 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 Government Accountability Office. 134

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)

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 mos with a dental visit # children enrolled for mos during the year

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

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)

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

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

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

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.

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

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 After Jan. 1, 2014, all individual and small group market plans - both inside and outside the exchange - must be certified as “qualified health plans” except for stand-alone dental plans. QHPs must provide all “essential health benefits”.

Dental Health Care Delivery Systems
Lecture 5 Dental Health Care Delivery Systems

Learning Objectives 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

Dental Care Delivery System
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

Where do we access dental care?
Vehicles of dental health care delivery “PUBLIC” Federal Government State Local “PRIVATE” Non-Profit For-Profit PRIVATE PUBLIC

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.

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

Where do we access dental care?
Vehicles of dental health care delivery “PUBLIC” Federal Government State Local “PRIVATE” Non-Profit For-Profit PRIVATE PUBLIC

Federal Government 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

FQHC: Federally Qualified Health Center
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

Federally Qualified Health Centers
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 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 FQHCs 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 Eligibility: "an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility (e.g., shelters) that provides temporary living accommodations, and an individual who is a resident in transitional housing" 1 million homeless served in 2011 at FQHCs Mobile dental clinics in shelters, grant funded programs 154

Federally Qualified Health Centers
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 155

Indian Health Service Program
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 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 Indian Health care system comprises of: Administrative office: 12 Area offices and 168 IHS and tribally managed service units Urban Indian Health Services and centers: 33 urban centers. 600,000 Indians receive services Operated by the Federal government Tribally operated health care services Administered by the Tribes themselves, with Federal government oversight 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

U. S Coast Guard 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

Veteran Affairs Government-run military veteran benefit system – including families of veterans 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.

Federal Bureau of Prisons
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

School Based Health Centers - Federal
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 , 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. SOURCE: Strozer, J., Juszczak, L., & Ammerman, A. (2010) National School-Based Health Care Census. Washington, DC: National Assembly on School-Based Health Care

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

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

New Dental Workforce Models

New Dental Workforce Models
Expanded dental workforce models Expanded function dental hygienists Expanded function dental assistants Alternate dental workforce models Non dental workforce models

Expanded Dental Workforce Models
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) 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. 165

Expanded Dental Workforce Models
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. 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. 166

Alternate Dental Workforce Models
Non-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)

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

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

Dental Health Aide Therapist (DHAT) Dental team member connected to a responsible supervising dentist, possibly via teledentistry Scope: preventive, restorative, pulpotomy, prophylaxis, and simple extractions Settings: Health and community settings such as clinics, schools, churches, senior citizen centers, Head Start Programs and other public settings DHAT come from the community in which they will serve

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

Financing dental care

Payment Sources Private Third Party System: Public 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

Reimbursement of third party plans
Fee schedule Usual, customary and reasonable fee (UCR fee) Table of allowances Discounted fee (Preferred provider organizations), Capitation Sliding Fee Schedule 174

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

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

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

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

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

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

Public Third Party Payment Public Financing of Care
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 Payment Public Financing of Care: Medicare
Section 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.

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

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

Acknowledgement Dr. Vinodh Bhoopathi Dr. Woosung Sohn Dr. Susan Reed
Diane Brunson Robin Knowles Karen Yoder Dr. Ana Karina Mascarenhas Dr. Kathryn Ann Atchison

Principles in Dental Public Health

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