Chapter 1: Status of Knowledge, Practice, and Perspectives

Oral health plays a vital role in the physical, mental, social, and economic well-being of individuals and populations (Peres et al. 2019). The oral cavity and its surrounding structures are essential parts of the human body, integral to its daily functioning and contributing substantially to the overall well-being of individuals. The oral cavity also is the main conduit of human interaction with society. Humans use it to verbally communicate with others, to take in nutrients and participate in communal eating, and to convey emotion. The appearance of an individual’s teeth and surrounding structures greatly influences how others perceive them and how they perceive themselves. This perception has an impact on an individual’s ability to work, contributes to one’s social status, and can affect a person’s socioeconomic position in society.

Although there is much to celebrate about ongoing improvements in oral health, many people still suffer from chronic oral conditions and lack of access to the dental care they need. Moreover, the incidence of oral diseases, like many chronic disease conditions, is socially patterned, with the largest burden of disease occurring among children living in poverty, racial and ethnic minorities, frail elderly, and other socially marginalized groups, such as immigrant populations. Marginalized groups include groups defined by race, religion, age, financial status, politics, and culture (Given 2008; Li et al. 2018; Hung et al. 2019). Others not defined by sociodemographic characteristics, but who have special health care needs (SHCNs), also can be marginalized. Not only do these groups suffer the highest burden of oral disease, they also face the greatest barriers to accessing routine preventive and other dental services (Parish et al. 2015; Velez et al. 2017; Lebrun-Harris 2021). The major barriers to accessing dental treatment include high cost, lack of accessible dental services in the community, geographic isolation, fear and anxiety, and other social and economic factors (National Advisory Committee on Rural Health and Human Services 2004; Nasseh and Vujicic 2014; Davis and Reisine 2015; Vujicic et al. 2016a; Gupta et al. 2019).

Beyond individual benefits, maintaining good oral health brings social and economic benefits to families and communities. As Listl and colleagues (2019) note, the effects of oral diseases are significant in economic terms. There are direct, indirect, and intangible costs, such as treatment expenditures, missed days from school and work, and lessening of the quality of life (Listl et al. 2015). In 2015, dental diseases around the world (with the exclusion of oral and pharyngeal cancers) accounted for approximately $545 billion (USD) in total costs, which included $357 billion in direct costs and $188 billion in indirect costs (Righolt et al. 2018). In high-income countries, such as the United States, significant numbers of days are lost every year from school, work, and daily activities, with productivity losses being similar to those associated with musculoskeletal injuries and disorders (Australian Research Centre for Population Oral Health 2012; Guarnizo-Herreño and Wehby 2012a; Hayes et al. 2013; Singhal et al. 2013). The academic performance of children, employment in adults, and productivity in the workplace are also affected (Mobius and Rosenblat 2006; Seirawan et al. 2012; Bóo et al. 2013; Singhal et al. 2013). In fact, securing employment and what one can earn is influenced by the appearance of the mouth and teeth (Hamermesh and Biddle 1994; Glied and Neidell 2010; Bóo et al. 2013). Oral diseases worsen the impacts of other diseases, too, such as diabetes. Importantly, research demonstrates that periodontal treatment can reduce total and diabetes-related health care costs (Nasseh et al. 2017). The out-of-pocket costs that dental care can impose are also of concern, as they can put economically insecure families at risk of poverty (Bernabé et al. 2017). Finally, poor access to dental care also affects the health care system, resulting in inappropriate use of physician offices and hospital emergency departments (Allareddy et al. 2014; Vujicic and Nasseh 2014; Singh et al. 2019). As can be seen from the above, the economic benefits of improved oral health and access to dental care are substantial.

There are three broad-ranging factors that contribute to oral health and oral disease as they manifest at the community or population level. The first theme explores the important concept that oral health is integral to overall health and should be embedded in the broad framework of the whole body’s health (Peres et al. 2019).

It has been more than 25 years since Surgeon General C. Everett Koop (Koop 1993) brought this notion to national attention when he said, “You’re not healthy without good oral health.” Having good oral health means, at a minimum, that an individual is free of oral infection and pain and has acceptable oral function and facial aesthetics. The FDI (French: Fédération Dentaire Internationale) World Dental Federation General Assembly recently updated its definition of oral health (Box 1) to emphasize that oral health must be thought of broadly and that it has numerous implications for an individual’s physiological, social, and psychological well-being (Figure 1) (FDI World Dental Federation).

Figure 1

Core elements of oral health.

The second theme emphasizes that the benefits of good oral health extend beyond the individual to families and communities. When considering oral health from a population perspective, it becomes clear that the burden of oral disease falls most heavily on the most vulnerable groups in U.S. society. Oral diseases disproportionately affect population subgroups that have limited economic resources, low levels of educational attainment, poor access to dental care, and lower levels of social influence or political capital. This leads to recognizable oral health disparities and inequities.

Identifying the factors that contribute to poor oral health among vulnerable groups can provide guidance for developing and targeting oral health promotion strategies and reducing inequities. To that end, models of oral disease development have been created that bring attention to the multilevel factors now known to contribute to oral health status. Peres and colleagues’ recent model (Figure 2) (Peres et al. 2019; World Health Organization 2020) shows that the determinants of oral health arise from the level of the individual, the family, the community, and the nation. Factors known to influence oral health status are classified into three levels, labeled as the structural, intermediate, and proximal determinants of oral health. Proximal determinants are related to an individual’s biology and behavior, and the relationship of these determinants to health status often is readily apparent. For example, an individual’s choices around diet, tobacco use, and oral hygiene all have clear links to oral health.

Figure 2

Social and commercial determinants of oral health (Peres model). Note: NCD = noncommunicable diseases.

The broader environmental context in which individuals live comprises both structural and intermediate determinants. Determinants at these levels generally are not under an individual’s direct control and their linkage to oral health can seem less clear. Nevertheless, determinants at these levels are well understood to play an important role in influencing health status. Collectively, these structural and intermediate determinants are referred to as the social determinants of health (SDoH).

The World Health Organization (WHO) (2020) defines SDoH as:

[T]he conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between [social groups].

This definition is now commonly expanded to include the commercial determinants of health when they have contributed in important ways to health status. The commercial determinants of health are defined as the “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” (Kickbusch et al. 2016 p. e895). Most notably, such products include cavity-promoting foods and beverages or substances such as tobacco products that are known to cause or promote oral disease. However, not all commercial determinants should be framed as negative, because commercial activity also results in continuously improving products for maintaining good oral health and can improve health education messages provided to the public about good oral hygiene habits.

The third broad-ranging theme involves the substantial ways in which dental care financing and delivery limit access to care and perpetuate disparities in oral health. The reasons that access to needed dental care remains challenging for many are complex, but they certainly are related to the historical separation of dentistry from overall health care, rendering dentistry one of the most siloed of the health professions. This partitioning of the dental profession is reflected in the educational model, in dental care financing (both public and private), and in how and where dental care services are provided. This contributes to an arbitrary disconnection between medicine and dentistry and results in dental care being viewed by some policymakers as a nonessential health service. This policy neglect is evident in the fragmented approach to dental care financing at both the federal and state levels. Public payment for dental care through Medicaid varies across states, with many offering only limited benefits, and in four states, no benefits at all for adults. Medicare, the main provider of medical insurance for older adults, contains no dental coverage. The scope of practice for some dental professionals, including, hygienists and dental therapists, also varies across states, and greater restrictions can contribute to the challenges of providing preventive dental services to reach vulnerable populations (including the institutionalized elderly, homeless people, and the rural poor).

When viewed from a population level, dental care financing and care delivery seem wholly insufficient to meet the needs of a diverse population. This existing system is not fulfilling its purpose (Vujicic 2018). Policy reform is urgently needed to resolve these structural barriers, to address social determinants that limit access to effective prevention, and to guarantee access to appropriate care for all. The benefits of these reforms can be demonstrated to fully justify the costs (Vujicic 2018).

Social Determinants of Health

SDoH have been a focus of public health for decades. Sydenstricker (1935) said that true improvements in population health required “control, so far as means are known to science, of all of the environmental factors that affect physical and mental well-being.” That, he explained, includes economic security, healthy housing, availability of nutrient-dense food, opportunities for exercise, and efforts to provide social security for all. Link and Phelan (1995) described social factors such as low socioeconomic status and lack of social support (and arguably industry and market forces) as fundamental causes of disease. They base this assertion on evidence that the effect of SDoH persists even when intervening mechanisms such as individual health behaviors change.

Adler and colleagues (2016) noted that the best available evidence suggests using public funds to invest in addressing SDoH to achieve better population health, less inequality, and lower overall health care costs. Moreover, social determinants are not restricted to those issues that have proximate links to health, such as tobacco policy, which means public health policies can be viewed more broadly to include those related to education, labor, criminal justice, transportation, and social welfare, given their potential contributions to population health. Patterns of health-promoting or health-damaging behavior emerge early as one develops physiologically and socially, and then continue to be shaped by positive and negative life circumstances. Oral health disparities, therefore, are attributable in part to public priorities and spending decisions. For example, insurance coverage and the amount of public spending on social programs in a nation influence both oral health and quality of life. Nations that spend more on social programs have populations with better oral health status (Guarnizo-Herreño et al. 2013). Similarly, the coverage and amount of social spending in a nation, particularly a welfare state, can influence the magnitude of income-related disparities in oral health or differences in oral health among income groups, but more research is needed to clarify different types of spending approaches (Sanders et al. 2009).

These effects extend to dental care utilization, as well. In nations with more public insurance coverage, differences among the numbers of dental visits reported by population groups are smaller (Palència et al. 2013). Further, this effect on dental care extends throughout the life course (Listl 2011; 2012). Because the U.S. public investment in dental insurance and direct provision of services is a mixture of programs that operate at the federal, state, and local levels, inevitable gaps are created in insurance coverage, in turn contributing to the development of oral health disparities and inequities.

Oral diseases are not equitably distributed within society as a result of the contributions to oral health status that arise from the social and economic environment. Viewed from a population perspective, it can readily be seen that the burden of many oral diseases disproportionately affects marginalized subgroups, giving rise to oral health inequities. However, when these disparities are the result of differences in the availability of social and economic health-promoting resources—including access to affordable healthy foods, professional dental prevention and treatment services, and dental insurance—they are considered avoidable, unnecessary, and amenable to policy action. As such, these disparities are viewed as unjust and are correctly described as inequities (Whitehead 1991; Braveman 2003). Leenan (1985) defined equity in health care using the following basic conditions:

• Equal access to available care for equal need;
• Equal utilization for equal need, and
• Equal quality of care for all.

Even at the local level of a neighborhood or built environment, the same effect is seen; namely, that the social, political, and economic characteristics of small residential areas are associated with oral health—independent of the characteristics of the individuals who live there. For example, among Black families with incomes below 250% of the federal poverty level, the quality of housing and available social supports appear to ameliorate the effect of poverty (Sanders et al. 2008b). Specifically, when low-income adults and children resided in better quality housing and had social supports, they were more likely to retain 20 or more teeth and have less tooth decay (Sanders et al. 2008a; Sanders et al. 2008b). This suggests that, in addition to the importance of addressing poverty, improving the built and social environments can result in resilience as a response to the harmful health effects of poverty itself.

The federal Healthy People 2020 initiative addressed SDoH as one of its four overarching goals for the decade, and this was reaffirmed and expanded in the launch of Healthy People 2030 in August 2020 (Hubbard et al. 2020; U.S. Department of Health and Human Services 2020a). This emphasis on SDoH also has been shared by other U.S. health initiatives, such as the U.S. Department of Health and Human Services’ (HHS) Action Plan to Reduce Racial and Ethnic Health Disparities (U.S. Department of Health and Human Services 2011) and the National Prevention and Health Promotion Strategy (National Prevention Council 2011). Healthy People 2030 is focusing on the following five key determinants: economic stability, education access and quality, social and community context, health care access and quality, and the neighborhood and built environment (Figure 3). These determinants are addressed by interventions related to food insecurity, housing instability, early childhood education, literacy, civic participation, social cohesion, access to primary care, and environmental conditions.

Figure 3

Social determinants of health.

When structured in favorable ways, all five determinants contribute to better oral health and facilitate favorable oral health trajectories during the life course (Gomaa et al. 2019). The new FDI definition of oral health (Box 1) and the Peres model (Peres et al. 2019) (Figure 2) reflect the importance of these factors in determining oral health status.

As part of the commitment by HHS to support improved health and well-being of the population, the Healthy People 2030 initiative sets 10-year measurable goals and objectives for the nation related to health promotion and disease prevention. Several of these objectives have an important role in oral health, such as reducing untreated dental disease, increasing water fluoridation, expanding access to dental insurance and improving access to care; improving population health through efforts to reduce added sugar consumption; and enhancing the dental public health infrastructure. It is noteworthy that Healthy People 2030 places strong emphasis on the importance of SDoH (Figure 3); all the social determinants listed in the figure are directly related to oral health. Focusing attention on their importance can foster both policy and research that leads to improved oral health for all.

Health professional education, including dentistry, also has identified SDoH as an important component of the curriculum of future professionals (National Academies of Sciences 2016; Sabato et al. 2018; Tiwari and Palatta 2019). In clinical dentistry as well, there is growing emphasis on understanding and incorporating SDoH as part of patient-centered care (Lévesque et al. 2016; da Fonseca and Avenetti 2017; Northridge et al. 2017; Edelstein 2018; Chi and Scott 2019).

Vulnerable Populations and Oral Health Disparities

Differences in oral health status among individuals and within groups can arise for a variety of reasons. Figure 2 provides a representation of these broad categories of disease determinants, including biological (genetics), behavioral (oral hygiene practices), and social or structural factors related to how society organizes, distributes, and incentivizes the use of resources such as dental insurance in ways that may either promote or harm oral health. The insidious effects of racism on health—not just as individually expressed bias, but as policies and practices that have been incorporated into the structures of health care delivery systems—also are now being recognized as major and complex determinants of health inequities (Bailey et al. 2021). The impact of these structural factors can be seen in dentistry as well.

Warnecke and colleagues (2008) make an important distinction between individual-level determinants and population-level determinants of health. Population-level determinants exert health effects, independent of individual characteristics, and consequently require population-level interventions to remediate their health-harming effects. They distinguish between population-level determinants that exert a health effect because of the inequitable distribution of health-promoting resources or that result from fundamental biological differences among groups. When it is the former, differences in health status are considered to be not only health disparities, but health inequities that require social or population-level remedies as a matter of social justice.

As defined by WHO, the SDoH are shaped by the distribution of money, power, and resources at global, national, and local levels. The distribution of money, power and resources are influenced by any number of policy choices (Marmot and Bell 2009). As a result, different forms of social and economic vulnerability or exclusion can be said to influence oral health and its related outcomes and result in disparities between groups when one is more advantaged and another less advantaged (Marmot and Bell 2009; World Health Organization 2020).

The federal government classifies certain groups as being at higher risk of developing health problems as a result of marginalization based on sociocultural status, reduced access to economic resources, age, gender, and ability. The Minority Health and Health Disparities Research and Education Act of 2000 [Public Law 106–525(d)] mandates that populations with health disparities include minority groups, as defined by the U.S. Office of Management and Budget, as well as rural populations, persons with low socioeconomic status, and sexual or gender minorities. The federal Healthy People 2020 initiative also identified the following groups as needing special attention and creative solutions to live a healthy life in the face of sobering health disparities and social injustices: (1) high-risk mothers, (2) chronically ill and disabled people, (3) people with HIV/AIDS, (4) mentally ill people, (5) individuals with substance use disorders, (6) homeless individuals, and (7) immigrants and refugees.

Several definitions of disparities have been adopted by the U.S. government. HHS describes health disparities as “differences in health outcomes that are closely linked with social, economic, and environmental disadvantage” (U.S. Department of Health and Human Services 2011, p. 2). The National Institutes of Health defines a health disparity as a “difference in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups in the United States” (National Institutes of Health 2010). When these between-group differences are the result of unjust distribution of health-promoting resources, they are more appropriately referred to as inequities in health.

High-quality national data are available to document oral health disparities for several different population subgroups, including those with low income, African Americans (Black), Hispanics, Asian Americans, American Indians and Alaska Natives (AI/AN), and individuals with complex health conditions. However, the lack of nationally representative data or an adequate literature base hinders understanding of how differences in oral health may exist for other groups, such as the frail elderly, those with mental illness, and lesbian, gay, bisexual, transgender, queer, and other individuals.

Low-Income Populations

The idea that “the poor oral health of poor people is explained by personal neglect” (Sanders et al. 2006 p. 71) is not supported by research from the United States and Organization for Economic Cooperation and Development nations. Instead, oral health is determined by numerous factors that operate at the personal, social, and environmental levels. These determinants include genetics, behavior, and diet, as well as social, economic, and living conditions (Lee and Divaris 2014; Peres et al. 2019).

It is now generally recognized that the adverse relationship between economic circumstances and oral health spans the entire income distribution, although people who are worse off financially have more dental disease, on average, than those who are more affluent. For dental caries, not only has an income gradient persisted over time among U.S. children and adolescents, it may be worsening. Using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) for three time points from 1988 to 2014, Slade and Sanders (2017) examined the income gradient for children and adolescents in three age groups. For each survey period, they computed four categories of the income-to-poverty ratio to illustrate this gradient in disease (Figure 4 A–D), adjusting for age, gender, race/ethnicity, rural–urban location, head-of-household education, and period since last dental visit. During 1988–1994, children aged 2 to 5 years living below the poverty threshold had 2.4 more decayed or filled primary tooth surfaces than their counterparts from families with income at least three times the poverty threshold. By 2011–2012, the disparity had increased to 4.2 affected tooth surfaces (Figure 4A). During the same interval, the disparity increased among older children in primary (Figure 4B) and permanent dentition (Figures 4C and 4D). For several groups, the magnitude of disparity in children’s dental caries experience almost doubled during this period.

Figure 4

Children’s dental caries experience by primary or permanent teeth in four income categories: United States, 1988–1994, 1999–2004, and 2011–2012. Notes: Δ = absolute difference in mean caries between lowest and highest (more...)

It is notable that this worsening of disparities in dental caries occurred during a period of increasing dental care utilization by low-income individuals aged 2 to 18 years, according to the Medical Expenditure Panel Survey. From 2000 to 2012, the rate of any use of dental services by children living in families below the poverty level increased from 27% to 36%, the greatest increase for any income group (Nasseh and Vujicic 2016b). Meanwhile, child poverty deepened in the United States, rising from 11% in 1999 to 15% in 2014 (Chaudry et al. 2016). Taken together, these findings demonstrate that, at a population level, increased utilization of dental care among low-income children did not lessen disparities in children’s dental caries. One explanation could be that dental office visits alone have a limited capacity to prevent development of future carious lesions in primary teeth when disease risk is being driven primarily by social and commercial determinants.

Rural Populations

More than 60 million Americans (18%) reside in rural areas; of these, 34 million live in a dental health provider shortage area (Barnett et al. 2018). Compared to their urban counterparts, rural residents face worse oral health outcomes across the lifespan, are less likely to receive preventive dental services, and are more likely to seek dental care in the ED (Walker et al. 2014; Geiger et al. 2019). Rural adults have nearly double the prevalence of edentulism (tooth loss) than nonrural populations (Vargas et al. 2002). Rates of untreated dental caries are higher among rural populations in the South but not in other parts of the United States (Vargas et al. 2003; Maserejian et al. 2008; Dawkins et al. 2013).

Oral health disparities that persist in other subpopulations are compounded by rurality. Rural persons of color, including Black and AI/AN populations and migrant workers and their children, face disproportionately higher rates of untreated dental disease and have lower rates of dental utilization than their suburban and urban counterparts (Quandt et al. 2009; Wu et al. 2012; Schroeder et al. 2019). AI/AN adults and children, many of whom reside in rural areas, have extremely high levels of dental disease, including untreated dental caries, periodontal disease, oral pain, and tooth loss (Phipps and Ricks 2015; Phipps and Ricks 2016).

The causes of worse oral health outcomes in rural communities are multifactorial. Rural communities have fewer dentists and require longer travel time to reach dental care (Cao et al. 2017; Barnett et al. 2018). They also have lower rates of insurance coverage and Medicaid eligibility (Martin et al. 2012). Although rural dentists are more likely to accept Medicaid than their urban counterparts, rates of acceptance are still not high enough to meet the need for oral health services in the rural Medicaid population (Cao et al. 2017). In general, when compared to urban areas, rural areas have lower dentist-to-population ratios, more residents who lack dental insurance, and higher unemployment and poverty rates. As a result, roughly 2 in 5 rural Americans are essentially without access to dental care (National Organization of State Offices of Rural Health 2013).

In addition to these structural barriers to care, cultural norms, such as dental anxiety and pessimism about the achievability of oral health, also may contribute to rural-urban disparities in oral health outcomes (Chen et al. 2019). Rural populations have lower average levels of oral health literacy, a risk factor for poor oral health-related quality of life in rural communities (Gaber et al. 2017; VanWormer et al. 2018). Oral health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic oral health information and services needed to make appropriate health decisions” (National Institute of Dental and Craniofacial Research 2005). Adding to these risk factors, rural populations have less access to the preventive benefits of fluoridated water and use tobacco products more—both combustible and noncombustible—than urban residents, with the accompanying increased risk of periodontal disease and oral and pharyngeal cancers (Roberts et al. 2016). Combined, these factors contribute to a rural oral disease disparity through increased disease liability and reduced access to preventive and reparative dental services.

Black or African American Populations

Despite progress in past decades, more recent data show there are persistent and significant disparities in dental caries experience and untreated caries between non-Hispanic Black and non-Hispanic White populations. National Health Survey data have shown that among children and adolescents aged 2 to 19 years, the prevalence of total dental caries experience and of untreated caries were significantly higher in non-Hispanic Black youth compared with non-Hispanic White youth (Figure 5) (Fleming and Afful 2018). However, for working-age adults, dental caries were highly prevalent and consistent regardless of race/ethnicity, but substantial disparities do exist with the prevalence of untreated caries affecting 2 in 5 non-Hispanic Black adults (Figure 6). Root caries were significantly higher among non-Hispanic Blacks (40%) compared with non-Hispanic Whites (less than 20%) (Griffin et al. 2012).

Figure 5

Percentage of youth ages 2–19 with total dental caries and untreated dental caries in primary and permanent teeth by race/ethnicity: United Stales, 2015–2016. Note: Includes dental caries in both primary and permanent teeth.

Figure 6

Percentage of adults ages 20–64 with dental caries and untreated dental caries by race/ethnicity; United States, 2011–2016. Notes: Prevalence of dental caries (DFT > 0) and untreated dental caries (DT > 0) in permanent (more...)

Most current National Health Survey data show that the prevalence of periodontal disease among adults aged 30 years or older is higher among non-Hispanic Blacks (57%) and Mexican Americans (60%) compared with non-Hispanic Whites (37%), with severe periodontitis being more than twice as prevalent among Blacks (15%) compared to Whites (6%) (Eke et al. 2018). There also are clear disparities in tooth loss between Blacks and Whites, with complete tooth loss more prevalent among non-Hispanic Black adults 65 years or older (28%) compared with their non-Hispanic White adult counterparts (17%) (Dye et al. 2019). About 17% of Hispanics aged 65 and older are edentulous.

An analysis of 2000–2010 Surveillance, Epidemiology, and End Results incidence data showed that non-Hispanic White men had a higher age-adjusted incidence rate of oropharyngeal cancer (14.1 per 100,000) than non-Hispanic Black men (11.9 per 100,000) (Weatherspoon et al. 2015). This is contrary to the historical trend that Black men had a much higher incidence than White men (Morse and Kerr 2006). This reversal of incidence rates was linked to decreased rates of smoking and heavy alcohol use among Black men, decreased incidence rates of human papillomavirus (HPV)-negative oral and oropharyngeal cancers, and an ongoing increase in the incidence of oropharyngeal cancer linked to HPV among White men and women (National Cancer Institute 2018). Non-Hispanic White women also had a higher age-adjusted incidence rate (5.3 per 100,000) than non-Hispanic Black women (4.0 per 100,000) (Weatherspoon et al. 2015).

Although the incidence trends in oral and oropharyngeal cancers have changed, disparities in survival rates persist. For example, in 2007–2013, the relative 5-year survival rate of cancers of the oral cavity and pharynx for Black men was 47%, compared with 68.7% in White men. A similar pattern was seen for Black and White women, with 60.3% and 70.1% survival rates, respectively (National Cancer Institute 2018).

Hispanic Populations

In the 1970s, ethnicity was introduced by the U.S. Census Bureau and used for categorizing Hispanics (Valdeón 2013); these were individuals who identified themselves as being of Spanish-speaking background. “Hispanic origin” currently is defined by the Census Bureau as “the heritage, nationality, lineage, or country of birth of the person or the person’s parents or ancestors before arriving in the United States. Individuals who identify as Hispanic, Latinx, or Spanish may be any race” (U.S. Census Bureau 2019). Hispanics comprise the largest ethnic group in the United States, estimated at 18.1% in 2017 (U.S. Department of Commerce 2018). Although Hispanics are of diverse heritage (Rumbaut 2006), the largest subgroup is of Mexican origin (Pew Research Center 2012; Brown and Lopez 2013). Available clinical oral health data from the NHANES has focused on the Mexican American subgroup because of an insufficient number of non-Mexican Hispanics for subgroup analysis.

Hispanic adults have a higher prevalence of oral disease than non-Hispanic Whites. Hispanic children appear to be worse off than their White counterparts on other indicators of oral or health status and access to care, based on national survey data. Analysis of the 2007 National Survey of Children’s Health (NSCH) found that Hispanic children aged 3 to 18 years had worse oral health status (based on mothers’ rating as “fair or poor”) and were less likely to have obtained preventive dental care services in the past year than were non-Hispanic White or Black children (Guarnizo-Herreño and Wehby 2012b). In 2016–2017 NSCH estimates, the condition of 7.2% of Hispanic children’s (aged 1–17 years) teeth was characterized as “fair or poor,” compared with 4.2% among non-Hispanic Whites (Data Resource Center for Child and Adolescent Health 2020).

NHANES estimates are available for Mexican Americans and those who identify as Hispanic. In the 2015–2016 NHANES, dental caries experience was highest among Hispanic youth compared to non-Hispanic Black, Asian, and White youth with more than half (57%) of youth aged 2 to 19 years having caries (Figure 5) (Fleming and Afful 2018). Based on the 2011–2016 NHANES, 37% of Mexican American adults aged 20 to 64 years experienced untreated dental caries (Figure 6) and, for Mexican American adults 65 years or older, 36% had untreated dental caries, the highest among race/ethnic groups for older Americans (Centers for Disease Control and Prevention 2019). National Health Survey data show that Mexican American adults 30 years or older had the highest prevalence of periodontal disease among all racial or ethnic groups (Eke et al. 2018).

Tooth loss is an oral health status indicator for which Hispanics appear to be doing as well as or better than other racial or ethnic groups. The prevalence of complete tooth loss among Hispanic adults 50 years or older was similar to non-Hispanic Whites (9% vs. 11%) from 2009–2014. However, larger differences benefiting Hispanics exist between them and non-Hispanic Whites living in poverty (12% vs. 28%) (Dye et al. 2019).

Currently, about half of Hispanic Americans were not born in the United States (Krogstad and Lopez 2014). Research with Hispanics often explores differences between U.S.-born and foreign-born people, and how those factors (e.g., duration of U.S. residence, level of acculturation, language preferences, ethnic identity) may influence health status and health behaviors. Acculturation plays a role in accessing adult dental services and may act to moderate differences in oral health behaviors and outcomes (Gao and McGrath 2010). English speakers are more likely to report a dental visit in the past year than Spanish speakers (Graham et al. 2005; Riley et al. 2008; Jaramillo et al. 2009). Spanish-speaking adults of Mexican origin in the 2009–2012 NHANES were 1.8 times more likely to have periodontitis than English speakers (Garcia et al. 2017).

A “Hispanic paradox” or “Latinx advantage” has been observed for many health conditions (McCarthy 2015), including some oral health status and related measures (Sanders 2010; Spolsky et al. 2012). Although many Hispanics live in poverty in the United States and may encounter access to care barriers, Hispanic immigrants often have better health outcomes than U.S.-born Hispanics. Better clinically assessed oral health also has been documented among Mexican immigrants compared to the U.S.-born (Spolsky et al. 2012) and the more acculturated immigrants (Gao and McGrath 2010). Better self-rated oral health quality of life also has been documented among first-generation Latino adults than among their U.S.-born Latino counterparts or Whites (Sanders 2010). However, varying elements of oral health quality of life can be influenced by the level of acculturation and Hispanic/Latino background (Silveira et al. 2020). Furthermore, a systematic review of Hispanic and immigrant paradoxes concluded that these health advantages are not consistently found across studies and groups (Teruya and Bazargan-Hejazi 2013).

American Indian and Alaska Native Populations

An estimated 5.2 million people identify as AI/AN, and about 29% live below the federal poverty line (Norris et al. 2012; Mauer 2017). For AI/AN adults, the burden of disease is greater than that of any other ethnic minority group (Batliner 2016). When compared to other racial or ethnic groups, AI/AN children aged 3 to 5 years have more than double the number of decayed teeth and nearly twice the overall dental caries experience than the next highest ethnic group, Hispanics (Mexican Americans), and almost three times that of White children (Figure 7) (Phipps et al. 2019). For AI/AN children aged 6 to 9 years, 80% have a history of dental caries compared with only 45% of the general U.S. population, and almost half of AI/AN children have untreated dental caries compared to just 17% of the general U.S. population in this age group.

Figure 7

Percentage of American Indian/Alaska Native (AI/AN) children ages 3–5 with early childhood caries (ECC) during 2018–2019 in relation to other same-age children in the United States by race/ethnicity during 2013–2014.

Severe periodontal disease was reported for 17% of AI/AN adults aged 35 years or older (28% for those who smoke), compared to 10% of U.S. adults (Phipps and Ricks 2016). Tooth loss was common in AI/AN adults aged 40 to 64 years, where loss of at least one permanent tooth occurred in 83% of AI/AN adults (Phipps and Ricks 2016), compared to 66% for adults in the U.S. population as a whole (NHANES 2011–2012) (Dye et al. 2015).

Oral Health and Structural Racism

The racial concerns that permeate American society unmistakably contribute to the oral health disparities that have been observed throughout the United States and, as described above, represent one of society’s greatest challenges. Systemic, or institutional, racism is created by factors embedded in a social structure that reflects the perspectives and needs of a white majority and that, consequently, disadvantage people of color. Structural aspects of public organizations focused on education, housing, criminal justice, and health care incorporate these biases in a variety of ways (Feagin and Ducey 2014), and dental care is no exception. Black populations, Hispanics, and some other minority racial populations have much lower family incomes and experience much higher rates of poverty than does the White population (Semega et al. 2020). These financial disparities interact with the dental health care system to create major disadvantages for members of racial minority groups. Structural features of the dental care system result in high out-of-pocket costs for many, and family-level economic factors such as income, poverty status, and dental insurance play critical roles in the ability to access routine dental care (Vujicic et al. 2016a). The delivery of dental care services usually requires the ability to pay personally or through individual insurance, thereby directly limiting care to those with greater financial resources. The ability to access dental insurance, which comes more readily with higher paying and more stable employment is, in turn, also linked to race. Moreover, dental services may not be readily available in areas where many people of color live, because the structure of payment for services provides lower incentives for providers who would locate in those areas. As a major contributor to the SDoH, systemic racism also indirectly impacts oral health through various structural, sociocultural, and familial mechanisms, that, like financial and educational resources, are differentially distributed across racial groups. Historical experiences with health care that can create mistrust of the system may be linked to race as well. A scoping review of the persistence of oral health disparities of African American children (Como et al. 2019) found numerous factors had contributed to poorer oral health among African American families, including less access to affordable non-cariogenic food, fear and distrust of the care delivery system, lower health literacy, and social stigmatization.

These patterns can be seen in the few published studies of inequity in dental care. Treatment for existing dental disease, a measure of access to dental care, is highly correlated with race/ethnicity (Gupta et al. 2018). This is reflected by the national data that show clearly that African American, AI/AN, and Hispanic populations all have higher rates of untreated dental caries and tooth loss, as well as poorer access to preventive services (Koppelman 2016a). Dentists’ treatment decisions, too, have been shown to be affected by unconscious racial bias; for example, in a randomized clinical study of tooth restorability, treatment recommendations were found to favor extractions over root canal treatment for Black patients (Patel et al. 2019). Adding to these broad social problems, the profession of dentistry reflects substantial underrepresentation of Black dentists in the workforce (Mertz et al. 2017).

Increasing the diversity of the dental workforce could contribute in important ways to oral health equity through changes in dental practice arrangements (Mertz et al. 2016b) and enhanced patient trust and satisfaction with care (Cooper et al. 2003).

Financing Dental Care

The dental care financing mix continues to differ significantly from that of medical care. In 2019, Centers for Medicare & Medicaid Services (CMS) programs accounted for 37% of medical care spending, with out-of-pocket payments accounting for 11% and private medical insurance, 31% (Centers for Medicare & Medicaid Services 2019a). In contrast, 10% of costs for dental care were paid by a CMS source, 40% were paid out of pocket, and 46% were covered by private dental insurance in 2018 (see Figure 3, Section 4 in this monograph) (Centers for Medicare & Medicaid Services 2020a). Dental care spending has grown more slowly than overall medical care spending with dental care accounting for 3.7% of total health care spending in the United States in 2017, compared to 4.5% in 2000 (American Dental Association 2017).

The cost of dental care remains an obstacle for many Americans, with dental care consistently presenting the highest financial barrier of any health service in the United States (Vujicic et al. 2016a). Dental insurance alleviates this concern for some, and in 2018, roughly 80% of Americans had some form of private or public dental coverage (National Association of Dental Plans 2020). However, dental insurance coverage varies substantially by age group in the United States with the percentage of coverage declining with age (see Section 2A, Figure 36). The majority of Americans, about two-thirds, received coverage through employment-based plans or through organizations like AARP, and a small percentage (around 10%) purchased coverage through private dental plans or as part of a medical plan (National Association of Dental Plans 2020). In 2018, publicly funded dental insurance provided coverage for roughly one-fourth of Americans through a variety of programs, including Medicaid, the Children’s Health Insurance Program (CHIP), the Veterans Health Administration, the U.S. Department of Defense (DoD), the Indian Health Service, and others.

The result is that dental insurance coverage, when available, consists of a patchwork of public and private plans that vary widely in eligibility requirements, the benefits provided, and the availability of participating dentists. Moreover, many of those with dental insurance still incur high out-of-pocket costs. In 2018, about 66.7 million Americans had no dental coverage with a dentally uninsured rate of 2.5 times higher than the medically uninsured rate (National Association of Dental Plans 2020). For those without coverage, routine dental care is often financially out of reach. For example, older adults are less likely to have employment-based dental insurance, yet as of this writing, Medicare, the primary provider of medical insurance for individuals aged 65 years and older, does not include routine dental care in its mandated services.

Having dental insurance, either public (Medicaid) or private, has been shown to improve access to dental care. Among older adults, having private insurance increased preventive service use by 25% and having Medicaid coverage increased major service use by 36% (Meyerhoefer et al. 2019). Expansion of dental coverage in Medicare also is estimated to improve access to dental care for older adults (Kreider et al. 2015). Insurance coverage alone will not be sufficient to increase access to dental services for older adults, however. Other factors, such as having an accessible and sufficient dental professional workforce, a culture of self-care and utilization of health care, and social support, particularly for older adults, must accompany improvements in dental care financing. Current federal government-sponsored dental health insurance programs include Medicaid and CHIP. Medicaid provides health coverage for millions of Americans, including eligible low-income adults, children, pregnant women, older adults, and people with disabilities. Medicaid is administered by states, according to federal requirements, and jointly funded by states and the federal government. CHIP provides health coverage to eligible children through both Medicaid and separate CHIP programs. To date, nearly all state Medicaid programs have expanded dental program services and are implementing a variety of models aimed at increasing dental care access and capacity for a growing number of eligible individuals, although earlier expansion had benefited children more than adults. There are currently two states that do not provide a Medicaid dental benefit to the adult base population (Figure 8) (Center for Healthcare Strategies, 2019).

Figure 8

Status of Medicaid adult dental benefit coverage by state: United States, 2019. Notes: ^a North Dakota does not offer adult dental benefits to its Medicaid expansion population.

Having dental insurance has been shown to provide a substantial increase in children’s use of needed dental services, resulting in less untreated disease. Importantly, children enrolled in public insurance programs such as Medicaid or CHIP have been shown to receive the greatest benefit in terms of access and disease reduction, compared to those who are not publicly insured (Yu et al. 2017). Moreover, when Medicaid coverage is offered to adults there is some evidence that the benefits go beyond increased access to care and include improved oral health, improved job outcomes, and possibly decreases in oral health disparities (Kieffer et al. 2021). Additional discussion on dental insurance can be found in Section 4.

In addition to dental insurance, the federal government supports funding for direct patient care through the Health Resources and Services Administration (HRSA). HRSA’s mission is to improve health outcomes and address health disparities through access to quality services, a skilled health workforce, and innovative, high-value programming (Health Resources and Services Administration 2019a). The agency provides primary health care to the geographically isolated and to the economically or medically vulnerable, such as people with HIV/AIDS, pregnant women, and mothers. HRSA supports the training of health professionals, the distribution of providers to areas where they are needed most, and improvements in health care delivery.

Oral Health and National Security

Maintaining the health status of members of the armed services is critical for ensuring an effective military force. Each branch of the armed services maintains a dental component charged with ensuring that dental conditions do not degrade military readiness. From this perspective, providing oral health care is essential for maintaining military readiness because service members are not deployable until they meet dental readiness criteria (Assistant Secretary of Defense for Health Affairs 2002). When concern arose over the large percentage of dental conditions and emergencies among service members (15% per year), DoD added dental readiness as one of the six categories of military readiness in 2002 (Lee et al. 2019).

The DoD dental readiness classification (DRC) system helps assess the oral health of personnel, with the following four levels of DRC for service members: 4 – Requires an annual examination because their dental readiness is unknown; 3 – Has some type of oral condition that is likely to result in a dental emergency within 1 year (these individuals are not considered to be worldwide deployable); 2 – Requires clinical preventive dental care or treatment for some type of oral condition which is unlikely to develop into a dental emergency within the next year (these individuals are considered to be worldwide deployable); and 1 – No dental treatment needed and are worldwide deployable (Assistant Secretary of Defense for Health Affairs 2002; King 2008; Assistant Secretary of Defense for Manpower & Reserve Affairs 2018). The predictive power of this classification system is reasonably good; for example, soldiers who were DRC 3 were up to 8 times more likely to have a dental emergency during field operations or deployment than soldiers who were DRC 1 (Chaffin and Moss 2008).

Dealing with dental injury and disease in a combat environment presents challenging logistical issues and must be properly managed to prevent loss of combat effectiveness. A RAND Corporation study of dental readiness noted the high cost in personnel time, and hence combat effectiveness, that result from dental emergencies in a combat zone (Brauner et al. 2012). The authors of the RAND study reported that, “a dental emergency can require three convoy vehicles with up to nine personnel for security in-theater for the sole purpose of medical evacuation” (Brauner et al. 2012 p. 3). Estimates of expected rates of dental emergency in deployed military members vary widely, depending on pre-deployment readiness and deployment length. Chaffin and Moss (2008) reported that rates between 156 and 170 dental emergencies per 1,000 deployed Army personnel should be expected. Monetary costs of dental injuries in deployed U.S. Army troops found that direct costs of dental conditions (nonbattle injury) totaled $21.9 million from July 1, 2010, through June 30, 2011; 32% of these injuries required additional follow-up care during a 2-year period (Colthirst et al. 2013).

Even in garrison, soldiers experience significant levels of dental treatment needs. The 2016 Sample Survey of Military Personnel showed that Army troops frequently experienced oral health-related difficulties that affected their daily lives (U.S. Army Research Institute for the Behavioral and Social Sciences 2016). Dental pain affected 23.5% of enlisted soldiers in garrison, and oral problems prevented 16.5% from eating certain foods, 26% from sleeping, and 20.6% from concentrating on work, and forced 14% to miss work because of sick call or healing time in quarters (Simecek et al. 2014).

The extent to which oral health affects military readiness of active-duty members varies by service branch and activity (i.e., combat, deployment, or garrison). All service branches are required to sort out the oral health status of incoming recruits and each service branch maintains its own oral health-related criteria for accepting new recruits. Poor oral health among potential recruits leads to either their disqualification for service or the need for costly dental treatment.

The U.S. Navy Dental Corps maintains dental readiness for a population of 327,577 active-duty sailors serving in the U.S. Navy and 185,830 active-duty marines serving in the U.S. Marine Corps across the world (Assistant Secretary of Defense for Manpower & Reserve Affairs 2018). The Navy Dental Corps comprises 1,125 active-duty dentists serving on a variety of platforms, including ships, Marine Corps bases, Navy Mobile Construction Battalions, and overseas and shore facilities (Assistant Secretary of Defense for Manpower & Reserve Affairs 2018). According to the Navy Bureau of Medicine and Surgery, Navy dental clinics provide more than 1,485,000 patient visits annually. All dental care is provided free of charge.

The U.S. Army Dental Corps workforce comprises a mixture of military, government service, and contracted civilians. This workforce consists of 1,170 dentists, 263 registered hygienists, 154 prophylaxis (tooth cleaning) technicians, and 2,801 dental assistants. Dentist-to-population ratios guide workforce determinations in the Army Dental Corps. Variations in the size of the active-duty soldier population or the proportion of non-Army treatment-eligible patients who receive treatment from Army dental facilities present challenges for developing and managing an effective dental workforce. For example, during 2018, there were nearly 417,600 active-duty soldiers, but active-duty Army soldiers composed 80% of the population treated; others eligible to receive treatment included members of the National Guard and Reserve, retirees, and family members. Thus, an estimate of the average eligible population is closer to 522,000, with the estimated dentist-to-population ratio between 1:500 and 1:600. Because poor oral habits are common in this population, about one-third of soldiers are prone to developing new dental treatment needs every year; consequently, the larger cadre of oral health providers will likely be needed for some time to come (Joint Chiefs of Staff 2018).

The U.S. Air Force Dental Corps consists of more than 900 active-duty general dentists and specialists, along with nearly 2,000 enlisted dental assistants, hygienists, and laboratory technicians who serve in group practices at 76 Air Force bases around the world. They provide dental care for more than 300,000 active-duty airmen and numerous additional DoD beneficiaries, totaling nearly 1.3 million dental visits annually.

The general trend toward improved oral health of U.S. adults is not fully reflected in U.S. military recruits. On average, about 17% of potential Army recruits are found to have disqualifying medical conditions upon examination, and about 44% of those identified are granted waivers for their conditions (Joint Chiefs of Staff 2018). As a result, an estimated 10% of those examined are rejected for medical conditions. In 2008, the DoD Recruit Oral Health Study (Leiendecker et al. 2011) found that only 25% of new recruits did not require restorative dental treatment, which was a marginal improvement from 20% in the 1994 study. Nearly 53% of 2008 Army recruits were DRC 3 and could not deploy until their conditions had been treated, an increase from 33% in 1994 and 42% in 2000. Data from 2018 revealed that out of 94,516 new recruits examined, 21,971 (23.3%) were placed in DRC 3 (Military Health System 2019). To ensure that most of the new recruits were deployable, the Army has implemented a program called First Term Dental Readiness (FTDR), which attempts to treat all incoming DRC 3 conditions. The FTDR program has succeeded in meeting the 95% readiness goal set by DoD Health Affairs, with a DRC 3 prevalence of 4.66% among graduating soldiers for 2018 (Gourley 2018).

Fewer than 1% of potential Air Force recruits are rejected because of significant dental caries or severe malocclusion. However, of those new recruits who do enter the Air Force, nearly all have some level of unmet dental treatment needs and about a quarter (23%) suffer from severe oral conditions that prevent them from deploying (Irwin 2019a). In 2001, nearly half (45%) of airmen had either DRC 2 or DRC 3 oral health conditions that required treatment.

Today, all branches of the service report that roughly 90% of their personnel are DRC 1 or 2, and therefore dentally ready to deploy. Managing dental problems during field training or deployments, however, remains a major focus of military dentistry. Dental problems have accounted for between 5–22% of all sick-call patients presenting to U.S. Army field medical treatment facilities (Allen and Smith 1992; Nasser and Storz 1994; Dunn 2004; Darakjy et al. 2006). The top three oral conditions that affected soldiers during deployment were dental caries (including the pulpal disease caused by it), periodontal disease, and painful or infected third molars (Simecek et al. 2014). Wojcik and colleagues (2015) noted that incidence figures for dental disease and non-battle injuries (DNBI) for Iraq and Afghanistan operations (Joint Chiefs of Staff 2018) were much higher than the DNBI rates they had previously found among admissions for other medical conditions. In the most recent systematic review of the impact of dental conditions on military readiness, Lee and colleagues (2019) estimated that nearly 12% of all troops deployed to hostile environments will experience a dental emergency or an oral-maxillofacial injury with dental emergency rates varying by service and duty environment (Figure 9).

Figure 9

Dental emergency rates by military service and environment: United States, 1966–2012. Notes: Means and standard deviations of dental emergency (DE) rates by service and environment. Number of DE rates reported for each environment and service: (more...)

The National Defense Authorization Act of 2017 began the process of shifting responsibility for delivering the health care benefit for military beneficiaries from individual services to a single, mostly civilian-run organization, the Defense Health Agency (DHA) (National Defense Authorization Act 2016). This ongoing effort cedes the management and control of all nondeployed or afloat military treatment facilities (MTF) to DHA, with the services providing much of the clinical and administrative staffing. Consolidating three service medical enterprises into one is intended to improve business practices and reduce duplication as part of DoD’s effort to reform business practices. Uniformed health care providers will be loaned to DHA-managed MTFs to maintain clinical skills and for educational purposes.

Quality of Oral Health Care

Transformation in the Quality Landscape

Over the past 20 years, many advances have been made across the public health landscape to improve the quality of programs and services. These advances have made their way to commercial and government programs focused on the development of quality measures for dentistry. Federal and state public health and delivery system programs are using quality measures to improve program performance. Such measures now are being used to drive quality assurance, as well as quality improvement processes. These steps support achievement of the Institute for Healthcare Improvement’s Triple Aim for Populations by applying integrated approaches to simultaneously improve the health of populations, enhance the experience of care for individuals, and reduce the per capita cost of health care (Berwick et al. 2008).

The 2000 Surgeon General’s report on oral health noted the lack of performance measures for assessing the oral health care delivery system. More than a decade later, the National Academy of Sciences and the National Academy of Medicine (formerly the Institute of Medicine [IOM]) issued reports focused on oral health and highlighted persistent access barriers and disparities in care. In doing so, they also brought into sharper focus the need for quality measurement and identified the lack of quality measures as a primary barrier to improving the quality of oral health care (Institute of Medicine 2011; Institute of Medicine and National Research Council 2011). The IOM’s report, Leadership by Example: Coordinating Government Roles in Improving Health Care Quality, noted that in “providing leadership to effect the needed changes in health care, the federal government should take full advantage of its unique position as a regulator, purchaser, health care provider, and sponsor of research, education, and training” (Institute of Medicine 2003, p. 6). Although Medicare, as a large public program, has the ability to drive market change, it has limited influence on dentistry because dental benefits are rarely provided through Medicare. Medicaid and CHIP, on the other hand, cover close to 40% of U.S. children and thus have the market power to effect change (Rudowitz et al. 2019).

In response to growing recognition of the need for dental quality measures, in 2009, the CHIP Reauthorization Act directed CMS and the Agency for Healthcare Research and Quality (AHRQ) to convene a representative group of stakeholders to develop health care measures for dentistry. CMS petitioned ADA to take a leadership role in this effort, which triggered the formation of the Dental Quality Alliance (DQA). DQA’s mission is “to advance performance measurement as a means to improve oral health, patient care, and safety through a consensus-building process” (Dental Quality Alliance 2019).

DQA has since accepted the definition of quality set forth by IOM as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Institute of Medicine 2001, p. 44). This definition addresses both individuals and populations, connects care delivery to outcomes, and is grounded in the best available knowledge. Thus, quality can be assessed at different levels within the care delivery system, including the clinician/practice level, facilities (for example, hospitals), Managed Care Organizations (MCO), and public insurance and public health programs. Currently, there are three adult and a dozen pediatric DQA quality measures related to oral health (Table). AHRQ’s National Quality Measures Clearinghouse has identified five clinical quality and population health measure domains: access, structure, process, outcomes, and patient/population experience (Agency for Healthcare Research and Quality 2019). These domains form the framework for quality measurement across both the public health and health care delivery systems, including those for dentistry.

Given that dental public health and dental delivery systems operate different types of programs and services, measures and metrics developed for one type of program may not be suitable for another. In addition, measures developed for use at the plan level may not be suitable at the provider level. Several measures developed in recent years demonstrated this challenge to state program policymakers when they were tested in various dental environments (Dental Quality Alliance 2019).

Using Quality Measures to Improve Care

Over the past several years, DQA, educational institutions, and MCOs have developed dental quality measures for use by Medicaid and CHIP dental programs. Such efforts have led the way toward advancing value-based programming and value-based care. In the quest for value for the dental care dollar, both CMS and state Medicaid administrators are seeking to understand whether the Medicaid system enables the delivery of quality oral health/dental health care services to program beneficiaries and improved population health management through medical-dental integration. Measures that have been developed and used by Medicaid programs during the past decade typically assess access and specific utilization of preventive services.

Table

Dental Quality Alliance (DQA) Administrative claims-based measures.

These measures help program administrators determine the degree to which program beneficiaries are receiving essential preventive dental services, whether health plans are promoting such quality services, and whether providers across their networks are centering care around primary prevention.

In 2020, CMS updated one of two oral health care measures within the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (CMS Child Core Set): receipt of sealants on first permanent molars replaced the former measure—dental sealants for children aged 6 to 9 years who are at elevated dental caries risk (SEAL-CH) (Centers for Medicare & Medicaid Services 2021a). The second measure—percentage of eligible children who received preventive dental services (PDENT-CH)—remained. While reporting of the Child Core Set measures currently is voluntary, it will become mandatory in 2024 (Center for Medicaid and CHIP Services 2020).

It should be noted, however, that dental program quality measurement continues to be hampered by limited infrastructure and capacity to effectively assess oral health status and the oral health care outcomes of beneficiaries. The current dental coding system, which does not account for patient-level oral health status and dental diagnostic information, is a primary contributor to this problem. Although other more advanced dental coding systems with diagnostic codes currently exist, the shift to such data systems has not yet been implemented at the dental care delivery level.

The move to Medicaid managed care and accountable care by state Medicaid dental programs has supported quality improvement across state Medicaid programs. In 2016, 68% of Medicaid beneficiaries were enrolled in comprehensive care programs, including some that provided dental benefits, and 9.7% of the total Medicaid population were enrolled in limited-benefit dental prepaid ambulatory health plans, including dental-only benefit plans (Medicaid and CHIP Payment and Access Commission 2021b). Within Medicaid managed care, a key lever for quality improvement is the requirement that states incorporate performance improvement projects (PIP) in their contracts with MCOs. A PIP is a quality improvement effort designed to address identified gaps in clinical or nonclinical aspects of care delivery, with the goal of achieving significant and sustained improvement through targeted interventions. To achieve this, MCOs must propose interventions and submit measurable objectives with metrics and adhere to strict timelines used by states to monitor performance and success. Such measures often are tied to financial incentives and disincentives. As such, the need for relevant, valid, and reliable oral health performance measures cannot be overstated.

As the current health care environment evolves, performance measures will be necessary to support plan and provider performance incentives, pay-for-performance programs, and population-based payments. The existing DQA measures provide a start. Monitoring their utility will be essential to ensure validity across all aspects of program measurement. From 2017 to 2019, CMS assisted three states under its Medicaid Innovation Accelerator Program to develop models to align payment with oral health care improvement goals. Such models will align payment with oral health care improvement goals (Centers for Medicare & Medicaid Services 2019b).

More recently, a move has emerged to identify and work with high-risk individuals with chronic conditions to measure the value of dental care based on the degree to which dental services may advance overall health and support medical care. These patients may seek dental care while still experiencing other critical health care gaps. Integrating medical screenings into dental visits provides the opportunity to identify high-risk medical patients and link them to care or programs that support and address SDoH. Measures for these types of programs are under development in some states. They do not yet exist at the national consensus level.

Chapter 2. Advances and Challenges

The oral health status of Americans, in general, has been improving since the 2000 Surgeon General’s report on oral health (Rozier et al. 2017). Dental caries severity in the permanent teeth of children has declined to historically low levels, and long-standing inequalities in untreated caries appear to be narrowing. Declines in caries prevalence affecting children’s permanent teeth have stabilized at a low level and likely will contribute to future reductions in caries experience in adults. Although the prevalence of periodontal disease is high in adults, only a small percentage have severe forms of the disease. Tooth loss as a consequence of dental disease has declined markedly during the last half century and has been all but eliminated in high income groups.

Although oral health is improving nationally, significant concerns persist. Dental caries, periodontal disease, and tooth loss remain significant public health concerns. As a nation, at least 4 out of 5 Americans aged 6 years and older have experienced tooth decay, irrespective of poverty or race/ethnicity status (Figure 10). The prevalence of dental caries increases as Americans age, and this has remained unchanged for the past 2 decades. But the overall prevalence of dental caries is starting to show a downward trend, especially among people younger than 45 years (Figure 10). However, most of this progress has only been realized for those living in households at 200% or higher of Federal Poverty Guidelines.

Figure 10

Percentage of individuals ages 6 and older with dental caries in permanent teeth by age group, poverty status, and race/ethnicity: United States, 1988–1994, 1999–2004, 2011–2014. Notes: Prevalence of dental caries (DMFT > (more...)

Overall, the prevalence of untreated dental caries in permanent teeth has not changed since the release of the 2000 report, with nearly 25% of all Americans aged 6 and older affected by untreated caries (Figure 11). Although untreated caries has declined for children, it has increased for working-age adults during this period. The prevalence of untreated caries is higher among working-age adults compared to children, adolescents, and older adults. Untreated caries among those living in poverty remains about twice that for those not living in poverty and disparities continue to persist by race/ethnicity status. These collective experiences clearly suggest that challenges persist in preventing dental caries in permanent teeth from occurring at the population level in the United States. Advances in reducing the loss of permanent teeth because of dental disease have been substantial. In general, tooth loss has been on the decline for all Americans in recent decades (Slade and Sanders 2017). When the Surgeon General’s report on oral health was published, people aged 6 years and older had on average six teeth missing attributable to dental disease, whereas now that has been reduced by half (from nearly six, to about three mean teeth lost) (Figure 12). Among all age groups, improvements in tooth loss have affected older adults the most, decreasing from about 16 missing teeth to less than 11 missing teeth. Although the decreases in mean tooth loss are also occurring across all income levels, significant differences between those living in poverty and those who do not still exist. The complete loss of teeth (edentulism) still affects 18% of adults aged 65 years or older in 2009–2014, with those living in poverty twice as likely to be edentulous, compared to those not living in poverty (Dye et al. 2019). Additional information on advances and challenges influencing oral health status across the lifespan is provided in Sections 2 and 3 of this monograph.

Figure 11

Percentage of individuals ages 6 and older with untreated dental caries in permanent teeth by age group, poverty status, and race/ethnicity: United States, 1988–1994, 1999–2004, 2011–2014. Notes: Prevalence of untreated dental (more...)

Figure 12

Mean number of missing permanent teeth due to dental disease among individuals ages 6 and older by age group, poverty status, and race/ethnicity: United States, 1988–1994, 1999–2004, 2011–2014. Notes: Mex Am = Mexican American, (more...)

Improvements in access to oral health care services have been observed steadily for the last 2 decades and have primarily helped children increase access to preventive and restorative care. State Medicaid and the Children’s Health Insurance Program (CHIP) have substantially facilitated the use of dental services among poor and near-poor children and adolescents (Centers for Medicare & Medicaid Services 2020b). A near-doubling of the percentage of children with public dental insurance from 1996 to 2015 resulted in a 15-point increase to 88% in any dental coverage among all children (Ku et al. 2013; Steinmetz et al. 2014). For older adults aged 65 and older, modest increases in both public and private dental insurance coverage decreased the proportion uninsured from 68% to 62%, whereas the percentage of working-age adults aged 19 to 64 years with no dental insurance increased slightly from an estimated 33% to 35% (Nasseh and Vujicic 2016a).

Progress in expanding public coverage for youth, which has contributed to the decrease in the numbers of uninsured children, has also paralleled a considerable reduction in out-of-pocket dental expenditures for children (from mean of $155 to $100) and for adolescents (from mean of $444 to $418) between these two periods (Figure 13). However, with no change in dental insurance coverage for older adults, mean out-of-pocket expenses have continued to climb even after adjusting for inflation (2015 dollars) from $539 to $568. This mean out-of-pocket expenditure relationship observed for children and older adults persists for overall mean dental expenses as well. The mean reduction in total dental expenses for children was nearly $62 between these two periods ($438 to $376) whereas for older adults there was a mean increase in overall dental expenses to nearly $851 from $731, after adjusting for inflation (Figure 14). The ongoing lack of dental benefit/insurance coverage remains a persistent challenge and is a growing dental public health problem. Because older adults are much more dependent on a fixed income, continual increases in outof-pocket dental expenditures, along with increasing overall costs for dental care, will result in increasing deferred dental care when substantial improvements in tooth retention are occurring for an aging population that is increasing in numbers in the United States.

Figure 13

Mean out-of-pocket dental expenditures per person in dollars (adjusted): United States, 1999–2004 and 2011–2014. Notes: Expenses adjusted to 2015 US Dollars (USD). FPG = Federal Poverty Guideline: < 100% FPG = poor; 100–199% (more...)

Figure 14

Mean total dental expenditures per person in dollars (adjusted): United States, 1999–2004 and 2011–2014. Notes: Expenses adjusted to 2015 US Dollars (USD). FPG = Federal Poverty Guideline: < 100% FPG = poor; 100–199% FPG (more...)

Vulnerable Populations and Oral Health Disparities/Inequities

Rural Populations

Although the 2000 Surgeon General’s report on oral health noted the gravity of rural oral health disparities, its conclusion was limited by lack of sufficient data. Since then, the health outcomes of rural populations have been prioritized. The Health Resources and Services Administration (HRSA) released reports on oral health in rural communities in 2004 and 2018 (Barnett et al. 2018). These reports identified agency priorities for improving rural oral health, most notably provider recruitment and training, oral health literacy and education, and medical-dental integration. In 2013, the Federal Office of Rural Health Policy funded the development of a publicly available Rural Oral Health Toolkit to disseminate successful rural oral health care delivery models (NORC Walsh Center for Rural Health Analysis et al. 2013).

Geographic and socioeconomic factors continue to create rural oral health disparities. More than half of all uninsured rural adults live in states that did not expand Medicaid under the Affordable Care Act, thus restricting their access to insurance coverage (Foutz et al. 2017). Variations in Medicaid coverage for dental procedures also affect rural providers and patients more dramatically than those in urban settings (Fish-Parcham et al. 2019). Recruitment of dentists to rural areas is an ongoing challenge, with the vast majority of dental school graduates—even those originally from rural areas—choosing to practice in more urban locations (Vujicic et al. 2016b). Because rural dentists are, in general, older than the average practicing dentist, the sustainability of the rural dental workforce may be increasingly under threat in the coming decades (Doescher et al. 2009).

One of the largest innovations since 2000 with the potential to have an impact on rural residents has been the adoption of dental therapy in the United States to address ongoing rural dental workforce challenges. Dental therapists are members of a dental team who provide preventive and restorative dental care. Although dental therapists have practiced globally in rural areas since the early 20th century, it was only in 2003 that the first cohort of dental therapists began to treat Alaska Natives as part of the Indian Health Service’s (IHS) Community Health Aide Program. In 2009, Minnesota became the first state to pass legislation permitting dental therapists to practice statewide, with subsequent adoption by the predominantly rural states of Vermont and Maine (Koppelman et al. 2016b). As of 2019, eight states had passed dental therapy legislation that allows these professionals to practice independently (Grant 2019) and 12 states allowed dental therapy in some capacity. Research indicates that dental outcomes were equivalent or superior when dental teams included therapists (Wright et al. 2013). In spite of these advances, there are only about 100 dental therapists practicing across the country (Koppelman et al. 2016b). See Section 4 for more information on dental therapists.

Scalability of effective oral health prevention interventions in rural areas is a special challenge. Water fluoridation in small, rural communities is costlier than in cities; however, the estimated return on investment for community water fluoridation in communities of fewer than 5,000 people still approaches $30 per person (Griffin et al. 2001; O’Connell et al. 2016). Higher use of well water rather than community water sources further complicates efforts to provide this important preventive measure. Yet, prevention is especially important in rural areas because many patients face long travel times to reach a dentist in rural dental health professional shortage areas. Limited transportation options, especially for older rural dwellers, may further restrict access (Arcury et al. 2005).

Low-Income Populations

The 2000 report on oral health highlighted the disproportionate burden of dental caries borne by people living in poverty. Overall, income and economic status disparities in oral health persist. Cost continues to be the greatest barrier to accessing dental care. Dental cost as a percentage of total income is a metric that highlights how low-income families often are unable to access professional dental services. Halasa-Rappel and colleagues (2019) analyzed 2018 Medical Expenditure Panel Survey data and reported two associated and troubling findings. Among individuals living in poverty, 93% had unmet dental care needs, compared to 58% of those in the high-income group. They also reported that as a percentage of income, individuals living in poverty spend nearly 10 times more of their income for dental care, compared to high-income families (Halasa-Rappel et al. 2019).

Public health interventions intended to reduce disparities can inadvertently worsen them; however, working with community partners can improve implementation practices that can increase the likelihood of success and improved health outcomes of community participants. For example, population level interventions that depend on voluntary behavior change typically are adopted by the most advantaged. As health technologies advance, such as in the field of precision dentistry, economically advantaged groups are likely to benefit most from these potentially costly services, resulting in a widening of income disparities in oral health. For example, as technologies have improved treatment outcomes over the past 2 decades, increases in tooth retention have led to more affluent adults having more natural teeth retained compared to those living in poverty, but observed disparities in tooth retention by income status increased (Dye et al. 2019).

Decreasing health disparities depends in large part on programs and policies aimed at providing more equitable distribution of evidence-based, health-promoting interventions. Generally, this means programs that are not dependent on individual behavior change or compliance, such as community water fluoridation programs. Increasing the proportion of the population served by community water fluoridation not only benefits the entire population but disproportionally benefits economically vulnerable groups, producing a flatter socioeconomic gradient in dental caries among children (Slade et al. 1995; Riley et al. 1999; McLaren and Emery 2012; McLaren et al. 2016) and reducing the need for expensive dental treatment.

To redress such inequities, the federal Healthy People 2000 initiative introduced an overarching goal to reduce health disparities. Healthy People 2010 expanded this goal based on characteristics of race and ethnicity, geographic location, gender, sexual orientation, disability status, educational attainment, and family income. Healthy People 2020 retained elimination of health disparities as an overarching goal and added achieving health equity and improving the health of al groups. This has been further expanded for Healthy People 2030, where an overarching goal is to eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all (U.S. Department of Health and Human Services 2020b).

Black or African American Populations

The gaps between the status of non-Hispanic Black populations relative to other racial groups remain similar to those reported in the 2000 Surgeon General’s report on oral health. A comparison of the National Health and Nutrition Examination Survey (NHANES) data from 1999–2004 and 2011–2014 revealed that the racial disparities between non-Hispanic Black and White school-age children for untreated dental caries have broadly not improved but when race and poverty are both considered, the disparities for low-income non-Hispanic Blacks aged 6–11 become more pronounced but are nearly eliminated among more affluent youth (Dye et al. 2017). Non-Hispanic Black populations in the United States continue to experience greater morbidity from oral diseases than their counterparts of other racial groups (Henshaw et al. 2018). For low-income Blacks in the United States, the challenges of having adequate dental benefits and access to a workforce that is willing and available to meet their oral health needs is an ongoing challenge. That only 3.3% of U.S. dentists are Black is an important aspect to this challenge (Mertz et al. 2017).

As the number of older adults in the United States increases, it is important to note that there are persistent disparities between Black and White older adults, especially with regard to untreated dental caries (Centers for Disease Control and Prevention 2019). Continuing barriers to receiving needed dental care services for older adults include lack of dental coverage in Medicare and limited access to adult dental benefits through Medicaid (Friedman et al. 2014a). Because many individuals lose their employment-based dental insurance upon retirement, Manski and colleagues (2011) estimated that non-Hispanic Black retirees were three times more likely to stop using dental services than were their White counterparts, even after controlling for other factors, such as income and education.

Effective promotion of oral health among non-Hispanic Blacks also requires an improved understanding of how social determinants function to influence oral health and access to care across cultures. Although living in poverty and disadvantaged neighborhoods, and having more exposure to chronic stressors (Sanders and Spencer 2004; Turrell et al. 2007; Finlayson et al. 2010; Braveman et al. 2011), can affect anyone living with those hardships, the interaction of these factors with race remains unclear. For example, among child populations where Medicaid and CHIP are available, the percentage of those who were uninsured varied in important ways across racial and ethnic groups. Among the insured, moreover, substantial differences exist between public and private insurance coverage. Among Black children, 49.1% had public insurance and 42.8% had private insurance, whereas for White children, 17.5% had public insurance and 76.2% had private insurance. Children with public insurance receive less dental care than those with private dental coverage. This often is attributed to lower reimbursement rates by Medicaid in most states, leading to a smaller number of dentists willing to provide services to Medicaid patients (Flores and Tomany-Korman 2008). These factors limit access to and utilization of regular dental services, especially preventive services (Edelstein and Chinn 2009; Pourat and Finocchio 2010). As a result, there are continuing disparities in access to important preventive services, such as dental sealants, between Black and White children (Figure 15) (Centers for Disease Control and Prevention 2019).

Figure 15

Percentage of youth ages 6–19 with dental sealants by age group, poverty status, and race/ethnicity; United States, 2011–2016. Note: FPG = Federal Poverty Guideline: < 100% FPG = poor; 100–199% FPG = near poor; and ≥ (more...)

Hispanic Populations

Hispanic Americans, especially those of lower socioeconomic status, continue to experience a high burden of oral disease and challenges with low dental utilization and access to culturally competent dental care. Based on National Health Interview Survey data, the proportion of Hispanic children without dental visits in the past year declined between 2000 and 2014 (Larson et al. 2016). However, dental coverage is more variable for adults than for children and dental care continues to pose a significant cost for many adults who report more financial barriers to obtaining dental services than other types of health services (Vujicic et al. 2016a).

Statistics from more current NHANES cycles revealed that young Hispanic children (aged 2–8 years) had higher prevalence of untreated decay in primary teeth and greater dental caries experience compared to other racial and ethnic groups (Satcher and Nottingham 2017). An important advancement since 2000 has been the development of more recent national data available for Hispanic adults aged 18 to 74 years for 2008–2011 (Beck et al. 2014). These data allow reporting on oral health status for different Hispanic subgroups, unavailable since the 1982–1984 Hispanic Health and Nutrition Examination Survey, which included Mexican Americans, Cubans, and Puerto Ricans (Ismail and Szpunar 1990). Baseline data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) provide a new national dataset that can support exploring diversity across Hispanic population groups in an attempt to better understand the connection between oral health and other diseases. For example, among all ethnic Hispanic subgroups, half have some form of periodontitis (mild, moderate, or severe), but more than a third of Cubans and Central Americans have the highest prevalence of moderate periodontitis among all subgroups (Jiménez et al. 2014). The HCHS/SOL enables accounting for traditional oral health risk factors, as well as other important cultural factors.

Acculturation, education, language barriers, transportation deficiencies, ethnic identity, and lack of dental insurance remain significant factors affecting dental utilization among Hispanic adults (Stewart et al. 2002; Eke et al. 2011; Strouse et al. 2013; Velez et al. 2017; Silveira et al. 2020). In addition, the lack of an ongoing relationship with a dentist, lack of available transportation, and difficulty getting time off from work for dental visits are more common barriers among Hispanic communities (Kim et al. 2012; Vujicic and Nasseh 2014). Hispanic dentists remain largely underrepresented among dentists nationwide and, like other minority dentists, Hispanic dentists tend to practice in communities with a large proportion of minorities (Mertz et al. 2016a).

American Indian and Alaska Native Populations

In 2010, IHS implemented an ongoing oral health surveillance system designed to monitor trends in oral health among the American Indian and Alaska Native (AI/AN) population served by IHS and tribal programs. Since the implementation of the surveillance program, oral health data have been obtained from four different age groups: preschool children (2010, 2014, and 2018–2019), elementary school children (2011–2012 and 2016–2017), adolescents (2012–2013), and adults (2015). The IHS Oral Health Surveillance Plan provides detailed information regarding past, present, and future-planned oral health surveys of the AI/AN communities (Indian Health Service 2015).

The IHS Division of Oral Health has conducted seven surveys since the launch of the original oral health surveillance plan in 2010 (Indian Health Service 2021a). Each survey used the Basic Screening Survey instrument (Association of State and Territorial Dental Directors 2021) as the tool to conduct community-based, clinic-based, and school-based surveys. Survey results are available as IHS Data Briefs on the IHS Division of Oral Health website (Indian Health Service 2021b). However, despite the fact that more recent data from the IHS surveillance system appear to be showing improvements in the oral health of some AI/AN preschool children (Figures 16 and 17), these children continue to suffer disproportionately from common oral diseases (Phipps et al. 2019).

Figure 16

Change in percentage of American Indian/Alaska Native (AI/AN) children ages 1–5 with early childhood caries (ECC) by select Indian Health Service areas between 2010 and 2018–2019.

Figure 17

Percentage of American Indian/Alaska Native (AI/AN] children ages 1–5 with early childhood caries (ECC] and untreated dental caries in 2010, 2014, and 2018–2019. Note: Information surveyed from 53 IHS service units.

The relative geographic isolation of many tribal populations may limit access to dental care. AI/AN patients also face difficulties in receiving routine and preventive dental care as a result of other reasons, such as the chronic shortage of dentists within IHS (Batliner 2016). The IHS struggles to attract physicians and dentists to rural and geographically isolated locations. The dentist-to-population ratio exceeds 1:5,000 in AI/AN communities (Mertz et al. 2017), compared to an average of 1:1,600 for the entire U.S. population (Munson and Vujicic 2018). In addition, dental services provided through IHS often are underfunded, resulting in a need to concentrate on providing basic emergency care services, with restorative and preventive care provided primarily to children. As a result, availability of adult restorative care may be compromised (Soeng and Chinitz 2010).

Sexual and Gender Minorities

Sexual and gender minority populations (SGM) likely constitute groups at higher risk for oral diseases and oral health inequities by virtue of their lower access to care and lower levels of social influence (Schwartz et al. 2019). The National Institutes of Health established an SGM Research Office to expand the knowledge base related to SGM health and well-being and to advance SGM-related research (National Institutes of Health 2020). However, to date, research related to the oral health of this group is extremely limited. In the 2000 Surgeon General’s report on oral health, attention was drawn to the lack of information on lesbian, gay, bisexual, transgender, queer, and other populations. Little has changed in the intervening 2 decades. The only current report is from Schwartz and colleagues (2019), which noted that “subjective measures of oral health were worse among gay, lesbian, and bisexual adults versus heterosexual adults” (Schwartz et al. 2019, p. 18).

Financing Dental Care

Dental spending has increased substantially in the past 2 decades. Much of this increase comes from increased access to public programs, in particular Medicaid, with smaller shares coming from private dental insurance and out-of-pocket spending. For example, in 2018, 10% of national dental spending was financed by public programs, and 40% was paid out of pocket by patients. Another 46% was financed by private dental insurance (See Section 4, Figure 3). In 2000, only 4% was financed by public programs, 44% through out-of-pocket payments, and 50% from private dental insurance. The shifts in the mix of dental care financing have been occurring gradually, driven largely by changes in dental care utilization patterns (Vujicic 2015b; American Dental Association 2020g).

Among adults 65 years and older, retirement often brings a loss of employment-based medical and dental insurance. After reaching age 65, older adults typically transition from employment-based medical insurance to Medicare. Because Medicare includes only limited coverage for dental care, an estimated 1 in 3 older adults have any dental insurance with the majority having some private dental insurance and a few enrolled in Medicaid (Nasseh and Vujicic 2016a; Yarbrough and Vujicic 2019). Consequently, older adults relying on Medicare for health insurance incur substantial out-of-pocket expenses for dental services. More than 40% of dental expenses are paid out of pocket, compared to only 9% of medical expenses for Medicare-enrolled older adults (Kreider et al. 2015). As a result, many adults fail to receive needed dental care. Fewer than half of Medicare beneficiaries (49%) had a dental visit within the past 12 months. For some ethnic groups, utilization rates for Medicare beneficiaries were even lower. Only 29% of Blacks and 35% of Hispanics aged 65 years and older had a dental visit in the past 12 months. Other older adult groups also had low utilization rates—only 30% of low-income and 41% of rural residents sought dental care in the previous 12 months. This is particularly concerning because older adults are at higher risk for periodontal disease and oral cancer, both of which have a worse prognosis if diagnosis and treatment are delayed (Medicaid and CHIP Payment and Access Commission 2020).

Current public insurance programs are struggling to provide coverage for many. This is primarily attributable to the expanding number of Americans eligible for public assistance. These numbers are growing, and states are challenged to keep up with the demand. Although federal law restricts routine dental care for Medicare beneficiaries, many Medicare enrollees more recently have begun to access preventive dental services under Medicare Advantage (MA) programs. These programs offer seniors dental services as incentives to plan selection (Freed 2021). In most MA plans, dental care is limited to preventive and simple restorative services.

Public Dental Insurance

Use of dental care services across population groups has steadily increased since 2000. Among Medicaid and CHIP beneficiaries, children enrolled in the Early and Periodic, Screening, Diagnostic, and Treatment program under Medicaid or CHIP were reported to have increased utilization of any dental service from 6.3 million in fiscal year (FY) 2000 to 19.6 million in FY 2019 (Centers for Medicare & Medicaid Services 2021b). Population growth and changing demographics across the United States have driven changes in Medicaid program policy, administration, and eligibility across states and have accounted for much of this increase. Medicaid expansion implemented in many states as a result of the Affordable Care Act (ACA) has led to steady increases in both pediatric and adult Medicaid enrollment since 2010. Similar enrollment increases have been observed across states with CHIP. Between 2013 and 2018, nonexpansion states observed only a 10.2% increase in Medicaid enrollment, compared to a 35.9% increase in expansion states during the same period (Medicaid and CHIP Payment and Access Commission 2020).

Since 2010, many states have combined their CHIP and Medicaid programs. This shift in program administration provides greater access to a wider range of dental benefits because Medicaid policy is less restrictive than CHIP. In 2017, only 13 states operated a separate CHIP program, compared to nearly all states in 2000 (Medicaid and CHIP Payment and Access Commission 2017). Increased enrollment of children in Medicaid can improve access to care and reduce untreated disease. However, the structure of dental coverage for children in the ACA has presented new challenges for implementation. These structural barriers include complex benefit designs, lack of affordability protections in some plans, and no mandate to purchase dental coverage (Snyder et al. 2014). The ACA does not require dental insurance for adults and the result has been negligible improvement in dental coverage among working-age adults. Nearly 2.5 times as many adults have medical insurance, compared to dental insurance (Kreider et al. 2015).

For adults, dental benefits are not mandated under federal law, although many state Medicaid agencies have expanded dental policies and benefits during the past 2 decades. This increase in access to dental care came about because of increases in enrollment through Medicaid expansion and the advancement of Medicaid dental policy for adults (Medicaid/Medicare/CHIP Services Dental Association 2019a; 2019b). Current status of dental Medicaid benefit expansion is shown in Figure 18. In 2017, more than half of state Medicaid dental programs reported including preventive and restorative oral health care services for adults: comprehensive oral examination (33 states), dental cleaning (33 states), and amalgam and composite fillings (32 and 31 states, respectively). Thirty states covered upper and lower dentures, 24 states covered root canal treatment for adults, and 31 states covered scaling and root planing and scaling services for pregnant women 21 years and older (Medicaid/Medicare/CHIP Services Dental Association 2019a).

Figure 18

Status of Medicaid expansion decisions by state: United States, 2020. Notes: Current status for each state is based on Kaiser Family Foundation tracking and analysis of state activity. ^◊ Expansion is adopted but not yet implemented in MO and OK. (more...)

Although the national average is 38% of dentists participating in Medicaid or CHIP to provide services for children, there is considerable variation across states. For example, the participation rate in Iowa is 85.5%, with greater than 70% participation in Alabama, Michigan, Montana, North Dakota, and Vermont. On the low end, with participation rates below 16%, were California, Maine, and New Hampshire. Factors that are associated with participation include dental provider gender and age, with participating providers more likely to be younger or female (American Dental Association 2020h). However, other factors, such as state poverty level, the number of health professional shortage areas within a state, and a state’s decision to not participate in the Medicaid expansion of the ACA, are associated with lower rates of dentist participation in Medicaid and CHIP (American Dental Association 2020g).

Still, there has been much improvement with regard to dental providers enrolled in Medicaid and CHIP since the early 2000s. According to the most recent data, 38% of general and pediatric dentists participate as Medicaid or CHIP providers. It is important to note that simple participation rates do not fully measure the availability of dental services for the Medicaid beneficiaries because they do not include billing rates or patients treated (Warder and Edelstein 2017).

Chapter 3. Promising New Directions

Quality of Oral Health Care

Quality oral health care delivery is advancing on several fronts. There is increased emphasis on the importance of full integration of medical and dental care as integral to a vision of Berwick’s Triple Aim, which deploys new patient-centered quality metrics for improved planning and evaluation, better surveillance of population health, and reduced health care costs. Support for integration came from the Institute of Medicine report (2011) that recommended integration of oral health in planning, programming, policies, and research in all U.S. Department of Health and Human Services agencies and programs.

A necessary condition for integration is an interoperable electronic health record (EHR) capable of rapidly updating a patient’s clinical status in a way that is accessible to members of the medical and dental teams. Jones and colleagues (2017) provided several examples of organizations that offer promising integration models. These include the U.S. Department of Veterans Affairs (VA), Kaiser Permanente (Permanente Dental Associates), HealthPartners, PACE programs, and some Federally Qualified Health Centers. A highly adaptable model that is not dependent on a unique health care delivery infrastructure is the DentaQuest Medical Oral Expanded Care program (CareQuest Institute for Oral Health 2021), which is both flexible and scalable. These models provide important guidance for others with interest in creating integrated health care.

Another innovation improving EHR effectiveness was motivated by state Medicaid policy requiring use of dental diagnostic codes (ICD-10 codes), now mandated in several states (American Dental Association 2015b). Requirements for diagnostic codes in private insurance are still evolving. Diagnostic codes are central to medical records and provide the foundation for assessing quality of care. As their use in dentistry increases, benefits for care integration and advancement toward the Triple Aim’s goals will be supported.

A focus on population health outcomes requires attention to nonclinical determinants of health, as well as clinical determinants. The relevance of SDoH, such as poverty status, is explicitly recognized in the National Quality Measures Clearinghouse framework (Figure 19). Section 1115 of the Social Security Act promotes experimental or demonstration projects likely to forward the objectives of the Medicaid program. Population health outcomes and value are measured separately from health care treatment outcomes. Recognizing this, some states are successfully gaining approval for Centers for Medicare & Medicaid Services’ 1115 demonstration projects to address the SDoH as a pathway to realizing improved outcomes. The North Carolina Department of Health and Human Services is piloting a comprehensive program that targets such social determinants as housing instability, transportation barriers, and food insecurity (North Carolina Department of Health and Human Services 2018). Florida obtained a waiver to pilot the provision of housing support services for adult Medicaid beneficiaries with severe mental illness and substance use disorders who are homeless or at risk for homelessness (Florida Agency for Health Care Administration 2016).

Figure 19

National Quality Measures Clearinghouse (NQMC) domain framework.

Evidence-based dental practice initiatives aimed at improving the quality of care have grown steadily in recent years. Professional organizations are leading the way in developing clinical practice guidelines aimed at bringing the best evidence into the hands of clinicians in ways that facilitate application in routine clinical practice. The American Dental Association is a leader in this area, having supported development of a number of important guidelines related to prevention, conservative dental caries management, and appropriate antibiotic use, among others. See Section 4, Table 8 for more information.

Chapter 4. Summary

There are several issues that influence oral health beyond the clinical realm in which dentists and their patients typically interact. By considering broad epidemiological, systemic, and policy perspectives and examining the best available data, it can be more clear where oral health is improving and where there is a continued need for concern and action (Box 4).

Many improvements in oral health have occurred in the past 2 decades. The prevalence of major oral diseases is declining. Access to care for low-income children has improved remarkably as a result of Medicaid and Children’s Health Insurance Program reform and, more recently, for low-income adults through Medicaid expansion under the Affordable Care Act. Despite ongoing improvements in oral health, poor oral health continues to be highly prevalent and remains a major concern for many Americans. For example, since the release of the last Surgeon General’s report on oral health in 2000, the current patchwork of dental care financing continues to create major gaps in access to affordable dental care for many vulnerable groups. These same groups tend to suffer disproportionate levels of dental disease, with little hope of obtaining needed care. Having large segments of society suffer from persistent untreated oral disease creates economic and societal costs that harm individuals, families, communities, and national security.

A new understanding has emerged that the causes of poor oral health are the result of complex interactions of determinants from many levels, including socioeconomic conditions and the food and beverage industries’ targeting of vulnerable populations with sugary or low-nutrition food items. The result is unacceptable disparities in oral health among population groups. Although these distal health determinants have previously been recognized in some form or another, they are now identified in the conceptually, empirically, and policy unifying language of the social and commercial determinants of health.

Lack of access to dental care continues to be a barrier to good oral health, especially among poor and rural communities, and has led to the increased use of emergency departments and urgent care facilities that can only provide palliative, not comprehensive, care.

As a consequence of these developments, policy reform is urgently needed to resolve the structural barriers that allow oral disease and oral disease inequities to persist. This requires that attention be directed toward social and commercial determinants that discourage healthy behavior and nutritional choices and fail to guarantee access to care for all. The benefits of these reforms will more than justify the costs. However, these policy actions will be politically challenging because they are embedded in larger debates about social and economic organization and will require us to engage in highly sensitive conversations about the ways in which historical, and still broadly based, biases create structural racism even in social and health care systems that are intended to support the well-being of all.

Fortunately, compared to 20 years ago, there is better understanding of where remedies are needed. Improved models of disease etiology have identified many new targets for public health and public policy interventions. Increased understanding of the importance of social determinants of health and the common risk factor approach provides a strong rationale for more upstream solutions. There is a broadening consensus that health care practices and patient outcomes would benefit from greater dental and medical integration. The technology infrastructure also is available to support that integration. The growing emphasis on quality metrics and value-based payments is prompting more emphasis on evidence-based practices, health literacy, patient-centered care, and population health outcomes. There also is compelling evidence that was not available 20 years ago that oral health conditions in the population have an economic cost in terms of employability and lost school days.

Looking forward, it is clear that a variety of stakeholders have important roles to play. Policymakers should understand the importance of oral health to individuals, families, and communities and recognize its importance in overall well-being. Significant human suffering and economic costs arise from dental policy neglect. All health care professionals should understand that oral health IS health and that they each have a vital role to play in helping individuals stay healthy. Alongside dental associations and other professional and advocacy groups, all health professions should have the opportunity to advance health promotion and oral health policy.

There is no question that high-quality dental services are routinely delivered in dental offices every day to a majority of Americans. However, significant numbers of Americans are unable to access this care. Approaches that include care outside of the dental office—in places such as nursing homes, schools, and community health centers—should be considered to ensure full access to everyone with oral health care needs. Further, providers and educators must communicate to members of their communities an understanding of the value of oral health and provide incentives for engaging in the healthy behaviors that will help to avoid chronic diseases or to assist in managing them. Most importantly, dentists, other oral health and health care professionals, insurers, and legislators need to understand that healthy behaviors are best achieved by improving social and living conditions and providing equal opportunity to live a good life. None of this is easy, but all of it is necessary to achieve a just and equitable system of health care that provides for everyone’s needs, including the experience of good oral health.

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