The USPHS and Access to Oral Health

Chester W. Douglass, DMD, PhDProfessor EmeritusHarvard University

May 25, 2010San Diego, CA

Access to Oral Health - Outline1. The U.S. PHS

– Mission and Goals– Careers in Dental Public Health

2. What is Access to Oral Health?3. Trends in the Market

– Population Trends– Disease Trends– Financing– Delivery Systems

4. Improving Oral Health (53 ways…)5. 30 Prevention Technologies6. USPHS Leadership

Mission

The mission of the U.S. Public Health Service Commissioned Corps is to protect, promote, and advance the health and safety of our Nation. As America’s uniformed service of public health professionals, the Commissioned Corps achieves its mission through:

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

The Commissioned Core

1. Provide essential public health care services to underserved and disadvantaged populations

2. Prevent and control injury and the spread of disease

3. Conduct and support cutting-edge research for the prevention, treatment, and elimination of disease, health disparities, and injury

Forces for Change

1. Demographic2. Disease distributions3. Scientific forces

• New technologies

4. Market forces• New delivery systems• Economic forces

5. Policy

U.S. Resident Population Projection: 2000-2050

250

300

350

400

Res

iden

t po

pula

tion

(in

mill

ions

)

Resident population projection assumes middle levels of fertility, life expectancy, and net immigration. Source: U.S. Bureau of the Census, Current Population Reports.

281.4

400 +

2000 2010 2020 2030 2050

Projected Elderly Population by Age:1990-2050

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

1990 2000 2010 2020 2030 2040 2050

Num

ber

in T

hous

ands

65 and over 85 and overSource: U.S. Census Bureau

Race / Ethnicity Composition of the Resident Population of the United States: 1997-2050

0

10

20

30

40

50

60

70

80

1997 2000 2010 2020 2030 2040 2050

Per

cent

of

Pop

ulat

ion

White (non-hispanic)Black (non-hispanic)American & Alaska native (non-hispanic)Asian and Pacific Islander (non-hispanic)Hispanic/LatinoSource: U.S. Census Bureau

Think Cohorts

Life experience with dental disease and dental care tends to determine each cohort’s oral health expectations and behavior

Patient Expectations By Age Cohort

• World War II Generation• 1900-1925

• Pepsi Generation• 1926-1945

• Baby Boomers• 1946-1964

• Atari Generation• 1965-1985

• New Age Generation• Since 1986

Trends in Dentistry: Opportunities for Business Growth

Demand Side Trends

• Disease Trends

Dispelling the Myth that 50 Percent of U.S. Schoolchildren

Have Never Had a Cavity

Burton L. Edelstein, DDS, MPH

Chester W. Douglass, DDS, PhD

Public Health Reports, Sept/Oct 1995: Vol 111

Percent of Schoolchildren with Caries

Percent of Schoolchildren with Caries

US Adult Population and Number of Teeth at Risk, 1972

Source: Reinhardt/Douglass: Future Need for Dentistry

AgeEstimated 1972

Population Teeth at Risk18-24 30.1 25,901,000 779,620,10025-34 26.6 27,397,000 728,760,20035-44 20.8 22,853,000 475,342,40045-64 15.5 * 42,789,000 663,229,50065-87 7.0 ** 19,324,000 135,268,00085+ 3.5 ** 1,559,000 5,456,500

139,823,000 2,787,676,700*mean of 45-54 and 55-64 categories

Functional Teeth per Individual

Cohort-specific Projections of Adult Teeth at Risk in the US, 1990

Source: Reinhardt/Douglass: Future Need for Dentistry

(middle series population projections)

AgeEstimated 1990

Population Teeth at Risk18-24 28.4 25,794,000 732,549,60025-34 26.7 43,529,000 1,162,224,30035-44 23.4 37,847,000 885,619,80045-64 18.3 * 46,453,000 850,089,90065-87 12.1 * 28,384,000 342,027,20085+ 8.2 ** 3,313,000 27,166,600

185,320,000 3,999,677,400*mean of adjacent catagories

(liberal estimate)

Functional Teeth per Individual

** assumed no difference than projected for year 2000

AgeEstimated 2030

Population Teeth at Risk18-24 28.4 26,226,000 744,818,40025-34 26.7 37,158,000 992,118,60035-44 23.5 40,168,000 943,948,00045-64 19.5 * 70,810,000 1,380,795,00065-87 15.0 * 55,969,000 839,535,00085+ 10.9 * 8,611,000 93,859,900

238,942,000 4,995,074,900*mean of adjacent catagories

Functional Teeth per Individual

Cohort-specific Projections of Adult Teeth at Risk in the US, 2030

Source: Reinhardt/Douglass: Future Need for Dentistry

(middle series population projections)

Trends in Percent Edentulism in AdultsAged 18 to 74: 1971-1994

05

101520253035404550

18-74 18-24 25-34 35-44 45-54 55-64 65-74

Per

cent

1971-1974 1988-1994

Age Groups

14.7

7.7

1.0 0.03.2

9.0

16.0

0.72.8

33.4

9.30

20.1

45.6

28.6

Source: U.S. Dept. of Health and Human Services, National Center for Health Statistics and National Institute of Dental Research

Mean number of Restored Coronal Surfaces, by Number of Teeth* (Adjusted for Age and Sex)

Number of Teeth

(Toothgrp)

Mean SE F Statistic P-value Group comparison

P-value

1-10 (1) 7.5 1.37 178.06 .0001 1 vs 2 .001

11-24 (2) 31.8 1.17 1 vs 3 .001

25-32 (3) 50.0 1.95 2 vs 3 .001

*ANOVA model with number of restored coronal surfaces as dependent variable and age, sex, and tooth group as main effects and possible interaction terms.

Mean number Sites with Pocket Depth ≥ 4mm, by Number of Teeth* (Adjusted for Age and Sex)

Number of Teeth

(Toothgrp)

Mean SE F Statistic P-value Group comparison

P-value

1-10 (1) 2.48 0.61 32.41 .001 1 vs 2 .001

11-24 (2) 6.96 0.47 1 vs 3 .001

25-32 (3) 10.50 0.84 2 vs 3 .001

*ANOVA model with number of sites with pocket depth ≥ 4mm as dependent variable and age, sex, and tooth group as main effects and possible interaction effects.

Validity of Prevalence of Pocketing

Method < 4 mm 4-6 mm >6 mm

All Sites Full Mouth 12.6% 65.9% 21.5%

Three Sites Full Mouth

17.3% 64.8% 17.9%

Two Sites Full Mouth

35.0% 55.8% 9.2%

Two Sites Half Mouth

49.8% 44.9% 5.2%

All pairwise comparisons on maximum pocket

depth p < 0.0001 – Wilcoxin Signed Rank Test

Trends in Dentistry: Opportunities for Business

Demand Side Trends

• Need for Dental Care

Formula for Calculation of Hours of Treatment for Operative Dentistry

TN = Σ[ ti · ci · 0.5 ] + Σ[ fi · 0.1 · 0.5 ]

TN = total hours of treatment needed

ti = age-specific number of teeth

ci = age-specific proportion of carious teeth

0.5 = one-half hour of service time needed per restoration

fi = age-specific proportion of teeth filled

0.1 = the proportion of restorations needing replacement in a given year

Future Operative Needs

Formula for Calculating Unmet Need for Fixed and Removable Partial Dentures

Total Need TN = n(%N)(pt)

where

TN = Total Needn = Number of People%N = Percentage of people who need an

FPR or RPDPt = Procedure time

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

Year need

FPDs + RPDs = Total Need

- Annual Supply

= Projected Unmet

2005 363.1 + 172.3 = 535.4 - 46.7 = 488.7

2010 378.2 + 185.3 = 563.5 - 47.8 = 516.7

2020 402.5 + 207.0 = 609.4 - 49.2 = 560.2

Formula for Estimating the Current and Future Market for Complete Dentures

Denture Market = Total amount of demand for dentures in any specific year

Age-specific Population = Number of men and women in each age group in any

specific year

Age-specific percent edentulism = Percentage of men and women with 1 or 2 edentulous

arches in any specific year

10-year trends in edentulism = Percent decline in edentulism over each 10-year period since 1960

Percent utilization of dentures = Percentage of persons who not only need but also acquire and use dentures

Denture Market = Age-specific population x Age-specific percent edentulism x 10-year declining trends in edentulism x Percent utilization of dentures (demand)

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

Age Group 1991 2000 2010 2020

25-34 858 670 613 601

35-44 3770 3841 2928 2614

45-54 5612 7332 7711 5850

55-64 7667 7836 10,232 10,595

65-74 7675 6837 7054 9164

75-84 6166 6613 5934 6381

85+ 1900 2287 2654 2681

Total 33,648 35,416 37,126 37,886

Demand at 90% Utilization

30,283 31,874 33,413 34,097

Total number of edentulous arches

53,839 56,493 59,265 61,043

Distribution of Public and PrivateU.S. Dental Schools as of 2001

Public Dental Schools

Private Dental SchoolsPuerto Rico

x

xxx

x

x

X New Dental Schools

U.S. Dental School Graduates 1956-2008

0

1,000

2,000

3,000

4,000

5,000

6,000

1956 1960 1964 1968 1972 1976 1980 1984 1988 1992 1996 2000 2004 2008Source: American Dental Association, Survey Center, Surveys of Dental Education

5,878

3,253

4,9763,875

Estimated Additions of Dentists to theDental Workforce: 1995-2040

Assumptions: number of graduates remains at 4050 retirement age of 65

-2000 -1500 -1000 -500 0 500 1000 1500

year 2014

year 2023-1706

year 1995

year 2040

year 2031

Source: American Association of Dental Schools

Net Change in Dentists Compared to Population Growth

Inflation Rates

Year Jan Feb Mar Apr May Jun Jul1993 5.6 5.8 5.9 5.9 6.2 6.0 5.21994 4.5 4.1 4.5 4.7 4.3 4.5 4.81995 5.9 5.8 5.5 4.8 5.1 5.0 4.81996 3.9 4.4 4.2 4.5 4.7 4.5 4.61997 5.2 5.0 5.3 5.2 4.8 4.8 4.71998 4.2 4.1 4.1 4.1 4.1 4.2 4.21999 4.7 4.8 4.7 4.8 4.8 4.8 4.72000 4.3 4.6 4.7 4.6 4.8 4.7 4.62001 4.3 4.2 4.1 4.1 3.9 4.0 4.1

Physicians’ FeesYear Jan Feb Mar Apr May Jun Jul1993 6.4 5.9 5.5 5.4 5.9 5.8 5.71994 4.8 4.8 4.8 5.1 4.2 4.3 4.31995 4.3 4.7 4.6 4.4 4.6 4.5 4.71996 4.6 4.1 4.0 3.9 3.6 3.5 3.41997 3.0 2.9 3.2 3.2 3.2 3.3 3.01998 2.5 2.8 2.6 2.6 2.6 3.0 3.01999 3.4 3.1 3.0 3.2 2.9 2.7 3.02000 5.9 3.4 3.8 3.7 3.8 3.9 3.62001 4.4 4.0 3.5 3.6 3.6 3.4 3.32002 3.2 2.6 2.6 2.1 2.3 2.2 3.42003 2.7 3.1 3.0 3.3 3.4 3.7 2.3

Dentists’ Fees

% A

nn

ual In

crea

se

Annual Inflation Rates of Medical Care, Dental Care, and All Goods & Services

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

DENTISTS

PHYSICIANS

ALL ITEMS

Current Delivery System

Limited access to care to most adults

Insufficient number of dentists

Increase in cost of services

Privatization of dental services

So what can we do?

• Preventive services, products, and programs

• Examples of successful prevention programs

• Prevention as a public policy measure

Market Forces

Need Demand Delivery Supply

Population Perceptions Prevent Diagnose Treat

Practice Settings Providers

Education

Disease Insurance Public Private

Price Regulations

Improving Access to Oral Health

Decrease Need Increase Demand

Improve Supply

Prevent the Disease

Improve Awareness and

Funding for Dental Care

Appropriate and Accessible Delivery

Systems

Improve SupplyWith More Appropriate Delivery System

1. Establish school-based dental clinic

2. Use mobile dental equipment for services in outreach sites

3. Allow foreign dental graduates credentialing

4. Train more dentists and dental hygienists

5. Require continuing education on access to care

6. Increase salaries of safety net providers

7. Require PGY-1

8. Have practitioners work in satellite clinics one or two days a week

9. Require payback programs for public service

10. Expand duties of allied dental personnel

Improve Supply (cont.)11. Have existing home visitors do oral health assessments

12. Train midlevel providers- ex. Alaska Dental Nurse- and midlevel prevention specialists

13. Remove supervision restrictions on dental hygiene practice

14. Improve diversity of provider supply

15. Integrate dental care into primary medical care

16. Train MDs to do oral exams

17. Establish dental clinic in nursing homes

18. Link oral health with smoking cessation program

19. Provide advanced training in management of special needs patients

20. Develop case management programs

21. Improve practice management

22. Adopt Electronic Records and Billing system

Increase DemandBy Improving Awareness and Dental Insurance

1. Develop media public awareness campaigns, such as “Watch Your Mouth”

2. Lobby for oral health funding

3. Encourage provider participation in the Medicaid program

4. Improve Medicaid claims processing speed

5. Improve Medicaid program by allowing case load limitations

6. Improve Medicaid program by increasing reimbursement rates

7. Promote oral health screenings and referrals through children health and welfare programs

Increase Demand (cont.)8. Have states mandate dental screenings for school-aged

children

9. Include oral hygiene education and practice in pre-natal visits for pregnant women

10. Include primary dental care services into Medicare

11. Include medically necessary dental care into Medicare

12. Change insurance regulations to encourage enrollment

13. Develop private insurance for lower income population

14. Encourage foundation support for oral health programs

15. Establish new foundations focused on oral health

Decrease NeedBy Preventing the Disease

1. Include oral health education in school health curriculum

2. Establish school-based sealant programs

3. Establish fluoride varnish programs

4. Create outreach programs in Head Start and Early Head Start

5. Create outreach programs in schools which incorporate education, screening, and referral to dental services

6. Implement salt fluoridation if no community fluoridated water systems

7. Promote self-care

8. Create outreach programs in nursing homes

Decrease Need (cont.)

9. Fluoridate and label bottled water

10. Promote early detection and referral by pediatricians

11. Have pediatricians apply fluoride varnish

12. Link oral health to systemic health through:

a) Patient education

b) Patient care from MDs and RNs

13. Provide nutritional counseling

14. Establish dental homes for all children

15. Promote preventive services by private dental practices

16. Fluoridate community water systems

Thirty Prevention Technologies by Mode of Delivery

A. Fluorides delivered systemically 1. Fluoride tablets 2. Salt fluoridation 3. Water fluoridation 4. Milk fluoridation

B. Topical fluoride delivered by providers

5. Fluoride gels 6. Fluoride varnish 7. Rx-level toothpaste

C. Topical self-use (rinse, gums, toothpaste) 8. Fluoride toothpaste 9. Chlorhexidine

10. Xylitol 11. Sorbitol 12. Fluoride rinse 13. Fluoride chewing gums D. Diet and habit modification – personal behavior 14. Reduce sugar intake / diet 15. Use sugar substitutes / diet habit 16. Oral hygiene / home care 17. Self-efficiency / motivation

E. Environmental health 18. Advertisements 19. Food availability 20. Food and drug safety 21. Water quality F. Dental procedures by dental care providers 22. A traumatic restorative technique 23. Fissure sealants 24. Prophylaxis G. Developing technologies 25. CPP-ACP 26. Probiotics 27. Non-fluoride chemistry 28. Early detection of demineralization / diagnostics 29. Minimally invasive technologies H. Risk Assessment Technology

30. Caries risk assessment

Conclusion

An ounce of prevention…..

……is worth a pound of cure!

Don’t mop the floor…….

Turn the spigot off…..

Conclusion

The Imperative

of Prevention

• Rapid and effective response to public health needs

• Leadership and excellence in public health practices

• Advancement of public health science