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  1. 1. The USPHS and Access to Oral Health Chester W. Douglass, DMD, PhD Professor Emeritus Harvard University May 25, 2010 San Diego, CA
  2. 2. Access to Oral Health - Outline <ul><li>The U.S. PHS </li></ul><ul><ul><li>Mission and Goals </li></ul></ul><ul><ul><li>Careers in Dental Public Health </li></ul></ul><ul><li>What is Access to Oral Health? </li></ul><ul><li>Trends in the Market </li></ul><ul><ul><li>Population Trends </li></ul></ul><ul><ul><li>Disease Trends </li></ul></ul><ul><ul><li>Financing </li></ul></ul><ul><ul><li>Delivery Systems </li></ul></ul><ul><li>Improving Oral Health (53 ways…) </li></ul><ul><li>30 Prevention Technologies </li></ul><ul><li>USPHS Leadership </li></ul>
  3. 3. Mission <ul><li>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: </li></ul><ul><li>Rapid and effective response to public health needs </li></ul><ul><li>Leadership and excellence in public health practices </li></ul><ul><li>Advancement of public health science </li></ul>
  4. 4. The Commissioned Core <ul><li>Provide essential public health care services to underserved and disadvantaged populations </li></ul><ul><li>Prevent and control injury and the spread of disease </li></ul><ul><li>Conduct and support cutting-edge research for the prevention, treatment, and elimination of disease, health disparities, and injury </li></ul>
  5. 5. Forces for Change <ul><li>Demographic </li></ul><ul><li>Disease distributions </li></ul><ul><li>Scientific forces </li></ul><ul><ul><li>New technologies </li></ul></ul><ul><li>Market forces </li></ul><ul><ul><li>New delivery systems </li></ul></ul><ul><ul><li>Economic forces </li></ul></ul><ul><li>Policy </li></ul>
  6. 6. U.S. Resident Population Projection: 2000-2050 Resident population projection assumes middle levels of fertility, life expectancy, and net immigration. Source: U.S. Bureau of the Census, Current Population Reports. 281.4 400 + 2000 2010 2020 2030 2050
  7. 7. Projected Elderly Population by Age:1990-2050 Source: U.S. Census Bureau
  8. 8. Race / Ethnicity Composition of the Resident Population of the United States: 1997-2050 Source: U.S. Census Bureau
  9. 9. Think Cohorts <ul><li>Life experience with dental disease and dental care tends to determine each cohort’s oral health expectations and behavior </li></ul>
  10. 10. Patient Expectations By Age Cohort <ul><li>World War II Generation </li></ul><ul><ul><ul><li>1900-1925 </li></ul></ul></ul><ul><li>Pepsi Generation </li></ul><ul><ul><ul><li>1926-1945 </li></ul></ul></ul><ul><li>Baby Boomers </li></ul><ul><ul><ul><li>1946-1964 </li></ul></ul></ul><ul><li>Atari Generation </li></ul><ul><ul><ul><li>1965-1985 </li></ul></ul></ul><ul><li>New Age Generation </li></ul><ul><ul><ul><li>Since 1986 </li></ul></ul></ul>
  11. 11. Trends in Dentistry: Opportunities for Business Growth <ul><li>Demand Side Trends </li></ul><ul><li>Disease Trends </li></ul>
  12. 12. Dispelling the Myth that 50 Percent of U.S. Schoolchildren Have Never Had a Cavity <ul><li>Burton L. Edelstein, DDS, MPH </li></ul><ul><li>Chester W. Douglass, DDS, PhD </li></ul><ul><li>Public Health Reports , Sept/Oct 1995: Vol 111 </li></ul>
  13. 13. Percent of Schoolchildren with Caries
  14. 14. Percent of Schoolchildren with Caries
  15. 15. US Adult Population and Number of Teeth at Risk, 1972 <ul><li>Source: Reinhardt/Douglass: Future Need for Dentistry </li></ul>
  16. 16. Cohort-specific Projections of Adult Teeth at Risk in the US, 1990 Source: Reinhardt/Douglass: Future Need for Dentistry (middle series population projections)
  17. 17. Cohort-specific Projections of Adult Teeth at Risk in the US, 2030 Source: Reinhardt/Douglass: Future Need for Dentistry (middle series population projections)
  18. 18. Trends in Percent Edentulism in Adults Aged 18 to 74: 1971-1994 Age Groups 14.7 7.7 1.0 0.0 3.2 9.0 16.0 0.7 2.8 33.4 9.30 20.1 45.6 28.6 Source: U.S. Dept. of Health and Human Services, National Center for Health Statistics and National Institute of Dental Research
  19. 19. 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.
  20. 20. 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.
  21. 21. 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
  22. 22. Trends in Dentistry: Opportunities for Business <ul><li>Demand Side Trends </li></ul><ul><li>Need for Dental Care </li></ul>
  23. 23. Formula for Calculation of Hours of Treatment for Operative Dentistry <ul><li>TN = Σ [ t i · c i · 0.5 ] + Σ [ f i · 0.1 · 0.5 ] </li></ul><ul><li>TN = total hours of treatment needed </li></ul><ul><li>t i = age-specific number of teeth </li></ul><ul><li>c i = age-specific proportion of carious teeth </li></ul><ul><li>0.5 = one-half hour of service time needed per restoration </li></ul><ul><li>f i = age-specific proportion of teeth filled </li></ul><ul><li>0.1 = the proportion of restorations needing replacement in a given year </li></ul>
  24. 24. Future Operative Needs
  25. 25. Formula for Calculating Unmet Need for Fixed and Removable Partial Dentures <ul><li>Total Need </li></ul><ul><li>TN = n(%N)(pt) </li></ul><ul><li>where </li></ul><ul><li>TN = Total Need </li></ul><ul><li>n = Number of People </li></ul><ul><li>%N = Percentage of people who need an FPR or RPD </li></ul><ul><li>Pt = Procedure time </li></ul>
  26. 26. Projected Amount of Need for FPDs and RPDs (in Millions of Hours) by Year
  27. 27. Formula for Estimating the Current and Future Market for Complete Dentures <ul><li>Denture Market = Total amount of demand for dentures in any specific year </li></ul><ul><li>Age-specific Population = Number of men and women in each age group in any specific year </li></ul><ul><li>Age-specific </li></ul><ul><li>percent edentulism = Percentage of men and women with 1 or 2 edentulous arches in any specific year </li></ul><ul><li>10-year trends in edentulism = Percent decline in edentulism over each 10-year period since 1960 </li></ul><ul><li>Percent utilization of dentures = Percentage of persons who not only need but also acquire and use dentures </li></ul>Denture Market = Age-specific population x Age-specific percent edentulism x 10-year declining trends in edentulism x Percent utilization of dentures (demand)
  28. 28. Number US adults (in thousands) who need one or two dentures
  29. 29. Distribution of Public and Private U.S. Dental Schools as of 2001 Public Dental Schools Private Dental Schools Puerto Rico x x xx x x X New Dental Schools
  30. 30. U.S. Dental School Graduates 1956-2008 Source: American Dental Association, Survey Center, Surveys of Dental Education 5,878 3,253 4,976 3,875
  31. 31. Estimated Additions of Dentists to the Dental Workforce: 1995-2040 Assumptions: number of graduates remains at 4050 retirement age of 65 year 2014 year 2023 -1706 year 1995 year 2040 year 2031 Source: American Association of Dental Schools
  32. 32. Net Change in Dentists Compared to Population Growth
  33. 33. Inflation Rates Physicians’ Fees Dentists’ Fees
  34. 34. Annual Inflation Rates of Medical Care, Dental Care, and All Goods & Services % Annual Increase
  35. 35. Current Delivery System <ul><li>Limited access to care to most adults </li></ul>Insufficient number of dentists Increase in cost of services Privatization of dental services
  36. 36. So what can we do? <ul><li>Preventive services, products, and programs </li></ul><ul><li>Examples of successful prevention programs </li></ul><ul><li>Prevention as a public policy measure </li></ul>
  37. 37. Market Forces
  38. 38. Improving Access to Oral Health
  39. 39. Improve Supply <ul><li>With More Appropriate Delivery System </li></ul><ul><li>Establish school-based dental clinic </li></ul><ul><li>Use mobile dental equipment for services in outreach sites </li></ul><ul><li>Allow foreign dental graduates credentialing </li></ul><ul><li>Train more dentists and dental hygienists </li></ul><ul><li>Require continuing education on access to care </li></ul><ul><li>Increase salaries of safety net providers </li></ul><ul><li>Require PGY-1 </li></ul><ul><li>Have practitioners work in satellite clinics one or two days a week </li></ul><ul><li>Require payback programs for public service </li></ul><ul><li>Expand duties of allied dental personnel </li></ul>
  40. 40. Improve Supply (cont.) <ul><li>Have existing home visitors do oral health assessments </li></ul><ul><li>Train midlevel providers- ex. Alaska Dental Nurse- and midlevel prevention specialists </li></ul><ul><li>Remove supervision restrictions on dental hygiene practice </li></ul><ul><li>Improve diversity of provider supply </li></ul><ul><li>Integrate dental care into primary medical care </li></ul><ul><li>Train MDs to do oral exams </li></ul><ul><li>Establish dental clinic in nursing homes </li></ul><ul><li>Link oral health with smoking cessation program </li></ul><ul><li>Provide advanced training in management of special needs patients </li></ul><ul><li>Develop case management programs </li></ul><ul><li>Improve practice management </li></ul><ul><li>Adopt Electronic Records and Billing system </li></ul>
  41. 41. Increase Demand <ul><li>By Improving Awareness and Dental Insurance </li></ul><ul><li>Develop media public awareness campaigns, such as “Watch Your Mouth” </li></ul><ul><li>Lobby for oral health funding </li></ul><ul><li>Encourage provider participation in the Medicaid program </li></ul><ul><li>Improve Medicaid claims processing speed </li></ul><ul><li>Improve Medicaid program by allowing case load limitations </li></ul><ul><li>Improve Medicaid program by increasing reimbursement rates </li></ul><ul><li>Promote oral health screenings and referrals through children health and welfare programs </li></ul>
  42. 42. Increase Demand (cont.) <ul><li>Have states mandate dental screenings for school-aged children </li></ul><ul><li>Include oral hygiene education and practice in pre-natal visits for pregnant women </li></ul><ul><li>Include primary dental care services into Medicare </li></ul><ul><li>Include medically necessary dental care into Medicare </li></ul><ul><li>Change insurance regulations to encourage enrollment </li></ul><ul><li>Develop private insurance for lower income population </li></ul><ul><li>Encourage foundation support for oral health programs </li></ul><ul><li>Establish new foundations focused on oral health </li></ul>
  43. 43. Decrease Need <ul><li>By Preventing the Disease </li></ul><ul><li>Include oral health education in school health curriculum </li></ul><ul><li>Establish school-based sealant programs </li></ul><ul><li>Establish fluoride varnish programs </li></ul><ul><li>Create outreach programs in Head Start and Early Head Start </li></ul><ul><li>Create outreach programs in schools which incorporate education, screening, and referral to dental services </li></ul><ul><li>Implement salt fluoridation if no community fluoridated water systems </li></ul><ul><li>Promote self-care </li></ul><ul><li>Create outreach programs in nursing homes </li></ul>
  44. 44. Decrease Need (cont.) <ul><li>Fluoridate and label bottled water </li></ul><ul><li>Promote early detection and referral by pediatricians </li></ul><ul><li>Have pediatricians apply fluoride varnish </li></ul><ul><li>Link oral health to systemic health through: </li></ul><ul><ul><li>a) Patient education </li></ul></ul><ul><ul><li>b) Patient care from MDs and RNs </li></ul></ul><ul><li>Provide nutritional counseling </li></ul><ul><li>Establish dental homes for all children </li></ul><ul><li>Promote preventive services by private dental practices </li></ul><ul><li>Fluoridate community water systems </li></ul>
  45. 45. Thirty Prevention Technologies by Mode of Delivery
  46. 46. Conclusion <ul><li>An ounce of prevention….. </li></ul>…… is worth a pound of cure!
  47. 47. Conclusion Don’t mop the floor……. Turn the spigot off….. The Imperative of Prevention
  48. 48. <ul><li>Rapid and effective response to public health needs </li></ul><ul><li>Leadership and excellence in public health practices </li></ul><ul><li>Advancement of public health science </li></ul>