Oral health is an often overlooked aspect of individual health and wellness. Poor oral health can affect nutrition, employment, education, and can cause health problems throughout the body. Limitations in coverage, challenges in workforce distribution, and poor oral health literacy are barriers to utilization of dental care for all populations.
- At least 75 million Americans (25%) have either limited or no access to oral health care.
- Almost 60% of children ages 5 to 17 have cavities.
- 26% of adults (ages 19 to 64) have untreated decay, and 5% of adults have no teeth.
- Those who are low-income or minorities are at higher risk for experiencing dental caries (cavities) and dental decay.
- Children and adults who receive regular dental care are more likely to have their decayed teeth diagnosed and treated.
- Water fluoridation is one of the most cost effective measures of prevention; every $1 invested in water fluoridation saves about $38 per year by in dental costs.
Dental Health Status
Dental problems plague adults and children alike, ranging from tooth decay to more serious conditions such as gum disease that can result in tooth loss and may be connected to diabetes and heart disease.
Among some racial and ethnic groups, there are significant disparities in oral health. Approximately three in ten African American and Hispanic children have untreated cavities, compared to one-fifth of White children. African American and Hispanic adults are also more likely to have untreated caries, compared to Whites. Seniors in particular, suffer the consequences of poor oral health care; one-quarter of adults older than 65 have lost all of their teeth, which can have a major impact on their health and well-being.
Coverage and Financing
Dental insurance is typically obtained as an employee benefit and can be extremely costly to purchase independently. In 2008, the majority (73%) of people under 65 had some type of private dental insurance, the majority as an employer benefit. Medicaid covers children under 21, but is an optional benefit for adults and is much more limited. Medicare typically does not cover dental services for its beneficiaries.
- Dental insurance coverage rates are significantly higher among people with employer based health insurance (8 out of 10) compared with people who directly purchase health insurance (3 out of 10).
- Insurance coverage does not guarantee affordability of dental care. Many dental plans have deductibles, up-front costs, annual coverage caps, or limited coverage for services that are important but may be considered “cosmetic,” such as orthodontics.
- The Affordable Care Act includes coverage of children’s dental care as an “essential health benefit”, in all new private plans offered in the health insurance exchanges, individually, and through small group plans beginning in 2014, which could increase access to dental care for millions of children.
Medicaid and Medicare
- Only 44% of children covered by Medicaid received dental services in 2010, far shy of the Healthy People 2010 goal of 56%.
- As of 2008, 44 states and the District of Columbia covered at least some dental services for adults on Medicaid. While a few states cover comprehensive care, most only provide emergency services such as tooth extraction.
- Dental coverage is not included as a basic Medicare benefit for seniors, except in cases when dental care is a necessary component of another procedure, such as reconstruction of the jaw following accidental injury.
- Some seniors obtain dental coverage through employer-sponsored retiree health plans, Medicare Advantage plans, Medicaid, or individually-purchased dental plans. However, even when covered, the scope of dental benefits varies widely across plans.
- An estimated 45 million individuals under 65 have no dental coverage. For these individuals and families, particularly for those who are low-income, private dental insurance can be unaffordable.
- Uninsured individuals pay about twice as much for dental services as those with insurance.
Access to Dental Care
Access to dental care can be a problem for individuals throughout their lives. Despite the American Academy of Pediatric Dentistry (AAPD) recommendation that children have a dental examination every 6 months (this recommendation continues into adulthood). Half (49%) of children ages 2 to 5 have never been to a dentist. There are racial and ethnic disparities in dental utilization, with children and adults who are black, Hispanic, or from low-income families are less likely to have had a recent dentist visit and often experience poorer oral health status. Seniors have even lower rates of dental care utilization than working age adults.
One of the major challenges in obtaining dental care is a dental workforce shortage, particularly in low-income and rural areas. Contributing factors to the shortage include limited slots in dental schools, an unwillingness of providers to work in rural areas, a large number of dentists retiring, and the growing trend of specialization in dental care. Many dentists do not accept Medicaid, due in part to low reimbursement rates, aggravating accessibility issues for low-income families.
The dental workforce in America consists of three major groups that can be generally defined as: dentists, dental hygienists, and dental assistants. The demographics of dentists are beginning to shift from primarily white men over age 45, to include more women and minorities, who may be more likely to practice in underserved communities and accept Medicaid patients. Dental hygienists typically work jointly with a dentist to provide preventive, educational, and therapeutic services. Dental assistants make up the largest part of the dental workforce, and require the least amount of training, typically supporting general dentists with clinical work, but also working in front-office positions, practice management, and as educators.
Various solutions to the workforce shortage have been proposed, including increasing the number of dental schools and available slots. Another solution is to increase the number of dental hygienists and expand their responsibilities, creating a mid-level practitioner comparable to a Physician’s Assistant or Nurse Practitioner. These “mid-level dental hygienists” are already being utilized in countries such as New Zealand and Australia, as well as Alaska, to reach rural and isolated populations that might not support a full time dentist.
Two cost effective methods for preventing tooth decay, fluoridation and dental sealants, are underutilized. Water fluoridation has been called one of the 10 greatest public health achievements of the 20th century and can reduce tooth decay by 25%. Utilization of fluoridated water is especially important in children and infants and can help strengthen teeth and prevent cavities and decay later in life. Despite the scientific research supporting fluoridation, some have opposed community water fluoridation efforts due to safety concerns.
The use of dental sealants has been shown to reduce tooth decay by up to 70%, and is an especially effective prevention tool for younger children. However, only 30% of children ages 6 to 11 have sealants, due to lack of awareness by providers and parents, limited dissemination about the newer research on the effectiveness of sealants, and limits on coverage by insurance plans.