Public dental service utilization among adults in South Australia

Background:  Longitudinal patterns of public dental service use may reflect access issues to public dental care services. Therefore, patterns of dental service use among South Australian adult public dental patients over a 3½-year period were examined.
Methods:  Public dental patients (n = 898) initially receiving a course of emergency dental care (EDC) or general dental care (GDC) at baseline were followed for up to 3½ years. Patient clinical records were accessed electronically to obtain information on dental visits and treatment received at those visits.
Results:  Some 70.7 per cent of EDC and 51.3 per cent of GDC patients returned for dental treatment post-baseline. EDC patients returned within a significantly shorter time period post-baseline, received significantly more courses of care and were visiting more frequently than GDC patients. A greater proportion of EDC patients received oral surgery, restorative, endodontic and prosthodontic services, but fewer received periodontic services. EDC patients received significantly more oral surgery and fewer preventive services per follow-up year, on average, than GDC patients. Large proportions of EDC (52.4 per cent) and GDC (63.8 per cent) patients who returned sought emergency care post-baseline.
Conclusions:  Patients appeared to be cycling through emergency dental care because of lack of access to general care services, highlighting access problems to public dental care.     

State case studies: improving access to dental care for the underserved

Introduction: This article, a supplement to the work of the Institute of Medicine's Committee on Oral Health Access, examines dental access disparities, reviews societal strategies for reducing disparities, explores the relationship between state level public health and dental safety net efforts and utilization/oral health outcomes, and describes selected public health and safety net programs with special promise. Methods: Data were obtained from interviews with state dental directors and safety net leaders and a review of the literature. Findings: There is a two-fold difference in utilization rates between low- (<30 percent) and high- (56 percent) income families. The three societal strategies for reducing disparities - Medicaid, dental safety net system, and increasing the supply of dentists - all have significant limitations. The primary factor positively related to oral health is per capita income. Five promising programs for reducing access disparities include a dental home initiative for young children; a virtual dental home for school children and nursing home residents; a women, infants, and children early oral education and prevention intervention program; an enhanced Medicaid reimbursement program for educational institutions in North Carolina; and a school-based dental care system run by Connecticut Federally Qualified Health Centers. Conclusions: There are wide disparities in access to dental care, and current societal strategies to reduce disparities have significant limitations. At the state level, the primary determinant of oral health status is per capita income. Several states have promising programs to reduce disparities but most are still at the demonstration level and have not been adequately evaluated.     

Challenges to dental access - England as a case study

Access to dental services because of an insufficient workforce is a historic challenge faced by many developing countries. In recent years, however, it has become a major issue for many industrialized countries. The growing demand for cosmetic dentistry, an increase in patients' willingness to pay for dental treatment, and growing numbers of older dentate patients have all put pressure on dental systems. Ways of meeting these challenges and ensuring reasonable dental access will vary from country to country, but the solutions often lie in how the dental workforce is regulated. This case study of the dental reforms currently being implemented in England highlights progress at a particular point in time (Summer 2005). It is clear that it will take a number of years to find a new national dental payment system (the National Health Service) to replace the system which has changed little since 1948. However, the political pressure to address poor access to state-funded dental services calls for more immediate actions. The initial approach was to increase the dental workforce via international recruitment, and in the medium term to increase the number of dental students in training and to expand the numbers of other members of the dental team. An additional stratagem is to retain those already providing dental care under the National Health Service by the introduction of a new method of remuneration. England is trying to improve both access to care and the oral health of the population by creating a workforce more suitable to public demands and changing oral health needs.     

Access to dental care for Head Start enrollees

OBJECTIVES: The objectives of this review are to characterize the oral health and dental access of Head Start children, describe barriers to their care, advance strategies to address those barriers, and consider how Head Start Performance Standards can be utilized to maximize oral health and access to dental care. METHODS: Published, programmatic, and solicited data describing oral health status and dental service utilization are reviewed together with reports of conferences exploring access barriers. Head Start performance measures for child health and development services, child health and safety, family partnerships, and community partnerships are individually evaluated for their potential to improve oral health. RESULTS: Head Start children, like all low-income children, enjoy the highest rates of dental coverage (because of Medicaid and the State Child Health Insurance Program), yet these children also experience the highest rates of tooth decay, the most unmet dental care needs, the highest rates of dental pain, and the fewest dental visits. Getting children the dental care they need is problematic because of: multiple barriers associated with public and private dental delivery systems, Medicaid program funding and administration, dental workforce sufficiency and distribution, and issues of culture and communication that stand between parents, children, and caregivers. CONCLUSIONS: To move beyond screening and to access necessary dental care requires integration between medical and dental care, recognition and elimination of barriers to care, an understanding of dental provider types and their capacities, a formally structured referral process, and regular monitoring to ensure that complete care is obtained. Action steps are suggested that can maximize the effectiveness of Head Start Performance Standards. Head Start holds tremendous potential to actively develop and implement policies that can markedly improve both access to needed dental services and the oral health status of young disadvantaged children.     

The School-Based Dental Care Systems of New Zealand and South Australia—a Decade of Change

The purpose of this paper is to review and update the highly successful school-based dental care systems of the country of New Zealand and the state of South Australia. These school-based systems have undergone changes in the past 10 years. The New Zealand Dental Service has greatly reduced the number of dental nurses in training. Declining birth rates, changes in disease patterns, revision of diagnostic criteria, and longer employment trends in women have all had an impact on the system. The South Australian School Dental Service has expanded rapidly in recent years to serve a high percentage of eligible South Australian children. This system also is responding to these factors with flexible programs to meet new trends. Both systems are examples of comprehensive programs of quality dental care that dissolve away SES utilization differences providing equal access to continuity of care for all children.     

Issues in Financing Dental Care for the Elderly

The elderly make up an increasingly larger segment of the patient population in dental practices. This article reviews recent epidemiologic, demographic, and health services research, and concludes that significant segments of the elderly are at high risk for oral disease and/or limited access to dental treatment, and consequently warrant classification as high-risk groups for policy considerations. It then proposes policy options to the dental community and public decision makers. Oral care can be viewed as having three components. Two basic components are the primary care component--which includes diagnostic, preventive restorative, and periodontal care--and the acute care component--i.e., the treatment of oral pain, trauma, and infection. The third, rehabilitative component, has to do with the restoration of oral function, including prosthodontics and cosmetic dentistry. Viewing dental care in this perspective may help link funding for dental primary care services with that for other primary health services, and link restoration of function and improvement of quality of life with similar health services, like hearing, vision, and social services. In addition, approaching dental care policy makers on several levels--i.e., federal, state, and local--will contribute to our ability as a profession, in the decades ahead, to meet the oral health needs of more elders: including the frail, those at high risk for oral disease, and those with limited access to care.     

Expanding Health Insurance Coverage and the Implications for Dentistry

Numerous proposals have been suggested for expanding health insurance coverage to the over 30 million Americans without health insurance. These proposals range from establishing a program of national health insurance modeled after the Canadian system to establishing statewide risk pools. Many of these proposals could have an impact on financial access to dental care for the approximately 120 million people without dental insurance. Dental insurance coverage has been shown to increase access to dental services and improve oral health status. Oral health professionals could facilitate discussions concerning health insurance expansion by informing policymakers about important preventive benefits to be gained by improving access to dental services. Dental public health professionals can serve as a bridge between organized dentistry and health policymakers by providing information to help formulate the priorities and characteristics of a dental health insurance program. This visibility and influence in the health policy arena would be beneficial to dentistry and could ultimately result in greater access to dental services and improved oral health for the uninsured.     

Addressing oral health disparities,inequity in access and workforce issues in a developing country

The health sector challenges in India like those in other low and middle income countries are formidable. India has almost one-third of the world’s dental schools. However, provisions of oral health-care services are few in rural parts of India where the majority of the Indian population resides. Disparities exist between the oral health status in urban and rural areas. The present unequal system of mainly private practice directed towards a minority of the population and based on reparative services needs to be modified. National oral health policy needs to be implemented as a priority, with an emphasis on strengthening dental care services under public health facilities. A fast-changing demographic profile and its implications needs to be considered while planning for the future oral health-care workforce. Current oral health status in developing countries, including India, is a result of government public health policies, not lack of dentists. The aim of the article is to discuss pertinent issues relating to oral health disparities, equity in health-care access, dental workforce planning and quality concerns pertaining to the present-day dental education and practices in India, which have implications for other developing countries.     

Developing primary health clinical teams for public oral health services in Tasmania

This paper reviews the problem of socio-economic health inequalities and highlights the relevance of these issues for the delivery of public oral health services in the Australian island State of Tasmania. It contends that unless there is reform of existing public oral health systems, inequities in oral health care linked to socio-economic factors and geographic location will remain. The challenge is, firstly, to understand the current situation and why it has occurred. Secondly, we need to ensure that this understanding is shared across educational and professional sectors for the development of innovative approaches to the problem. Thirdly, we must carry out preliminary research and evaluation for any reforms. Using a combination of approaches, i.e., primary health care, a 'common risk' approach and increasing workforce numbers has been identified as a method showing the most potential to improve access to equitable oral health care. An outline of a current research project evaluating the impact of the integration of primary oral health care clinical teams into public oral health services is provided. The clinical teams combine the skills of the dentist and an expanded role for dual trained dental therapists/dental hygienists. The teams focus on the development of innovative clinical practice in the management and prevention of common oral diseases that take into account the broader determinants of oral health inequality. This project will be conducted in Tasmania, where the dominance of small rural and remote communities, adverse socio-economic factors and shortage of oral health professionals are key issues to consider in planning public oral health services and programmes. The results of the evaluation of the Tasmanian pilot model will contribute to the evidence base that will support the introduction of new approaches to public oral health care.     

Eligible Veterans'' Choice Between VA-covered and Non-VA-covered Dental Care

Veterans who were eligible for dental care in Department of Veterans Affairs (VA) facilities at no monetary cost responded to a mailed questionnaire. Seventy-one percent were aware that they were actually eligible for VA dental care. However, only 48 percent reported the VA as their only or primary source of dental care. Eligibility status, perceived quality of VA dental care, use of VA medical care, perception that one's income meets expenses, and perceived need for dental care were significant correlates of using the VA as one's current source of dental care. Level of formal education, perception that one's income meets expenses, transportation pattern, geographic distance from a VA facility, and eligibility status were significant correlates of using the VA as one's current medical care source. Research on VA utilization offers the opportunity to study issues of access to, and use of, a large public health care system whose patients largely receive care at no monetary cost. Veterans' use of VA dental and medical care is apparently influenced by a wide variety of factors, ranging from barriers to access to non-VA systems, to characteristics of the VA delivery system itself, to need for treatment.     

The virtual dental home: a critique

The Virtual Dental Home is a concept of the Pacific Center for Special Care of the Arthur A. Dugoni School of Dentistry in San Francisco. It is designed to improve access to dental care for underserved populations, specifically children and institutionalized adults. This article describes the development and implementation of the Virtual Dental Home, subsequently critiquing the concept. The criteria for a dental home are not met by the program. It is the equivalent of a traditional public oral health prevention and screening program, with the additional dimension of allowing dental hygienists and assistants to place interim glass ionomer restorations in dental cavities. The critique questions the need to insert a “cloud” dentist into the process. The routine utilization of radiographs is also challenged. The VDH not only lacks the attributes of a dental home, it has not been shown to be as efficient and effective as traditional programs staffed by dental hygienists and dental therapists. The article concludes by describing how programs utilizing dental therapists could address the deficiencies of the Virtual Dental Home, effectively improving access to oral health care for underserved populations.     

Some current factors restricting the potential of private general practice.

This background paper focuses on two or three aspects which, in the writer's opinion, are crucial to the healthy development of general dental practice, although the rapidly progressing health reforms have already altered the relevance of some comments made. The first aspect is equitable access, especially for the financially disadvantaged in this time of economic recession. The ability and inclination of providers to treat the financially disadvantaged has not currently been matched by the political will of funders, even though an effective system could simply be organised. Access problems also apply to the elderly. A smooth transitional system of oral health care should exist for every aging patient, whether economically, physically, and mentally healthy, or in a state of total dependence, and this should be an integral part of general dental practice management. Generally it is not. Secondly, the fragmentation of the New Zealand dental workforce, and the lack of a real team approach have hindered the logical development of oral health services and prevented many possible options from being offered. Dialogue to reduce the fragmentation must continue, hopefully to a successful conclusion. Perhaps the catalyst for meaningful change may be contained in the current health reforms. Certainly opportunities for change have been clearly signalled.     

Illegal oral care: more than a legal issue

Affordable, safe and appropriate oral care, including preventive services, is not available for large parts of the world's population. In many low- and middle-income countries patients have to rely on a range of illegal oral care providers who are often socially accepted and part of the cultural context. Although filling a gap in service provision for poor populations, illegal provision of oral care is a serious public health problem, resulting in situations of low-quality care and risks for patients. It is a complex phenomenon going far beyond the legal context. It should be seen as a symptom of underlying health system and society deficits, ranging from lack of access to care and health inequities to problems of governance and law-enforcement. This paper analyses the problem based on the country case of Guyana, explores the public health, legal, professional, social, economical and ethical dimensions of the problem and proposes a differential view on illegal practice by grouping illegal oral care situations in four broad categories; each of them requiring different solutions to tackle underlying issues leading to the problem of illegal oral care.     

The delivery of oral care services to elderly people living in a noninstitutionalized setting

Advances in medical science are enabling people to survive more illness and disability. As people live longer, their mobility and/or ability for self-care often are reduced by physical or mental disability and other chronic diseases. It may become unreasonable or impractical for them to access mainstream dental services. Increasing numbers of dentate elderly people with expectations of oral health higher than earlier cohorts of elderly people are likely to bring increasing demands to the dental profession for their continuing care. Thus, the oral care for disabled elderly people in noninstitutionalized settings may pose a challenge. The oral care options available to this group of people include the dental surgery/operatory, a mobile dental service, home-based or domiciliary dental care, a mix-and-match combination of surgery-based and domiciliary care, and cyberspace. Noninstitutionalized, disabled elderly people may have to rely on domiciliary care services for their oral health care. This paper explores the training implications, the necessary knowledge and skills base, the benefits and limitations to both the service provider and user, the equipment available, and the cost/funding of domiciliary dentistry. Domiciliary dental care services need to be developed by improving pre- and postdoctoral training programs and by establishing realistic remuneration for dental teams providing this care so that noninstitutionalized, disabled elderly people can access oral health care.     

Cost as a barrier to dental care among people with disabilities: a report from the Florida behavioral risk factor surveillance system

Many individuals who have disabilities or complex health conditions do not have adequate access to comprehensive oral health care. An examination of the literature indicates a variety of contributing factors. This study reports on cost of care as a barrier to oral health care. Data from the 2007 Florida Behavioral Risk Factor Surveillance System (BRFSS) were used (n = 33,777). Respondents who reported activity limitation or the use of special equipment were considered to have a disability. Lack of access to dental care due to cost during the past year was assessed. More individuals with a disability reported not seeing a dentist due to cost versus people without disabilities (30% vs. 16%). After adjusting for confounding variables, Floridians with disabilities were 60% more likely to report cost as a barrier to dental care (OR = 1.60, 95% CI 1.32–1.94). Cost of dental care is an access to oral health barrier for Floridians with disabilities. Improving access to dental care for this population will require consideration of financial issues.     

National Health Care: Whither Goeth Dentistry?*

National health insurance is reemerging as an important issue on the national health policy scene. The continuing escalation of health care costs in the US and increasing numbers of individuals without access to health services are stimulating a variety of proposals to redesign the structure and financing of the American health care system. Some change in the current system toward a more national approach to health care is inevitable in the years ahead. While dental care is subject to pressures similar to other health care services, little attention is being accorded dental services in the various national health care proposals that are being advanced. This may be due largely to organized dentistry's reluctance to define a role for itself. If dentistry is to be included in such a plan, it is essential that concerted efforts start soon and that the various public and private sectors of dentistry work collaboratively to develop the dental component to such a plan. The future oral health of the public and the future health of dentistry as a profession depend on it.     

Job satisfaction among dental therapists in South Africa

Objectives: This article forms part of a larger research project on the dental therapy profession in South Africa. The objective of this study was to determine the level of job satisfaction among dental therapists trained at one South African university. Methods: This study was conducted using the qualitative research approach, where purposive and convenience sampling was used to select interviewees. They were asked a single question: “Do you think that dental therapists in South Africa are satisfied within their present careers?” The narrative data was interpreted using thematic analysis, and the data was validated by using the markers of trustworthiness. Results: All stakeholders believed that dental therapists trained at this university were not satisfied in the private and public sectors. In the private sector, they expressed frustration with their limited scope of practice. In the public service, lack of posts, poorly functioning dental facilities, and inadequate remuneration caused high levels of dissatisfaction. Many dental therapists chose this profession as a stepping stone to dentistry. Conclusions: The roles and scope of practice of all members of the oral health team needs to be redefined within the context of the primary health care approach. Universities need to recruit students appropriately to fulfill their role within this team. Dental services in the public sector need to be upgraded to meet the oral health needs of the country.     

Institutional barriers to providing oral health services for underserved populations in New York City

Objectives : We sought to explore institutional barriers to the provision of oral health services for the underserved among inner-city health centers. Methods : Mail-based survey of Medicaid-approved health centers in New York City without oral health services. The importance of four barrier categories was rated: resource issues, dental provider difficulties, referral problems, and low priority of dental care. Results : 36 health centers completed the survey. The most important barriers were resource issues (66.7% agreed), dental provider difficulties (29.4%), referral problems (24.2%), and low priority (15.2%). Top individual barriers were lack of start-up funds (88%), lack of physical space (74%), lack of available funding sources (71%), and low reimbursement rates for dental services (69%). Most centers (78%) identified a need for dental services for their patients. Conclusions : Access to oral health care remains a large problem for the underserved. Institutional barriers will need to be addressed to close the gap.     

Solutions to dental access disparity: Blueprint of an innovative community health center-based model for rurally based communities

Dr. David Satcher issued the first Surgeon General Report on oral health in the United States in 2000, drawing attention to a prevailing oral health access crisis. Dr. Satcher's report resonated in Wisconsin where a statewide growing dental access crisis was in progress and inspired grassroots efforts by a Family Health Center to establish a practice-based multi-site dental infrastructure that was integrated into a large regional multi-specialty medical clinic serving a largely rural population. An overview is provided of fundamental elements and relationships that supported establishment of the infrastructure, services, outreach and expanded access offered inclusively to all patients. Further, this community action report presents a blueprint that delineates key dimensions critical to planning and establishing a regionalized infrastructure offering access to all patients. Feasibility of establishing inclusive dental care is documented, and our model is proposed as a potentially replicable prototype for increasing dental access across other federally qualified health centers. Finally, this report is responsive to Dr. Jerome Adam's solicitations for feedback that will inform his plan for issuing a new Surgeon General report that updates status of oral health in America and progress in reversing oral health access disparities.