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Transcript of The USPHS and Access to Oral Health Chester W. Douglass, DMD, PhD Professor Emeritus Harvard...
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