Oral Health Disparities, Access To Care, & Team-Based Care Karl Self, DDS, MBA Pre-Dental Club Monday, April 25, 2016

DISCUSSION QUESTION Over the past 20 years is oral health in the United States getting better or worse?

ANSWER Both

ORAL HEALTH IMPROVEMENTS Emphasis on prevention  Water fluoridation  Sealant use up 13%  Oral hygiene instructions Decrease in diseases  Cavities down 6% in adults  Total tooth loss down 6% for those 60 years and older CDC/NIH study

ORAL HEALTH IMPROVEMENTS Linking oral health to general health  Diagnosis of oral cancer  Periodontal disease and pregnancy Better treatment options  Implants  Esthetic services

MN Mission of Mercy 2013 June 14-15, Bemidji

ORAL HEALTH PROBLEMS Dental care is the most prevalent unmet health care need of children in the US Half of all children have untreated tooth decay by age 9; 70% have at least one cavity by 18 Decay rate has increased for kids 2-5 years of age 30% Americans over the age of 65 have no teeth

ORAL HEALTH PROBLEMS “It is abundantly clear there are profound and consequential disparities in the oral health of our citizens. What amounts to a ‘silent epidemic’ of disease … restricts activities in school, work, and home, and often significantly diminishes the quality of life.” - Oral Health in America: A Report of the Surgeon General, 2000

ORAL HEALTH PROBLEMS Dental caries the single most common chronic childhood disease – five times more common than asthma Nationally, almost 2.5 million days of work and more than 51 million school hours are lost each year to dental related illness Current research is finding associations between oral disease and diabetes, heart disease, stroke, and poor birth outcomes

ORAL HEALTH PROBLEMS “There is an indisputable need in Minnesota for access to dental services for low income patients, and with the catastrophic budget situation we face, those needs are expected to get worse.” - Lee Jess, DDS MDA president 2009

DISCUSSION QUESTION Do the access to oral health care problems surprise you? – Why? – Why not?

HEALTH CARE DISPARITIES Disparity – differences between any two or more groups Health care disparities refers to differences in:  Health Status  Health Outcomes

ORAL HEALTH DISPARITIES 80% of cavities occurs in 25% of children - poor children have twice as much decay as more affluent children Black males have the greatest incidence of oral cancer Oral Clefts occur twice as often among AI than Whites

ORAL HEALTH DISPARITIES Death from oral cancer is 82% higher for Black men as compared to White men Minority children are 3 times less likely to have dental sealants than white children Minorities are roughly 30% of population yet they are 52% of the uninsured

ORAL HEALTH DISPARITIES Adults in rural areas:  Have more cavities and other dental care needs  Are less likely to have dental insurance  Are less likely to have a dental visit in the past year  Are 2x more likely not to have teeth

ORAL HEALTH DISPARITIES Minnesota ranks third in the nation for public water systems receiving fluoridation About 75% of Minnesotans have access to municipal water supplies which are virtually all fluoridated (98%) About 25% of the state’s population live in rural areas with private wells – probably not fluoridated

ORAL HEALTH DISPARITIES MN 2010 Basic Screening Survey  Statewide sample of 3 rd graders Results show MN is better than National average. Yet Disparities Do Exist Oral Health VariableMN EstNational Est Dental sealants on molar (#2) 64.1%23.0% Caries experience (#11) 54.9%52.0% Untreated tooth decay (#4) 18.1%29.0%

ORAL HEALTH DISPARITIES MN rd Grade BSS

ORAL HEALTH DISPARITIES MN rd Grade BSS

DISPARITIES FACTORS Socioeconomics “Most of the people who suffer from inadequate access to dental care do so because they simply do not have their own funds to pay for dental care.” -From Burt & Eklund: Dentistry, Dental Practice and the Community

DISPARITIES FACTORS Socioeconomics Socioeconomic status is a factor, but … The majority of studies, however found that racial and ethnic disparities remain even after adjustment for socioeconomic differences and other health care related factors. -Institute of Medicine report “Unequal Treatment”

DISPARITIES CHALLENGES The independent, unbiased, Institute of Medicine (IOM) found:  Health outcomes were worse for minorities than for the general population  Minorities are more likely to be treated with disrespect  Racial differences in the quality and comprehensiveness of care is substantial and beyond a reasonable doubt

ACCESS TO CARE Usually discussed in terms of Utilization of Services Access is related to these disparities factors:  Race/Ethnicity  Age  Gender  Location  Income/Education  Insurance

Percent of Patients With a Dental Visit, by Patient Race/Ethnicity & Education Visits by Race/EthnicityVisits by Patient Age Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1996 and 2004.

ACCESS STATISTICS Females have a slightly higher rate of use than males Location: Suburban areas >Urban areas >Rural areas Those without insurance are 2 times more likely to have not visited a dentist in 5 years or more as than those who do have commercial insurance

Percent of Patients With a Dental Visit, by Patient Age & Family Income Visits by EducationVisits by Family Income Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1996 and 2004.

MN ACCESS DISPARITIES Robert Wood Johnson Foundation 2012

MN ACCESS DISPARITIES Pew Center for the States, 2010

ACCESS TO CARE “The availability of dental care does not, in and of itself, constitute access. Rather, access occurs when care is available and people are able and willing to utilize it.” Future of Dentistry, ADA

ACCESS & WORKFORCE Workforce Size Workforce Location Workforce Composition

MN DENTIST STATS Minnesota Specific (2011) Dentists 3,249Practicing Dentists (20% Report Specialty Training) 2,600General Practice Dentists 76%U of M SOD Graduates

59 of 87 MN Counties have Designated Dental Health Professional Shortage Areas (DHPSA) MN DENTIST STATS Minnesota Department of Health 2014

DENTIST STATS Ratio of DDS per 100,000 population* –Nationally – 63 –Minnesota – 61 Practitioners needed to remove all DHPSAs** –Nationally – 7,208 –Minnesota – 94 *Source: MDH, September 2013 ** Source: HRSA 2015

MN DENTIST STATS MN Dept of Health Workforce Data

MN DENTIST STATS Active Dentists by Age, 2013 Source: Minnesota Board of Dentistry, December 2013

MN DENTIST STATS The average age of rural dentists is 57 compared to the average age of urban dentists at 53 MN Dept of Health 2011

MN DENTIST STATS Source: MDH Workforce Survey,

MN DENTIST STATS 69% of dentists are in the Mpls-St Paul metropolitan statistical area From , only 16% of U of M School of Dentistry graduates went outside the 7-county metro area

MN DENTIST STATS 44% 37% 10% 9%

THE ORAL HEALTH CARE TEAM Dentist Team Leader Dental Hygienist Dental Assistant Dental Lab Tech Dental Therapist Patient

THE ORAL HEALTH CARE TEAM Minnesota Specific 3,249Practicing Dentists 4,503Practicing Dental Hygienists 6,288Active Dental Assistants 54 Licensed Dental Therapists (~33 DT students in the educational pipeline)

THE ORAL HEALTH CARE TEAM Roughly 80% of active dentists are general dentists Over 69% of dental practices employ dental hygienists Roughly 94% of dental practices employ dental assistants First US dental therapists graduated in 2011

DENTAL HYGIENIST What is a Dental Hygienist? Dental hygienists are licensed oral health professionals who focus on preventing and treating oral diseases - both to protect teeth and gums, and also to protect patients' total health

ALLIED PROVIDERS ADA 2005

DENTAL THERAPIST What is a Dental Therapist? A member of the oral health care team who is educated to provide evaluative, preventive and restorative dental care DTs are also educated to engage in community-based oral health promotion and disease prevention

MN DENTAL THERAPY PROGRAM In 2009, MN became first State in the country to authorize Dental Therapy Workforce issues in MN Rural areas and for low-income patients The purpose was to extend dental care to underserved communities Not a “ Mini Dentist”

PRACTICE SETTINGS Minnesota dental therapists are limited to primarily practicing in: –settings that serve low-income, uninsured, and underserved patients; or –a dental health professional shortage area

DT PROGRAM PRINCIPLES The “standard of care” taught to dental therapists will be identical to that taught to dental students Health promotion & disease prevention will be core elements of the educational program Education will occur in a professional environment which includes dental hygienists & dentists, to ensure graduates are prepared to work in a team setting

DT EMPLOYMENT STATS 54 Licensed Dental Therapists (March 2016) –23 of those have achieved ADT certification

Dental Therapy Employment Locations * Metro Area– 57% Greater MN – 43% HRSA Rural – 34% (* November 2015)

Decreased travel and wait times Clinics saw more new underserved and Medicaid patients Increased dental team productivity Reduced clinic operating costs No complaints or concerns about quality or safety DTs working in a variety of treatment settings MN DENTAL THERAPY IMPACT

FINAL THOUGHT The elimination of oral health disparities will require important changes in the ways health care is delivered, financed, and documented

DISCUSSION