1. ACCESS TO ORAL HEALTH CARE IN THE U.S. Jonathan Shenkin, DDS, MPH Clinical Associate Professor of Health Policy, Health Services Research and Pediatric Dentistry Boston University

2. Outline US Dental Delivery Trends in dental access Decay rates in the U.S. Dental crisis in the U.S.?—Adults!! New Zealand vs the U.S. The myth of Maine’s oral health How can we improve oral health effectively in the US

3. US Dental Delivery System For Children: Expanding number of children covered through private benefits and Medicaid Greatest increase in delivery of care has been to children with Medicaid For Adults: Since recession, Medicaid cuts have resulted in more use of ERs Declining use of dental services for those with private dental benefits

4. Dental Care Use

5. Percentage of Children Ages 2-18 with a Dental Visit in the Year by Dental Benefits Status, 2000-2012

6. Caries Prevalence in the Primary Dentition for Youths age 2-5 years Dental Caries Prev (dft > 0) Untx Caries Prev (dt > 0) Dye 2014

7. Adult Private Dental Benefits Trend has resulted in higher deductibles More plans have maximum annual allowable expenditures of less than $1,500 More plans are requiring “in network” dentists with lower reimbursement. More out of pocket expenditures, with decline in dental care utilization.

8. Percentage of Adults Ages 19-64 with a Dental Visit in the Year by Dental Benefits Status, 2000-2012

9. Pew: A Costly Destination “…830,590 visits to ERs nationwide in 2009—a 16 percent increase from 2006. For many low-income children, emergency rooms are the first and last resort because their families struggle to find a dentist who either practices in their area or accepts Medicaid patients.”

10. ER use in the US, 2006-2009 AHRQ, 2009

11. ER spending for Dental in Maine

12. Decay in NZ vs US BeforeAfter *NZ report notes that 17% of NZ children ages 5-11, have untreated decay in primary teeth. This is higher than in the US. What’s the best Intervention?

13. Percent of Children with a Dental Visit in the Past Year, Commercially and Medicaid Insured

14. Maine’s Oral Health Stats NOHSS-2012 3 rd graders Untreated decay-14.6% 2 nd lowest in nation Caries experience 32.7% Lowest overall in nation Sealants 68.5% Highest in the nation

15. Dentists vs IPDHs in Rural Maine

16. Conclusions How can we improve oral health in the US? Maintain and improve water fluoridation Drastically improve oral health literacy Improve patient navigation through CDHCs For children: Increased early preventive care Improved Medicaid administration and financing More use of evidence based sealant protocols For Adults: Fund adult dental Medicaid Address declining quality of private dental benefits for adults Fill the knowlege gap!

17. Mean dmft/DMFT by age group, and village water fluoridation status, in five rural Alaska villages and the US, 2008 MMWR, Sept 2011