Facing the future and deciding what we want oral health to become

For more than 2 years COVID-19 has dominated our lives. This pandemic has not only affected oral health care but has reinforced the broader importance of health inequities in our society. These inequities carry a high toll in terms of excess mortality, morbidity, and economic costs. These same inequities also are reflected in oral health, with the more vulnerable and disadvantaged experiencing more oral disease and greater challenges in accessing oral health care.

In 2000, then surgeon general David Satcher outlined the importance of oral health to overall health and well-being, a concept at that time not widely understood.¹ Today, our knowledge of the relationship between oral health and overall health and well-being has advanced substantially. Moreover, we have considerably more understanding of the social determinants of health, poor oral health, oral health disparities, and inequities. Yet many who are low income, are of racial or ethnic minorities, are older, have special health care needs, or grapple with substance use disorders or mental illness continue to be affected disproportionately with poorer oral health. Oral diseases, such as caries and periodontitis, are chronic conditions that are highly influenced by a variety of social determinants, but they are generally preventable and easily treatable when the disease is addressed early. Nonetheless, many people have limited access to prevention or early treatment owing to a variety of challenges affecting access to affordable care.

A 2021 report from the National Institutes of Health entitled Oral Health in America: Advances and Challenges ² provides an exhaustive review of every aspect of oral health and chronicles both the challenges and the promising new directions that can guide us to achieving better health for our people and communities. In this issue of The Journal of the American Dental Association, a perspective article titled “Oral Health in America: Implications for Dental Practice,” by Fellows and colleagues³ outlines several of the report’s major findings related to dental workforce and practice topics. In their concluding comments, they provide 3 key strategies that we should take collectively to help improve the delivery of oral health care in this country.

Fellows and colleagues³ discuss 4 broad areas: oral care delivery, oral health integration, insurance coverage and financing, and dental workforce—all directly affecting access to care. Much has changed in oral health over the past 20 years. The number of people receiving oral health care in federally qualified health centers has almost quadrupled, and one-third of these are children and adolescents. Dental support organizations also have increased, with many now serving traditionally underserved populations. It is clear that the dental safety net has expanded in this country, but that expansion has not helped everyone in need. In the United States, we still have large numbers of people regularly seeking oral health care in hospital emergency departments for a variety of dental problems, although the care provided in these settings is almost always palliative rather than definitive.

Fellows and colleagues³ remind us that the increase in dental insurance coverage in our country over the past 20 years has benefited mostly children and young adults. Moreover, a substantial share of this increase can be attributed to Medicaid and Children’s Health Insurance Program expansions resulting from the implementation of the Patient Protection and Affordable Care Act. Today, as a nation, we are close to having universal dental coverage for youth in America. However, this is juxtaposed with the continuing challenge that many older adults struggle with—affordable oral health care.

In their perspective article, Fellows and colleagues³ clearly describe the important changes over the past 20 years related to oral health care integration. Two big-picture integration models have been emerging. One focuses on increasing access to oral health care services for underserved populations, generally in nondental clinic settings, such as primary health care offices and schools. The other aims to improve patient-centered care, mostly for insured populations. The authors discuss another important concept that has risen to prominence as a result of the COVID-19 pandemic—the ongoing question of whether oral health care is part of the primary health care system in this country and whether it is an essential health care service. Although it may seem obvious to dental care professionals that oral health care is essential, we still have a difficult journey ahead to educate and advocate before this becomes universally accepted.

Although the supply of dentists in the United States has increased by 23% in the past 20 years, Fellows and colleagues³ point out that we continue to be challenged with areas in our country that experience oral health care provider shortages. Among the dental specialties, the number of pediatric dentists has doubled in the past 2 decades. Today, among all active practicing dentists in the United States, 9 of 10 are in private practice. But with dental practices generally concentrated in urban and suburban areas, rural communities are more likely to experience provider shortages. Because of persistent oral health care provider shortages, new workforce models have emerged, such as expanding the scope of practice for dental hygienists and introducing dental therapy—initiatives intended to address persistent access-to-care challenges.

Dental clinicians and educators play an important role in the effort to improve substantially oral health for all. Educators not only provide the knowledge and skills required to become and to remain competent health care providers, they also provide the guidance needed to remind us of the social contract that exists between a health care profession and the public. New technologies and advances in materials and practice alone will not improve substantially the public’s oral health. Working collectively to substantially address the persistent challenges affecting access to care will be the most important factor and critical role for our profession in the near future.

Fellows and colleagues³ have described a path forward that will help expand dental coverage and improve access to care. The 3 strategies highlighted are (1) to make dental care services an essential benefit for private and public insurance, (2) to incorporate dental or oral health care services demand into workforce planning, and (3) to increase the integration of oral and medical care delivery. The second strategy is of particular interest because we do not have a clear estimate of how many oral health care providers (for example, dentists and dental hygienists) are needed to meet current demand in the United States. Our country is large and diverse, and our demographic makeup is changing. Understanding this would provide invaluable guidance to our academic institutions about the type of providers and the skills needed for our next generation of oral health care professionals to not only be successful professionals but also to improve oral health in America.

The United States is not alone in these challenges.⁴ Oral diseases and disorders are the most prevalent adverse health condition globally. The distribution and severity of oral diseases varies across countries, regardless of their low- or high-income status. Nevertheless, our success in reducing the prevalence and severity of oral diseases and improving care delivery in our country has the potential for providing pathways for other countries as well.

Conclusions

Fellows and colleagues³ have clarified the actions that will be needed if we are to improve oral health for all. The greatest challenge to this achievement will be providing the adequate access to care necessary to ensure oral health equity. As a profession, we are reaching a defining moment for deciding the direction we should pursue and how we want to shape the future.

As a profession, we are reaching a defining moment for deciding the direction we should pursue and how we want to shape the future.

The decisions made will have profound impact on our country’s oral health for decades to come.

Biographies

Dr. Dye is a professor and the chair, Department of Community Dentistry and Population Health, School of Dental Medicine, University of Colorado, Aurora, CO, and a dental epidemiologist, National Institute of Dental and Craniofacial Research, Bethesda, MD.

Dr. D’Souza is the director, National Institute of Dental and Craniofacial Research, Bethesda, MD.

Dr. Albino is a professor emerita of public health, University of Colorado Anschutz Medical Campus, Aurora, CO.