Disparities in the oral health of children

A report in the journal Pediatrics identified dental care as the most prevalent unmet health need for children in the United States. Numerous studies, many of which are cited in the Surgeon General’s Report , document the profound and significant disparities in oral health among America’s children. Dental caries is the nation’s most common childhood disease. It affects 58.6% of children between the ages of 5 and 17 years and is, therefore, five times more common than childhood asthma and seven times more common than hay fever. By mid-childhood more than 50% of children are affected by dental caries, and by late adolescence 80% have dental caries. Children lose 52 million hours of school time each year because of dental problems, and poor children experience nearly 12 times as many restricted-activity days from dental disease as do children from higher income families. Toothaches are the single most significant health problem encountered by elementary school teachers. Decay in the primary dentition is a predictor of decay in the permanent dentition, and children who have poor oral health often continue such a pattern into adulthood, potentially affecting speech, nutrition, economic productivity, and quality of life. Eighty percent of the dental disease of children is found in 20% to 25% of children (approximately 18 million children) who predominately are from African American, Hispanic, American Indian/Alaskan Native, and low-income families. Seventy-nine percent of American Indian/Alaskan Native children aged 2 to 5 years have tooth decay—frequently early childhood caries that results from improper feeding habits in infancy—and 68% of the tooth decay is untreated. The prevalence and severity of dental disease are linked to socioeconomic status across all age groups.

Workforce barriers to accessing care for children

Multiple barriers to ensuring access to care for children have been identified. Significant among these barriers are the limitations of the professional dental workforce, that is, an inadequate number of dentists as well as their suboptimal distribution, ethnicity, education, and practice orientations.

The dentist to population ratio is declining from its peak of 59.5/100,000 in 1990 and will drop from the current 58/100,000 to 52.7/100,000 in the year 2020—a decline of 10%. One estimate suggests the ratio could fall as low as 45 dentists/100,000 people by 2020. Beginning in 2008, more dentists will be retiring than graduating; this trend will continue until 2020. The number of pediatric dentists is not sufficient to provide adequate access to care for children. Although the number of pediatric dentists has increased significantly during the past 30 years, there are only 4357 such trained specialists practicing in the United States today. In 2000, the president of the American Academy of Pediatric Dentistry stated, “Even with a Herculean increase in training positions [for pediatric dentists], improved workforce distribution, and better reimbursement and management of public programs, pediatric dentistry will never be able to solve this national problem [of disparities] alone. We need help.”

Compounding the issue of the number of dentists is the location of dental practices. The overwhelming majority of dentists practice in suburbia, with few practicing in rural and inner city areas where the children with the greatest need live. The number of federally designated dental shortage areas increased from 792 in 1993 to 1995 in 2002 and to 4048 in 2008, with 48 million people living in these areas. Although Approximately 12% of the population but only 2.2% of dentists are African American. Individuals of Hispanic ethnicity make up another 10.7% of the population, but only 2.8% of dentists are Hispanic. Less than 6% of entering student dentists are African American, and less than 6% are Hispanic. The demographics of oral disease indicate that these two minority groups comprise a significant proportion of the problem of disparity in care.

A further issue is graduating dentists’ general lack of instruction and experience in treating children. The typical college of dentistry curriculum provides an average of only 177 clock hours of didactic and clinical instruction in dentistry for children. A recent study found that 33% of dental school graduates had not had any actual clinical experience in performing pulpotomies and preparing and placing stainless steel crowns, common therapies required for children. Official American Dental Association (ADA) policy also questions the adequacy of the dental curriculum in preparing dentists to treat children. In 2000, an ADA House of Delegates resolution called for “a review of the predoctoral education standard regarding pediatric dentistry to assure adequate and sufficient clinical skills of graduates.” The background statement supporting the resolution suggested that inadequate educational preparation for treating children could be a barrier to children’s access to care. There is no evidence of a subsequent increased emphasis on children’s dentistry in predoctoral education. In fact, in a recent study entitled “U.S. Predoctoral Education in Pediatric Dentistry: Its Impact on Access to Dental Care,” the authors concluded “results suggest that U.S. pediatric dentistry predoctoral programs have faculty and patient pool limitations that affect competency achievement, and adversely affect training and practice.”

An additional dimension of the workforce problem is the practice orientation of many dentists. Dentists generally do not treat publicly insured children, that is, children covered by Medicaid or the State Children’s Insurance Program (S-CHIP). It is difficult to discuss the issue of access to care, particularly when focusing on the disparities that exist in oral health among America’s children, without referencing the public insurance system. Medicaid provides an entitlement to comprehensive dental services for children who live at or below 150% of the federal poverty level, and S-CHIP provides the entitlement to children living at or below 200% of the federal poverty level. Medicaid and S-CHIP, however, fail to meet the oral health needs of America’s children. Among the several factors contributing to this failure is dentists’ unwillingness to provide care in their offices for children who have publicly financed dental insurance. Dentists offer multiple reasons for this failure, including low reimbursement schedules, demanding paper work and billing requirements, and the frequent failure of the parents of these children to keep scheduled appointments. A 1996 study indicated that only 10% of America’s dentists participated in the Medicaid. A more recent study indicates approximately 25% of dentists received some payment from Medicaid during a given year; however, only 9.5% received $10,000 or more.

Workforce barriers to accessing care for children

Multiple barriers to ensuring access to care for children have been identified. Significant among these barriers are the limitations of the professional dental workforce, that is, an inadequate number of dentists as well as their suboptimal distribution, ethnicity, education, and practice orientations.

The dentist to population ratio is declining from its peak of 59.5/100,000 in 1990 and will drop from the current 58/100,000 to 52.7/100,000 in the year 2020—a decline of 10%. One estimate suggests the ratio could fall as low as 45 dentists/100,000 people by 2020. Beginning in 2008, more dentists will be retiring than graduating; this trend will continue until 2020. The number of pediatric dentists is not sufficient to provide adequate access to care for children. Although the number of pediatric dentists has increased significantly during the past 30 years, there are only 4357 such trained specialists practicing in the United States today. In 2000, the president of the American Academy of Pediatric Dentistry stated, “Even with a Herculean increase in training positions [for pediatric dentists], improved workforce distribution, and better reimbursement and management of public programs, pediatric dentistry will never be able to solve this national problem [of disparities] alone. We need help.”

Compounding the issue of the number of dentists is the location of dental practices. The overwhelming majority of dentists practice in suburbia, with few practicing in rural and inner city areas where the children with the greatest need live. The number of federally designated dental shortage areas increased from 792 in 1993 to 1995 in 2002 and to 4048 in 2008, with 48 million people living in these areas. Although Approximately 12% of the population but only 2.2% of dentists are African American. Individuals of Hispanic ethnicity make up another 10.7% of the population, but only 2.8% of dentists are Hispanic. Less than 6% of entering student dentists are African American, and less than 6% are Hispanic. The demographics of oral disease indicate that these two minority groups comprise a significant proportion of the problem of disparity in care.

A further issue is graduating dentists’ general lack of instruction and experience in treating children. The typical college of dentistry curriculum provides an average of only 177 clock hours of didactic and clinical instruction in dentistry for children. A recent study found that 33% of dental school graduates had not had any actual clinical experience in performing pulpotomies and preparing and placing stainless steel crowns, common therapies required for children. Official American Dental Association (ADA) policy also questions the adequacy of the dental curriculum in preparing dentists to treat children. In 2000, an ADA House of Delegates resolution called for “a review of the predoctoral education standard regarding pediatric dentistry to assure adequate and sufficient clinical skills of graduates.” The background statement supporting the resolution suggested that inadequate educational preparation for treating children could be a barrier to children’s access to care. There is no evidence of a subsequent increased emphasis on children’s dentistry in predoctoral education. In fact, in a recent study entitled “U.S. Predoctoral Education in Pediatric Dentistry: Its Impact on Access to Dental Care,” the authors concluded “results suggest that U.S. pediatric dentistry predoctoral programs have faculty and patient pool limitations that affect competency achievement, and adversely affect training and practice.”

An additional dimension of the workforce problem is the practice orientation of many dentists. Dentists generally do not treat publicly insured children, that is, children covered by Medicaid or the State Children’s Insurance Program (S-CHIP). It is difficult to discuss the issue of access to care, particularly when focusing on the disparities that exist in oral health among America’s children, without referencing the public insurance system. Medicaid provides an entitlement to comprehensive dental services for children who live at or below 150% of the federal poverty level, and S-CHIP provides the entitlement to children living at or below 200% of the federal poverty level. Medicaid and S-CHIP, however, fail to meet the oral health needs of America’s children. Among the several factors contributing to this failure is dentists’ unwillingness to provide care in their offices for children who have publicly financed dental insurance. Dentists offer multiple reasons for this failure, including low reimbursement schedules, demanding paper work and billing requirements, and the frequent failure of the parents of these children to keep scheduled appointments. A 1996 study indicated that only 10% of America’s dentists participated in the Medicaid. A more recent study indicates approximately 25% of dentists received some payment from Medicaid during a given year; however, only 9.5% received $10,000 or more.

An International Approach for Improving Children’s Access to Care

In 1921, a group of 30 young women entered a 2-year training program at Wellington, New Zealand to study to become school dental nurses; in 1988 the designation was changed to “school dental therapists.” Recent literature in the United States has designated this position as a “pediatric oral health therapist.” School dental therapists transformed the oral health of the children of New Zealand and laid the basis for what was to become an international movement. New Zealand’s School Dental Service continues to this day and has developed an enviable record in caring for the oral health of children in New Zealand (W.M. Thomson, Associate Professor of Dental Public Health, School of Dentistry. University of Otago, Dunedin, New Zealand, personal communication, May 2003, and ).

The traditional curriculum in dental therapy in New Zealand enrolls high school graduates who spend 2 academic years, each of 32 weeks’ duration, in the dental therapist’s curriculum. During the first year topics of study include the basic biomedical sciences (general anatomy, histology, biochemistry, immunology, and oral biology) as well as clinical dental sciences (dental caries, periodontal disease, preventive dentistry, patient management, radiography, local anesthesia, restorative dentistry, dental materials, and dental assisting). In the second year, the course content includes pulpal pathology, trauma, extraction of primary teeth, clinical oral pathology, developmental anomalies, health promotion/disease prevention, New Zealand society, the health care delivery system, and record keeping, as well as administrative and legal issues associated with dental therapy practice in New Zealand. Approximately 760 hours of the 2400-hour curriculum are spent in the clinic treating children; most of this experience occurs in the second year. Graduates entering the School Dental Service must serve for 1 year in a preceptorship with another school dental therapist (W.M. Thomson, personal communication, May, 2003, and ).

In New Zealand 610 registered dental therapists provide care for the country’s 850,000 children. Ninety-seven percent of New Zealand’s children are cared for by dental therapists who are assigned to every elementary and middle school in New Zealand. They work under the general supervision of a district dental officer. A recent report of the oral health of New Zealand’s school children documented that at the end of a given school year essentially none of New Zealand’s children in the School Dental Service had untreated tooth decay (W.M. Thomson, personal communication, May 2003, and ).

The model developed in New Zealand has spread to 52 other countries. Currently more than 1500 dental therapists provide the overwhelming majority of dental care for children in Australia.

Malaysia employs dental therapists to provide free dental care for its 3 million children in 17,000 elementary schools and 2000 secondary schools through a network of 2000 public dental clinics for children. All dental care for children in Malaysia is provided by dental therapists.

Dental therapists have practiced with Health Canada, Canada’s Ministry of Health, since 1972 (GM Schnell, unpublished data). Approximately 100 of the 300 dental therapists practicing in Canada are employed by Health Canada to treat Canada’s First Nation people (L. White, National Dental Therapy Program Officer, Health Canada, personal communication, 2007). The remainder practice in Saskatchewan, where dental therapists are recognized as full members of the dental team, with many practicing in dental offices, complementing the work of dentists in much the same manner dental hygienists practice in the United States. Double-blind comparisons of the work of the Canadian dental therapists and dentists indicate the quality of restorations placed by dental therapists is equal to that of restorations placed by dentists. Econometric research has documented the cost–benefit effectiveness of the dental therapists working for Health Canada.

Great Britain recognizes dental therapists as important members of the dental team. Currently, 700 dental therapists are practicing in a variety of oral health care settings in the United Kingdom. Great Britain recently expanded the training opportunities for dental therapists and now graduates more than 200 dental therapists each year from its 15 programs.

Recently, the Netherlands adopted a combined dental therapist/hygienist model as a major dimension of its dental delivery system and now matriculates 300 individuals per year to be dually trained in their vocational schools. At the same, time the Dutch are reducing the number of dentists accepted to their dental schools by 20% and also are adding an additional year to the education of a dentist. The justification advanced for this change is that in the future dental therapists will provide significant aspects of basic preventive and restorative care, with dentists performing more complex procedures and treating the increasing number of medically and pharmacologically compromised patients. This new policy reduces the absolute number of dentists to control the costs of dental education—a significant issue in the United States—and develops dental therapists both to improve access to care and to reduce the costs of care.

Throughout the world the use of dental therapy is growing in popularity, primarily because of a dental workforce that otherwise is to provide adequate access to oral health care.

Dental therapist training typically has been accomplished in 2 academic years. Recently, however, New Zealand, Australia, Great Britain, and now The Netherlands, have integrated their dental hygiene and dental therapy programs into programs lasting 3 or more academic years to train individuals in both hygiene and therapy.

Early efforts to train school dental nurses in the United States

In 1949 the Massachusetts legislature passed a bill authorizing the acceptance of funding by Forsyth Dental Infirmary for Children from the Children’s Bureau to institute a special 5-year program of dental research. The research would prepare “feminine personnel” in a 2-year training program to prepare and restore cavities in children’s teeth under the supervision of a dentist in a dispensary or clinic approved by the Commissioner of Health. The program was to be conducted under the supervision of the Department of Health and the Board of Dental Examiners. The passage of this legislation provided for the establishment of an experimental dental care program for children similar to the school dental nurse of New Zealand.

The reaction and response of organized dentistry was swift and strong. The ADA House of Delegates passed multiple resolutions: “deploring” the program; expressing the view that any such program concerning the development of “sub-level” personnel, whether for experimental purposes or otherwise, be planned and developed only with the knowledge, consent, and cooperation of organized dentistry; and stating that a teaching program designed to equip and train personnel to treat children’s teeth cannot be given in a less rigorous course or in a shorter time than that approved for the education of dentists. Harold Hillenbrand, Executive Director of the ADA, communicated the ADA House of Delegates’ position to the Commissioner of Health of Massachusetts in October, 1949. Of interest is the response to Hillenbrand by Vlado Getting, a physician, who was the Massachusetts Commissioner of Health at the time. In a long and thoughtful letter, Getting provided considerable background information regarding the proposal and the involvement of dentists belonging to the ADA throughout its development. He challenged the ADA, asking how the organization could “logically object to a research project designed to evaluate new methods of meeting the problem of dental disease.” He suggested that the ADA response might have been “hurried and therefore inconsistent with the declared objectives of the ADA,” which, he went on to say, were consistent with those of the Department of Health in Massachusetts, “namely the improvement of dental health.” Faced with increasing pressure from organized dentistry in Massachusetts and nationally, however, Massachusetts Governor Paul Dever signed a bill in July, 1950 rescinding the enabling legislation that had been passed the year before.

In February, 1972 John Ingle, Dean of the University of Southern California School of Dentistry, proposed the use of school dental nurses, as employed in New Zealand, to address the problem of dental caries among America’s school children. In the spring of that year Ingle authorized the submission, on behalf of the University of Southern California, of a proposal for a training grant of $3.9 million from U.S. Public Health Service to train school dental nurses, with Jay Friedman as the program director. At the same time, California Governor Ronald Reagan established a committee to study the functions of all dental auxiliaries and to make recommendations to the California legislature and the State Board of Dental Examiners. As a result of these two significant developments the two California Dental Associations then extant established a committee to study the New Zealand dental care system and the relationship of the school dental nurse to private practice; to assess the work of the school dental nurse; and to compare the New Zealand and California systems. Their report was published in April, 1973 in the Journal of the Southern California Dental Association and subsequently was summarized in the Journal of the American Dental Association ( JADA ). The report stated that “there is little doubt that dental treatment needs related to caries for most of the New Zealand children age [2.5] to 15 have been met.” The report concluded, however, that the public of California probably would not accept the New Zealand type of school dental service, because it would be perceived as a “second-class system.” Ingle and Friedman wrote sharp rebukes of the Committee’s report, pointing out the inconsistencies of the objective findings of the investigation in relation to the subjective conclusions of the report, which they judged was drawn to placate the practicing profession in California. Dunning also criticized the report’s conclusions in a letter to the editor of the Journal of the American Dental Association ; and Goldhaber, in an article in the Journal of Dental Education , called the committee’s conclusion “absurd.” Coincidentally, the grant application of Drs. Ingle and Friedman was not funded.