Opportunities and Challenges

Opportunities and challenges are numerous in this focus area. Challenges likely exceed the opportunities because barriers inhibiting access to dental preventive and restorative care continue to affect many select populations. Access to care generally refers to one-to-one delivery of health care, whether it is preventive or treatment by a health care provider to an individual patient. Access remains a problem, especially for residents in rural areas or inner cities (where dentists are less likely to locate), select racial and ethnic populations, children, older individuals, and persons in lower socioeconomic populations.

Since the late 1980s, the number of available dentists per 100,000 people has dropped from 57 to 48, a decrease of approximately 16 percent.³ This trend is likely to continue in the immediate future because dental school enrollments are projected to remain steady and the large cohort of practitioners who graduated at the time of maximum class size as a result of the 1971 Health Professions Act⁴ is now nearing retirement. Moreover, many private dental practitioners do not accept Medicaid payment nor do they locate their practices in rural or low-income areas.^{5, 6, 7, 8, 9} However, because productivity is also influenced by use of auxiliary personnel and treatment choices, the number of dentists is not the only key determinant related to limited access to care.

Geographic isolation is another major challenge to providing readily accessible care. For example, Alaskan Tribal programs experience a 25 percent vacancy rate and a 30 percent average annual turnover rate for dentists.¹⁰ The Alaska Dental Health Aide Program (ADHAP) is an initiative that is addressing geographic and dental access challenges. A component of the 38-year-old Community Health Aid Program (CHAP) operated by the Alaska Native Tribal Health Consortium and authorized by Federal law only in that State,¹¹ ADHAP sends individuals from remote villages for training to be dental health aides in six levels. These individuals are certified by CHAP to provide care either by direct or general supervision of a dentist. Other initiatives using different types of health aides or expanded duty auxiliary personnel also are under way.

The dental caries process is complex and includes diet, such as carbohydrates, especially those highly refined, as well as infectious agents and host factors. A challenge for oral health as for obesity is the amount and types of high carbohydrate foods and drinks available. Frequent consumption of such foods and beverages is associated with a higher risk of dental decay.¹² The 2005 Dietary Guidelines for Americans includes a key recommendation to "reduce the incidence of dental caries by practicing good oral hygiene and consuming sugar- and starch-containing foods and beverages less frequently."¹³ Changing eating behaviors is difficult to achieve and will require complex and multifaceted interventions. Equally challenging will be establishing policy among schools to change what is offered from vending machines and à la carte school lunches.

Healthy People 2010 serves as a framework to help the Nation understand oral health disparities. Policy development, program planning, and resource allocation and monitoring can be implemented more effectively through the use of standardized data to identify high-risk populations and to develop strategies for addressing the root causes of oral health disparities. These causes include lack of access to preventive and restorative services and poor oral health literacy.^{10, 14}

Several initiatives have been launched by the U.S. Department of Health and Human Services to address dental disparities. The National Institute of Dental and Craniofacial Research (NIDCR) has supported five disparity centers that will provide new information related to disease prevention among high-risk populations. The National Institutes of Health has launched a program to fund studies on health literacy, which NIDCR is supporting.¹³ The Centers for Disease Control and Prevention (CDC) has continued to support preventive activities, which include expanding fluoridation programs, supporting sealant programs in school-based and school-linked settings, and developing cost-effective surveillance measures for periodontal disease.^{15, 16} CDC issued a program announcement (03022) to fund States to address oral health disparities by describing the burden of oral disease and targeting populations with disparities by the expansion of sealant and fluoridation programs.

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