Gender and Age Distribution

The gender distribution of the U.S. oral health workforce differs by professional type. As of 2019, U.S. dentists were predominantly male; women accounted for only 33% of active dentists (American Dental Association 2020b), but their numbers are increasing as older dentists retire and a more gender-balanced group of dental school graduates moves into practice. An estimated 95% of dental hygienists and assistants are female (Health Resources and Services Administration 2018a).

The distribution of currently practicing dentists is relatively balanced across age groups but varies considerably by gender (Table 1). Among female dentists, approximately 56% were under 45 years of age, and 5% were 65 years and older. By comparison, nearly 32% of male dentists were under 45 years of age, and 22% were 65 years and older (American Dental Association 2021a). Among dental hygienists, 30% are under 35 years of age, and 52% are 35 to 55 years of age; 50% of dental assistants are under 35 years, and 40% are 35 to 55 years (Health Resources and Services Administration 2018a).

Table 1

Distribution of dentists by age group and gender: United States, 2018.

Racial and Ethnic Distribution

Overall, the oral health workforce is predominantly White and non-Hispanic, but this varies by professional type (Table 2). Federal data from 2017 indicate that 75% of dentists are non-Hispanic White, 14% are Asian, 6% are Hispanic, and 3% are Black/African American. A 2017 study of underrepresented minority dentists found that fewer than 1% of dentists are American Indian/Alaska Native (AI/AN) (Mertz et al. 2017a). Dental hygienists are 83% non-Hispanic White, 7.5% Hispanic, 4% Asian, and 3% African American. Dental assistants are 62% White, 22.7% Hispanic, 7% African American, and 6% Asian (Health Resources and Services Administration 2018a). It is commonly understood that increasing the health care workforce’s diversity will also increase that workforce’s ability to effectively address all Americans’ health care needs, leading to a healthier nation (Cohen et al. 2002).

Table 2

Distribution of dentists, dental hygienists, and assistants by race/ethnicity: United States, 2011–2015.

Employment Settings

Dentists, dental hygienists, and dental assistants work mainly in dental offices, whereas laboratory technicians most often work in offices and laboratories of medical equipment and supplies manufacturers. Other employment settings include academia, hospitals, or industry and state and federal government. Private dental practices deliver the majority of oral health care. In a growing business model for delivering health services, dental support or service organizations (DSOs) contract with dentists to provide administrative support services, enabling dentists to focus primarily on providing dental care (Association of Dental Support Organizations 2021). Dental services also may be provided in clinics within retail stores or via mobile clinics at job sites, schools, and nursing homes.

Private and Public Practices

More than 9 out of 10 dentists actively practice in privately owned, nongovernment settings (Table 3). The remaining 9% of active dentists are distributed among federal services (e.g., U.S. Department of Veterans Affairs, U.S. Public Health Service) (1%), academic settings (2%), armed forces (2%), state or local government (less than 1%), and other settings, such as other health or dental organizations and hospitals (1%). A small proportion (2%) of these dentists are either graduate students or residents or professionals working part-time, either as faculty or in private practice (American Dental Association 2019a). Practicing dentists are solo practitioners (50%), group-practice owners (30%), employees (17%), or independent contractors (4%) (Table 4). As of 2019, a small but increasing percentage of dentists (10%) are affiliated with large, multigroup DSOs, either as employees or owners (American Dental Association 2019b). DSOs provide business management, technology services (e.g., imaging and dental records), and nonclinical operations support to dental practitioners (Association of Dental Support Organizations 2021). In 2017, DSO-affiliated dentists were more likely to be female than male (12% vs. 7%, respectively). Large group settings and DSOs may appeal to younger dentists with high debt levels and those who are especially interested in work-life balance or exclusive focus on patient care activities (Parker 2012; Cole et al. 2015).

Table 3

Distribution of working dentists by practice setting: United States, 2018.

Table 4

Distribution of working dentists in private practice by ownership status: United States, 2018.

Other Dental Professional Employment

In 2017, 95% of 211,600 dental hygienists worked in dental offices. In 2016, 91% of 327,290 dental assistants worked in dental offices. In 2018, 79% of 34,480 dental laboratory technicians worked in medical equipment and supplies manufacturing; 17% worked in dental offices. The remainder in each of these categories worked in physicians’ offices or outpatient care centers, federal government agencies, or other settings (Table 5).

Table 5

Distribution of dental hygienists, assistants, and laboratory technicians by employment setting: United States, 2016–2018.

Burnout, Well-Being, and Resilience

Dentistry is a demanding and stressful profession. About 1 in 5 dentists report feeling burned out (LoSasso et al. 2015). Burnout is a state of emotional exhaustion, depersonalization, and loss of a sense of personal accomplishment associated with impaired job performance, including absenteeism and turnover (Chapman et al. 2017). Burnout and work dissatisfaction can lead to emotional distress for dentists and other oral health professionals, as well as disengagement from work and patients and a reduced quality of care and patient compliance (Hakanen and Schaufeli 2012; Starkel et al. 2015).

There is little published information on burnout in the U.S. dental profession compared to that for medical professionals, but studies have reported high levels of burnout among dentists internationally. Between 8% and 44% of dentists and dental students report stress beyond their ability to cope (Calvo et al. 2017). Burnout also is found among dental hygienists, as demonstrated by a study of dental hygiene educator/administrators. More than 40% of respondents in that study reported a moderate to high level of burnout and called for training in stress management (Hinshaw et al. 2010).

Burnout occurs when a training program or job overwhelms an individual’s ability to manage the resulting stress. Occupational stressors, detailed work under time pressure, frequent emergencies, and clinical mistakes can have serious consequences. One survey found that about 58% of solo and small group practice dentists reported feelings of job stress, whereas only 38% of dentists in group practices were stressed (LoSasso et al. 2015). The same survey found that 20–23% of dentists experienced work-related burnout. A systematic review of poor well-being and moderate burnout reported a significant correlation with patient safety problems. Thus, the consequences of burnout are serious for employees, patients, and institutions (Hall et al. 2016).

Providing Dental Services During a Public Health Emergency

Every dentist’s academic preparation includes instruction in basic medical principles and practices, including taking a medical history, diagnosis, radiographic (imaging) interpretation, wound suturing, and formulating a medical diagnosis on the basis of clinical signs and symptoms. Because these are valuable skills in any catastrophic event, dentists can make substantial contributions in collaborative efforts to assist communities affected by natural disasters. The National Disaster Medical System (NDMS) is a federally coordinated system that augments the nation’s medical-response capability (U.S. Department of Health and Human Services 2020a). Its purpose is to provide a single integrated national medical response that assists state and local authorities in dealing with the medical impact of major peacetime disasters. The NDMS has six special teams, each with a particular field of expertise, including forensic dentists and dental hygienists. Members are required to maintain appropriate certifications and licensure within their discipline. Activated members are temporary federal employees who work under the guidance of local authorities.

Dental officers within HHS agencies (e.g., IHS, CDC, FDA) and those within non-HHS agencies staffed by U.S. Public Health Service dental officers (e.g., BOP, USCG) also are available to provide oral health care services to disaster survivors, once a disaster is classified as a federal emergency (U.S. Department of Health and Human Services 2020a).

Allied Provider Programs

In the United States, there are 256 accredited dental assisting programs, 330 accredited dental hygiene programs, 3 dental therapy programs (with 3 additional programs seeking accreditation), 2 denturist programs, and 15 dental laboratory technology programs (Brickle and Self 2017; Commission on Dental Accreditation 2020b; National Denturist Association 2021).

Dental assisting certificate programs vary in length from 39.5 weeks (public institutions) to 57.3 weeks (private for-profit institutions) (American Dental Association 2019c). Dental hygiene programs are offered by public, private nonprofit, private for-profit, and private state-related institutions and can grant either an associate degree (an average of 84 credit hours) or a baccalaureate degree (4 years, an average of 120 credit hours). Hygienists who have an associate degree from a community college also can enroll in a program designed for them to complete a bachelor’s degree (American Dental Education Association 2021a). Master’s degree programs also are available to prepare hygienists for specialized careers, such as in public health dentistry or dental hygiene education.

The ADA Survey of Allied Dental Education for dental assisting schools in the 2018–2019 academic year showed that of 6,222 students, 47.7% were non-Hispanic White, 19.5% were Hispanic or Latino, 16.9% were Black/African American, 1.7% were Asian, 1.7% were AI/AN, and 5.9% were of unknown race; the remainder were members of two or more racial groups or were nonresident aliens (American Dental Association 2020c). Of the first-year student body, 93% of students were female and 7% were male.

The same survey reported first-year enrollments of 8,286 dental hygiene students in the 2018–2019 academic year, of which 94% were female and 6% were male. The report on race or ethnicity showed that 64.3% of the total number of dental hygiene students were non-Hispanic White, 15.4% were Hispanic or Latino, 8.2% were Asian, 4.7% were Black/African American, and the remainder were AI/AN, Native Hawaiian or other Pacific Islander, members of two or more racial groups, or nonresident aliens, and unknown race (American Dental Association 2020d).

First-year enrollment in dental laboratory technology programs in 2018–2019 was 306. Of students enrolled in these programs, 25.6% were non-Hispanic White, 14.8% were Hispanic or Latino, 11.2% were Black/African American, 14% were Asian, 0.2% were Native Hawaiian or other Pacific Islander, 1.3% were members of two or more races, and 3.4% were nonresident aliens (American Dental Association 2020e).

The profession of dental therapy in the United States is still in its infancy; there are three dental therapy programs in the United States, one in Alaska and two in Minnesota (Mertz et al. 2021). Nationwide data on these programs have not been collected, so demographic and other information is not available. In Minnesota, for example, there are two educational programs for dental therapy, and as of December 2018, a total of 92 dental therapists had licenses to practice. In that state, dental therapists are primarily women (86%); 82% are White, 5% are Hispanic, 4% are American Indian, and 2% are Black/African American (Minnesota Department of Health 2019).

Dental Programs

Dentistry is a highly technical profession. Depending on their level, students must attain established levels of basic, clinical, materials, and social science foundational knowledge in addition to clinical experience and skills. In the United States, the typical educational pathway to become a dentist includes completing a 4-year undergraduate study leading to a baccalaureate degree followed by a 4-year professional (predoctoral) program leading to a Doctor of Dental Surgery (DDS) or Doctor of Medicine in Dentistry (DMD). After obtaining degrees, graduates of dental schools may go into practice or may opt to attend one of 12 recognized advanced training programs, obtain research degrees, or attend postdoctoral training to enhance their general dentistry skills.

As of 2018, there were 66 dental schools in the United States, including 40 in public institutions, 22 in private institutions, and 4 that were private, state-related. CODA requires all U.S. dental schools to provide the equivalent of 4 years of training for the DDS/DMD degrees offered for dental programs; one school achieves this in a 3-year period. Total first-year enrollment of dental students for the 2018–2019 academic year was 6,250, of which an estimated 49% were male and 51% were female. Ten percent were Hispanic or Latino; 24% were Asian; 6% were Black/African American; 4% were AI/AN, Native Hawaiian, or two or more races; and 4% were nonresident aliens (American Dental Association 2019d). There were 627 advanced-standing and international dentists enrolled in the 38 international programs to become eligible for licensure in the United States (American Dental Education Association 2020a). There are two dental schools at Historically Black Colleges and Universities and a few schools that are members of the Hispanic Association of Colleges and Universities that provide programs, scholarships, and research training to assist underrepresented minority students to become competitive for admission to dental school and to develop research competence.

Specialty and Advanced General Dentistry Programs

Dentists may enroll in further training to become specialists, in intensive residency training for general practice, or for additional degrees. In the 2019–2020 academic year, there were 493 accredited specialty and 270 postgraduate dental education programs, of which 177 were General Practice Residency (GPR) programs and 93 were Advanced Education in General Dentistry (AEGD) programs (American Dental Association 2020f). GPR and AEGD programs are 1- or 2-year programs that enhance general dentists’ skills. They have similar goals, with GPR programs having an additional goal to “function effectively within the hospital and other health care environments” (Commission on Dental Accreditation 2020c, p. 8).

As of April 2020, there were 12 ADA-recognized specialties in dentistry requiring 1 to 6 years of training in a university or hospital (Table 6). Accredited programs for these specialties are required to train residents in research, and many specialty programs require residents to obtain a master’s degree (e.g., Master of Science in Oral Science, Master of Medical Science in Oral Biology, Master of Science in Dentistry) or a doctoral degree (e.g., Doctor of Philosophy, Doctor of Medical Science, Doctor of Science) concurrently with a certificate in specialty training. There are 100 accredited Oral and Maxillofacial Surgery (OMFS) programs, 46 offering a medical degree; 51 OMFS programs are housed in dental schools.

Table 6

Specialty and advanced general dentistry programs in the United States.

In academic year 2019–2020, there were 1,237 GPR and 924 AEGD enrollees. Of these enrollees, 52.4% were male and 47.5% were female. Their racial and ethnic composition included 52.6% non-Hispanic White, 22.8% Asian, 8.9% Hispanic, 4.7% Black/African American, less than 1% AI/AN or Native Hawaiian, 1.2% members of 2 or more races and not Hispanic, and 7.3% nonresident aliens (American Dental Association 2020f). A total of 5,082 graduate students and residents were enrolled in the 12 recognized specialty programs. Of these enrollees, 56% were non-Hispanic White; 23% were Asian; 7% were Hispanic or Latino; 4% were Black/African American; less than 1% were AI/AN, Native Hawaiian, or other Pacific Islander; 1% were members of two or more racial groups, and 7% were nonresident aliens; 63% were male and 37% were female, and 1% identified as other (American Dental Association 2020f).

Educational Cost and Debt

The cost of education varies by type of school (public, private, or private state-related, and for some allied programs that take place in community colleges) and by whether the tuition the student is paying is in district or out of district. The cost also varies for those attending vocational schools that train students for specific occupations.

Dental Programs

The rising total cost of an undergraduate college and dental education plus the slowing of dentist income has raised questions of a dental career’s value and what is expected from the social contract between dentists and the public. Dentists typically have the highest debt among major health professionals (currently approaching $300,000) after completing dental school training (American Dental Education Association 2019b). However, veterinary medicine (163%), optometry (130%), and pharmacy (111%) have higher debt-to-income ratios, compared to dentistry (99%) and family medicine (84%) (Asch et al. 2013; American Dental Education Association 2015; Nicholson et al. 2015; Formicola 2017).

The first year of dental school for the 2018–2019 academic year ranged from a resident’s cost at the University of Puerto Rico of $12,000 or $18,288 at Texas A&M University to $111,925 at the University of the Pacific. The average annual tuition and fees for first-year students at a U.S. public dental school was $49,537 for residents and $66,440 for nonresidents (American Dental Association 2021g). The average total tuition and fees for all 4 years of dental school in academic year 2018–2019 ranged from $251,223 for students attending a dental school within their state of residency (regardless of whether it was public or private) to $321,575 for students attending dental school as a nonresident (regardless of whether it was public or private). The average debt level in 2017 for students graduating from a private dental school was $341,190 and from a public dental school, $239,895. The average debt of all students with debt for all dental schools was $292,169 in 2019 (Figure 1) (American Dental Education Association 2019a). The high cost of dental education is an important factor in where graduates choose to practice.

Figure 1

Reported total educational debt of graduating dental school seniors: United States, 2019. Note: *Standard 10-year term (120 level payments).

Curriculum, Licensure, and Certification

Program-specific education standards guide the curricula of all CODA-accredited dental education programs. Advances in technology and factors related to licensure and national board examinations, as well as social changes, have resulted in new approaches to education and new content in basic, behavioral, and clinical or technical sciences. Some schools have adopted online education programs, electronic health records (EHRs), and increased problem-based or case-based education (i.e., more active learning, less lecture-based activity). Some have introduced competency-based assessments and use them to evaluate a broader set of skills (self-assessment, critical thinking, use of evidence-based resources, and lifelong learning). In clinical areas, some schools have introduced interdisciplinary “group” practices to prepare students to work in the practice environment, and schools have been placing students in a wider variety of community-based practices (Kassebaum and Tedesco 2017). The majority of dental schools and dental hygiene schools provide intraprofessional and interprofessional experiences (didactic, laboratory, and clinical). Some encounter barriers as a result of scheduling, geographic distances, workforce limitations, timing of courses and clinics, and facility limitations (American Dental Education Association Council of Deans and Council of Allied Dental Program Directors 2016).

States regulate the pathway for dental and allied licensure and may set the professional standards they deem necessary to protect patients. For example, New York requires a postgraduate year of training before a graduate is eligible for licensure (see Chapter 3 for more detail on licensure). State dental boards require that dental hygienists and dentists graduate from CODA-approved programs and successfully complete a written and clinical license examination (American Dental Association 2020g). States also define the scope of practice for dentists and midlevel providers. By completing continuing education courses and clinical cases, general dentists can earn certification in areas such as aesthetic dentistry or implant dentistry. All states specify the amount of continuing education courses required to maintain licensure, and most depend on courses certified by ADA (American Dental Association 2020h).

Continuity of Education and Training During a Public Health Emergency

Training and education programs would be wise to consider the impact of natural disasters or public health crises on their ability to continue functioning and provide needed emergency health care for local jurisdictions and to develop needed guidelines. For example, on August 29, 2005, Hurricane Katrina caused extensive damage to the city of New Orleans, with extensive damage to the Louisiana State University medical campus, destroying medical and dental facilities and closing the health sciences campus for about 2 years. During that time, the university conducted academic operations in borrowed facilities in Baton Rouge (Armbruster et al. 2011). Fourth-year students were sent to private practices to complete their clinical competencies (Fidel and Pousson 2007).

Hurricane Maria, the worst catastrophic event to hit the island of Puerto Rico in nearly 100 years, produced physical damage that closed the University of Puerto Rico for 3–4 weeks in fall 2017 and left the island with an unstable power grid and scarce provisions. The school adjusted its academic calendar and worked on repairing structural damage. With support from the profession, it provided personal hygiene products, support, and headlights, plus water and one hot meal a day, to students and staff for about 3 months.

In early 2020, as the novel coronavirus (COVID-19) health crisis was developing, many dental schools worked quickly to limit the virus’s spread in a large population with persons interacting in proximity (students, residents, staff, faculty, and patients). Dental professional schools have large open spaces with numerous clinical operatories, elevators, and classrooms. Schools and academic health centers sent students home, if possible, to reduce the on-campus census. They also stopped providing elective surgeries to prepare for an influx of patients needing specialized care and to preserve personal protective equipment (PPE). In addition, some schools initiated teledentistry and teledentistry training during the pandemic (Weintraub et al. 2020). All nonessential faculty and staff were transitioned to work from home, and plans were made for faculty to deliver instantaneous remote education.

During a 6-week time frame, four phases were proposed to manage the pandemic’s course. During phase 1, many states issued stay-at-home orders to avoid community spread of the virus. Schools developed online education programs for the didactic components of their curriculum, curtailed their preclinical programs, and closed their clinics except for patient emergencies. Research activities were curtailed except for essential research. CODA offered flexibility in revising programs to allow graduating students and residents to complete “equivalency assessments.”

The second phase was one of continuity. Schools maintained emergency services with rigorous PPE on the basis of revised clinical guidelines from ADA, CDC, and the Occupational Safety and Health Administration. Academics and operations continued, employing virtual classrooms, exercises, and remote secure “assessments” (computer-based examinations with self-proctoring tools). Clinical licensing examinations and national board examinations were suspended.

A third phase evolved in which states offered guidelines as schools and dental practices reopened using newly developed protocols. Schools resumed some nonemergency services, research, and didactic and preclinical education while maintaining social distancing and utilizing updated PPE guidelines. The timeframe for opening depended on the COVID-19 situation within each state. Patient screening protocols maintained social distancing. Priority was given to completing care, rather than to seeing new patients. Admissions protocols for candidates to dental school also had to change because dates for the Dental Aptitude Test were delayed, preventing applicants from taking an examination that dental schools often require for screening.

In the fourth phase, dental education programs were adapted, beginning with early laboratory courses in which student dentists developed their skill in using dental handpieces to offer restorations, root canals, and teeth cleaning. Because most uses of the handpiece results in the generation of aerosols, affected courses had to be altered with corrective actions submitted and approved by local public health agencies to accommodate social distancing and protection from aerosols. New protocols were developed to screen patients before they came to school clinics; to reduce the numbers of patients within buildings to maintain social distancing and protect patients and dental personnel from dental aerosols; and to rotate students, faculty, and staff through spaces in teams to enable team members to isolate in case a COVID-19 infection was identified within a team. Materials were developed to reassure patients about treatment safety and to allay patient, staff, and student concerns about coming to dental clinics.

Privately Owned Dental Practices

Privately owned dental practices typically serve patients who have dental insurance, purchased either individually or through employers, or who personally pay for dental care. In 2017, 51% of dentists worked as solo practitioners, ranging from 32% in South Dakota to 65% in Utah. The percentage of dentists who owned a solo practice in 2017 varied by gender. Fifty-six percent of solo practice owners were men, and 39% were women. Sixty-three percent of solo practice owners were aged 55 to 64 years, and 21% were younger than 35 years of age (American Dental Association 2017a). DSOs employed 7% of all dentists in private practice, although the percentage was twice that for dentists aged 21 to 34 years (Garvin 2017). The number of dentists per DSO ranged from 6 to 1,500, with a mean of 213 (Langelier et al. 2017a). Dentists are attracted to DSOs because they offer guaranteed salaries, an ability to transfer management responsibilities, and a more favorable work-life balance.

Publicly Owned Dental Practices

Publicly owned dental practices or clinics provide safety nets for the country’s underserved populations—the uninsured, Medicaid recipients, and other vulnerable populations who may not always have been well served by private dental practice settings. These practices include FQHCs, community clinics, and dental school clinics. In 2020, nearly 93% of all FQHCs provided preventive dental services to nearly 5.2 million patients (Health Resources and Services Administration 2021a). Nongovernment community clinics often receive community funding and grants and sometimes rely on volunteer providers. These safety net providers offer oral health care for many underserved children and adults who ordinarily would not receive these services because of their socioeconomic status, geographic location, or lower levels of health literacy. In addition, specialized government dental clinics offer care for active-duty members of the military, veterans, AI/ANs, and incarcerated populations.

The dental safety net also includes dental schools and education centers that train dentists, dental assistants, hygienists, and therapists. These academic institutions serve as dental care sites for those with Medicaid, the Children’s Health Insurance Program (CHIP), or no insurance. In 2016–2017, dental students provided care during more than 3.1 million dental visits in community settings (Contreras et al. 2018).

Nontraditional Settings

Not all patients can access private or public dental settings—for example, if they are homebound, institutionalized, or lack transportation. Some organizations and entities are taking a proactive approach by providing oral health services where members of the community live and learn. Nontraditional dental locations include settings where children learn—including day care centers, Head Start centers, and schools attended by underserved groups of children—and where persons live, including assisted living, group homes for persons with disabilities, nursing homes, rural community centers, and even where individuals shop or work. Such place-based care may use dentists or allied providers with expanded functions, such as dental hygienists working under general supervision to perform preventive procedures or dental therapists providing onsite routine restorative care. Integrated managed-care organizations have explored the value that interprofessional practice can add to patients’ overall health. For example, pediatric medicine clinics are providing oral health examinations, and dentists are addressing broader health concerns by discussing preventive oral health behaviors or providing tobacco cessation guidance (Rindal et al. 2013; Kranz et al. 2015; Mosen et al. 2016).

A goal of these scenarios is for the entire dental team to work at the total capacity of their licensed scope of practice, meaning that the team members provide the full scope of services that they have been taught and are licensed to provide. Other nontraditional types of practice may include the use of teledentistry to facilitate place-based care via telecommunication, with a remote supervising dentist as needed. Patients in such settings who have more complex dental needs may be referred to a traditional dental clinic.

Services Provided

Dental practice largely focuses on preventing disease through regular dental services, including examinations, imaging, dental cleanings or prophylaxis, and applying preventive agents such as fluoride and dental sealants. More than three-quarters (76%) of all dental procedures are diagnostic and preventive, with only 12% of procedures representing restorative dental care (Guay 2016). Dental clinics also provide other preventive health care services, including tobacco cessation training, because many manifestations of tobacco use are in the oral cavity (Brown et al. 2019; Chaffee et al. 2020). Dental offices in some states screen for diabetes, and Oregon now allows dental practitioners to administer vaccines, including for influenza and human papillomavirus in the dental setting (Solana 2019). In 2020, states began implementing regulatory changes to allow oral health professionals to provide COVID-19 vaccines, and in March 2021, the 7th Amendment to the Public Readiness and Emergency Preparedness (PREP) Act permitted dentists in every state to administer COVID-19 vaccines (Health Resources and Services Administration 2021b; Machado 2021).

Dental Practice Technology

Dental practice uses an array of technology, including computers; lasers; scanning and milling technology; updated radiographic technology to enhance diagnostic information; and EHRs. Computers are a foundational technology within dental offices, connected with scanning technology to create new restorations, and used to manage EHRs. Digital scanning for orthodontics has largely replaced alginate dental impressions. The scanning eliminates the need for study models to be poured in stone and enhances treatment planning. The resulting models are easily passed to insurance companies through secure means when orthodontics is being completed for medically necessary reasons and must be reviewed by an insurer. Lasers are used to whiten teeth, to remove decay from a tooth, or to remove soft tissue. Scanning and milling technology is a part of the growing computer-aided design/computer-aided manufacturing (CAD/CAM) technology used to fabricate new bonded ceramic and resin-based composite restorations within the dental office (Trost et al. 2006).

The use of chairside CAD/CAM systems is promising in all dental branches in terms of minimizing time and effort made by dentists, technicians, and patients for restoring and maintaining patient oral function and aesthetics, while providing high-quality outcomes (Baroudi and Ibraheem 2015). Dental cone beam computed tomography is a novel X-ray technique used to make three-dimensional images of teeth, bones, and soft tissue (U.S. Food and Drug Administration 2020). For more information on advanced dental technologies, see Section 6 of this monograph.

An EHR is an information system that can accomplish many tasks for a busy dental practice, including creating dental records; storing billing, payment information, and radiographs; and sharing information with other providers’ EHRs. Dental practices are increasingly using EHRs to: (1) improve quality, safety, and efficiency; (2) reduce health disparities; (3) engage patients and family; (4) improve care coordination and population health; and (5) maintain the privacy and security of patient health information (Office of the National Coordinator for Health Information Technology 2019). Many large dental institutions such as dental school clinics, FQHCs, and group practices have transitioned to an EHR, but fewer than half of dental practices utilize the full potential of EHR chairside (Moffitt and Steffen 2018). Section 6 offers more discussion on EHRs.

Telehealth includes the use of technology to facilitate the delivery of health care services at a distance, as well as patient and health professional education, and to conduct public health and administrative activities (Daniel et al. 2015). Teledentistry encompasses a wide array of oral health services that can be delivered from a remote setting, both live and through a “store and forward” method. For example, an oral surgery specialty consultation can be conducted using teledentistry so that a patient does not have to travel a long distance before a procedure (see Section 6 for additional information). It can reduce the cost and time of care and improve access to specialists (Banbury et al. 2014; Acharya and Rai 2016; Powell et al. 2017). Optimal telehealth systems are fully integrated into the health record. Telehealth collaboration reduces the risk for redundancies in patient care, such as duplicate tests and treatments (Fathi et al. 2017).

Provision of Dental Services During a Public Health Emergency

Whereas publications may have described the impact of public health crises on access to and delivery of medical care in affected communities, they often have ignored the impact on access to and delivery of dental care, and they generally have not described dental professionals’ roles and contributions as crisis event responders, including provision of dental care and victim identification. A number of disasters and public health crises have affected dental practices during the past 20 years (Box 1). In 2005, Hurricane Katrina affected the lives of an estimated 1,185 licensed dentists in Louisiana and Mississippi (Mosca 2007). The affected dental professionals experienced prolonged displacement and disruption of their practices, and patients lost a vital workforce. Since Hurricanes Maria and Irma in 2017, the oral health systems in Puerto Rico and the U.S. Virgin Islands have faced numerous challenges, including an increase in demand for dental services and shortages of oral health professionals (Hall et al. 2018; Sharac et al. 2018). In 2018, more than 58,083 wildfires burned 8.8 million acres in California, destroyed an entire town, and killed 85 persons, making 2018 the deadliest wildfire season in that state’s history (Insurance Information Institute 2020). The 2018 California wildfires displaced at least 17 dentists and 47 dental office staff members in the disrupted area.

Unlike regional crises, the COVID-19 pandemic, which began to affect the United States in early 2020, disrupted access to dental care for the entire nation. While the pandemic is still ongoing, COVID-19 resulted in closure of dental offices for all but emergency care for many months; this varied by state. Necessary PPE was difficult to access for hospitals and unavailable for most dental offices. Because of the national shortage of PPE, dental providers made a concerted national effort to donate their stock to local hospitals. State and federal agencies requested that elective medical and dental care be deferred because of fears the virus would spread. Under ADA recommendations, dental offices limited their services to emergency care or were closed (O’Reilly 2020). The closure of an estimated 80% of dental offices, at least temporarily, increased the number of patients going to the ED for dental care.

Nationwide, states viewed dentistry through different lenses, with 30 states designating dentistry as essential and 20 allowing only emergency dental procedures. Sixteen states allowed the provision of essential procedures, and 7 states had no mandate regarding dental practice (American Dental Association 2020i). After 6 weeks of COVID-19 challenges, states started to allow dental practices to reopen. Most states determined that dentistry is essential and offices could reopen. Even states with shelter-in-place initiatives began to prepare for the reopening of dental practices.

Governors and CDC raised a number of considerations that guided states’ decisions to reopen various businesses and services, including dental practices: (1) regional COVID-19 infection rates and the impact on health facilities, especially hospitals; (2) whether health systems had an adequate supply of PPE; (3) local availability of testing that provided prompt results; (4) local public health officer rulings for the state, city, or county; (5) availability of qualified staff within the practice team; and (6) existence of a COVID-19 infection control plan (California Dental Association 2020).

ADA’s Health Policy Institute polled dentists nationwide to gather information on plans regarding COVID-19 closure and reopening. An early survey conducted in April 2020 showed that 80% of dentists had closed their practices, and 95% or more reported a significant financial impact as measured by practice collections (Carey 2020). The April data further showed that the proportion of dentists fully paying staff salaries had dropped from 27% in March to 11% in April and that the proportion paying no staff salaries had risen from 28% to 44% during the same period. A number of COVID-19 relief bills established under the Coronavirus Aid, Relief, and Economic Security Act offered federal loan programs to help small businesses, including dental practices, cover up to 8 weeks of payroll costs, interest on mortgages, rent, and utilities.

According to the ADA Health Policy Institute, more than 90% of the 19,000 surveyed dentists had applied for one such program, the Paycheck Protection Program (Garvin 2020a). On October 1, 2020, HHS announced that an additional $20 billion in government funds would be available to offset revenue lost because of the COVID-19 pandemic. This new funding, the Provider Relief Fund, applied to dental providers as well (Garvin 2020b).

Dental Insurance Coverage

At the end of 2016, an estimated 249 million Americans, or 77% of the population, had some form of dental insurance. Two-thirds of them (164 million) had private or commercial dental coverage, and another 84 million had dental benefits through public programs such as Medicaid, Medicare Advantage, CHIP, or IHS. An estimated 47% of Americans received dental coverage from their employers, 27% received such coverage from Medicaid or another public program, 4% had private insurance but were self-paying patients, and 22% had no dental coverage in 2018 (Figure 4).

Figure 4

Dental insurance enrollment based on coverage sponsor: United States, 2018.

Cost sharing is a normal part of dental insurance and takes the form of deductibles, copayments, and other costs for dental procedures that exceed an insurance plan’s defined benefits. Even for those with dental insurance, cost can be a barrier to care. Vujicic and colleagues (2016a) reported that financial barriers play a larger role in access to dental care than for any other type of health care. Almost 25% of adults with incomes below 100% of the federal poverty level deferred needed dental care in 2014–2015 because they could not afford it (Vujicic et al. 2016a). A substantial portion of the $55 billion consumers paid out of pocket in that same year was in the form of deductibles and copayments under dental benefit plans.

Impact of Dental Insurance on Access to Care

Dental benefits increase preventive care use by 19% and the use of restorative services by about 16% (Meyerhoefer et al. 2014). Moreover, private insurance (not government) alone has been shown to increase demand for dental services (Mueller and Monheit 1988).

For government programs such as Medicaid, increasing reimbursement to dentists tends to increase utilization of preventive services (Nasseh and Vujicic 2015). Research has shown that increased reimbursement to dentists is necessary, but not sufficient, to persuade dentists to sign up to accept Medicaid patients or expand the numbers of such patients they accept. This means that increasing the numbers of dentists who accept Medicaid patients is complex and cannot be explained by reimbursement alone (California Health Care Foundation 2008).

FQHCs treat underserved populations and charge for services differently. For patients who lack dental insurance, some community clinics and FQHCs use a sliding-fee schedule to discount fees in accordance with a patient’s ability to pay, usually calculated with reference to the FPL for income and family size. The sliding fee makes dental care more affordable but still requires those seeking care to make payments.

In addition, FQHCs are paid differently when they treat Medicaid patients and receive reimbursement from the federal government. Federal law requires Medicaid payers to use a prospective payment system (PPS) to reimburse FQHCs. States also can establish an Alternative Payment Methodology (APM) as long as the APM pays an FQHC at least as much as the PPS reimbursement (Medicaid and CHIP Payment and Access Commission 2017). Sometimes this system is referred to as payment according to encounter rates, whereby the center receives one lump payment for each valid patient visit. The Medicare, Medicaid, and SCHIP [State CHIP] Benefits Improvement Act of 2000 created the PPS methodology used in reimbursing FQHCs. The CHIP Reauthorization Act of 2009 enacted similar PPS rate language for CHIP (Medicaid and CHIP Payment and Access Commission 2017).

Medicare generally provides medical coverage for those aged 65 years and older and some younger who have specific disabilities or diseases. Medicare beneficiaries have the option to stay in traditional Medicare, administered by the Centers for Medicare & Medicaid Services, or to opt for a Medicare Advantage Plan (MAP), administered by one or more private companies. MAPs are required to offer all the same benefits as traditional Medicare, but they can add additional benefits such as dental or vision as an incentive for members. In 2019, 22 million persons were enrolled in a MAP, of which 67% had an extra dental benefit (Jacobson et al. 2019). Although Medicare Advantage dental coverage can vary from plan to plan, they normally include dental examinations, cleanings, and imaging (e.g., x-rays).

Nonmonetary Benefits of Dental Insurance

In addition to directly supporting dental care, dental insurance has indirect benefits for both patients and dental practices. For the latter, participating in a dental benefits program directs consumers to them, because consumers gain value by seeking their care from a dental provider within their insurer’s network. Dental insurance also affords consumers a right to appeal the quality of dental care provided within the insurance network. In addition, dental insurers may offer programs to educate consumers about when and why to use their dental benefits and the importance of maintaining regular examination and prevention schedules. Some dental benefit programs provide coordination of care between dental and medical plans. In addition, dental benefits play an important role in ensuring quality by requiring providers to adhere to specific standards of care, as well as other patient safety rules and regulations.

Populations with Problems Accessing Care

Many Americans have difficulty accessing regular dental care, particularly those with limited financial means, those with no dental insurance or with limitations in veterans, Medicare, and Medicaid health insurance, among others. Collectively, identifiable groups of individuals who cannot access the dental care needed for adequate oral health are considered underserved. These underserved populations may be defined as poor and may include some racial or ethnic minorities; children under the age of 5 years; those with disabilities; place-bound older adults; many veterans; lesbian, gay, bisexual, transgender, queer, and other (LGBTQ+) individuals; persons with special health care needs; and those with complex medical conditions such as HIV/AIDS. Other underserved groups are those that lack adequate access to dental care because providers are unwilling to accept payments from federally funded programs such as Medicaid and those who reside in areas with professional workforce shortages, such as inner-city or rural areas. Other factors that can affect access to care include the lack of professionals trained to care for patients needing complex care, the inability of government programs to attract dental providers, poorly integrated health systems, and the fact that persons with limited means may lack the ability to pay out of pocket for preventive and restorative dental care (Yarbrough et al. 2014; Allen et al. 2017).

The Institute of Medicine (renamed the National Academy of Medicine) report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations (Institute of Medicine and the National Research Council 2011, p. 1), described “persistent and systemic” barriers, including “social, cultural, economic, structural, and geographical” barriers to receipt of oral health care. The report concluded that:

• Improving access to care is critical to improving oral health outcomes and reducing disparities.
• The lack of integration of oral health care with medical health care contributes to poor access to care.
• The sources of financing for vulnerable and underserved Americans are limited and tenuous.
• Multilevel solutions are required not only at the provider level, but also by the organizational, community, and policy sectors.

Population-Focused Integration Models

Two integration frameworks developed in the United States since the 2000 Surgeon General’s Report on oral health emphasized safety net populations and partnerships with private and public health organizations, governments, and academic institutions (Harnagea et al. 2017; Harnagea et al. 2018). HRSA proposed the first model, Integration of Oral Health and Primary Care Practice (IOHPCP), in 2014. The IOHPCP model includes risk assessment, oral health evaluation, preventive interventions, communication and education, and interprofessional practice collaborations. A team of primary care physicians, dentists, policymakers, and professional associations commissioned by the National Interprofessional Initiative on Oral Health developed the second model, the Oral Health Delivery Framework, which has been implemented in some medical offices and community clinics to coordinate oral and primary care providers in a convenient location.

The primary population-focused strategy has been the extension of the patient-centered medical home (PCMH) to include oral health care (Brownlee 2012; Braun and Cusick 2016). Linkage to payment has primarily driven the uptake in PCMH practice transformation. As of 2018, 29 states had implemented payment reform that provided incentives for PCMH practice transformation (most often through National Committee for Quality Assurance recognition), generally by paying providers a per-member per-month fee in addition to regular fee-for-service payments for Medicaid patients (Gifford et al. 2018). In addition to PCMH models that focus on primary medical care, other “health home” models have been developed to target either specific populations or medical specialties.

The health home model developed under the Affordable Care Act targets improvement of care for high-need, high-cost individuals with multiple chronic conditions.

ACOs use fixed global budgets and quality metrics to manage patient care and reduce costs while maintaining care quality (Shortell et al. 2015). As of 2018, 21 states had adopted health home programs, which receive an enhanced 90% federal match for services provided to this population during the first eight quarters of the program. Most ACOs do not include primary dental services (Mayberry 2017). Oregon is an exception, having enrolled 90% of its Medicaid patients in a program that includes comprehensive dental care for children (McConnell 2016). FQHCs frequently serve as health homes for Medicaid and uninsured populations, and many have co-located dental offices (Atchison et al. 2019).

Patient-Focused Integration Models

Health systems with well-defined populations have sought to integrate dental and medical care as a strategy to address the Institute for Healthcare Improvement’s Triple Aim initiative, particularly for patients with chronic conditions or special needs. Suter and colleagues (2009) described key principles for successful health systems integration, including offering a comprehensive range of services with shared goals and organized interprofessional teams providing a standardized set of services that focus on the needs of a large, defined population. Other aspects of patient-focused integration models include clearly defined roles and responsibilities for team members, professional autonomy, system processes, and communication strategies to support the coordination of patient services. These structures generally support the provision of care and evaluate care quality and cost using modern electronic records and information systems. Distributing primary oral and medical care tasks to meet patients’ current needs wherever they are seen can increase access to care (Institute of Medicine and the National Research Council 2011; Atchison et al. 2018), improve quality (Mosen et al. 2021), and reduce health care costs (Jeffcoat et al. 2014; Nasseh et al. 2017). These changes will require broadening the scope of clinical competencies to support the distribution of tasks among dental and medical providers. The full impact of these changes on workforce demand and supply are still unknown.

Insurance companies, integrated commercial health systems (HMOs, PPOs), and public health systems with well-defined patient populations, such as the VA and the U.S. Department of Defense, have proposed integration strategies (Joskow 2016; Atchison et al. 2018). The goals are to use vertical and horizontal integration to distribute care delivery activities among clinical staff, who employ the full range of their skill sets and scopes of practice. Health systems providing dental and medical care have the ability to integrate oral and systemic health care delivery by taking advantage of clinic co-location, integrated information systems, and shared management and financial systems. Access to care remains a concern, which is reflected in efforts to limit patient wait times for nonemergency appointments.

In one integration model, insurance companies have sought to tailor dental benefits and manage care for patients with certain chronic diseases (e.g., diabetes, heart disease) and for pregnant women. Aetna initiated a dental-medical integration program offering free dental care to “at-risk” members (Albert et al. 2006; Aetna 2013). Cigna attempted to improve health and lower costs through extended benefits to expectant mothers, patients with diabetes, and patients with cardiovascular disease (Cigna 2013). United Concordia studied the association between treating gum diseases and savings in terms of reduced annual medical costs for patients with diabetes, stroke, or heart disease (Bramson 2016).

Private integrated health systems such as Kaiser Permanente Northwest (Portland, Oregon), HealthPartners (Bloomington, Minnesota), and Marshfield Clinic (Marshfield, Wisconsin) provide comprehensive health care services, including those related to medical, dental, and behavioral health, to their members. Each has a leadership and organizational commitment to oral health integration and coordinates oral and medical staff to provide the right care, at the right place, at the right time, using professional staff at the peak of their capabilities and scope of practice. Capitated payment for professional services promotes financial risk sharing and a focus on quality. Each organization currently employs fully integrated health records systems. Direct communication through the electronic medical record between dentists, physicians, hygienists, pharmacists, and nurses enables quick and easy coordination of patient care in both medical and dental settings.

Patient Safety System

Malpractice claims constitute the most widely used surveillance system in dentistry, although their primary purpose is to help patients receive compensation for injury incurred during dental care. Liability providers are obligated to report payments made at the state level to the National Practitioner Data Bank (Health Resources and Services Administration 2021c), which collects information on adverse events as well as malpractice claims. Unfortunately, these reports and the data collected are isolated, often voluntary, and not integrated consistently within the continuum of education, licensure, and practice.

The problem of safety is larger than these poorly organized efforts suggest (Burger 2019). Growing scientific evidence confirms that patient harm occurs in dental offices (Weiman et al. 1995; Lee et al. 2007; Lee et al. 2013). Dentists, like physicians, routinely perform highly technical procedures in complex environments. Reports, both in medical literature (Obadan et al. 2015) and in the FDA Manufacturer and User Facility Device Experience database (Hebballi et al. 2015), describe deaths associated with dental treatment as well as a range of other adverse events—for example, the swallowing of endodontic files (Weiman et al. 1995) and the swelling of tissue as a result of tooth bleaching (Spencer et al. 2007). Reviews of electronic dental records have confirmed a broad array of harmful events during or following dental surgery, including an adjacent tooth inadvertently being dislodged, a patient found nonresponsive following anesthesia and transferred to the emergency room, and lip numbness lasting weeks as a result of nerve injury (Kalenderian et al. 2018).

Oral health specialty professional organizations, such as the American Academy of Pediatric Dentistry (AAPD) and the American Association of Oral and Maxillofacial Surgeons, exemplify how the dental profession is working to model the safety culture of medical professional organizations. These organizations have undertaken initiatives to raise the awareness of safety issues, emphasize the need for transparency when problems occur, and advocate for standardized protocols for treatment, including clinical practice guidelines (CPGs) and checklists (Wyckoff 2019; American Association of Oral and Maxillofacial Surgeons 2021). For example, AAPD co-developed guidelines with the American Academy of Pediatrics to address the special challenges involved in using sedation techniques with children (Coté and Wilson 2019).

Checklists have been developed to reduce dental errors (Pinsky et al. 2010), minimize wrong-site extractions or procedures (Lee et al. 2007; Perea-Perez et al. 2011; Saksena et al. 2014), and reduce misdiagnoses of temporomandibular joint disorders (Beddis et al. 2014). However, improving safety requires a systems perspective that considers individual variables, technology, organizational factors, processes and procedures, and the environments within and surrounding medical and dental practice (Carayon et al. 2014).

Communication to Promote Patient Safety

The medical community has long recognized health literacy’s importance in developing health care providers’ and organizations’ effective communication with patients in medical environments. Health literacy has an impact on safety, as well as quality, in the dental setting. The Joint Commission, which governs education programs in health care, initiated a public policy initiative in 2007, to improve providers’ delivery of safe, high-quality health care. In particular, it highlighted making effective communication—including health literacy—an organizational priority to improve patient safety, pursue policy changes that promote effective practitioner-patient communications, and incorporate strategies to address patients’ communication needs across the care continuum (The Joint Commission 2007).

IOM describes a health-literate health care organization as one that “makes it easier for people to navigate, understand, and use information and services to take care of their health” (Institute of Medicine 2012, p. 2). It has called for required provider education on communication and cultural competency to improve effective use of patient communication strategies. The ADA Council on Advocacy for Access and Prevention developed an action plan to create health-literate communication information for dental practices (American Dental Association 2009; Rozier et al. 2011; Bress 2013). A culture of patient safety in oral health involves not only making oral health information clear and accessible, but also contextualizing that information to patients’ lives (Horowitz et al. 2012; Maybury et al. 2013).

EHRs are another important resource patients can use to understand their dental problems, treatment plan, and care providers’ instructions. Patient portals allow patients to securely log in, view and correct personal information, get test results, and email questions to health care providers. Regulations issued to implement the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 included requirements focused on patients being able to receive a clinical summary after office visits as well as being able to access their health information via internet-based tools, such as patient portals. This after-visit summary is designed to help patients remember the visit’s content, support patient engagement in decision-making, and improve the quality of information in EHRs (Hummel and Evans 2012). Opportunities remain for improving the adoption and use of patient portals to ensure these innovative tools are fully integrated into the workflow of the oral health care delivery system (Irizarry et al. 2015).

Clinical Practice Guidelines

IOM defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Institute of Medicine 2001, p. 44). Scientific evidence has grown at such a rapid pace that dental providers are on their own to sift through new knowledge and to update their decisions about clinical care. ADA defines evidence-based dentistry as the integration of “the dentist’s clinical expertise, the patient’s needs and preferences, and the most current, clinically relevant evidence” (American Dental Association 2020j). The process of translating scientific evidence into clinical practice has been described as taking place in three phases: synthesis, dissemination, and implementation (Pitts 2004a; 2004b; 2004c). Calls have recently been made advocating evaluation of CPGs as part of this process.

The synthesis phase consists of collecting and summarizing relevant, high-quality clinical research so it can be used to answer a specific question. Such systematic reviews concisely lay out the benefits and harms of treatment or diagnosis. During the dissemination phase, the evidence summary is adapted to promote clinicians’ understanding so they can adopt information in routine clinical practice. Common dissemination strategies include webinars, continuing education courses, and journal articles.

A more formal type of evidence adaptation, the CPG, has now found its way into dentistry. High-quality CPGs present clear recommendations regarding the benefits and potential harms that patients could receive from a particular course of treatment. Essentially, a sound CPG should lead to improvement in dental care (Faggion 2013). Although the main goal of CPGs is to ensure that high-quality evidence, known to provide patient benefits, reaches appropriate patients, the general quality of CPGs can vary considerably (Mubeen et al. 2017). Major producers of CPGs include professional organizations, such as ADA, AAPD, and Cochrane; and government agencies including CDC and the U.S. Preventive Services Task Force.

The third phase of translation is implementation. Much research-generated evidence fails to find its way into routine clinical practice in a timely way, a phenomenon referred to as the “know-do gap” (Institute of Medicine 2001). The know-do gap is in play when treatments known to be beneficial and based on high-quality evidence differ from the care patients actually receive. Research shows that evidence-based beneficial treatment often is not adopted in clinical practice unless accompanied by an implementation plan that addresses the barriers for a given clinical setting. Many of the barriers to implementation (e.g., financing, provider training, information technology support, scope of practice, workflow concerns) exist within a clinical care setting, and much of an implementation plan focuses on system-level changes. Effective implementation plans need to be specific to the clinical setting for which they are intended. In the United States, ADA has led efforts to disseminate information on the use of evidence-based decision-making in clinical care (Carrasco-Labra et al. 2015) and to develop and promote a set of clinical guidelines for certain procedures (American Dental Association 2020j). Some are calling for a “fourth phase” that refers to evaluation, but is more aligned with improving rigor in the creation of CPGs (AGREE Next Steps Consortium 2017; Benavidez and Frakt 2019).

Measurement of Quality

Health care performance measurement systems include at least three common uses of quality measures (Institute of Medicine 2006). Accountability includes information to assist patients, health plans, and accrediting organizations in making choices about dental providers or clinics. Responses by patients to questions such as “How often did your regular dentist treat you with courtesy and respect?” and “Did the dental practice offer translators for non-English-speaking patients?” are used by dental administrators and national surveys (Dental Quality Alliance 2012; 2015). Quality improvement measures provide information to improve care in organizations. Examples of quality indicators are the percentage of health center patients aged 18 and older who have had a dental examination in the past year (Health Resources and Services Administration 2014b), the percentage of children 6 to 9 years of age who received at least one sealant on a permanent first molar within 6 months of an oral evaluation or assessment, and the percentage of patients aged 1 to 5 years who received a follow-up oral evaluation within 3 months of a well-child visit. Calls continue for improved development, standardization, and implementation of oral health measures, including patient-reported oral health outcome measures (Dental Quality Alliance 2012).

Population oral health measures assist stakeholders in making decisions about access to services (e.g., public insurance benefits and coverage), support those involved in community-wide programs and efforts to address racial and ethnic disparities and promote healthy behaviors, and are used by public officials responsible for disease surveillance and health protection. Examples of an access-to-care measure is “children 2–11 years of age with untreated decay” or “the percentage who reported they were unable to get needed dental care in the past year.” An example at the national level is the Healthy People 2030 objective to “increase the proportion of children, adolescents, and adults who use the oral health care system” (U.S. Department of Health and Human Services 2020b).

Lack of Dentists in Underserved Areas

Multiple barriers exist to improving access to oral health services for underserved patient populations. In 2018, there were more than 5,800 dental health professional shortages areas (HPSAs) affecting almost 58 million people in the United States. A HPSA is identified by a defined geographic area and must have a population-to-provider ratio meeting a defined threshold, for dental care that ratio is generally 5,000 to 1. Figure 5 depicts dental HPSAs in the United States and it shows that every state has dental shortage areas, from Delaware (10) to states such as California, Texas, Michigan, Georgia, and Florida, which have between 208 and 473 areas (Health Resources and Services Administration 2020c). Population groups, such as some served by the Indian Health Service (IHS), accounted for the majority of the shortage designations, totaling 1,834 designations and serving more than 47 million individuals (Health Resources and Services Administration 2020b). It is estimated that only 50% of the dental needs among underserved population groups were met. Rural areas accounted for more than two-thirds of all shortage areas (National Advisory Committee on Rural Health and Human Services 2018).

Figure 5

Dental health professional shortage areas (HPSAs): United States, 2018. Note: Number of HPSAs refers to the number of shortage areas within each state.

In a survey of executive leaders and chief executive officers at health centers, 45% reported having at least one dentist vacancy; of those vacancies, 47% had lasted longer than 6 months (National Network for Oral Health Access 2018). In 2019, IHS reported having more than 100 openings for oral health professionals (Indian Health Service 2021). Only a small percentage of dental students come from rural areas, but increasing their number is important because they are most likely to return to their hometowns or other rural areas to practice (Vujicic et al. 2016b). Job opportunities in local and federal health centers are not widely promoted or advertised, which leaves dentists unaware of these opportunities.

Redefining the Roles of Oral Health Care Providers

Several strategies have emerged in the last 20 years to address inadequate oral health care in underserved areas. The most notable change in that time has been the introduction of dental therapy into the United States. The profession of dental therapy began with the establishment of New Zealand’s School Dental Service in 1921 and has since expanded to more than 50 countries. Dental therapists have been providing dental care in other countries for many years, and that care has been shown to improve population and individual oral health in underserved communities. These allied professionals prepare and fill cavities using a hand drill and perform nonsurgical extractions—procedures reserved for dentists in the United States. This allows oral health services to be delivered to many who might not otherwise receive them.

In 2004, the U.S. version of the dental therapist, the dental health aide therapist (DHAT), was introduced in Alaska when the first Alaska Native students graduated from the University of Otago dental therapist program in New Zealand and returned home to address their villages’ and communities’ oral health needs. In 2007, the Alaska Native Tribal Health Consortium opened a 2-year DHAT education program in partnership with the University of Washington School of Medicine’s physician assistant training program. In 2015, the program transferred its academic affiliation to Iḷisaġvik College, a tribal college based in Utqiaġvik, Alaska, and was renamed the Alaska Dental Therapy Educational Program. Graduates of this tribal college program earn an associate degree in applied science. The program recruits students from the communities where they will return to work. In the nearly 15 years of DHAT practice in Alaska, 74% of those trained are still practicing.

The awarding of an associate degree positioned the program to meet the Accreditation Standards for Dental Therapy Education Programs of the Commission on Dental Accreditation (CODA) (Commission on Dental Accreditation 2015). Therefore, in August 2020, the 3-year Alaska Dental Therapy Educational Program at Iḷisaġvik College became the first CODA-accredited dental therapy program in the United States. Now, culturally appropriate training and student support from a tribal college open a door to higher education that was once closed to many rural Alaskan youth. Students gain the skills and confidence they need to go on to higher education and careers.

After graduation, DHATs must complete a minimum of 3 months or 400 hours of preceptorship under the direct supervision of a licensed dentist. Upon approval by the supervising dentist, DHATs can apply for certification from the Community Health Aide Program Certification Board. DHATs are recertified every 2 years, a process that includes continuing education requirements and competency assessments in all procedures in their scope of practice. Certified DHATs work under indirect and general supervision of a dentist in accordance with established standing orders. As of March 2021, there are 35 certified DHATs in Alaska.

A 2010 study looked at many aspects of DHAT practice and supervision, including blinded evaluations of work by both DHATs and dentists, and found that DHATs in Alaska provide safe, appropriate, and effective care that patients value (Wetterhall et al. 2011). Since then, a number of studies in Alaska’s southwestern region have shown that communities receiving more days of coverage by a DHAT had fewer cavities and extractions and that both children and adults in those communities received more preventive services than those in communities without DHAT coverage (Chi et al. 2018). Other studies of DHATs have yielded positive findings regarding quality of care (Wetterhall et al. 2011), access to care (Minnesota Department of Health 2014), and cost-efficiency for practices employing these professionals (Apple Tree Dental 2018).

The success of the DHAT program has prompted other states to revise state practice acts to allow dental therapy practice. The first state to successfully add dental therapy to a practice act was Minnesota in 2009. The resulting legislation allows for dental therapy practice at differing levels and includes a requirement for these therapists to practice under a dentist’s supervision and to primarily serve low-income, uninsured, and underserved patients. Dental therapists licensed in Minnesota are required to graduate from a program approved by the Minnesota Board of Dentistry or accredited by CODA with at least a baccalaureate degree. Currently, all Minnesota dental therapy program graduates are eligible to practice both dental therapy and dental hygiene. As of 2019, there were 92 licensed dental therapists with 95% working in their field.

Innovations are expanding the role of dental hygienists through additional functions, alternative programs, and independent practice. Since 2001, there have been important changes in the scope of practice for dental hygienists in many states (Langelier et al. 2016a; Langelier et al. 2016b). A number of states now permit dental hygienists to provide preventive oral health services in public settings, including schools, nursing homes, day care centers, and Head Start programs, which creates a new point of entry for underserved populations to receive preventive oral health services (Langelier et al. 2017b; Keough et al. 2020). Dental hygienists can now also provide new materials and technology, such as silver diamine fluoride and interim or atraumatic restorations, without prior authorization from a dentist (Langelier et al. 2016b). These therapeutic agents are especially helpful in stopping or slowing decay progression so that children, the elderly, and others may be protected from pain and further tooth deterioration.

This provides lower-cost preventive and basic restorative care, especially to those who have not received regular dental care—or any dental care at all. In some states, public health dental hygienists are licensed to practice under a dentist’s general supervision after successfully completing at least 10 hours of continuing education (e.g., in infection control, in risk management for practice in a public health setting, involving hands-on experience in a public health setting). The scope of practice for dental hygienists varies by state and is generally expanding (Langelier et al. 2016b). Evidence suggests that in states in which they have a more autonomous scope of practice, dental hygienists have had a more positive impact on population oral health (Langelier et al. 2016b).

Barriers to Development of Workforce Models

Despite payment system reform and other progress, barriers continue to limit the development of new workforce models (Frogner et al. 2020). Health care organizations can limit flexibility by using privileges based on established professional boundaries (Frogner et al. 2020). Restrictive state practice acts, health care, and/or educational requirements limit the expansion of new and existing workforce models. State practice acts vary considerably; many states do not authorize dental therapists, and they may restrict the scope of practice of dental hygienists, preventing them from providing the full range of services for which they are trained. In 2018, a federal report titled Reforming America’s Healthcare System Through Choice and Competition recommended that states should evaluate emerging health care occupations, such as dental therapy, and consider ways in which their licensure and scope of practice can increase access and drive down consumer costs while still ensuring safe, effective care (U.S. Department of Health and Human Services 2018). Restrictive rules remain, despite a lack of evidence that they are necessary to protect against unsafe care. In short, a better-performing, wider-reaching oral health delivery system cannot be achieved without legislative and regulatory change.

Many professions have raised educational requirements without any increase in scope of practice. Studies in nursing demonstrate that these requirements do not improve patient outcomes or increase wages for practitioners, but they do decrease the satisfaction of practitioners, who cannot use their full scope of knowledge. Professional organizations often encourage “degree creep” or “credential creep,” found in many educational programs (Garvin 2013; Fuller and Raman 2017). Minnesota’s educational requirements for dental therapists exemplify this kind of overtraining with respect to the state-permitted scope of practice. CODA dental therapy standards require much less education than the bachelor’s and master’s level of education mandated in Minnesota legislation, yet Minnesota hygienists and therapists are allowed no broader scope of practice than is permitted with the associate degree in Alaska. It should be noted, too, that higher degrees require more time and money to complete, which can discourage lower-income individuals, persons of color, and others from underserved and rural communities from entering the health professions (Ashford 2013).

Effect of Unserved Oral Health Needs on the Health Care System

Examining the risks and benefits of dental care reform provides one perspective on why reform has been slow. For the most part, the outcomes of unaddressed dental disease do not fall to the dental field to deal with. Instead, they are borne by the medical system in the form of emergency department (ED) bills to manage pain and infection resulting from untreated oral disease and by patients who have difficulties chewing associated with loss of their teeth (McDonough 2016; Rowland et al. 2016). An indicator of an underperforming delivery system is the number of persons who seek hospital ED care for preventable dental conditions during regular office hours (Wall et al. 2014). In 2016, there were 2.2 million oral health-related ED visits at a cost of $2.4 billion (American Dental Association 2019e). Likewise, the broad potential benefits of improving dental care access and oral health—such as superior diabetes care, improved management of cardiovascular health, prevention of childhood diseases, and employment of low-income adults—are not tied to tangible incentives within the dental care system (Mertz and O’Neil 2002). The consequences experienced outside the dental care system underpin many calls for system integration by policymakers (Koppelman et al. 2016).

Increasing Programs to Diversify the Workforce

The 2000 Surgeon General’s Report on Oral Health in America documented the disparities in oral health among specific populations and emphasized the importance of addressing the lack of racial and ethnic diversity in the dental workforce. By 2050, racial and ethnic minorities will make up half the population of the United States (Colby and Ortman 2015). Yet in 2015, nearly 3 out of every 4 dentists were White, and Hispanic/Latino, Black/African American, and American Indian/Alaska Native (AI/AN) dentists continued to be underrepresented in relation to their proportions in the general U.S. population (Table 7).

Table 7

Percentage of dentists and new dental graduates bv race/ethnicity compared to the overall population: United States, 2016.

The Indian Health Care Improvement Act (Public Law 94-437, as amended) (1976) authorizes the IHS Scholarship Program, Loan Repayment Program, health professions training-related grants, and recruitment and retention activities—all to improve Native Americans’ health while attracting them to the dental workforce and to the numerous workforce shortage areas within IHS settings.

These IHS programs work synergistically with tribal organizations and federal authorities to recruit and retain health professionals to provide high-quality primary care and clinical preventive services to AI/AN individuals and to increase the number of sites eligible to participate in the scholarship and loan repayment programs. In fiscal year 2018, the IHS Loan Repayment Program made 100 awards to dentists and dental hygienists, including 39 new awards and 61 contract extensions.

Reaching parity in representation of populations of color among dental practitioners is critically important because concordance between practitioners and patients enhances patient satisfaction and the quality of care. Minority practitioners treat a disproportionate number of low-income and minority patients (Mertz et al. 2016). Yet in the 2018–2019 academic year, six dental schools enrolled no Black/African American students, and another nine each enrolled only one (American Dental Association 2019d).

Burnout, Well-Being, and Resilience

Addressing the potential for professional burnout remains a challenge. A Mayo Clinic study found that more than 50% of physicians reported at least one symptom of burnout, and other health providers are similarly affected (Talbot and Dean 2018). There are two philosophical approaches to dealing with burnout or overwhelming stress, and the differences have sometimes led to contentious national debate.

One approach to burnout addresses individuals, with the goal of increasing resilience and coping skills to make the stressors less overwhelming to the practitioner. Because dental school, residency, and the practice of dentistry are inherently stressful, dentists must develop the ability to manage these stressors without being overwhelmed. Resilience requires that providers be taught specific skills, including conflict management, emotional regulation (how to calm down after being upset), and perspective taking (looking at a situation from both persons’ point of view). A perspective-taking intervention was found to increase patient satisfaction with medical students’ clinical examinations (Blatt et al. 2010).

The other approach is to consider external stressors a systemic problem so that the goal is to decrease them. This approach starts with the assumption that the structure and practice of dentistry and dental training is unnecessarily stressful and inevitably produces burnout. In other words, no one should have to become resilient to something that they should not have to endure. An example of a systemic approach was the Accreditation Council for Graduate Medical Education’s 2003 call to reduce medical resident working hours to no more than 80 hours per week, a change that reduced medical errors as well as stress experienced by residents (Agency for Healthcare Research and Quality 2019). Other proponents of the need for systemic change point out that an increasingly business-like health care environment overwhelms a busy provider with tasks (e.g., maintaining profitability, completing electronic health records) unrelated to actual patient care (Talbot and Dean 2018).

Multiple groups are examining burnout and the fallout associated with burnout within the health professions, including the American Dental Association (ADA), the American Dental Education Association (ADEA), and the National Academy of Medicine. The risk of professional burnout, which has been associated with such negative effects as medical errors and malpractice suits, may be somewhat ameliorated by the practitioner’s workplace (Dyrbye et al. 2017). For example, surveys of community health center providers found high levels of professional satisfaction (National Network for Oral Health Access 2014; 2018). Most providers working in such health centers chose these settings out of a desire to provide care for underserved populations. In 2013, 84% of dentists and 94% of hygienists in community health centers planned to remain there (National Network for Oral Health Access 2014). Satisfaction remained high in 2018, with 70% of dentists and 87% of hygienists intending to remain in this setting (National Network for Oral Health Access 2018).

However, these levels of satisfaction may not apply across the entire oral health care landscape, and are being addressed by groups who think it is important to examine burnout’s impact on professional satisfaction. The National Academy of Medicine, one of the three institutes that make up the National Academies of Science, Engineering, and Medicine, launched the Action Collaborative on Clinician Well-Being and Resilience in 2017 (National Academy of Medicine 2021). The initiative was in response to leaders from professional health care associations, educational institutions, large health care centers, public and private payers, health information technology vendors, government agencies, trainees, and patient and consumer groups expressing the need for an initiative to address “concerns from the clinical community about rising challenges to clinician well-being and resilience.” The collaborative is committed to three goals: raising the visibility of clinician stress, burnout, depression, and suicide; improving baseline understanding of challenges to clinician well-being and consequences for clinicians, patients, and the health care system; and advancing evidence-based, multidisciplinary solutions to improve patient care by caring for the caregiver. In addition, as an update to the Triple Aim, addressing burnout has been included in the Quadruple Aim (Bodenheimer and Sinsky 2014). This approach is now being supported by the Agency for Healthcare Research and Quality (AHRQ) to help facilitate a more effective health care delivery system (Figure 6) (Agency for Healthcare Research and Quality 2019).

FIGURE 6

The Quadruple Aim and the Optimization of Health Systems.

The collaborative’s Clinician Well-Being Knowledge Hub emphasizes a systems-centered approach to address burnout and promote well-being that is structured around three key areas: (1) causes of burnout, such as organizational factors, learning and practice environment, society and culture, rules and regulations, personal factors (Figure 7); (2) effects of burnout, including safety and patient outcomes, clinician well-being, turnover and reduction of work effort, and health care costs; and (3) solutions to burnout, such as individual and organizational strategies and measurement of burnout. The collaborative has begun to break the culture of silence around this issue by initiating dialogue across the health care professions about challenges to clinician well-being and identifying resources for understanding the factors affecting clinician well-being and resilience. ADA has developed a Well-Being Initiative, which includes online resources on burnout, stress, and building resilience (ADA Center for Professional Success 2020).

Figure 7

Factors affecting clinician well-being and resilience.

Allied Provider Programs

Since 2000, the types of educational programs in operation or under accreditation have expanded to include dental therapists, advanced-standing dental hygienists, and CDHCs to meet the demand for more providers. First-year enrollment in dental hygiene programs grew from 6,486 students in 2000 to 8,370 students in 2016. The new CDHC programs have grown quickly to 39 states as of 2019, with 150 students enrolled, 305 CDHC graduates, and 17 schools offering, or planning to offer, training. On the other hand, first-year enrollment in dental assisting programs decreased from 6,150 to 6,080 during the same time period. Similarly, first-year enrollment in dental laboratory technician programs fell from 444 to 324 (American Dental Education Association 2018a).

Dental Programs

Between 2000 and 2017, the number of U.S. dental schools grew by 20%, from 55 to 66. There were four new public and eight new private dental schools, as well as the closure of one school (American Dental Education Association 2018b). First-year enrollment in Doctor of Dental Surgery or Doctor of Medicine in Dentistry programs grew from 4,327 students in 2000 to 6,317 in 2020, an increase of 46% (American Dental Education Association 2021b), which can be attributed both to new schools and increases in class sizes at existing dental schools.

Specialty and Advanced General Dentistry Programs

The number of accredited specialty programs increased from 416 to 457 between 2000 and 2016. Although some specialties lost programs (dental public health lost three and prosthodontics lost nine), the number of enrollees increased in all specialties. The top three specialty programs in terms of overall enrollee growth during that period were oral and maxillofacial surgery, which grew from 848 to 1,195 enrollees; pediatric dentistry, which grew from 442 to 921 enrollees; and orthodontics, which grew from 714 to 1,043 enrollees (American Dental Association 2016).

The number of advanced dental education enrollees also grew between 2000 and 2018. The number of General Practice Residency enrollees grew slightly, from 1,063 to 1,237. The number of enrollees in advanced education for general dentistry increased from 614 to 924 (American Dental Association 2016; 2020f).

Educational Cost and Debt

Most college students in America take on debt as they seek bachelor’s or higher degrees. Average dental school debt has grown greatly, from $87,605 in 2000 to $242,289 in 2019 (American Dental Education Association 2020c). The proportion of dental school graduates reporting debt greater than $150,000 increased from 20.9% in 2000 to 71.4% in 2019 (American Dental Education Association 2020c). Annual tuition and fees also have risen sharply for dental hygiene education programs, from an estimated $26,000 to $41,000 (American Dental Association 2020k). Graduating debt for dental hygiene students is not well known, although the Institute for College Access and Success states that the average college graduate accumulates $28,650 of debt (The Institute for College Access and Success 2018). Although federal and private loans and some scholarships assist some students, significant challenges remain.

Although debt represents a major challenge for many students as they select a career or start their careers, there are no national data that document debt’s impact on career or location choice. Studies have found that the strongest “predictors of postgraduate educational plans were mentoring and encouragement from significant others, including family members and dental school faculty” (Scarbecz and Ross 2007). Wanchek and colleagues (2014) found a mild positive correlation between educational debt and intended employment choice, but student characteristics had more impact. Among the foreign-trained dentists, higher levels of debt have been reported associated with International Dentist Programs (IDPs). Black dentist respondents in a workforce survey reported an average total debt of $167,792 compared to an average of $147,871 in 2012 dollars for all students, with those graduating from IDPs having the greatest debt (Mertz et al. 2017b). This suggests that debt may have a greater impact on the numbers of African American and Hispanic dentists given that workforce studies indicate that 49% of Hispanic/Latino dentists and 85% of Black dentists were born in the United States (Raja et al. 2017; Mertz et al. 2017c).

Debt does not appear to have deterred U.S.-born applicants from applying to dental school. The number of applicants to dental school between 2000 and 2018 rose from 7,770 to 11,298, a 45% increase (American Dental Education Association 2018a). A strong concern, however, is whether debt deters underrepresented minorities and lower-income individuals from choosing dentistry as a career. Available data do not answer this question. Moreover, it is not clear whether options for reducing debt—for example, by committing to practice in workforce shortage areas or through loan repayment programs—are understood or convincing for potential minority applicants (California Dental Association 2011; American Dental Education Association 2019a).

Diversity

The 2000 Surgeon General’s Report on oral health highlighted the challenges in recruiting and retaining women and underrepresented minorities in the dental workforce. Since that time, efforts have been made to diversify the student bodies in both dental schools and allied professional programs. The Historically Black Colleges and Universities (HBCUs) were early responders to develop supportive programs for underrepresented minority students to enter medicine and dentistry. A workforce study of Black dentists reported that the majority of U.S. trained Black respondents older than 49 years of age had attended an HBCU dental school and only 35% attended a public dental school, but the pattern had reversed for younger black dentists suggesting that pipeline programs have successfully extended to a broader cadre of dental schools (Mertz et al. 2017b). In addition to pipeline programs, schools adopted holistic admission reviews (Price and Grant-Mills 2010), minority recruitment, and community-based dental education programs (Formicola et al. 2010). Enrichment and recruitment programs (Johnson et al. 2013) and combined advanced education programs (Davies et al. 2019) have shown positive results in selected populations and schools (American Dental Association 2021h).

Postbaccalaureate programs were designed to provide additional support, such as Dental Admission Test preparation, academic courses in the sciences, mentoring, and clinical observations, for highly motivated applicants initially denied dental school admission (Alexander and Mitchell 2010). A study of seven such programs showed that four programs accepted students at a rate of 90–95% and the three remaining schools accepted students at a rate of 45–72%. Graduation rates for students in all seven schools were more than 95%. Most of these programs target students who are committed to providing patient care in underserved communities (Wides et al. 2013; Johnson 2017).

Diversification of the dental workforce also is supported through the entry of foreign-trained dentists. Dentists have several pathways by which to acquire a U.S. dental license through further education, as described in Chapter 1 (see Pathways to U.S. Dental Practice for Foreign-trained Dentists) (Allareddy et al. 2014). Another method is through an immigrant H-1B visa, supported by a dental school to serve as academic faculty. Vujicic (2017b) reported that the number of foreign-trained dentists in U.S. academic settings increased from 3.3% in 2003 to 13.1% in 2016.

Dental education loan repayment and scholarship programs are important tools for enhancing workforce diversity. As of 2020, numerous federal and state programs were available to reduce the high cost of dental education (American Dental Education Association 2020b). For example, Illinois specifically provides financial support for minority dental education (American Dental Education Association 2020b).

As a result of these initiatives, the racial and ethnic composition of dental students has become more diverse. Between 2000 and 2018, among all dental students, there were decreases in the proportion of non-Hispanic White students (62% to 51%) and increases in that of Asian (22% to 24%) and Hispanic/Latino students (5% to 9%). Enrollments of Black/African American students have remained unchanged since 2000 (5%). The percentage of male dental students decreased from 60% to 49%, and the proportion of female students increased from 40% to 50% (American Dental Association 2019d).

With regard to allied dental programs, the ADA Survey of Allied Dental Education showed similar trends for dental hygiene students between 1998 and 2018. Representation grew for Hispanic/Latino (5% to 15% of total dental hygiene students), Asian (5% to 8%), and Black/African American students (3% to 5%) (American Dental Association 2020d). Racial and ethnic representation in dental assisting programs increased similarly: Hispanic/Latino (9% to 19% of total students in dental assisting programs), Black/African American (12% to 17%) and Native American (1% to 1.7%) (Haden et al. 2001; American Dental Association 2020c).

Dental hygiene schools reported the use of career days, counseling, and representatives at job fairs (Moore 2012) to boost their diversity. Hunter and colleagues (2015) noted that CODA standards did not require a diverse student body, and only 43% of dental hygiene programs had a recruiter. A proposal has been made for consideration to add a statement in 2021 CODA Accreditation Standard 1—Institutional Effectiveness that “the program must have a humanistic culture and learning environment by fostering diversity of faculty, students, and staff” (Commission on Dental Accreditation 2020d, p. 18).

Curriculum

Because of new CODA standards, curriculum changes have resulted in more integration of the behavioral, clinical, and basic sciences as well as interprofessional training (Elangovan et al. 2016). Active, problem-based, or case-based learning (Elangovan et al. 2016), critical thinking, self-assessment, and the use of evidence-based approaches also have been incorporated. Both specialty and advanced graduate education programs and allied provider programs reported more education on integrated systems (Wides et al. 2013), person-centered care, collaborative care, and team-based practice (Elangovan et al. 2016). Requirements were added for dental education to make opportunities available for students to engage in community-based learning experiences. Although this is not a replacement for basic education on the importance of social determinants of health or principles of dental public health, it gives students experiential education on application of cultural competency. Pathways for career advancement (new training programs, continuing education, licensure, and practice models) have changed to allow more options and geographic mobility.

The Association of American Medical Colleges developed oral health competencies for medical students in 2011 with funding from the Health Resources and Services Administration (HRSA). It also created an initiative funded by ADEA to encourage faculty members to develop peer-reviewed training modules to address the oral health competencies as a means of training future physicians (Krisberg 2018).

Students and faculty will be challenged to navigate a future that includes a rapidly changing U.S. population, technological change, increasing emphasis on evidenced-based dentistry and quality control, and growing connections with the rest of the health care system. In addition, person-centered care in both dental school and a broader range of community clinical settings will be stressed, including care provided in long-term care facilities and other areas where the growing older population resides. Major technological changes include use of virtual reality by some dental schools, even for preparing teeth in the laboratory before working on patients.

Given the graying of America, an additional topic for interprofessional education (IPE) is considerations surrounding end-of-life oral health palliative care. Hospitals and long-term care facilities might value an approach that offers oral health care services and provides needed personnel to address these issues. The current challenge to providing these services is that professionals rarely receive any formal education or training in providing palliative oral care in hospitals, hospices, and assisted-living facilities. Dental schools and residency programs have an opportunity with IPE partners to advance knowledge and skills for providing the needed care for this population (Treister et al. 2020). A 2013 study reported that the majority (89%) of dental schools offered didactic training in treatment of older adults, and less than one-quarter offered specific clinical training on older adult care (Levy et al. 2013).

The maintenance of oral health for an aging population suggests attention needs to be paid to incorporating curriculum on age-appropriate prevention and treatment of disease, as well as end-of-life oral health palliative care, into dental and resident training programs. Community-based programs that include long-term care facilities are needed for hands-on training to manage care for functionally declining elders and to train caregiver staff in regard to oral health (Macdonald et al. 2020).

Studies indicate that academic dental clinics, in particular, stand to benefit from an increased focus (in didactic and clinical settings) on quality and patient safety (Ramoni et al. 2014). Administration of the Medical Office Survey on Patient Safety Culture, developed by the Agency for Healthcare Research and Quality, revealed that dentistry scored lower on all patient safety dimensions than did medicine. In addition, many studies chronicle the stresses students face during their dental school experiences (Elani et al. 2014). The negative effects of stress demand an increased emphasis on educational programs within the curriculum that help professionals manage stress throughout their careers (meditation, yoga, and promoting good nutrition and sleep) (Alzahem et al. 2011).

Licensure and Certification

After many years of an extremely restrictive state-based licensure process, change is occurring. For example, nearly half of U.S. states (shown as dark green) now allow alternative pathways to dental licensure (Figure 8). Whereas there were 53 licensure examinations in the United States in 1968 (Catalanotto 2017), there currently are just five testing agencies: the Council of Interstate Testing Agencies, Inc.; Commission on Dental Competency Assessments; Southern Regional Testing Agency; Central Regional Dental Testing Service, Inc.; and Western Regional Examining Board. The first two of these agencies also administer the dental hygiene examination.

Figure 8

Adoption of alternate pathways toward dental licensure in the United States.

Five structural pathways to licensure are available in the United States—the traditional format, curriculum-integrated format (CIF), postgraduate residency (PGY-1), objective structured clinical examination (OSCE), and portfolio-based examination. The five testing agencies offer the traditional examination. Following the 2019–2020 academic year, some states modified their examination processes for licensure because of the COVID-19 pandemic. Organized dentistry, state regulators, and educators have developed clear plans to implement the OSCE, which will replace the single-encounter, patient-based examination, which both the profession and the public have questioned. Four of the agencies offer the CIF, which enables students to take the examination in sections during a period of time. The PGY-1 pathway allows students to gain licensure if they complete 1 year of accredited PGY-1; Delaware and New York mandate this pathway; and it is an option in Minnesota, California, Colorado, and Ohio. The state of Washington will accept completion of a PGY-1 offered in certain state-approved programs. Minnesota accepts the Canadian OSCE, California accepts a portfolio-based examination, and Colorado has announced it will accept all options (American Dental Association 2021i).

Interprofessional Education and Practice

Education and training programs in oral health promotion for predoctoral and medical residents as well as medical practitioners have been developed over the past 20 years. Programs for pediatricians have incorporated the provision of oral health services—examinations, oral hygiene instruction, fluoride varnish, education, and anticipatory guidance—and parental education about the need for a dental home with regular dental care for children, including children with special needs and other vulnerable populations (see Section 2 for more information) (Mouradian et al. 2003; Rozier et al. 2003; Hummel et al. 2016). Common risk factors for diseases and social determinants of health in which lack of dental insurance, of a dental home, or of access to community water fluoridation are increasingly seen as issues both medical and dental personnel should address (Petersen 2009; Watt and Sheiham 2012). Moreover, training of dental providers has begun to incorporate chairside medical screening into dental practices (Barasch et al. 2012).

The National Network for Oral Health Access convened national experts in 2008 to discuss caries disease prevention and to update and recommend strategies for health centers and other safety net dental programs that would enable medical providers to deliver preventive oral health services to pregnant women and children (National Network for Oral Health Access 2008). Care options for persons with special health care needs also advanced in areas of community-based and portable dental care, essential care, and general awareness (Havercamp and Scott 2015).

Although important advances have been made in the past 2 decades, challenges persist. The barriers to and facilitators of sustainable IPE (Lawlis et al. 2014) and oral health integration (Savageau et al. 2019) are well documented. In the past 10 years, the opportunities for academic and practice organizations to accept IPE have increased (e.g., the publication and adoption of Smiles for Life, a national curriculum that is said to be the most widely used resource for primary care physicians) (Deutchman et al. 2011). Nonetheless, professional medical and dental education face challenges related to competing demands, coordination of calendars, difficulties in planning meaningful exercises, and lack of appropriate multi-professional assessment modalities.

Although many accrediting bodies require IPE and practice, challenges remain in implementing meaningful, profession-wide exercises that truly gauge students’ competency. Currently, students are being taught IPE, but have limited experience with interprofessional practice and how it can be applied after graduation. The coalescence of a diverse set of leaders from across the health professions could provide impetus for a new model of health professions education that mirrors the nation’s health care needs.

Dental education must also be integrated within dentistry itself. Despite a call for more productive clinical care, with providers working to the full extent of their licenses, dental education remains largely a solo endeavor for the dentist-in-training, with little involvement of dental hygienists, dental assistants, dental therapists, or behavioral- and mental-health professionals. Functioning as an efficient, productive team requires training.

In addition, the concept of a career ladder—a formal progression from entry-level positions to higher levels of education, responsibility, salary, and skill—is needed. An education and training system that allows individuals to assume some professional responsibilities at an entry level and advance through education and training could be an important strategy for addressing workforce diversity and shortage issues. For example, New York passed a law in 2017 requiring not a baccalaureate degree (Bachelor of Science in Nursing, or BSN) at licensure, but rather that licensed registered nurses obtain a BSN or higher in nursing within 10 years of initial licensure. Similar strategies could construct career ladders in dentistry for individuals who enter the profession as dental assistants, therapists, or dental hygienists.

Changes in Education and Training as a Result of a Public Health Crisis

Following the terrorist attack on the World Trade Center in 2001, calls accelerated for changes in curriculum and policy related to preparation of dentists to assume roles in disaster relief and management. Professional associations and dental schools developed relevant symposia (Guay 2002), curricula, and training (More et al. 2004; Glotzer et al. 2006; Psoter et al. 2006; University of Illinois at Chicago College of Dentistry 2019). A curriculum on bioterrorism (Palmer 2003) and published journal and association magazine articles (Mages 2002; Chmar et al. 2004) aimed at clarifying the role of dentists in these crises.

As the novel coronavirus (COVID-19) pandemic advanced, the U.S. Department of Education quickly finalized new rules that governed distance learning for higher education to ensure a robust capacity for remote teaching. The guidelines emphasized ensuring student competency during the time allotted and simplified the requirements for direct assessment programs (U.S. Department of Education 2020). Schools focused on creating revised assessment of competency for graduating students and residents, in lieu of completion of requirements for graduation. Dental clinics implemented teledentistry to maintain contact with patients who called with problems and to triage those patients who required in-person emergency appointments. Content was delivered online, virtual meetings took place for small group learning, and assessments were completed using self-proctoring technologies.

Because many dental school clinics are set up in large open spaces, adapting new practice models in these settings has presented special challenges. Because students’ clinical experiences were truncated in Spring 2020, schools also were confronted with the need to identify new ways of training and managing in-person patient experience despite social distancing in limited space. Moreover, understanding patient COVID-19 status became critical to appropriate treatment and required use of personal protective equipment (PPE). Many dental schools have attempted to incorporate point-of-care testing for COVID-19, but preference for access to testing was most often granted to hospitals, leaving dental schools with limited access to accurate patient status. Some dental schools strengthened their relationships with their academic health centers by sharing spaces, donating PPE, and collaborating on testing services for COVID-19.

External bodies that control the process for licensing of new graduates also adapted to the pandemic. Some licensing bodies substituted simulation-based exercises for the live-patient components of their examinations, and at this time, it’s unclear if this change will become permanent after the end of the current public health crisis. In addition, some local boards of registration created new pathways toward licensure, with some issuing temporary licenses.

Diversion Programs in Emergency Departments

Since the turn of the century, use of EDs to manage orofacial pain and nontraumatic conditions remains a continuing challenge. In addition to efforts that would include integrating dentists into the hospital setting, a number of innovative programs were created to divert patients to primary care locations (Leavitt Partners 2015). Improved care coordination programs were established to create linkages between hospitals or primary care providers and dental offices or community clinics. In some cases, dentists were brought into hospitals to treat emergencies or to screen patients and refer them to local dental clinics to treat the emergency. In others, case managers assessed the patient’s need and triaged the problem (Langelier et al. 2015). Increased awareness, coupled with diversion programs and some expansion of adult dental benefits, showed some early results in decreased ED utilization for dental problems.

Although local programs have showed short-term potential in diverting dental emergencies from EDs to primary care settings (Leavitt Partners 2015), long-term efforts are needed to ensure that patients seek urgent care in private and public practices, rather than in hospital EDs. The use of the emergency room to manage or treat dental problems increased from 1.1 million visits in 2000 to 2.2 million visits in 2012 (Allareddy et al. 2014; Okunseri 2015), and research has shown that dental visits in these settings are less likely to be categorized as immediate or urgent compared to non-dental visits (Wall et al. 2014). Almost two-thirds of dental ED visits occur outside of normal business hours, suggesting that the emergency room is the only place for patients to seek care because dental offices rarely have night and weekend hours. Diversion of ED visits to a dental office could save up to $1.7 billion per year (Nasseh et al. 2014).

Dental Practice Technology

During the past 2 decades, several technological advances have impacted the delivery of oral health care in dental practices, including the introduction and near universal use of digital radiography and the incorporation of computer-aided design/computer-aided manufacturing (CAD/CAM). See Section 6 for an in-depth discussion on technological changes in dental practice.

The use of CAD/CAM systems in dental education and practice has become more widespread (Poticny and Klim 2010; Prager and Liss 2020). CAD/CAM systems have evolved to eliminate the need for physical impressions of patient teeth, as well as for construction of the restoration. Even more appealing for dental practice is that newer systems and materials make it possible for dental practices to deliver crowns and prostheses with same-day appointments, saving patients and dental practices time, although not money.

A survey of U.S. and Canadian dental schools reported that 93% of reporting schools utilized CAD/CAM digital scanning, and the majority of schools made some use of digital intraoral impressions (Prager and Liss 2020). Of those schools with digital scanning in the clinic, some also were using the technology to deliver same-day restorations. Because of increased use of this technology in dental schools, more recent graduates are using the technology to support care delivery in their practices.

Many EHR computer systems provide decision support to busy providers, reminding them to provide preventive services or warning them when they consider prescribing medications that may interact with others a patient takes. EHRs also support improvements in safety and quality of care through use of clinical decision support, which “provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care” (Mullins et al. 2016). Clinical decision support currently is being used in dentistry to calculate a patient’s risk for dental caries or periodontal disease and to suggest appropriate management strategies (Mullins et al. 2016).

Although primarily a tool for providers, EHRs also are an important resource for patients. Many EHRs are connected to patient portals, online websites on which patients can securely log in, manage appointments, complete medical intake forms, access after-visit summaries, obtain patient educational resources, and securely email their providers (Irizarry et al. 2015). EHRs have not yet fully lived up to their expected benefits in transforming and improving the state of health care (Howe et al. 2018). A major challenge with the existing generation of EHRs is that they are not interoperable among health care systems. There is no central repository that allows health practitioners to add individual health records to an integrated data collection platform or that allows providers to incorporate data from other providers into their records. Instead, the industry still relies on individual clinics or practices to send patients’ medical or dental records to requesting providers.

A limiting factor for the meaningful use of dental EHR data for quality improvement has been the lack of universal diagnostic criteria. Although academic institutions and some large group practices have adopted standardized diagnostic terminologies (Kalenderian et al. 2011; Tokede et al. 2013), the vast majority of dental practices do not use them, and neither the dental insurance industry nor government funders request the diagnostic codes. Connecting a diagnosis to treatment would improve the measurability of the care provided and, ultimately, the quality of oral health care. More information on the EHRs are provided in Section 6.

Since 2000, important advances in the use of telehealth have occurred in the United States. Telehealth includes the use of technology to deliver health care services at a distance, as well as patient and health professional education and public health and administrative activities (Daniel et al. 2015). Although teledentistry has been slower than telemedicine to be adopted, it is becoming more widespread across the United States and in other parts of the world (Kopycka-Kedzierawski et al. 2008; Irving et al. 2018). To facilitate the addition of teledentistry in oral health, HRSA offered grant support to state oral health workforce programs to develop teledentistry facilities, supporting four such facilities in 2016–2017 and 42 in 2017–2018 (Health Resources and Services Administration 2018b).

Teledentistry was used primarily in rural areas for oral health screenings, specialty consultations, referrals, education, and emergency care (Ojima et al. 2003; Kopycka-Kedzierawski and Billings 2011; Queyroux et al. 2017). For example, the virtual dental home program enables dental hygienists on location to communicate with dentists to provide care to underserved and vulnerable patients in remote locations (Glassman et al. 2012). Both synchronous (real-time) and asynchronous (delayed) teledentistry hold promise for improving access to care, especially among disadvantaged children. Teledentistry may improve satisfaction with oral health care; reduce costs to the oral health care system, such as staff administrative efforts and patients’ time to access and utilize oral health care services; and foster treatment completion.

Innovative uses of teledentistry emerged during the COVID-19 pandemic. Teledentistry was utilized to triage and screen patients and to provide remote diagnosis in order to decrease person-to-person contact. In addition, some providers started to explore how teledentistry could reduce patient contacts and save PPE during routine preventive visits for dental cleanings. Ordinarily, a dentist would perform an in-person dental examination after a dental hygienist makes any required radiographs and performs prophylaxis, which requires fresh PPE for each patient the dentist is treating and any time they revisit a patient during the patient’s appointment. Instead of in-person examinations, the dentist would utilize teledentistry to conduct the examination from another operatory to save PPE and result in fewer person-to-person contacts within the dental setting, thereby reducing the opportunity to spread the virus. Increased use of teledentistry in the post-COVID-19 pandemic era, especially around consultations and urgent or emergency conditions, is likely to increase. Oral surgeons normally have in-person consultations with patients before their surgical appointments. Many of these consultations may be handled using teledentistry, and this use of teledentistry will likely increase because of consumer demand. Both full consent of patients and transparency in communications are important for these new applications of teledentistry to work.

Teledentistry also needs to become a viable adjunct to mainstream clinical dentistry, but various challenges to widespread use must be addressed. Permanent changes in state and federal rules and regulations are needed to allow reimbursement in these settings and reinforce data quality and security. In addition, with technology’s ability to cross state borders, provider licensure transferability is a key issue that states are examining to expand access and improve efficiency in the existing workforce. The U.S. Department of Veterans Affairs (VA) Authority of Health Care Providers to Practice Telehealth in any VA facility, regardless of state licensure, provides an important model for facilitating this mode of care (U.S. Department of Veterans Affairs 2018). Additional information on teledentistry can be found in Section 6.

Dental Insurance Coverage

Progress has been made since 2000 in providing dental benefits to U.S. children and adults. As shown in Figure 9, the percentage of Americans covered by dental benefits grew from 55% in 2009 to 78% in 2017—an estimated 40% increase (National Association of Dental Plans 2018). Two-thirds of the U.S. population with dental insurance, or 166.2 million Americans, had private or commercial dental coverage in 2017. However, the expansion in dental insurance coverage has mostly benefited children and adolescents.

Figure 9

The number of people covered by publicly funded and commercial dental insurance relative to the percent of the US population with dental insurance coverage: United States, 2007–2017.

Dental services are part of pediatric services and, in that context, are one of the ACA’s 10 essential health benefits (EHB). However, the rules on dental coverage differ from those governing other EHBs. On health care exchanges, dental insurance often is sold as a stand-alone benefit, and most states do not require that families purchase dental care as part of a health plan (Norris 2020). Large-employer group plans and self-funded plans also are not required to offer pediatric dental coverage as part of their essential benefits (Waltman 2017). Because many of the dental insurance plans fall into the category of “not required to comply” with the pediatric dental EHB, not all children receive the benefit of having dental insurance.

The percentage of uninsured children declined from 22% in 2000 to 10% in 2015 (Nasseh and Vujicic 2016b; American Dental Association 2017c). A smaller percentage of children had private dental benefits in 2015 (51%) compared to 2000 (58%) because more children received dental coverage through Medicaid and CHIP, with the proportion increasing from 21% in 2000 to 39% in 2015. The Children’s Health Insurance Program Reauthorization Act of 2009 mandated that states provide dental benefits under CHIPE and extended coverage options under Medicaid for former foster youth up to age 26 (Rudowitz et al. 2014).

Whereas there is an EHB for children’s dental insurance coverage, no such provision exists for adults, even those for whom it would be medically beneficial. This results in challenges for many adults in accessing dental care. In addition, adult dental benefits are optional in many states for low-income adults who rely on Medicaid. Consequently, states may choose to exclude dental benefits from their adult Medicaid programs. As of 2019, most states and the District of Columbia provided some adult dental benefits under Medicaid, with 18 states and the District of Columbia providing extensive benefits, 17 states providing limited benefits, 12 states providing emergency-only benefits, and 2 states offering no benefits (see Figure 8, Section 1). Between 2014 and 2017, enrollment in public programs providing dental benefits increased 140%. This large increase resulted from a combination of factors: state Medicaid expansion, the addition of coverage for adult dental services in many states, the guarantee of funding for state CHIP programs, and an increase in older Americans selecting a Medicare Advantage Plan (MAP) with a dental benefit. Medicare does not currently cover dental care except in very limited circumstances. For example, Part A covers inpatient hospital care for emergency or complicated dental procedures, but not the dental care itself.

In the past 20 years, enrollment in MAPs has increased from about 7% to 22%, with two out of three enrollees in these plans having a dental benefit, which may have helped indirectly by covering the cost of some dental care (Jacobson et al. 2019). MAPs are managed by private health insurers, and dental benefits have normally been limited to dental examinations, cleanings, and imaging. A new trend for 2019 and 2020 plans has emerged, with some insurers expanding dental benefits under these plans to attract consumers. Unfortunately, MAPs typically do not help many lower-income older adults living in assisted-living facilities, hospice, or similar settings to overcome challenges in accessing the oral health services they need. Another concern is that although MAPs are increasing, it is not clear that they have expanded proportionately to rural areas, where adult dental services are less available and dentists may not accept public insurance.

Risk-Based Dental Benefits Coverage

Traditional dental insurance has not been risk based, meaning that all consumers have similar benefits, regardless of their risk for dental disease. As risk assessment becomes more accepted in the dental community, dental benefit plans are emerging that provide additional evidence-based benefits to those at risk. Health through Oral Wellness, a patient-centered program that leverages a dental risk assessment to offer additional evidence-based procedures such as fluoride applications for those at risk for disease (Northeast Delta Dental 2017), is one example of the personalization of benefits, which may continue to grow.

Impact of Dental Coverage on Medical Costs

The health insurance industry is beginning to look at ways to improve health care effectiveness. Oregon implemented statewide Medicaid reform in 2012, promising to improve health care access and quality at reduced cost by focusing on prevention and primary care across the medical and dental systems (Oregon Health Authority 2018b). One component of the reform was a program to fund pilot projects and programs that local agencies and providers believed would improve performance metrics on care (Atchison and Rozier 2017; Atchison et al. 2019). Projects were selected on the basis of their likelihood of achieving specific quality improvement milestones, such as increasing the numbers of diabetes mellitus patients or pregnant women who saw a dentist. Achieving such milestones would result in performance payments.

Research using claims data from dental services provided through medical financing shows how the provision of dental care can positively affect overall health and its associated medical costs. Medical insurers use dental claims analyses to understand the impact of oral health care services on medical conditions, particularly birth outcomes and chronic conditions such as type 2 diabetes, cardiovascular disease, and cerebrovascular disease. Research shows that dental care can help reduce overall health care costs as measured by savings on medical costs and number of hospitalizations. Jeffcoat and colleagues (2014) reported that providing an insured population with periodontal disease with the appropriate dental treatment saved $2,840 per person annually for persons with diabetes and $5,691 for those with cardiovascular disease. A similar United Healthcare Services study reported that affording certain individuals with chronic health conditions appropriate dental care for gum conditions resulted in an average of $1,037 in savings in health care expenditures (United Healthcare Services 2013).

These findings demonstrating the potential to reduce overall medical costs are having an impact on insurance benefit designs, with insurers placing increased emphasis on improving access to dental services through integrated dental and medical services and the provision of additional dental services supported by medical insurance plans.

Impact of the COVID-19 Crisis on Dental Practice Finances

State-ordered quarantines and closures for elective dental care because of COVID-19 resulted in higher levels of unemployment and many furloughed employees in the oral health care workforce. The Paycheck Protection Program allowed employers to keep their employees on payroll, receiving paychecks, even if the employer’s business was closed due to the pandemic restrictions (U.S. Small Business Administration 2020). This also allowed employees to keep their health and dental benefits during this period. Additionally, many dental insurers across the country developed unique and innovative programs offering financial assistance for dental practices. The Delta Dental plans of Washington and Iowa were the first to come out with such programs, offering dentists advances on future claims. These programs were designed to ensure that dental offices could stay in business and the insurers’ members could continue to have access to dental services. ADA has a complete list of these programs (Burger 2020).

By November 2020, nearly all dental practices had reopened with 4 out of 5 practices reporting that patient volumes were similar to pre-COVID-19 levels, but the rates varied from 75% in the largest U.S. cities to 83% in nonurban areas, with staffing in dental offices reaching 91% of pre-COVID-19 levels (American Dental Association 2020m). At this time, the long-term impact of this pandemic on dental practice remains unclear, in part because of the large number of U.S. workers who have lost employment, and with it their dental insurance. This could lead to lower utilization of dental services, lower revenue in the dental industry, and ultimately, worse oral health for the nation as a whole.

Policy Advancements

Key policy measures that accelerated improvements in access to oral health care included the Health Center Growth Initiative of 2001, which strengthened and expanded existing health centers’ capacity and created new health centers with open positions for graduating dentists interested in group and community practices (Shi et al. 2010). Other policies, including the Children’s Health Insurance Program Reauthorization Act of 2009, the Patient Protection and Affordable Care Act of 2010, the growth in MAPs, and the expansion of Medicaid benefits for adults in some states have had a direct impact on expanding the covered dental population to private dental practices (Horner et al. 2009; Farrell et al. 2011; Jacobson et al. 2019). The ACA’s recognition of pediatric dental care as an essential health benefit (Centers for Medicare & Medicaid Services 2020b) required states to cover medical benefits for children up to age 26 on their parents’ health insurance, resulting in most commercial dental plans voluntarily offering the same age coverage (Nasseh et al. 2015).

The growth in HRSA initiatives in health workforce education and training brought diversity to the workforce and provided clinical training sites accompanied by loan repayment support for selected dental graduates in selected areas, such as pediatric dentistry, as well as the possibility of a career in the federal dental service (Health Resources and Services Administration 2018b; Jacobson et al. 2019).

The multidisciplinary study, Improving Access to Oral Health Care for Vulnerable and Underserved Populations, concluded with a goal that all persons should have “access to quality oral health care across the life cycle” (Institute of Medicine and the National Research Council 2011). The report recommended changes to the proposed dental education, financing, and regulation system; that clinicians should prioritize disease prevention and health promotion; that oral health services should be provided in a variety of settings; that care should rely on a diverse and expanded array of providers who are competent, compensated, and authorized to provide evidence-based care; that services should include collaborative and multidisciplinary teams working across the health care system; and that continuous improvement and innovation should be fostered. Some of these changes are underway, particularly with respect to the competencies and education of dentists, physicians, and other non-dental health care providers to integrate oral health into primary care.

Populations with Challenges in Accessing Care

There are several reasons why many Americans lack regular access to dental care within their communities: because there is a limited number of providers within a geographic area to provide care, as in rural areas; because providers may not accept the patient’s form of public insurance; or because distances are large and transportation options are few. Rural areas have many special oral health challenges, including large numbers of persons with loss of all teeth (edentulism), shortages of dental care providers, and higher-than-average rates of chronic and population diseases (Mitchell et al. 2013; Jacobson et al. 2019). In December 2018, there were an estimated 5,833 dental health professional shortage areas (HPSAs), representing almost 58 million persons and an estimated need for 10,635 additional dentists (Health Resources and Services Administration 2020c). Every state has HPSAs, ranging from 10 in Delaware to 446 in California. These designations reflect the poor distribution of dentists across the United States, particularly in rural and inner-city locations.

HRSA’s State Oral Health Workforce Program allows states to identify their individual state’s oral health workforce gaps and address them through a variety of mechanisms. In addition to the expansion of access through teledentistry, the program supports the integration of loan repayment, the development of community-based prevention service programs for underserved populations, and the expansion of the state dental office to support grant activities such as enhancing capacity to develop and analyze data and policy related to oral health access and workforce needs to identify Dental Health Professional Shortage Areas (HPSAs) (Legal Information Institute 2021).

Regulations and Policies that Impede Access to Care

The practice of dentistry is regulated by each state’s Dental Practice Act, with authority delegated to the state dental board, which regulates the practice of all dental providers in the state as a way of ensuring public safety. However, some regulations function in ways that actually limit access to care. For example, dental hygienists in some states are prohibited from providing care in community-based settings without a dentist’s physical presence, or from sealing teeth in school settings without the child’s prior examination by a dentist. These regulations persist, although there is no evidence that they promote safety. Although many states now allow hygienists to work in public health settings, such as schools or long-term care facilities, other states restrict hygienists to providing preventive services in public health settings only when a dentist is present for supervision. In actual practice, then, these regulations prohibit professionals from providing the treatment for which they are trained unless a dentist is present.

Regulations and policies also affect how practitioners are allowed to treat children and adults covered by government programs such as Medicaid, Medicare, and CHIP. Whereas Medicaid and CHIP offer comprehensive care for children, Medicaid’s coverage for adult dental care is optional and varies widely by state. Some states support dental care for adults whose incomes are at or below 138% of the federal poverty level, but may restrict that care to specific providers and settings, thereby limiting the value of the benefit for many. In some states, dental hygienists providing services in community-based programs are required to bill Medicaid through a supervising dentist, and dentists may be restricted with respect to employment or supervision of hygienists in such programs (The Pew Charitable Trusts 2018). Before the COVID-19 pandemic crisis of 2020, a number of states would not reimburse for consultations provided through telehealth technology (Seidberg 2017). All of these rules impede care to underserved and vulnerable populations. Similarly, Medicare covers only limited dental care and only in hospital or emergency department settings, or for procedures that are necessary prerequisites to pending medical care (Centers for Medicare & Medicaid Services 2021). Moreover, dental services provided in hospital EDs are costly and unlikely to fully meet oral health needs.

Low Dentist Participation in Medicaid

Although the number of individuals with Medicaid coverage has grown since the ACA took effect, challenges in finding dentists who accept it and are capable of treating vulnerable populations remain. States vary widely, from 15% to 85%, in the percentage of dentists who participate in Medicaid. As of 2016, 39% of dentists participated in pediatric Medicaid or CHIP programs. In comparison, an estimated 70% of physicians accepted Medicaid (Decker 2011). Dentists who are female, are younger, or are in general or pediatric practices are more likely to participate in these public-insurance programs (American Dental Association 2020l). Dentists who are employed by a dental service organization also are more likely to participate in Medicaid (Langelier et al. 2017a).

Researchers have evaluated the impact of various policy levers on the receipt of dental services by Medicaid recipients and the participation of dentists in Medicaid or CHIP programs. Increased Medicaid fee-for-service reimbursement has had an impact on dental care use and dentist participation in public programs (Decker 2011; Beazoglou et al. 2015; Buchmueller et al. 2015). Increasing outreach to boost the number of dentists participating in the Medicaid program and encouraging eligible populations to seek care showed an increase in dental care use as well. Reducing the administrative burden of the Medicaid program also has been successful and has significantly increased dental care use among low-income children (Beazoglou et al. 2015). Using an all-age Medicaid billings data set in Wisconsin, Wagner and colleagues (2019) showed that the difference between dentist billings for preventive services and paid reimbursements grew significantly between 2001 to 2013, with a more pronounced escalation at the high range of dentist billings.

Volunteer Programs

Community-level dental programs that offer care by professionals who volunteer their services have helped address persistent access issues in many underserved and dental health shortage areas in the United States. Dental volunteerism often takes the form of public-private partnerships combining national, state, and local dental professionals; dental education institutions; dental associations; volunteer organizations; and public health programs, along with support from the dental industry to source materials and laboratories. These partnerships augment local dental professionals with a volunteer workforce, equipment, tools, and patient education resources. Public health programs and community-based organizations help identify patients with unmet oral needs and link them to local health programs.

Examples of local, state, and national volunteer programs that feature aspects of public-private partnerships include the following:

• Give Kids A Smile^® (GKAS) is a national program involving dental associations and dental equipment and supply companies (American Dental Association 2020n). Since 2003, GKAS has recruited more than 500,000 community and dental volunteers to administer oral care for more than 5.5 million underserved children. GKAS activities include free restorative treatment (44% of services provided), oral health education (23%), and screening and preventive care (33%) (Alexander 2019).
• Mission of Mercy, an initiative of the America’s Dentists Care Foundation offers free clinics in 31 states with support in equipment and funds from industry and foundations. Since 2008, the group has provided volunteer dental care worth at least $190 million for more than 275,000 patients (America’s Dentists Care Foundation 2021).
• Bright Smiles, Bright Futures^® (BSBF) provides a fleet of mobile dental vans for dental and nonprofessional volunteers to use to provide education, dental screening, and treatment referrals annually for more than 10 million children in underserved rural and urban communities. One million children have received $39 million in donated dental care, and 3.5 million children have participated in BSBF’s classroom curriculum (Hannan 2019); Colgate-Palmolive 2020).
• Appalachian Miles for Smiles, a regional volunteer program, provides dental services to uninsured residents of primarily rural areas of Tennessee and Virginia (Appalachian Miles for Smiles 2017). Dental volunteers see an estimated 50 patients daily in a mobile dental unit. In 2017, the program provided free dental care to 3,000 individuals.
• Donated Dental Services improves the oral health of people with disabilities, the elderly, the homebound, or the medically fragile by linking a nationwide network of 15,000 dentists and 3,700 volunteer laboratories to patients (Dental Lifeline Network 2019; 2021). Dentists volunteer time and office supplies to create free dental care, and laboratories donate their services. Donated Dental Services has provided $378 million in donated services for 120,550 individuals.
• CDA Cares is a program through which the California Dental Association (CDA) provides access to dental care through clinics that have engaged more than 25,000 volunteer dental professionals and community members, local health plans, hospitals, county health departments, community-based organizations, and social service agencies at 15 clinics throughout the state. CDA Cares has provided in excess of $23 million in dental services to more than 28,000 people who self-identify as Latino or Hispanic, travel less than 50 miles to the clinic, and state they have not previously sought care because they have no dental insurance and are not able to afford care.

Although community-level volunteer dental programs provide valuable care to those with no regular access to care, they cannot be considered an adequate substitute for comprehensive care, and they do not provide a dental home, which would go far to ensure ongoing care. Moreover, volunteer clinics usually are held once per year in any specific area, leaving persons without dental care for unacceptably long periods of time. The existence of these special events, and the value placed on them, demonstrate the level of need for more comprehensive dental care provided at workplace, state, and federal levels. It is common for people without access to dental care to drive long distances and wait in long lines to access free care available in these volunteer programs.

Population-Focused Integration Strategies

Two integration demonstrations were created specifically to integrate safety net populations (Harnagea et al. 2018). These involved partnerships among private and public health organizations, governments, and academic institutions to create two models: the Integration of Oral Health and Primary Care Practice (IOHPCP) model and the Oral Health Delivery Framework (OHDF) model.

Both models focused on risk assessment; prevention, including fluoride varnish treatment; and patient education and involved interprofessional collaboration. The IOHPCP model was implemented by FQHCs and Ryan White HIV/AIDS Program funded clinics (Health Resources and Services Administration 2019b), with onsite dental services. It also established a medical-dental referral process for further dental care. The OHDF coordinated oral and primary care providers in 19 settings in five states at private practices (hospital-based, independent, and part of a large, integrated delivery system) as well as community health centers (mostly FQHCs) (Hummel et al. 2016; Qualis Health 2016). Most sites reported success in implementing at least three aspects of the OHDF: oral health screenings, fluoride varnish application, and dentist referral.

Both care models used interprofessional practice collaborations to integrate oral health into medical care. They were implemented in school-based settings, federal- or state-affiliated health systems, academic institutions, and safety net programs and within rural communities and nonmetropolitan areas (Crall et al. 2016; Harnagea et al. 2017; Dalal et al. 2019).

Patient-Focused Integration Strategies

Insurance companies and commercial and public health systems have used medical-dental integration strategies to improve patient-level care while controlling care cost. Insurance companies such as Aetna, Cigna, and Delta Dental of Wisconsin have focused on integration strategies that expand dental insurance benefits and manage care for patients with chronic diseases, pregnant women, and children. Studies of medical and dental claims have found savings to health and benefits organizations and lower hospital readmission rates as a result of dental care utilization by patients with chronic diseases such as diabetes, cardiovascular disease, and cerebrovascular disease (Albert et al. 2006; United Healthcare Services 2013; Cigna 2019). One study found that patients with diabetes who received an oral periodontal intervention had lower total and diabetes-related medical costs compared to similar patients without periodontal treatment (Nasseh and Vujicic 2016b).

Commercial health systems such as Kaiser Permanente Northwest, HealthPartners, and the Marshfield Clinic, as well as VA, are taking advantage of clinic co-location to promote medical-dental integration through technology and EHR use. A fully integrated health record promotes transparency, information sharing, and coordination of patient care with other health care departments across the enterprise. The interoperability of EHR has led health systems to pilot new clinic and workflow designs to integrate primary care service delivery within dental office settings (Jones et al. 2017).

In 2017, a national convening of 44 rural interprofessional oral health stakeholders, key opinion leaders, and policymakers stated that oral health interprofessional practice could help achieve the goals of the Institute for Healthcare Improvement’s Triple Aim initiative (to improve care delivery, patient outcomes, and cost of care) in rural environments if dependable and bidirectional interprofessional care coordination, telehealth, and a value-based financial structure were implemented (Boynes et al. 2018).

Whether in rural or urban settings, children tend to be a focus for initial forays into interprofessional practice or medical-dental integration (Achembong et al. 2014), possibly as a result of pediatric dental care becoming a mandatory covered service as part of the ACA. The ACA model incorporated earlier medical team intervention in regard to oral disease development, an important aspect because many dentists are uncomfortable seeing children younger than 2 years of age, and the well-child medical visit structure can provide an easier integration pathway (Bernstein et al. 2016; Phillips and Hummel 2016; Boynes et al. 2017). Components of well-child oral health visits encountered most often include oral health risk assessment, health coaching or guidance, fluoride application, closed-loop referral and specialty consultation, and financial and policy support (Deutchman et al. 2011; Douglass and Clark 2015; Phillips and Hummel 2016).

Interprofessional Care at the VA

A cornerstone of VA-provided care is the integration of VA dentistry with all aspects of medicine, pharmacy, laboratory, and administration to provide comprehensive care for the nation’s veterans. VA’s EHR system accelerates care coordination and has been a mechanism through which data-driven operational improvements and dental quality measures have been implemented, resulting in systemwide improvements. One dental quality measure—fluoride treatment for patients at high risk for dental caries—implemented during fiscal year 2009, increased the appropriate use of fluoride in high-risk patients. Collection of national data about the quality measure from EHR allowed VA to conduct a clinical-effectiveness study, which showed the benefits of professionally applied or prescription self-applied fluoride in preventing future dental restorations (Gibson et al. 2014; Jurasic et al. 2014). VA also integrated dental care into rehabilitation programs for homeless veterans. VA studies show that not only does dental care improve veterans’ quality of life (Gibson et al. 2008), but it also is associated with improvements in homeless rehabilitation program completion, employment, and housing after program completion (Nunez et al. 2013).

System-Level Barriers

Barriers to integration at the system level include the decades-long separation between medical and dental practices (Valentijn et al. 2015). This barrier is perpetuated by a lack of interest in merging the professions among dentists and primary care physicians and their professional organizations. Other obstacles include poor understanding of the population’s oral health status, the low prioritization of oral health on political agendas, and a dearth of appropriate oral health policies (Harnagea et al. 2017). Moreover, federal policies perpetuate the separation of oral and medical insurance through provisions that limit public dental insurance for adults, permit inconsistent insurance coverage across states, and exclude oral health services from quality metrics as part of the ACA (Donoff et al. 2014; McDonough 2016; Damiano et al. 2019).

The lack of insurance coverage across oral health and medical professions creates a barrier to interprofessional practice. Payments to medical providers for oral health services vary by state and payer. Payment reform often lags clinical innovations, failing to keep pace with increases in evidence and public support for change (Hernandez et al. 2015). In short, to advance health integration, federal and state policy reforms are needed, along with private and public health insurance coverage, regardless of provider type, for appropriate oral and medical care services for children and adults (Donoff et al. 2014).

Organizational Barriers

Organizational barriers to integration include the lack of agreements among professional organizations that promote integration, shared governance over scope of practice and guidelines for care, and lack of the accountability mechanisms needed to deliver comprehensive care to a defined population by a group of providers (Valentijn et al. 2015). In 2019, 14 states reported serving at least some of their Medicaid beneficiaries through an ACO model, up from 7 states in 2015 (Kaiser Family Foundation 2019). Most ACOs do not include dental services (Shortell et al. 2015), and others lack the physical and organizational integration of dental and medical providers (Damiano et al. 2019). Harnagea and colleagues (2017) found that the most commonly reported barriers were limited organizational resources (e.g., time, staff) to support integration activities.

Organizational culture and climate for change are important factors for integration (Cunha-Cruz et al. 2017). Some integrated health systems have adopted the use of quality measures in dental as well as medical care, but most stand-alone dental providers and insurers have been slower to implement quality-based performance and compensation measures that are common for medical providers (Institute of Medicine and the National Research Council 2011; Glassman 2014). This lack of integration of the clinical workflow into the care process is associated with poor referral systems and connections between provider organizations.

Professional Barriers

A common understanding of each provider’s competencies and roles, within the context of delivering comprehensive health care, is key to professional integration (Valentijn et al. 2015) because scope-of-practice laws govern the range of services that different health care providers can perform. These limits define the interprofessional practice relationships that allow the coordination of oral and medical care services. The lack of clinical guidelines for treating oral health problems, limitations on primary care providers’ knowledge of oral health, and time to support integration activities are all challenges to professional integration (Harnagea et al. 2017). Medical providers also report difficulty in referring uninsured and Medicaid patients to dental professionals when additional care is needed (Lewis et al. 2000). The lack of knowledge about medical health promotion and preventive services is a similar barrier for dental professionals (Naleway et al. 2018).

The absence of interoperability among EHR systems creates a substantial barrier to interprofessional integration (Damiano et al. 2019). The lack of integrated health records leads to poor interprofessional communication, information duplication, and inconsistencies between systems, as well as a lack of adherence to treatment guidelines used by coordinating providers (Rudman et al. 2010). A survey of physicians and dentists at four academic health centers found that nearly 70% of dentists reported experiencing instances in which access to an EHR would have improved patient care (Simon et al. 2019).

Even in organizations with interoperable EHR systems, care coordination is challenging because most dental providers do not utilize diagnostic codes (Kalenderian et al. 2016). EHR software vendors increasingly support records integration, but they face barriers in the requirements for standardized diagnostic and billing systems (Rudman et al. 2010). Lack of common diagnostic codes, unless changed, will continue to be an obstacle to future integration, thereby limiting interprofessional communication and care coordination (Kalenderian et al. 2016; Damiano et al. 2019).

Clinical Barriers

Harnagea and colleagues (2017) found that clinical-level barriers to integration were the most commonly reported.

A survey conducted by Lewis and colleagues (2000) showed that most pediatricians (85%) reported they were very likely to visually screen children under 5 years of age for dental caries and provide preventive counseling at well-child visits, and 90% agreed that assessment for dental problems and providing oral health counseling should be a routine part of well-child visits. However, fewer than 15% agreed with the American Academy of Pediatric Dentistry (AAPD) recommendation at the time to refer children to a dentist by 12 months of age (Lewis et al. 2000).

When considering how receptive providers are to expanding their scope of practice, the issue of developing efficient clinical workflows arises, along with the question of whether insurance, government programs, or patients will pay for the extra services. Expanding the scope of practice for both dental and medical providers means more services (e.g., health screenings, fluoride varnish, education) must be provided during an office visit, which affects clinic workflow and time. An early review by Close and colleagues (2010) found that most pediatricians were concerned about whether they could adjust schedules to plan new workflow processes incorporating the extra time for oral health screening and services. Experienced providers may view scope-of-practice changes very differently from younger graduates with more integrated training experiences. Change is more likely to occur with appropriate financial and other performance incentives.

Challenges to Rural Health Integration

Rural communities face multiple challenges, including long distances from health care providers, low incomes, poor insurance coverage, and aging populations with complex care needs (Skillman et al. 2010). Increasing access to oral health care for rural populations requires a multipronged approach that is flexible across communities with different care needs, resources, and cultural and political environments. Financial resources and the flexibility to develop and implement innovative strategies are critical for increasing the availability of high-quality oral and overall health care. Interprofessional care, shared goals, health informatics, and telehealth and other technologies can be used in conjunction with community-wide public health programs and new workforce models to improve access to care for underserved patients while improving the quality of care.

Communication to Promote Patient Safety and Quality of Care

The medical community has long recognized the importance of health literacy in developing providers’ skills for communicating effectively with patients. The Joint Commission (2007) launched a new component of its safety initiative highlighting health literacy as a way to protect patient safety, on the basis of three components: (1) making effective communications an organizational priority to protect the safety of patients, (2) incorporating strategies to address patients’ communication needs across the care continuum, and (3) pursuing policy changes that promote improved practitioner-patient communications.

Federal legislation also has promoted appropriate communication by all health care providers. The Plain Writing Act of 2010 (Plain Language Action and Information Network 2011) requires federal agencies to offer health information in clear communication that the public can understand and use. ACA Section 1557, the Act’s nondiscrimination provision, states that individuals with limited English proficiency are entitled to language assistance services, including a qualified interpreter when seen in publicly supported health care settings, including dental clinics (U.S. Department of Health and Human Services 2021).

Health providers are increasingly communicating with patients using digital technology, which helps bridge language gaps between providers and patients. For example, websites and applications for tablets and smartphones, some designed for medical and dental purposes, can instantly translate spoken or written words (Chen et al. 2017; Tine Health 2017). Info buttons are now being used to link to context-sensitive information contained in the EHR and to provide digital support to clinicians (Dragan et al. 2015). For example, clicking on a small icon next to a patient’s diagnosis or prescribed medication displays a patient-friendly explanation of the diagnosis or medication from an external source or an expanded explanation for a clinician. This information can be used to support shared decision-making at the point of care (Cook et al. 2017).

Clinical Practice Guidelines

Evidence-based clinical practice guidelines (CPGs) are slowly being adopted for use in dental practice. Larger dental care organizations and FQHCs have put effort into adopting these guidelines, which can result in fewer treatment variations. During the past 20 years, ADA has taken a leadership role in the production of high-quality evidence in a number of areas of general practice dentistry. Its process involves prioritizing information needs among general dentists, and then developing systematic reviews and associated CPGs. In addition to ADA guidelines, some group practice models, such as Permanente Dental Associates, develop and employ a wider set of CPGs to guide their practitioners. (For examples of CPGs issued by ADA, see Table 8.)

Table 8

Clinical practice guidelines from the American Dental Association.

Following a review of pediatric deaths associated with deep sedation or anesthesia, the American Society of Anesthesiologists, the Society for Pediatric Anesthesia, the American Society of Dentist Anesthesiologists, the Society for Pediatric Sedation, AAPD, and the American Academy of Pediatrics issued joint updated guidelines for the monitoring and management of children during deep sedation and general anesthesia at dental facilities (American Society of Anesthesiologists 2019). The guidelines for safe sedation of children emphasize that a systematic approach should be utilized for any sedation procedures taking place outside of a hospital or surgery center, including in a dental office. They include the use of sufficient numbers of appropriately trained staff both to carry out the procedure and to monitor the patient during and after the procedure, utilizing a properly equipped and staffed recovery area, and providing appropriate discharge instructions (American Academy of Pediatric Dentistry 2021). With the increasing number of evidence-based CPGs, many have focused on preventive practices (Slayton et al. 2018). ADA has issued 10 guidelines since 2008, and the U.S. Preventive Services Task Force has published one recommendation, “Dental Caries in Children from Birth through Age 5 Years: Screening” (U.S. Preventive Services Task Force 2014). Although some group practice models employ CPGs, their use is less common in smaller and solo practices, where most patients are served. Linking insurance payments to appropriate use of nationally approved quality measures would represent a major step in ensuring quality of care.

Measurement of Quality

Progress in developing stronger quality measures has occurred on multiple fronts. Efforts have been made to develop performance measures for dental plans (Bader et al. 1999a; 1999b). Measures from national surveys and reports (e.g., National Survey on Children’s Health; Form CMS-416, Annual Early and Periodic Screening, Diagnostic and Treatment Participation Report) were used to assess population access and health state. A 2002 report from the Agency for Healthcare Research and Quality noted the lack of standardized quality measures (Dougherty and Simpson 2004). Three environmental scans conducted a decade later, between 2012 and 2015, documented the disparate set of measures used in the oral health sector and the continued lack of standardization (Dental Quality Alliance 2012; 2015); National Quality Forum 2021). In 2008, CMS reached out to include dentistry in the broader health care quality movement. Engaging ADA in a leadership role, CMS triggered the formation of the Dental Quality Alliance (DQA) to identify and develop evidence-based oral health care performance measures and advance their use and improvement (Hunt and Aravamudhan 2014). DQA members include federal agencies and payer, provider, education, and research organizations that provide a strong foundation to support quality measurement in dentistry.

Examples of quality measures DQA currently advocates are a number of measures for children, such as newly diagnosed carious lesions, caries risk, receipt of at least one sealant on a permanent first molar, receipt of fluoride varnish, and receipt of a follow-up oral evaluation within 3 months of a well-child visit.

HRSA has developed and implemented a number of clinical quality measures within its Health Center Quality Improvement initiative. For HRSA’s Ryan White HIV/AIDS Program, one example of a performance measure is the percentage of patients, regardless of age, with a diagnosis of HIV and an HIV viral load less than 200 copies/milliliter at the last viral load test during the measurement year (Health Resources and Services Administration 2021d; 2021e). Giving providers the ability to compare their performance against that of peers initiates efforts to improve quality. Practices that serve publicly insured populations (e.g., Medicaid) have been at the forefront of quality measurement and improvement efforts, driven by the need to achieve the Institute for Improving Healthcare’s Triple Aim goal of healthier patients, healthier communities, and lower per capita cost. Dental providers who regularly interact with medical providers in FQHCs now measure “dental sealants on permanent molars among children aged 6 to 9 years with moderate to high risk of caries” and “tobacco screening among adults and percent who received cessation counseling” (Health Resources and Services Administration 2020d).

As measurement of quality began in dentistry, so did efforts to improve dental care and outcomes. Several initiatives across the nation that incorporate aspects of the Institute for Healthcare Improvement’s learning collaborative model have demonstrated improved outcomes (Institute for Healthcare Improvement 2003). By using quality improvement principles and techniques to improve care, the Early Childhood Caries Collaborative demonstrated a 28% reduction in patients with new cavities, a 27% reduction in pain, and a 36% reduction in referrals to the operating room (Ng et al. 2014). FQHCs participating in the University of California, Los Angeles’s 21st Century Community Dental Homes Project demonstrated a 3.3-fold increase in preventive services for children from birth to age 5 years (Ruff et al. 2018).

Information from patients is another important source of information for improving dental care quality and safety. Patient-reported outcomes (PROs) are commonly used during clinic visits, and some dentists now use text messaging or email surveys to solicit information after the office visit and adjust patients’ postoperative management. Measuring patients’ experiences is an important component of assessing health care quality (Manary et al. 2013). Some PROs have been formalized and are included in surveys to assess patient experiences with dental plans and dental offices (Agency for Healthcare Research and Quality 2019).

Although some dental practices have begun to implement quality measures, their numbers are limited, and many opportunities to introduce quality measures to the broader delivery system have not been acted upon. Student dentists are being trained in the use of diagnostic codes and integration; however, when new dentists enter the workplace, they often are forced to revert to legacy systems that are dependent on procedure codes.

Dental offices use the Code on Dental Procedures and Nomenclature (CDT codes) to document dental care for submission to insurers for reimbursement (American Dental Association 2021j). The CDT code set describes the treatment provided (e.g., a dental filling) but does not describe the patient’s problem or diagnosis (the reason a filling was needed). In October 2015, the U.S. adopted ICD-10-CM (International Statistical Classification of Diseases and Related Health Problems [ICD]-10) the World Health Organization set of diagnostic codes that includes dental codes (Centers for Disease Control and Prevention 2014). Although EDs, FQHCs, other larger clinics, and physicians who provide oral health services use ICD-10 dental codes, few dentists in private practice have adopted them. Use of the ICD-10 codes, however, is urgently needed in order to evaluate the quality and effectiveness of dental care; for example, how many patients have procedures (such as crowns and root canals) that fail.

Patient Safety During a Public Health Emergency

COVID-19 resulted in CDC’s strong reiteration of standard precautions since their implementation during the HIV/AIDS epidemic. In the 1980s, those infection control procedures had been developed to address bloodborne pathogens, rather than for viruses that can be spread through droplets or airborne routes as is the case for COVID-19. These comprised essential guidance for the practice of dentistry, where the use of highspeed handpieces and air-water syringes can create droplet splatter and aerosols that increase exposure to disease transmission. Concern over transmission of COVID-19 while treating asymptomatic dental patients led ADA to urge HHS to include dentists as federally recognized practitioners permitted to administer point-of-service COVID-19 tests authorized by the U.S. Food and Drug Administration. That request was denied (Garvin 2020c).

As the pandemic evolved, a number of challenges arose. Dental offices struggled to keep the needed PPE in stock. These generally included gloves, gowns, face shields, and tight-fitting N95 respirators that reduce exposure to smaller particle aerosols. CDC has continued to release new PPE guidelines as appropriate, offering tiered level-of-care guidance to match different PPE requirements to various procedures and in consideration of virus transmission in the community. Another major challenge has become the need for coordinated workforce policies to protect the well-being of clinicians involved in treating patients with COVID-19 (Dzau et al. 2020), especially because patients with the virus may be asymptomatic.

Although it is too early to predict the need for permanent changes to practice, it may be important to reconsider scope-of-practice regulations to protect dentists, dental assistants, dental therapists, and hygienists.

Oral Health Care Delivery in Nontraditional Settings

A project in North Carolina, Into the Mouths of Babes, demonstrated the value of expanding scope of practice by incorporating preventive oral health services (POHS) into primary care practices. This project trained pediatricians to include POHS, such as oral assessment, fluoride varnish, and referrals to dental professionals. About 43% of Medicaid-eligible children enrolled for at least 10 months had four or more POHS visits during their first 42 months of life (Atchison et al. 2019). Appropriate training of the pediatricians enabled them to efficiently incorporate POHS into their workflow and to improve access to care. In another effort, National Interprofessional Initiative on Oral Health partners developed an online education system to educate non-dental providers and health educators about oral health and provided web-based and interactive educational resources aimed at integrating oral health and primary care (Box 3). This free resource addresses educational objectives based on Accreditation Council for Graduate Medical Education competencies.

Collaboratives with Population-Specific Entities

The U.S. Public Health Service workforce increases access to care for isolated communities through unique collaborations with other entities. By working in tandem with numerous entities—including Head Start; elementary schools; day care centers; the Special Supplemental Nutrition Program for Women, Infants, and Children; and community health representatives—the Indian Health Service increased by 7% the number of children up to 5 years of age with a dental visit between 2010 and 2014. The percentage of children aged 1 to 5 years with decay experience and untreated decay declined by 5% and 14%, respectively (Phipps et al. 2019).

Coordinating the oral health workforce with a changing population’s care needs will require new strategies to match the supply of oral health providers with the demand for their services.

Demand Modeling in Workforce Planning Projections

The World Health Organization’s Global Strategy on Human Resources for Health aligns investments in health personnel with specific populations’ current and future needs (World Health Organization 2016). Limited planning of human resources for (oral) health has been conducted using simplistic targets for the dentist-to-population or constant-services-to-population ratios, which do not reflect levels of, or changes in, population need (Ono et al. 2013). Incorporating need explicitly into oral health workforce planning and program design would decrease the possibility that supply will be influenced by oral health care providers whose professional interests may not accurately reflect population needs (Listl et al. 2019).

Needs-based oral health services and workforce planning must be connected to enable more effective matching of the composition of oral health providers to the population’s specific oral health care needs and must go beyond matching providers to the population’s size, age, and racial-ethnic profile. More accurate modeling leads to policies that change oral health providers’ scope of practice, including increasing the independence of some allied providers. An example is the proposed California bill, prompted by a shortage of primary care physicians, to license nurse practitioners to work without physician supervision (L.A. Times Editorial Board 2020). It is critical to recognize that individuals’ need for oral health care, as well as population disease patterns, will vary over time and that the type of services appropriate to address patient need also may change over time as a result of medical-technical innovation or changes in the skill mix of a provider group (Birch et al. 2009; Ahern et al. 2019; Listl et al. 2019).

The National Advisory Committee on Rural Health and Human Services released a policy brief and recommendations for an extensive modeling and workforce planning program (National Advisory Committee on Rural Health and Human Services 2018).

The committee noted that challenges of oral health were one of the greatest unmet needs in rural America, affecting 34 million Americans. Although improvements in care had been made, such as use of silver diamine fluoride, expanded telehealth, and implementation of dental therapists, the committee made recommendations to study a variety of options for improving the oral health of young children in Head Start programs. Their recommendations included comparing opioid-prescribing patterns in rural and urban centers, assessing differences in Medicare Advantage insurance options to better serve rural adults, and developing an overall action plan to improve oral health. The report suggests an excellent opportunity to develop stronger modeling programs that can improve a variety of oral health programs in America, using the needs of rural sites as a first test.

Needs-based planning could create a framework to identify changes in the oral health workforce that would better match providers’ skills and capabilities to patient care needs and help set priorities for dental curricula and future research. For example, implementing a model that would employ the least expensive type of provider—that is, the one who is able to provide safe and effective care at the least cost to produce—would effectively match skills to need. A dental student requires 8–9 years of education, resulting in an estimated debt of $300,000. In contrast, a bachelor’s-level dental hygienist requires 4 years of education and accumulates under $30,000 in debt (The Institute for College Access and Success 2018). Thus, the United States can produce at least nine dental hygienists for the cost of producing one dentist. More important, this reflects the change in the mix of services typically provided in dental practice, which are now more commonly diagnostic and preventive, rather than restorative. State public health departments have excellent opportunities to work with their boards of licensing and dental provider schools to design and test needs-based workforce models to help their communities.

Patient-/Person-Centered Care

Patient- or person-centered care has been proposed as a way to help a diverse patient population access and navigate medical and oral health care with the assistance of professionals and technology. Health integration models embrace this approach to achieve the Institute for Health Care Improvement’s Triple Aim initiative to improve care delivery and patient outcomes and reduce the cost of care. Such models also offer opportunities for training allied, predoctoral, and postdoctoral students. Although much work will be needed to achieve patient-centered care within dental education, the Commission on Dental Accreditation has laid the groundwork with standards calling for a “commitment to patient-focused care” and a “formal system of continuous quality improvement” at dental schools (Commission on Dental Accreditation 2020c, p. 9, 27).

Although dental school based clinics have not fully embraced the tenets of patient-centered care, medical education has explored including it as part of student training (Philibert et al. 2011). Barriers to implementation include school culture, the physical environment, and time and other constraints. There have been early successes, such as teaching medical students to offer patients informed choice, rather than informed consent, and instituting patient advisory councils to improve clinic performance.

Adoption of a patient-centered care approach in dental education institutions, along with a strong emphasis on evidence-based practice and effective communication strategies with team members and patients, will prepare graduates for successful entry into residency and practice. It also will help dental school clinics become more successful safety net institutions. There is ample opportunity for research on curricular approaches to education that identify best practices for clinic based oral health education.

More recently, the concept of person-centered care has been supported by the idea of technology that captures data from individuals and customizes care, which could revolutionize the diagnosis, management, and prevention of many chronic diseases, including oral conditions (Walji et al. 2017). In addition, dental schools should be encouraged to implement teledentistry and integrated models of clinical care in shared sites with allied and predoctoral students from all health care professions in their community-based programs.

Interprofessional Practice

Whenever possible, dental education learning experiences should be integrated with those of other health professional students to lay the groundwork for implementing interprofessional education and interprofessional practice. Following publication of the Core Competencies for Interprofessional Collaborative Practices (IPEC Interprofessional Education Collaborative 2016), recommended models were tested, resulting in the current accreditation requirements for interprofessional education in all health professions. However, interprofessional practice models are not yet as well developed as didactic courses, and opportunities need to be created so that all dental professional students work with other professional groups during their training.

The overall effectiveness of interprofessional practice across geographic and socioeconomic models is still being evaluated, and consensus on national guidelines has not yet been reached (McKernan et al. 2018). When successful, interprofessional practice involves data-driven integration and coordination of care implemented holistically by a diverse health care team (Harnagea et al. 2017; McKernan et al. 2018). By bringing together fragmented care teams and different points of care delivery, interprofessional practice can facilitate the integration of medical and dental systems and positively affect disparities in oral health access and care (Institute of Medicine and the National Research Council 2011; Harnagea et al. 2017).

Curriculum and Licensure

Community-based dental education has grown steadily during the past 10 years, giving dental students the experience of treating disadvantaged patients in a variety of community settings and integrated health centers (Andersen and Davidson 2009). The Advancing Dental Education in the 21st Century project recognized the need to bolster didactic education with a population-focused curriculum to prepare students for the demands of future practice. The focus is on understanding changes in population characteristics, such as demographics, health disparities, and the prevalence of disease; cultural diversity and sensitivity; health literacy; and communication skills (Weintraub 2017). Because the majority of oral health providers live and work in urban areas, access to oral health care is often a challenge for rural America. To address this issue, several organizations and dental schools are working to expose future health care providers to rural health issues and to connect rural residents to an integrated medical-dental care model. For example, the Family Health Center of Marshfield (Wisconsin) has embraced the need for early training of dental students and developed a program to offer students a population-based clinical rotation that exposes them to rural health needs (Box 4).

Licensure changes that have streamlined the pathways to licensing and licensure by credential (holding a license in another state) for dentists are now well accepted and can serve as models for licensing procedures for allied providers. The challenges facing better integration of dental hygienists and dental therapists mirror the problems that faced the nursing profession (Institute of Medicine 2011b). Like dental hygienists, nurses provide care both in homes and in public health settings. Allied dental providers would benefit from the four key messages that were developed with regard to nurses: (1) practice to the full extent of their education and training; (2) achieve higher levels of education and training through seamless academic progress; (3) enable nurses (or hygienists) to be full partners with physicians and other health professionals in redesigning health care in the United States; and (4) encourage the country to develop better workforce planning and policymaking to create an improved information infrastructure.

To achieve these goals, standardized scopes of practice based on professional competence would ensure that dental hygienists and dental therapists practice to the full extent of their education and training. Interstate licensure compacts, such as those used in nursing, medicine, and physical therapy, could expand and expedite licensure for oral health professionals such as hygienists. The ability to move forward in training, through dental-specific programs structurally modeled on Advanced Practice Nursing programs, would guarantee that allied oral health providers could help meet the country’s oral health needs. Such training also would facilitate the use of telehealth, which currently is challenged by state rules that restrict dental providers from working across state lines in virtual practice settings. Interstate licensing compacts could support more effective and efficient oral health care delivery.

Provision of Dental Services During a Public Health Emergency

The response to the novel coronavirus (COVID-19) crisis by the Kaiser Permanente dental program (KP Dental) provides insight into how interprofessional delivery systems could mobilize coordinated care during a disaster. Kaiser Permanente developed a regional control center (RCC) to create a centralized decision-making, policymaking, and communication body during the crisis. The RCC consisted of all medical directors and senior leaders from the health plan’s ambulatory care, hospital care, and other departments, including dental services. In concert with the Kaiser Permanente Northwest health plan, KP Dental limited delivery of dental services to urgent and emergent medical and dental conditions, using a triage model adapted from the Military Health System, to conserve personal protective equipment (PPE) so that it could be redirected to medical operations. This reduced the risk of exposure and community spread to patients and providers in health care settings. It also maintained the capability of providing emergency dental care to prevent diversion to EDs.

A workforce model was designed to support four dental offices located strategically in terms of geography. Each dental office consisted of a general dentist who performed telephone triage, a general dentist with a broad scope of practice, and 1 of 3 dental specialists (oral maxillofacial surgeon, pediatric dentist, or endodontist). Guidelines were updated to include management of dental emergencies while limiting splash, splatter, and aerosols. Dentists were assigned to patient-facing pools, virtual pools, and on-call and quarantine pools. The University of Puerto Rico School of Dental Medicine used a similar model for integrating dental students teamed with the Medical Sciences campus to conduct assessments of vulnerable areas, execute triage and crowd control, and prepare communication groups at all levels (Lopez-Fuentes 2019). Dental educators could expand on existing disaster curricula for working more closely with public health emergency responders to better equip the United States for dealing with future disasters.

Oregon lifted its pandemic-prompted suspension of dental practices on May 1, 2020. Before resuming full operations, KP Dental developed a plan for a phased opening of dental offices structured on prioritizing care on the basis of patient need, types of care, and location characteristics. It developed a guideline to standardize priority levels for dental care that covered emergency dental services, urgent dental care, routine care, and hygiene services. All patients who had appointments cancelled or who called for an appointment were classified on the basis of the priority level of their dental needs. Dental services were categorized from higher- to lower-priority services. Types of procedures were classified either as aerosol-generating procedures (AGPs) or non-AGPs; these two procedure types require different levels of PPE. Protocols to modify procedures to prevent aerosols were developed and distributed to care teams. KP Dental directed different priority levels and procedure types (e.g., AGPs) to different locations, depending on the amount of PPE in those offices. Hours of operation were expanded, with fewer providers assigned per shift to allow for increased infection control processes and social or physical distancing.

Teledentistry also was used to triage patients with urgent dental needs into appropriate in-office dental visits. Expansion of teledentistry into routine care (e.g., dental examinations, consultations) will be designed to reduce the number of in-person interactions with each patient. With the establishment of a robust COVID-19 testing protocol, patients requiring procedures that produce aerosols can be tested 48 hours before care and treated with standard PPE, assuming a negative test result.

The dental community’s ability to respond to the COVID-19 pandemic quickly, efficiently, and in a carefully targeted manner provides a model of how dental expertise, infrastructure, and flexibility can be utilized to respond to other national disasters, such as hurricanes, fires, and earthquakes, and other natural or human-caused catastrophes.