Public Policy Options for Better Dental Health : Report of a Study [1 ed.] 9780309577267

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PUBLIC POLICY OPTIONS FOR BETTER DENTAL HEALTH Report of a Study

Division of Health Care Services INSTITUTE OF MEDICINE December 1980

National Academy Press Washington, D.C.

Copyright © 1980. National Academies Press. All rights reserved.

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the Councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 Congressional charter responsibility to be an advisor to the Federal Government, and its own initiative in identifying issues of medical care, research and education. This publication is one of a series, “Issues in Dental Health Policy,” sponsored by the W. K. Kellogg Foundation, Battle Creek, MI 49016 2101 Constitution Avenue, N.W., Washington, D.C. 20418 Area (202) 389-6178 Publication IOM 80-06

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COMMITTEE FOR A STUDY OF PUBLIC POLICY OPTIONS FOR BETTER DENTAL CARE Dorothy P. Rice (Chair) Director, National Center for Health Statistics Robert M. Ball Senior Scholar Institute of Medicine Lois K. Cohen Special Assistant to Director National Institute of Dental Research Melvin A. Glasser Director, Social Security Department, U.A.W. Detroit, Michigan Harold Hillenbrand Executive Director Emeritus American Dental Association I. Lawrence Kerr Practitioner of Dentistry Endicott, New York C. Arden Miller Professor and Chairman Department of Maternal and Child Health School of Public Health University of North Carolina Alvin L. Morris Associate Vice President, Health Affairs - Government Relations Professor, Dental Care Systems University of Pennsylvania Uwe E. Reinhardt Professor of Economics and Public Affairs Princeton University Max H. Schoen Professor and Chairman, Section on Public Health and Preventive Dentistry UCLA School of Dentistry Anne A. Scitovsky Chief, Health Economics Division Palo Alto Medical Research Foundation Jeanne C. Sinkford Dean, Howard University College of Dentistry

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INSTITUTE OF MEDICINE Frederick C. Robbins, M.D. President Study Staff* Linda Demlo Director, Division of Health Care Services (March 1977 - September 1979) Carleton Evans Director, Division of Health Care Services (October 1979 - present) Chester Douglass Study Director, Harvard University Dennis Gillings University of North Carolina William Sollecito University of North Carolina Martha Fales University of Washington Katherine Cole University of North Carolina John Day University of North Carolina Nancy Benotti Harvard University Marie Kerr Institute of Medicine Doris Pollard Secretary, University of North Carolina Naomi Hudson Secretary, Institute of Medicine Lauren Cammack Secretary, Harvard University Special Consultation and Assistance Ken Bernardi California Dental Service Corporation Harry Bohannan American Fund for Dental Health William Fullerton Fullerton, Jones, and Wolkstein, Inc. John Greene Assistant Surgeon General, USPHS John Ingle Palm Springs Seminars Joseph Lipscomb Duke University Preston Littleton Bureau of Health Manpower, DHHS Kent Nash American Dental Association Richard Scheffler George Washington University

*The Institute of Medicine contracted with the University of North Carolina for the staff services of Chester Douglass, Dennis Gillings, William Sollecito, Katherine Cole, John Day, and Doris Pollard. After Dr. Douglass moved to Harvard University midway through the study, Martha Fales (a fellow at Harvard), Nancy Benotti, and Lauren Cammack also assisted in the staff work for this study.

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CONTENTS v

CONTENTS

1 Conclusions and Recommendations The Rationale for Insuring Dental Services Recommendations Dental Auxiliaries in the Recommended Prevention Programs 1 2 4 10

2 Need for Dental Treatment and Utilization of Services Indicators of Need for Treatment Utilization of Services Summary and Conclusions 13 13 14 25

3 Epidemiology and Prevention of Dental Diseases Dental Caries Periodontal Diseases Malocclusion Summary and Conclusions 27 28 38 43 45

4 The Supply of Dental Services Practitioners Practice Settings Dental Practice Productivity Summary and Conclusions 47 47 60 65 71

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CONTENTS

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5

Dental Care Expenditures and Insurance Public and Private Insurance of Dental Services Characteristics of Various Financing Systems Utilization Review and Quality Control Summary and Conclusions

73 76 83 87 91

6

Benefit Priorities and Their Estimated Costs A Model for Projecting Expenditures Projected Expenditures for Four Dental Plans Expenditure: Demand v. Need-based Projections Summary and Conclusions

93 95 103 105 107

References

109

Appendix 1.

Statistical Notes: Health and Nutrition Examination Survey

1-1

Appendix 2.

Individual Comments by Members of the Study Committee

2-1

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LIST OF TABLES

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LIST OF TABLES

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Percent of Persons Needing Dental Treatment, By Type of Treatment and Age, 1971-74 Percent of Persons Needing Repair of Dentures or Bridges, By Age, 1971-74 Percent of Persons in Need of Dental Treatment, By Age and Sex, 1971-74 Percent of Persons with Dental Treatment Needs, By Type of Treatment, Age, and Race, 1971-74 Percent of Persons with Dental Treatment Needs, By Type of Treatment, Age, and Income Level, 1971-74 Indicators of Dental Utilization: Selected Years, 1963-1977 Average Number of Dental Visits Per Person Per Year, By Age and Sex, 1971-74 Percent of Persons with a Dental Visit Within a Year, By Race and Income, 1977 Percent of Persons with Dental Visits, By Time Interval, Income, Educational Levels, and Occupations, 1977 Number of Dental Visits Per Person Per Year, By Selected Occupational Characteristics: United States, 1977 Average Number of Decayed, Missing and Filled Permanent Teeth of Children, By Age and Sex, 1971-74 Average Number of Decayed, Missing, and Filled Permanent Teeth of Adolescents, By Age and Sex, 1971-74 Average Number of Decayed, Missing, and Filled Teeth of Dentulous Adults, By Age and Sex, 1971-74 Estimated Annual Cost-Benefit Ratios of Systemic Fluorides

15 16 16 17 18 19 19 21 22 23 29 30 30 33

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LIST OF TABLES

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15

34

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Recommended Dosages of Dietary Fluoride Supplements, By Age and Level of Fluoride in Water Supply of Locality Estimated Cost-Effectiveness of Topical Fluoride Procedures Number of Active Dentists and Dentist-to-Population Ratios: Selected Years, 1950-79 Dentist/Population Ratio and Selected Practice Characteristics, By Geographic Region Utilization Rates by Region, 1977 Appointment Delay and Practice Activity, By Size of City, 1975 Total Number of Specialists and Specialists By Type, Selected Years First-Year Enrollment in Dental Auxiliary Programs, 1967-1977 Average Number of Patient Visits Per Week by Dentists in General Practice, With Different Numbers of Auxiliaries, By Age of Dentist, 1977 Selected Characteristics of Three Types of Dental Auxiliaries Patient Visits Per Hour for Dentists Reporting in the Sample By Method of Compensation Number of States and Territories Providing Dental Services, By Type of Service, Fiscal Year 1978 Time Worked and Visits Per Unit of Dentist Time, By Size of Practice Financial Characteristics of Dental Practices Percent of Dentist Time Spent in Rendering Services, By Type of Service and Size of Practice, 1977 Expenditures for All Personal Health Services and For Dentists' Services, Selected Years 1929-1978

35 49 51 52 52 53 55 56 58 61 63 67 67 70 74

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LIST OF TABLES

31 32 33 34 35 36 37 38 39 40 41 42

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Estimated Expenditures for Dentists' Services, By Type of Service, 1977 National Dental Expenditures, By Age, Fiscal Year 1977 Personal Health Care Expenditures, By Type of Expenditure and Source of Funds, 1978 Number and Percent of Civilian Population Covered Under Private Dental Insurance Plans, 1962-1978 Benefit Expenditures of Private Health Insurance for Dental Care, Selected Years 1970-78 Expenditures for Dentists' Services, By Type of Public Program and Source of Funds, Calendar Year 1978 Pretreatment Review Requirements, By Payer Groups, 1976 Posttreatment Review Procedures Used, By Payer Groups, 1976 Dental Care Services and Projected Unit Costs, By Priority Plan, Fiscal Year 1980 Need-Based Projection of Expenditures for Dentists' Services Under National Health Insurance, Fiscal Years 1980-84 Projected Expenditures for Dentists' Services under Current Dental Care Systems Compared with Expentitures Under National Health Insurance, FY 1980 Expenditures for Dentists' Services Based on Need and Demand, Fiscal Year 1980

75 76 77 78 81 82 89 90 98 101 104 106

APPENDIX I

Table I II III

Standard Error for Percentage of Persons Aged 1-74 Years with Need for Dental Treatment by Age and Type of Service Standard Errors of Estimates of Aggregates Standard Errors, Expressed in Percentage Points, of Estimates

1-3 1-4 1-5

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LIST OF TABLES x

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FOREWORD

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FOREWORD

It should be unacceptable in the 1980s for dental health policy to emphasize a patchwork approach to acute care service delivery, when we know full well the major dimensions of the dental care problems with which we must deal and we know that an acute care model is inappropriate. To make the shift to a preventive world view will require significant changes in the scope, organization, patterns of practice, and financing of dental care. Our present knowledge is inadequate to tell precisely how this should be done, but we can be absolutely certain that a strong commitment to prevention holds great promise for the future. Dental disease remains the most prevalent of all pathological conditions afflicting Americans. While we have the means at hand to prevent or control the problem, a number of barriers have served to preclude the implementation of appropriate means to meet this goal. Significant among these barriers has been our failure to develop a rational and effective national policy for the prevention of dental disease, and to systematically examine the possibilities for alleviating the financial barriers which prevent millions of Americans from receiving appropriate dental care. Both represent complex policy issues warranting long and careful study. The Kellogg Foundation has been pleased to support efforts by the Institute of Medicine to address these matters and believes that the resulting policy recommendations have the potential for dramatically altering the patterns of dental health and disease within the United States. This work represents an important element in a series of Foundation funded projects designed to accumulate and organize more and better information by which the profession and the public could develop rational dental health policies. Among these various approaches, the Foundation wished to encourage expanded efforts in the prepayment of dental care services to include experimentation with different modes of payment and delivery with special attention to cost in relation to the quality and appropriateness of care to be delivered. It is important to recognize that this work was undertaken in 1977 and the conclusions largely drawn near the end of the project in 1980. Within this relatively short interval, far-reaching economic and social factors have emerged which will inevitably impact the public demand for dental care services as well as the private and public resources available to initiate and maintain new services.

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FOREWORD

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Nonetheless, the central and recurring theme in this report urges the implementation and financing of primary prevention programs. The importantance of addressing this consideration at appropriate levels with the view to achieving a national policy commitment cannot be overemphasized. The technology is available, the costs are reasonable and the benefits predictable. This emphasis alone should make this volume a centerpiece in the “Issues in Dental Health Policy” series promoted and sponsored by the Foundation. Ben D. Barker, D.D.S. Program Director W. K. Kellogg Foundation

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PREFACE

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PREFACE

This study was initiated by the Institute of Medicine because of interest by the Institute membership in analysis of issues that had received too little attention in the debates over national health insurance. In spite of the prevalence of dental disease and the extensive resources directed to dental care, it has largely been ignored in the current public policy discussions, except for local flurries of concern about the fluoridation of public water supplies. Dental care has also been neglected by most private health insurance plans until recent times. The lack of analysis and discussion, even as private dental health insurance is experiencing rapid growth, seemed to justify an independent activity by the Institute to focus attention on the policy issues relating to the financing and provision of dental services. The W. K. Kellogg Foundation, which has a long-standing interest in dental care, was willing to provide financial support for the study. This support was part of a broader effort by the foundation to stimulate analysis of dental health policy issues at the national and state levels. A committee representing the multiple disciplines and perspectives relevant to dental health policy was appointed by David Hamburg, president of the Institute, to direct the study. The charge to the committee was to consider alternatives for the inclusion of dental care, particularly dental care for children, under national health insurance plans. At the first meeting of the committee in May, 1977 the committee agreed with the suggestion by Julius Richmond, who was the chairman of the committee before his appointment as Assistant Secretary for Health and Surgeon General, that the committee regard benefits to dental health as the primary criterion for evaluating alternative dental health plans. The analysis of options also was to include consideration of economic implications, acceptability, and feasibility. But the ultimate assessment used in the study has been the improvement in quality of life through better oral health, as measured by the prevention and control of the two principal oral diseases--dental caries and periodontal disease. The committee also agreed that the scope of the study should not be limited to the traditional boundaries of health insurance--third party payment of expenses incurred for a stated package of benefits--but should extend to consideration of alternative forms of provider payment and service delivery mechanisms which could be more effective for achieving the objectives of improved oral health than an insurance benefit alone.

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PREFACE

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In conjunction with the initial meeting of the committee, a conference was held at which invited speakers described the dental care systems of several industrialized nations and suggested lessons that might be learned from their approach to the prevention and control of dental problems. The committee conducted a public hearing as part of its second meeting. A variety of dental care providers, as well as interested consumers, repeatedly emphasized the importance and feasibility of prevention measures in controlling dental disease. A school-based program of prevention care also was mentioned frequently, and this alternative was pursued in subsequent committee deliberations. The committee met seven times over the life of the study. The findings, conclusions, and recommendations were endorsed by the entire committee, with the exceptions noted in the additional comments by several committee members and printed at the end of the study text. The committee benefited greatly from comments and suggestions made during the review of the draft report by the Institute Council. Chapter 1 of this report contains the commmittee's conclusions and recommendations concerning dental health policy. Chapter 2, Chapter 3, Chapter 4 through Chapter 5 provide a review of the existing literature and data on need for dental services, utilization of those services, epidemiology of dental disease, evidence for the effectiveness of preventive services, expenditures for dental care, and the current characteristics of dental health insurance. Because of our intent to be concerned about the impact on oral health of dental policy alternatives, the committee believed that it was necessary to examine the nature and distribution of dental disease, the efficacy of interventions, and the current financing of dental services in order to make informed judgments about the changes that altered financing and organization of services would cause in oral health status. This approach contrasts with much of the history of the growth of insurance for the costs of medical care, which evolved largely in response to financial and income protection considerations. Chapter 6 displays cost estimates for each of the benefit packages for which priorities are recommended in Chapter 1. These cost estimates are based on estimates of need for dental services, and methods for arriving at those estimates are described. The needs-based estimates are then compared with current expenditure projections and with an actuarial (demand-based) estimate derived from actual experience under an existing dental insurance plan. The committee believed that the comparison of cost estimates based on need and demand forms a useful context for consideration of

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PREFACE

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dental policy alternatives. A reasonable objective of such policy would be to recommend financial and service alternatives that would stimulate a pattern of utilization that is as closely matched as possible to needs. This intent contrasts with the history of medical care insurance, which has tended to reinforce a pattern of demand that emphasizes expensive services. I enjoyed chairing this committee. I believe that the extent of agreement among this diverse group is a tribute to their willingness to learn from each other as well as a recognition of the compelling nature of the evidence that we reviewed. The work of the committee has been greatly facilitated by the work of the staff, especially Chester Douglass, who as staff director for the study assembled and analyzed a wide array of information and data on dental services. Dr. Douglass was able to draw upon the assistance of many others who are noted in the acknowledgments. The committee joins with Dr. Douglass in expressing our appreciation for all of their help, without which the study would not have been complete. I also want to acknowledge on behalf of the committee the help and support of Dr. Hamburg and the senior staff of the Institute, especially Linda Demlo, Carleton Evans, Wallace Waterfall, and Karl Yordy, all of whom helped the report achieve its final shape. Finally, the committee gratefully acknowledges the support provided by the W. K. Kellogg Foundation. The Foundation's willingness to support this initiative and the understanding of Ben Barker, the program officer, made possible the committee's work. We also acknowledge support from the Initiatives Fund of the Institute, which assisted in the completion of this study. Dorothy P. Rice

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ACKNOWLEDGEMENTS

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ACKNOWLEDGEMENTS

Several organizations, agencies, foundations, and universities have contributed to this study. Ben Barker, program director for the W. K. Kellogg Foundation, facilitated communication with other projects of the Foundation related to dental care issues. This coordination resulted in the sharing of data and background papers with concurrent projects being conducted by the Council of State Governments, the American Association of Dental Schools, and the Quality Assurance Programs of the American Fund for Dental Health. Three sources of unpublished data have been provided for use in the study. The National Center for Health Statistics provided its Health and Nutrition Examination Survey dental disease data, the California Dental Service Corporation provided cost estimates and certain requested actuarial data, and the Bureau of Health Manpower provided their continuing estimation of dental care providers and their information on productivity in dental practice. The National Institute of Dental Research, the Health Care Financing Administration, and the American Dental Association provided documents, the scientific knowledge of their staffs, and their most current data. The National Preventive Dentistry Demonstration Project, funded by the Robert Wood Johnson Foundation, also furnished ideas and preliminary information generated by the project. An added thank-you is owed to the administration of the Harvard School of Dental Medicine for the time and extra staff support devoted to the study, and to many faculty colleagues who provided valuable advice and technical information relating to specific scientific questions. Special recognition should go to John I. Ingle, who as a member of the IOM senior staff participated in the initiation of the study. Finally, and most important, I wish to express my appreciation for the opportunity to work with the committee under the leadership of Dorothy Rice, who assumed chairmanship of the committee after Julius Richmond's resignation. Chester W. Douglass Staff Director

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CONCLUSIONS AND RECOMMENDATIONS

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CHAPTER 1 CONCLUSIONS AND RECOMMENDATIONS

Americans have a substantial unmet need for dental care, as is indicated by surveys employing objective professional examinations of persons to determine their dental health. At the same time, proved methods exist for preventing and reducing dental diseases, which if untreated, are important causes of pain, discomfort, and disfigurement and can contribute to nutritional deficits or impaired social function. The coexistence of these circumstances provides an opportunity for improving dental health through direct support of an efficacious prevention program and implementation of an insurance plan to cover costs of dental services that can help control dental disease, reduce the backlog of need for care, and improve the quality of life for most Americans. The national program to improve dental health described in this report proposes that dental care resources be allocated to meet more closely the population's need for dental care. Included as the highest priority is a proposed public program of preventive services for children, ranging from fluoridation of water supplies to professionally administered preventive agents and oral hygiene education. Prophylaxis and preventive and education services are proposed to be initiated through school systems in a manner that would be more timely for prevention, more equitable for access by the poor, and less costly than the existing majority of fee-for-service care. In addition to this public program of preventive services, priorities are recommended for a national program of dental insurance leading to the availability of comprehensive dental service to all Americans. These priorities are intended to introduce a set of incentives to improve the oral health of the population by fostering an emphasis on prevention and early treatment rather than expensive dental repair and reconstruction. These priorities should also serve as a guide for the design of private health insurance plans. The committee felt that the national goal for dental care should be the eventual availability of comprehensive dental services to all Americans through a combination of public and private financing

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CONCLUSIONS AND RECOMMENDATIONS

2

arrangements and administrative mechanisms that will emerge over time. Only if that goal is met, can the dental health of the nation be maximized. The overall approach proposed implies that an increased investment in preventive measures for new generations of Americans will result in a population that has better dental health and a noticeable improvement in quality of life. This improvement would result not only from the reduction of acute and often disabling incidents of pain and discomfort, but also from the longer-term beneficial effects--less disfigurement, clearer speech, improved ability to eat healthful food--all of which can contribute to physical health and social well being. Chapter 2 contains the data that describe the unmet need for dental care in the United States and itemizes the lower utilization of dental services along the lines of lower socio-economic status. The existing measures of proved efficacy in preventing and reducing the most common dental diseases are discussed in Chapter 3. The projected adequacy of supply of dental care personnel, with or without the inclusion of dental benefits in a national health insurance plan, is discussed in Chapter 4. Also discussed are possible modifications of the dental care delivery system--including a greater role for dental hygienists and other auxiliary personnel--to promote more cost-effective service methods, particularly in the area of prevention. The rise of dental care expenditures over the past decade--at a rate slightly greater than expenditures for all health care--is described in Chapter 5. That section also reviews the experience of private programs of thirdparty payment for dental care and public programs for direct services, all of which together have accounted for a proportion of dental care expenditures that rose from about 9 percent to 23 percent in the past decade. The increase, however, is almost all due to the growth in private insurance plans; public expenditures have decreased as a proportion of the total. Still, 75 percent of all expenditures for dental care are out-of-pocket outlays. In addition, Chapter 5 describes various approaches to containing the costs of dental care and redirecting limited resources toward the goal of better oral health through better disease control. THE RATIONALE FOR INSURING DENTAL SERVICES A fundamental question for this study committee was whether health insurance, either public or private, should be extended to cover dental care, either now under existing plans or under an eventual national health insurance program.

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CONCLUSIONS AND RECOMMENDATIONS

3

During the course of this study, the likelihood has decreased that any national health insurance plan will be enacted in the near future. Enactment of a broad plan including dental benefits seems even more unlikely. However, the priorities developed by the committee for dental services should provide guidance to any future actions concerning dental benefits under national health insurance. Meanwhile, the recommendations should prove useful in assuring that additional funds committed to the extension of private dental insurance benefits will have a greater impact on oral health. The issues in dental insurance differ from those in medical insurance because the services they cover differ. Hospital care, which is the biggest item of coverage by medical insurance, is needed by only a minority of people and at a reasonably predictable rate among a population with known characteristics, and is very expensive. Hospitalization meets the three major criteria for casualty insurance: the event or expense insured against (1) is relatively rare for the individual person but occurs at known rates for groups, (2) is very costly, and (3) cannot generally be controlled by the insured. Dental care typically lacks all three of these characteristics. Most persons have or need some dental care each year. The services usually are not as expensive as other types of health care; it usually is the patient's decision to use dental services; and the patient's desires are an important factor in determining what kind of dental services are received, the dentist's suggestions notwithstanding. Control of the use of dental services by patients seems to be borne out by the experience of existing insurance plans. For example, when dental insurance was extended to a group, a relatively few more people began using dental services--perhaps an increase in individual utilization from 50 percent to 60 percent. However, there was a marked increase in expenditures because of increases in the number and expense of services received by those who were already receiving some services. These basic differences between dental and other health services might lead traditional insurers to conclude that dental services should not be insured. However, additional factors in dental services are important to a consideration of their insurability. First, utilization of services is highly correlated with income, education and occupational status (Chapter 2). Second, much more is known about the etiology of dental disease than of many medical diseases, and effective preventive measures are already developed, proved, and available (Chapter 3). Third, patterns of current use and provision of dental services indicate that many consumers are not receiving the mix of services that could be most cost-effective for the individual and the nation. Fourth, although private dental insurance is growing rapidly and includes some preventive services, the committee finds that the current pattern of benefit coverage encourages treatment late in the disease process, such as more expensive reconstructive services, rather than prevention or early treatment.

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CONCLUSIONS AND RECOMMENDATIONS

4

If private dental insurance continues its present rate of growth and its present patterns in coverage, and if other public programs to improve dental health remain unchanged, the result may be that some of the most costeffective preventive measures to improve dental health will be underutilized, while some of the less costeffective reconstructive procedures will likely increase in use because they are covered (Chapter 6). A drift by much of the population into an emphasis on reconstructive over preventive services would parallel the pattern the country has followed in acute medical care services and would fail to obtain the maximum in oral health benefits for the costs incurred. The committee concluded that well-designed public and private dental health insurance would be useful for achieving important objectives in dental health and that this advantage outweighs the inapplicability of some of the traditional insurance principles to dental care benefits. Specifically, the committee concluded that properly designed dental insurance could (1) permit budgeting of family dental expenses over time and over differing needs of family members; (2) avoid financial hardship; (3) encourage and expand, by covering under insurance, those services that clearly are needed and cost-effective, but that may be under-used without insurance coverage; (4) create incentives to restrain growth in expenditures over time; and (5) improve the effectiveness and accessibility to various dental care delivery systems. RECOMMENDATIONS To help achieve the purposes stated above and thus improve the quality of life for Americans, the committee recommends that properly designed health insurance covering dental care services be considered an appropriate component of a national health insurance plan. The committee also recommends that these purposes be supported by appropriate design of existing public and private dental insurance coverage. A Basic Public Plan for Preventive Services A major issue in the design of insurance plans for dental services is whether certain services, primarily preventive, should be provided through public financing to the entire population as a foundation upon which services covered under dental health insurance (public and private) should be built. Important subsidiary questions are how such basic preventive services should be delivered, and what relationship should be established between the basic services and the services covered by public or private insurance systems.

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CONCLUSIONS AND RECOMMENDATIONS

5

The evidence in Chapter 2 and Chapter 3 justifies a foundation of community fluoridation and preventive care as essential to improvement of dental health. The committee further believes that some preventive services might best be provided in or through the nation's school systems based on existing experience described in Chapter 4. The private dental office was considered by the committee as an alternative to school-based settings for delivering the preventive services that are recommended. Because many preventive services can be delivered by auxiliary personnel in a group or classroom setting, there are many efficiencies and economies to be gained in a school-based setting. In addition, a school-based setting provides greater access to the individual services (e.g., screening examination) for children from lower income families, who tend to underutilize private office dental services. Therefore, because certain basic preventive services are necessary to improving the dental health of the nation, the committee recommends that a basic system assure the delivery of preventive services to all children, whether or not dental health insurance is included in national health insurance or there is continued growth in private dental insurance. The committee suggests further that the most efficient way to accomplish this objective may be to encourage and enlarge school-based preventive dentistry services that have been initiated in many school districts throughout the nation, and to initiate such services where they do not now exist. This program constitutes the committee's first priority. The committee did not recommend the specific details of the financing and operation of such a program, which would require detailed consideration of mechanisms for encouraging and funding these services through schools. However, the following is an outline of how such a program might work. Financial support on a capitation basis might be provided to cover the reasonable full costs of providing a basic set of educational and preventive services in the schools to all children and adolescents. All children in the grades covered would receive two types of services as part of the school curriculum. The first type would be solely educational and could be integrated with the general physical and health education methods appropriate to each grade level that have been found to improve physical awareness and general health behavior most effectively. The second type would be a set of preventive services furnished directly to each child, either individual or within classroom groups, with continuing emphasis on children of greatest need and the development of personal responsibility of child and family. Services to be considered for inclusion would be a screening examination, prophylaxis (cleaning) and, if needed, sealants and topical fluoride applications. The specific set of services in this second

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CONCLUSIONS AND RECOMMENDATIONS

6

segment would be modified periodically on the basis of recommendations from a continuing body of experts established for this purpose. Targeting of selected preventive procedures would be desirable for particular age groups and persons with particular dental disease risks. The school system might provide the services directly or contract for their provision, or the school-based services might be provided by a public health agency. Parents and any family dentist identified for each child would receive a report of the results of the examinations, including need for fillings or other dental care. Parents would be allowed to exempt their children from the second type of services. However, no payment would be provided by public insurance programs for such services outside the school-based program.* The committee believes that the particulars of such an approach deserve full discussion as the preferred alternative to including such services under either national health insurance plans or a comprehensive national health policy. Because children would not be eligible for a school-based program before the age of five or six, it is recognized and expected that children should have earlier encounters with professional dental care from their family dentist, pedodontist, or community-based child care program. In order to ease the financial barrier to this initial dental care for children of low income families a recommendation regarding the priority of this special population group is under the following outlined insurance priorities. Dental Insurance Priorities With the highest priority given to a school-based preventive education and services program described above and assuming its adoption whether or not a national health insurance program is enacted the committee grouped other dental services into three broad categories in decreasing order of their long-range costeffectiveness in improving oral health (Chapter 6). If economic or other constraints limit an eventual national health insurance program initially to less than comprehensive medical and dental benefits, the committee recommends that benefits be phased in according to the priorities indicated by their long-range cost-effectiveness. The committee recommends the following priorities for coverage of dental care under a national health insurance program:

*See additional comments by committee members, Appendix 2.

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CONCLUSIONS AND RECOMMENDATIONS

7

Priority One: Prevention for children and adolescents (to be provided through the basic public plan described above) a) Integration of dental health education and plaque control into general education program b) Screening examination, prophylaxis (age 12-17 years only), an appropriate type of fluoride application, and sealants where applicable Priority Two: Comprehensive services (other than prevention) for children and adolescents from birth to 17 years a) b) c) d) e) f) g) h)

Examination Radiographs Space maintainers Extractions Restorations Crowns Endodontic treatment Treatment of handicapping malocclusion

Priority Three: Prevention for adults - 18 years and over a) Screening examination and prophylaxis b) Prophylaxis Priority Four: Comprehensive services (other than prevention) for adults a) b) c) d) e) f) g) h)

Examination Radiographs Extractions Periodontal treatment Restorations Crowns Endodontic treatment Replacement services

1. bridges 2. full and partial dentures If these priorities are followed as a basis for phasing in dental insurance coverage, some committee members believe that emergency services for everyone should be included in Priority One. The rationale for such inclusion would be the inappropriateness of any financial barrier to obtaining services that would relieve the intense discomfort of dental emergencies. However, it is the judgment of the majority of the committee, while appreciating the concern about alleviation of suffering, that this benefit in the absence of comprehensive benefits would prove unworkable. There would be strong pressures to define many dental visits as emergencies to make them eligible for insurance

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CONCLUSIONS AND RECOMMENDATIONS

8

payments. In addition, greater incentive might be provided to extract teeth as an emergency procedure, particularly for low income patients, unless the backup of reconstructive services was available.* Special Population Group Priority The committee believes that private dental insurance can play an important role in assuring access to dental care. It also wishes to stress that private insurance is unlikely to lead to the most cost-effective dental care for the nation as a whole. The current patterns of private insurance coverage would tend to provide comprehensive coverage, including preventive and basic as well as the less cost-effective reconstructive procedures, for one segment of the population, primarily the employed who obtain insurance coverage through their employment, but leave large groups of the population without any coverage of dental services. If national health insurance with universal coverage for dental benefits is not enacted, the question remains regarding the public role in assuring access to dental care for the poor. As stated in Chapter 4, the present Medicaid program is inadequate in covering dental services for the poor. Many states do not cover dental services at all; and many of those that do have severe limitations on coverage. Such unevenness in a program funded in substantial part by federal tax dollars seems to the committee to be inequitable. Evidence is presented in Chapter 2 to suggest that the markedly lower utilization of these basic services would be expected to persist if such financial aid were not made available to this special population group. The committee believes that achievement of better equity in access to improved dental health status requires that the child from a poor family who has been found to need such basic preventive, emergency, and restorative dental services under the school-based program recommended above should have the opportunity to receive these services. Therefore, the committee recommends that at a minimum, and even if national health insurance is not enacted, steps should be taken to assure that the children of low-income familes have access to the basic dental services described in Priorities One and Two above. Cost Sharing for Dental Benefits The literature on medical care includes studies and analyses on the effects of cost-sharing by the individual on utilization, costs, and accessibility of health care services. If dental coverage is part of national health insurance, the committee assumes that the basic decisions on cost-sharing alternatives for medical care will likely apply in the same fashion to dental care benefits.

*See additional comments by committee members, Appendix 2.

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CONCLUSIONS AND RECOMMENDATIONS

9

The committee considered the positive effects of cost sharing on containing expenditures as well as the negative consequences resulting from inhibiting or discouraging the use of services. It seems especially important in dental care to encourage the individual to utilize those preventive services essential to future dental health. Any impediment to the use of appropriate preventive services, financial or other, should be avoided. Therefore, the committee recommends that cost-sharing not be applied to preventive dental services. Financing and Delivery Systems In considering the types of delivery systems that should be covered under a dental component of a national health insurance program, a variety of payment methods, reimbursement systems, and practice setting organizations seem to show some promise. Several such delivery systems are either in place or could be created and appear to have the potential for containing expenditures while assuring quality care (Chapter 4). Dental practice organizations along the general lines of health maintenance organizations, or with other risksharing characteristics, reflect certain cost-effective features. The California Dental Service Corporation administers such an HMO-like program, along with a number of private dental insurance plans. Private dentists of that state have made arrangements with the corporation to provide dental services to Medicaid patients under a risk arrangement, which has proved successful in constraining costs of the service benefits provided by Medicaid. The dentists agree to provide all the covered services at a capitation rate, and the individual dentists participating in the plan receive a fee-for-service payment for services provided to Medicaid patients. Two important results came out of this experience. First, many more Medicaid patients have had access to dental care, because a very large proportion of dentists participated in the organization's plan; and second, costs were held substantially below what they would have been had there not been an organized plan to provide the benefits. A similar experiment is under way in Massachusetts. Such direct experience with dental care and the positive results of a variety of forms of medical care organizations along the general lines of health maintenance organizations (HMOs) have shown to be efficient and effective in providing ambulatory health services and have contributed to a substantial body of experience supporting development of alternative dental care delivery systems. The committee recommends that alternative prepaid delivery systems and capitation reimbursement systems be made an integral part of a dental health program under national health insurance and that a substantial

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CONCLUSIONS AND RECOMMENDATIONS

10

research and development effort to establish, improve, and refine alternative methods of prepaid delivery of dental care be included in a national health insurance program. DENTAL AUXILIARIES IN THE RECOMMENDED PREVENTION PROGRAM The data and analysis support the finding that dental auxiliaries are competent to provide a series of preventive services that meet desirable standards of quality (Chapter 4). The use of dental hygienists and expanded function dental auxiliaries in providing preventive services in a school-based preventive program for children and adolescents, such as that recommended by the committee, would have two important effects. First, program expenditures can be better contained because the limited scope of services provided by such dental auxiliaries do not require the extensive training provided to a dentist and thus the labor costs of their services are substantially less. Second, the availability of dental auxiliaries for preventive services would help assure that an adequate number of dentists will be available to meet the increasing demand for treatment services as dental insurance continues to grow. Legal constraints on the use of auxiliaries for the direct provision of preventive services purport to protect the public from inadequately trained personnel. However, the results of many demonstrations do not support this assertion. Even if dentists are available to perform these services, the use of dental auxiliaries will be more economical and will restrain the cost of a universal school-based program (Chapter 4). Therefore, the committee recommends that dental hygienists and dental assistants with appropriate training be used to provide preventive care in the recommended school-based system and that those few state legal restrictions to carrying out this recommendation be negated. Quality Assurance and Utilization Review Restorative dental services include of procedures that range from the removal of plaque and maintenance care, to an optimal level of extensive occlusal reconstruction. Although the decision to seek dental care is predominately determined by the patient, the kind of procedures and services actually delivered are heavily influenced by the dentist. Of importance, then, is the level (preventive, basic, or reconstructive) of restorative services that dental insurance should cover and that should be delivered to each patient. Therefore, mechanisms to assure the appropriate fit between provider resources and patient needs are necessary.

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CONCLUSIONS AND RECOMMENDATIONS

11

Various kinds of dental services and intended levels of dental health require different types of review mechanisms in order to assure the quality of care and the appropriateness of the services provided. Preventive measures such as topical fluorides, plaque removal, and teeth sealants will require one type of quality assurance mechanism, while restorative procedures may require other mechanisms such as preauthorization and record reviews. However, in order to evaluate the quality and level of the services actually provided, some system must be instituted so that there is a continuing assurance that the insured benefits are being appropriately utilized and delivered. The committee recommends that sound mechanisms of quality and utilization review for ambulatory dental care be demonstrated and analyzed and that an effective system be included in any national health insurance system. Information System The administration of a national health insurance plan will require a population-based information system in order to provide several kinds of data. For example, it will be necessary to have accurate current information on the persons enrolled, services received, provider identification, and resulting treatment patterns. In addition, program management will require data on expenditures and uses of various types of resources. Continuing analysis will be required of the effect of the dental services provided on the entire dental care system and the oral health of the nation. Thus, data are needed to provide information necessary for management of operations, policy analysis, and overall program evaluation. The committee recommends that an information system be instituted as an initial component of a national health insurance program. Funds to support these management, analysis, and evaluation activities should be allocated as part of the operating budget of national health insurance as an integral component of annual administrative expenses.

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CONCLUSIONS AND RECOMMENDATIONS 12

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NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES

13

CHAPTER 2 NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES The first and perhaps most basic questions raised by the committee centered on the need for and utilization of dental services. The major sources of data used to analyze these questions are the national surveys of the need for dental care and dental visits. This information on variations in unmet need and differences in dental visit patterns by certain sectors of the population was required for the committee's consideration of priorities in benefits for certain subpopulations. This chapter also includes a discussion of motives, learned behavior, and beliefs related to the use of dental services. These behavioral factors were considered by the committee in making recommendations that would encourage and support behavior that results in more appropriate use of services. There are differences in patterns of dental care utilization, demand, and unmet need in various groups of the population. Although certain characteristics of population, such as income, age, and race, are associated with differences in need and utilization, there appear also to be factors of socioeconomic class, education, and value systems that are more predictive of differences in utilization. Studies have found these differences persisting even after financial and physical access to treatment are equalized by prepaid dental plans. INDICATORS OF NEED FOR TREATMENT Needs of a population for dental treatment usually are inferred from indicators of oral pathology. Dental caries is described by the number of decayed, missing, or filled teeth (DMF); the inflammation and the recession of gum and bone because of periodontal disease is scored on a periodontal index (PI). These indices are accurate clinically and useful epidemiologically, but their value in estimating national needs for specific dental services is limited. Extent and severity of dental disease in a population is only an indirect indicator of the types and amount of treatment needed. The primary dental health status data in this chapter are from the 1971-74 Health and Nutrition Examination Survey (HANES) conducted by the National Center for Health Statistics (NCHS). The examiners in this

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NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES

14

study ascertained the actual needs of the sample population. Because these examinations did not use radiographs, a correction factor for underestimation of disease has been incorporated in the method for projecting expenditures. “Need” in this chapter refers to unmet patient requirements for specific quantities of dental services as determined in a national population-based survey by dentist examiners performing a standardized examination. The services include removal of debris and calculus; treatment of gingivitis, other periodontal disease, severe malocclusion, and decay in both permanent and primary teeth; and provision of fixed bridges and partial and full dentures. The data are summarized below 1/. Demographic Factors Age Table 1 displays the data by age groups. Sixty-four percent of the entire population is in need of some kind of dental care. Prophylactic and restorative services are most commonly needed from an early age through adulthood. The need for treatment of malocclusion is a phenomenon of childhood and adolescence; the requirements for extraction and dentures tend to increase with age. Treatment of gingivitis, debris and calculus, periodontal disease, decayed teeth, and bridge and denture work constitute the dental problems of adults. Onethird of persons aged 65-74 are in need of repair of dentures or bridges. This is further shown in Table 2. Sex More males are in need of dental treatment than females. This is true at all ages and in almost all categories of care, though the differences are not great (Table 3). Race The HANES data show a consistently greater need for treatment among blacks than among whites (Table 4). Differences are most marked in the needs for the treatment of tooth decay and periodontal disease. Income Table 5 shows that a greater need for dental services exists among low income groups in every age category except persons over age 65, who have fewer teeth. UTILIZATION OF SERVICES Various social, economic, psychologic and demographic variables are independently associated with differences in who uses dental services, how frequently, and for what reason. (The impact of dental insurance on utilization is discussed in greater detail in Chapter 5.) The proportion of people who have never seen a dentist has declined over the last fifteen years (Table 6), but about 30 percent of the population under age 17 in 1977 had never been to a dentist 2/. A 1964 survey of households found that less than two percent of the population accounted for twenty-five percent of all dental visits 3/.

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Source: Health and Nutrition Examination Survey (HANES), National Center for Health Statistics 13/

Table 1. PERCENT OF PERSONS NEEDING DENTAL TREATMENT, BY TYPE OF TREATMENT AND AGE, 1971-74 Age Group Treatment Needed All Ages 1-5 6-11 Total Number of Persons* 193,916 16,996 23,356 Percent General (at least one of the following) 64.1 16.6 63.5 Removal of debris and calculus (prophylaxis) 19.1 2.4 28.2 Gingivitis treatment (prophylaxis and scaling) 3.9 0.0 1.9 Periodontal disease Treatment (curettage and root planing) 10.1 0.0 0.1 Severe malocclusion (banded treatment) 2.0 0.1 6.4 Decay treatment permanent and primary teeth 41.1 16.1 52.7 Extractions due to any reason 4.8 0.1 0.4 16.0 -0.1 Fixed bridges and/or partial removable dentures *Population in thousands 18-44 73,882 72.7 22.4 13.8 12.2 0.9 49.3 5.8 25.3

12-17 24,654 67.5 27.5 13.4 2.0 7.1 53.6 0.6 5.8

67.5 13.5 6.9 19.3 -30.1 8.4 23.3

45-64 42,303

61.0 8.4 3.5 15.4 -17.9 9.8 8.5

65-74 12,774

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NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES 15

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Sources: Health and Nutrition Examination Survey (HANES), National Center for Health Statistics 15/

Table 3. PERCENT OF PERSONS IN NEED OF DENTAL TREATMENT, BY AGE AND SEX, 1971-74 Age Groups Sex All Ages 1-5 6-11 12-17 Both Sexes 64.1 16.6 63.5 67.5 Males 67.5 17.1 66.5 68.4 61.0 16.1 60.5 66.4 Females

Source: Health and Nutrition Examination Survey (HANES), National Center for Health Statistics 14/

Table 2. PERCENT OF PERSONS NEEDING REPAIR OF DENTURES OR BRIDGES, BY AGE, 1971-74 Total 18-24 25-34 Treatment Needed Total Number of Persons* 128,996 24,672 26,928 Repair or realign denture or bridge 4.5 0.2 2.1 10.0 0.8 4.3 Construct full dentures *Population in thousands 35-44 22,264 4.6 7.8

18-44 72.7 76.9 68.9

45-54 23,310 6.2 12.4

45-64 67.5 72.3 63.1

55-64 19,048 8.6 19.5

65-74 61.0 68.2 55.5

65-74 12,774 8.5 24.8

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NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES 16

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Source: Health and Nutrition Examination Survey (HANES), National Center for Health Statistics

Table 4. PERCENT OF PERSONS WITH DENTAL TREATMENT NEEDS, BY TYPE OF TREATMENT, AGE, AND RACE, 1971-74 Age Group 1 to 5 6 to 11 12 to 17 18 to 64 Treatment Needed Total White Black White Black White Black White Total Number of Persons* 191,975 14,220 2,519 19,707 3,458 21,063 3,381 102,997 Total White 169,561 Total Black 22,414 Percent General --(at least one of the following) 64.1 15.9 19.9 62.2 71.5 64.5 84.7 68.5 Removal of Debris and Calculus 36.7 2.0 5.1 28.8 36.4 38.6 64.0 40.3 Gingivitis Treatment 17.2 -0.1 1.6 3.8 13.6 24.7 21.3 Periodontal Treatment 10.0 -0.1 0.1 0.2 1.4 5.8 13.1 Decay -- Permanent Teeth 36.9 0.1 0.8 28.8 40.6 48.4 75.5 39.7 Decay -- Primary Teeth 6.6 15.4 19.1 39.7 42.4 3.5 1.7 -Extractions due to Periodontal Disease 2.7 ------3.0 Other 3.0 0.1 -0.5 0.1 0.6 0.5 3.8 16.0 --0.2 0.1 5.0 9.1 23.3 Fixed Bridges/Partial Removable Dentures *Population in thousands 65 to 74 White 11,573

59.5 23.9 13.3 14.1 16.6 -6.8 3.6 8.0

Black 11,917

90.4 67.1 42.6 26.9 65.5 -8.5 8.7 36.0

75.2 27.5 19.0 17.7 32.5 -20.1 12.4 14.2

Black 1,138

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NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES 17

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Source: Health and Nutrition Examination Survey (HANES), National Center for Health Statistics, 1971-74, Unpublished data

Table 5. PERCENT OF PERSONS WITH DENTAL TREATMENT NEEDS, BY TYPE OF TREATMENT, AGE, AND INCOME LEVEL, 1971-74* Age Group Less than 6 6 to 11 12 to 17 18 to 64 Treatment Total Low High Low High Low High Low High Needed Income Income Income Income Income Income Income Income Percent Total Number 90,058 of Persons Low Income 25,943 High Income 64,115 3,221 3,481 4,418 4,566 3,715 6,676 12,330 45,909 General -- (at 64.1 22.3 9.4 75.8 43.7 83.4 54.5 80.9 63.3 least one of the following) Removal of 36.7 4.4 1.2 39.2 22.1 63.9 27.6 53.2 37.4 Debris and Calculus Gingivitis 17.2 0.0 -3.0 0.3 23.3 7.8 34.1 18.1 Treatment Periodontal 10.0 0.1 -0.1 -3.8 0.6 21.5 11.5 Treatment 36.9 0.6 0.3 38.7 15.7 66.1 37.5 55.6 34.9 Decay -Permanent Teeth Decay -6.6 22.0 8.9 49.4 24.5 3.6 2.9 --Primary Teeth Extractions 2.7 ------7.7 2.2 due to Periodontal Disease Other 3.0 --0.0 0.9 0.6 0.2 6.3 3.7 16.0 ----8.5 4.3 25.0 21.0 Fixed Bridges/ Partial Removable Dentures *Low Income = Below poverty level; High Income = Income at least three times higher than poverty level Population in Thousands

High Income

3,483 63.2 33.8 16.9 17.6 20.1 -6.3

3.2 9.5

65 to 75 Low Income

2,259 66.3 18.2 12.3 11.2 21.0 -12.4

8.4 8.5

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NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES 18

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1969 56.7 13.3 1.5

Source: Health Inteview Survey, National Center for Health Statistics 32/

Table 7. AVERAGE NUMBER OF DENTAL VISITS PER PERSON PER YEAR, BY AGE AND SEX, 1971-74 Sex All Ages Under 17 17-24 25-44 Total 1.6 1.5 1.7 1.7 Male 1.4 1.4 1.5 1.4 1.7 1.7 2.0 1.9 Female

Source: Health Interview Survey, National Center for Health Statistics, 18, 19, 20, 21, 22, 23 and 24/.

Table 6. INDICATORS OF DENTAL UTILIZATION: SELECTED YEARS, 1963-1977 1963-64 Indicator Percent of persons with a dental visit within 2 years 54.6 Percent of persons who have never been to a dentist 16.6 1.6 Number of dental visits per person per year 1970 58.4 12.7 1.5

45-64 1.7 1.5 1.8

1973 59.9 11.2 1.6

1976 61.9 9.7 1.6

65 and older 1.1 1.0 1.1

1975 61.2 10.0 1.6

1977 62.9 9.3 1.6

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NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES 19

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Demographic Factors A number of studies have identified characteristics associated with differences in utilization and have demonstrated the disparity between need for and utilization of dental care 4, 5, 6, 7, 8, 9, 10 and 11/. Age People under 5 and over 65 use dental care least, probably because of the natural history of dental disease and the number of teeth at risk. Also, a social bias against the treatment of primary teeth may contribute to low utilization rates by younger children. Among persons 65 and over, according to the Health Interview Survey of 1971, more than 50 percent had no natural teeth 12/. Awareness of need for treatment of permanent teeth is indicated beginning in the 5 to 14 age group by a sharp rise in the percent of the population who visit a dentist in any one year, and in the number of dental visits made per year 25, 26 and 27/. Patterns of utilization and utilization rates of adults seem to be changing, perhaps as a result of increased private dental insurance. Earlier studies showed peak rates between the ages of 6 and 24, followed by a gradual decline to age 65 28, 29, 30 and 31/. Table 7 contains more recent data indicating that the number of dental visits remains constant between ages 17 and 65. Sex Many studies and surveys show that women use dental services more than men up to age 65 33, 34, 35 and 36/. Beyond 65 the utilization rates are about the same 37 and 38/. Race Racial differences in utilization also have been demonstrated 39, 40, 41, 42, 43 and 44/. Table 8 shows these differences at various income levels. Socioeconomic Factors In general, the higher one's income, educational level, and occupational status, the more likely one is to visit a dentist (Table 9). Dental insurance seems to have a positive influence on the utilization of services 46/, as is discussed more fully in Chapter 5. Income In middle and high income groups, there is a strong correlation between increments in income and increased utilization (Table 8). Lower income groups do not demonstrate such a strong relationship 47 and 48/.

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Table 8. PERCENT OF PERSONS WITH A DENTAL VISIT WITHIN A YEAR, BY RACE AND INCOME, 1977 White Other Races Income Level Under $5,000 35.4 29.9 $5,000-9,999 38.9 34.3 58.6 41.9 $10,000 and over

Source: Health Interview Survey, National Center for Health Statistics 45/ Education The education of the head of a household appears to be the strongest predictor of rates of utilization of dental services by family members. As education increases, utilization increases 49, 50, 51 and 52/. Table 9 shows the 1977 data from the Health Interview Survey. Variation is greater when related to educational achievement than when related to income. Although there is a study of several isolated communities in which the black population does not completely fit the model 53/, in the general population education is a very strong predictor of utilization. Occupation To a great extent occupation is a product of education and a determinant of income. The data in Table 10 from the Health Interview Survey and other studies 54, 55 and 56/, show that utilization varies with occupation, and that people in white collar occupations use dental services more than those in blue collar jobs. This difference appears to persist long after financial barriers are removed. In a case study of workers in a prepaid dental plan, different occupational groups continued to show markedly different utilization rates even after six years in the plan 57/. Other Aspects of Utilization Socioeconomic status (SES) is usually measured by income, education, and occupation. But SES also implies differences in beliefs, attitudes, and specific behavior patterns associated with social class values. Although lower SES implies less disposable income and therefore reduced ability to pay for health care, cost is not the only reason differences in utilization occur. Individual behavior is particularly important in the consideration of preventive health behavior. Many preventive practices, such as toothbrushing, entail almost no cost, yet members of lower SES groups are less likely to follow them than are people from higher groups 60/. Demographic and socioeconomic variables do not fully explain differences in utilization of dental services. There are underlying sets of attitudes and behaviors. Three conceptual approaches to these are 1) motives and barriers affecting utilization, 2) learned behavior, and 3) the health belief model.

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Source: Health Interview Survey, National Center for Health Statistics. 58/

Table 9. PERCENT OF PERSONS WITH DENTAL VISITS, BY TIME INTERVAL, INCOME, EDUCATIONAL LEVELS, AND OCCUPATIONS, 1977 Time Interval Since Last Dental Visit Characteristic Total Less than 1 Year 1 to 2 Years More than 2 Years Never All Persons a/ 100.0 49.7 13.1 26.8 9.3 Income Level Under $3,000 100.0 35.9 11.7 40.4 11.1 $3,000-$4,999 100.0 32.7 11.8 42.8 12.0 $5,000-$6,999 100.0 36.0 13.0 38.0 12.2 $7,000-$9,999 100.0 39.7 14.1 32.7 12.7 $10,000-$14,999 100.0 46.8 14.4 27.1 11.0 $15,000 or more 100.0 61.9 12.9 17.8 6.4 Education level of Head of Household Under 9 years 100.0 30.2 11.5 46.0 11.2 9-11 years 100.0 39.8 13.7 34.0 11.6 12 years 100.0 51.9 14.1 24.0 9.0 13-15 years 100.0 58.9 14.1 18.3 7.9 16 or more years 100.0 68.5 11.7 11.9 6.8 Selected Occupations b/ Household workers 100.0 33.9 13.2 50.2 2.1* Non-farm laborers 100.0 42.4 13.9 38.4 3.3 Craftsmen 100.0 46.8 15.0 35.4 1.3 Clerical 100.0 59.3 15.7 23.0 0.6 100.0 66.6 14.1 18.1 0.3 Professional and Technical *Figure does not meet standards of reliability or precision. a/ Includes persons with unknown family income, as well as persons for whom education of household head is unknown. b/ Of currently employed persons only. 0.6* 1.9 1.5 1.4 1.0

1.1 0.9 1.0 0.8 1.1

1.0 0.7 0.8 0.8 0.7 0.9

Unknown 1.1

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NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES 22

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Table 10. NUMBER OF DENTAL VISITS PER PERSON PER YEAR, BY SELECTED OCCUPATIONAL CHARACTERISTICS: UNITED STATES, 1977 Characteristic Visits per person per year All Persons 1.6 Total white collar 2.1 Professional 2.1 Managers/Administrators 2.0 Clerical 2.0 Sales 2.1 Total Blue Collar 1.3 Crafts 1.3 Operators 1.3 Laborers (non-farm) 1.3 Total Service 1.5 Private household 1.2 Other service workers 1.6 Total Farm 1.2 Farm managers 1.2 1.3 Farm laborers and foremen Source: Health Interview Survey, National Center for Health Statistics 59/

Motives and barriers There is a relationship between social class and the motivation to maintain healthy, natural dentition 61 and 62/. Attitudes toward the cosmetic and social usefulness of healthy teeth vary with socioeconomic level. Persons in higher levels attach more importance to attractive teeth than do those in lower groups. However, the strength of an individual's motivation must be considered with regard to barriers to care-real or perceived--for a better understanding of the differing patterns of utilization. Cost is one barrier to seeking dental care. Several studies have cited it as the most frequent reason needed care was not sought 63 and 64/. However, lower utilization persists in populations with access to free or prepaid dental care 65, 66 and 67/. Lack of financial resources may be more related to not seeking needed dental work than for going to the dentist for preventive care 68/.

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Problems in access to dental care also can involve physical factors, such as distance, availability of transportation, and other matters of convenience. The convenience of making and keeping an appointment tends to be related to socioeconomic level. The person paid hourly wages is not likely to have great flexibility in setting work hours, and time off work is costly. It may also be more complicated, because leave must be requested in advance 69/. If people have difficulty in finding dentists who have lower fees or who will accept delayed payment, they may have to select dentists who do not practice in or near their neighborhoods 70/. Anxiety or fear of pain are significant barriers to seeking health care 71, 72 and 73/. Because persons from lower socioeconomic groups have more extractions and less preventive treatment, they may be more fearful of dental visits. But fear and anxiety have been shown to be associated with differences in preventive care utilization at all income levels, with no apparent differences between socioeconomic levels 74 and 75/. A lack of knowledge or understanding of dental disease and the need for treatment may result in a low priority for dental care 76 and 77/. A study of persons of lower socioeconomic groups found that they tended to choose false teeth when presented with a hypothetical case involving a choice between having their teeth fixed or being given dentures 78/. Learned behavior In this concept, behavior must be viewed apart from attitude and beliefs, particularly the behavior related to preventive care. Positive attitudes do not necessarily evoke preventive behavior. A belief in the usefulness of tooth brushing and visiting the dentist may have little influence on the frequency of preventive visits 79 and 80/. Studies have demonstrated, however, that learned behavior is closely related to dental services utilization 81, 82 and 83/. Those who visit a dentist first before they are 13 are more likely to make visits when they are asymptomatic. Generally, those who take one health-related action are more likely to repeat it than those who have not. Kriesberg and Treiman state, “Apparently the use of dental services is a specific pattern of behavior which is learned by precept and example and may be learned without a comprehensive set of supporting beliefs, attitudes and values.” 84/ The health belief model This postulates that readiness to seek care without having disease symptoms depends on a combination of beliefs: (1) that one is susceptible to the disease in question, (2) that the disease is potentially serious, and (3) that an action to prevent or alleviate the disease is available.

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In a study of 430 factory workers whose care was covered by a company-financed dental plan, almost 80 percent of those who held all three beliefs made preventive dental visits 85/. In a three year follow-up of the same population, the association between beliefs and behavior persisted. More than 65 percent of those who believed both in the susceptibility to dental disease and the benefits to be derived from preventive care had made preventive visits to the dentist between the studies, while only about 40 percent of those who did not hold either belief had made preventive dental visits 86/. Associations between beliefs in susceptibility and benefits and other kinds of preventive health actions also have been found 87, 88, 89 and 90/. None of the behavioral science models outlined above adequately explains all differences in utilization. However, a relationship between socioeconomic status and the utilization of dental services has been confirmed repeatedly. SUMMARY AND CONCLUSIONS There is a substantial unmet need for dental services in the United States; national surveys show that almost two thirds of the population is in need of some kind of dental care. The needs vary according to age, sex, race, income, and occupation. Among schoolage children, removal of debris and cavities and treatment of decayed primary and permanent teeth are the greatest needs. Many of these conditions could be prevented by community fluoridation and preventive care. The committee therefore concluded that a basic public program is required to assure the delivery of preventive services to all children. More men are in need of dental treatment than women, and blacks have a greater need for dental treatment than whites. The unmet need for dental services among low income groups is significantly greater than those with incomes above the poverty level. The use of dental services also is highly correlated with income: the higher one's income, educational level, and occupational status, the more likely one is to visit a dentist. Financial barriers to obtaining needed dental services among low income groups led the committee to conclude that the needs of children in low-income families must be addressed, and that, at a minimum, steps should be taken to assure that they have access to the comprehensive dental services. Variations in learned behavior, attitudes, and beliefs are associated with differences in socioeconomic class and the use of the dental services. National health policy with regard to dental services, therefore, should not only address issues of equity in

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NEED FOR DENTAL TREATMENT AND UTILIZATION OF SERVICES 26

financial and physical access to care, but also encourage and support behavior that results in more appropriate utilization of these services. Thus, the committee emphasizes preventive services, particularly for children, in its recommendations.

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EPIDEMIOLOGY AND PREVENTION OF DENTAL DISEASES

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CHAPTER 3 EPIDEMIOLOGY AND PREVENTION OF DENTAL DISEASES The committee considered dental benefits that are specific to three major oral diseases and conditions-dental caries, periodontal disease, and malocclusion. Central to the recommendation of specific benefits is the question of efficacy of professional interventions at various stages of the disease process. The committee's choices among alternatives are based in part upon the potential impact of services on oral health. The etiology, epidemiology, prevention, and treatment of dental diseases are examined in this chapter. Emphasis is placed on the prevention of caries and periodontal disease because control of the amount and severity of these two major bacteria-related conditions will greatly affect oral health. Malocclusion is also analyzed because it can seriously affect child growth and development in its severe or handicapping forms. The primary function of human dentition is efficient chewing. Healthy teeth enable consumption of a varied and nutritious diet. Untreated dental disease causes dysfunction and eventual tooth loss. In 1971 about 11 percent of the American population was toothless, including about 51 percent of those aged 65 and over 91/. Although full dentures usually enable one to eat an adequate diet, no denture can approach the efficiency and comfort of healthy natural teeth. In the most recent National Health Interview Survey, about 30 percent of denture wearers indicated that their dentures needed to be refitted or replaced 92/. Speech can be affected by tooth loss or deviations in dentition and oral tissues 93/. In children 18 months to 4 years of age, the absence of primary incisor teeth can permanently affect the quality of certain speech sounds 93, 94 and 95/. Disfigurement and pain caused by oral pathology or abnormalities can lead to impaired social function. A number of studies have emphasized the social and psychological importance of facial appearance 96, 97, 98, 99, 100, 101 and 102/. A recent report of the National Research Council stated that dental disease, if left untreated, places an increasing burden

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on a person's emotional well-being, because pain and disfigurement lead to diminished comfort and poor self image 103/. Abnormal dentofacial appearance can evoke discrimination and an increased likelihood of an individual adopting a dysfunctional social role 104/. Pain is the most common consequence of untreated oral disease and is often the stimulus for seeking professional dental attention. The three most prevalent dental pathologies--caries, periodontal disease, and malocclusion--are discussed in the following pages. DENTAL CARIES Etiology Dental caries (tooth decay) is the progressive destruction of the teeth by organic acids produced locally by bacteria 105/. Carious lesions may begin to appear soon after teeth erupt. Caries has a complex etiology that includes at least three factors--diet (predominately sugars), acid-producing bacteria, and susceptible teeth. Sugars are cariogenic because they are easily fermented to acid. Sucrose may have a special role because some oral bacteria act on sucrose to produce sticky polysaccharides, which in turn enable the acid-producing bacteria to adhere to the surface of the teeth in a film known as dental plaque. Epidemiology Dental caries is the most common dental disease in the United States and is the primary cause of tooth loss through young adulthood: by age 35, the average American has lost five teeth and has 11 more attacked by caries 106/. The most widely used measure of dental caries is the DMF index, which is usually expressed as the total number of decayed (D), missing (M), and filled (F) permanent teeth per person. DMF measures the total cumulative experience with the disease at any one point in time, but the three components reflect different aspects of a person's experience with dental caries. D represents the number of permanent teeth with untreated decay. The F component reflects the number of filled or restored teeth, which indicates experience with dental care received. M theoretically is a measure of teeth extracted because of decay but because teeth can be lost for reasons other than decay, M should be interpreted cautiously. For the over-35 age group, in which severe periodontal disease often causes tooth loss, the M component is an inappropriate indicator of caries experience. The combined DMF may not portray changes in oral health. The F can increase and the D decrease, leaving the DMF unchanged, although more filled teeth and fewer untreated decayed teeth mean a change for the better in oral health.

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The epidemiological data on dental disease in this report, including the DMF were obtained in the 1971-74 Health and Nutrition Examination Survey (HANES) 107/ conducted by the National Center for Health Statistics.* The HANES data show a direct relationship between age and dental caries in a susceptible population. One indication of this relationship is that girls 3 to 5 years old, whose teeth usually erupt earlier than boys, tend to have more caries than boys of the same age 108/. Adult women have a slightly higher DMF rate than men. A review of the incidence and prevalence of dental caries by age is of interest. Thirty-three percent of elementary school children aged 6 to 11 have two or more decayed teeth 109/. Within this age group an average of 2.7 primary teeth have been attacked by caries. In addition, the total DMF for permanent teeth is 1.7 (Table 11). The prevalence of caries in permanent teeth increases with age among children, and by age 11, more than 75 percent of all children have experienced tooth decay 110/. Table 11. AVERAGE NUMBER OF DECAYED, MISSING, AND FILLED PERMANENT TEETH OF CHILDREN, BY AGE AND SEX, 1971-74 Total DMF Decayed (D) Missing (M) Filled (F) Age Male Female Male Female Male Female Male Female Total 1.7 0.7 0.1 0.8 6 .2 .3 .1 .1 .0 .15 .1 .1 7 .5 .6 .3 .4 .1 .0 .1 .2 8 1.3 1.2 .6 .6 .1 .0 .6 .6 9 1.9 2.4 1.0 .9 .3 .1 .7 1.4 10 2.5 2.5 .9 .9 .2 .2 1.4 1.5 2.6 3.1 1.1 1.1 .4 .3 1.1 1.7 11

Source: Health and Nutrition Examination Survey (HANES), National Center for Health Statistics 111/. Table 12 shows the incidence and prevalence of disease, as measured by DMF, for adolescents aged 12 to 17. Rising about 1.0 DMF tooth per year, the incidence of caries among adolescents is twice that of children, although part of the difference is due to the presence of more teeth at risk.

*The HANES study is described in Chapter 2. A description of sampling and standard errors can be found in the appendix.

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The DMF increases steadily with age (Table 13). The portion of the DMF representing decay among adults is highest in the 18-to-24 year-old group, with an average of more than two decayed teeth per person; this figure gradually declines to less than one by age 65. The missing (M) component rises with age. The filled (F) component of the DMF reaches a high of around nine teeth in the 25-to-44 age range, dropping to about six among the elderly, largely because of the extraction of filled teeth. Table 12. AVERAGE NUMBER OF DECAYED, MISSING, AND FILLED PERMANENT TEETH OF ADOLESCENTS, BY AGE AND SEX, 1971-74 Total DMF Decayed Missing Filled Age Male Female Male Female Male Female Male Total 6.4 1.8 0.6 3.7 * 12 3.9 3.7 1.0 1.4 .3 .4 2.6 13 4.8 5.2 1.9 1.7 .4 .4 2.4 14 5.1 6.6 1.7 2.0 .5 .9 3.0 15 5.4 7.1 1.6 1.9 .5 1.0 3.3 16 7.1 8.3 2.1 1.9 .6 1.6 4.4 8.1 9.4 2.1 2.4 1.6 1.6 5.4 17

Female

1.9 3.0 3.7 4.4 5.1 5.4

Source: Health and Nutrition Examination Survey (HANES), National Center for Health Statistics 112/. Table 13. AVERAGE NUMBER OF DECAYED, MISSING AND FILLED TEETH OF DENTULOUS ADULTS, BY AGE AND SEX, 1971-74 Total DMF Decayed Missing Filled Age Group Male Female Male Female Male Female Male Female Total 16.9 1.4 7.4 8.1 11.0 2.2 1.9 1.7 1.8 6.6 7.3 18-24 10.5 25-34 14.9 15.8 1.8 1.7 4.1 4.9 9.0 9.2 35-44 18.4 20.0 1.2 1.1 8.4 9.9 8.8 9.2 45-54 19.2 20.5 1.0 0.9 9.9 11.1 8.3 8.5 55-64 20.7 21.5 1.0 0.8 12.4 12.6 7.3 8.1 21.8 22.5 0.7 0.5 15.6 14.8 5.5 7.2 65-74

Source: Health and Nutrition Examination Survey (HANES), National Center for Health Statistics 113/.

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Treatment Dental caries is usually treated by removing the decayed portion and reconstructing the tooth. Teeth have limited capacity for self repair, therefore carious lesions become worse with time. The type of treatment depends on how early it is instituted. Reconstructive services fall into three main categories--fillings, inlays and onlays, and crowns. The filling materials generally are silver amalgam for posterior teeth, tooth colored composite resins for anterior teeth, and cast gold inlays/onlays for teeth that have lost substantial amounts of tooth structure. A full crown is the treatment of choice when there is little or no supporting enamel remaining after the decay is removed. If the destruction caused by the decay has affected the tissues of the pulp chamber, endodontics (root canal therapy) may be needed if the tooth is to be retained. When the most extensive treatment (root canal filling and a crown) cannot be performed, the tooth must be extracted. The dental treatment then consists of replacing the lost tooth or teeth with either removable partial dentures or fixed bridges. Partial dentures usually are held in place by means of clasps on the adjacent natural teeth. The loss of all teeth calls for full dentures. Because treatment of dental caries increases in complexity as the disease process advances, prevention of disease or early diagnosis and treatment are important. Prevention Several preventive strategies for dental caries are available. These include plaque removal and diet modification and the use of fluorides and tooth sealants. Fluoride There is ample and convincing scientific evidence of the effectiveness of fluoride in reducing dental caries. Fluoride can be administered in treated drinking water, in dietary supplements, or can be applied directly to the teeth by the individual or by professionals. The most effective and efficient method of exposing teeth to fluoride is to consume it in drinking water. A recent symposium speaker on caries prevention stated: Water fluoridation involves a minimum per capita outlay for a tremendous saving in the cost of replacing decayed and missing teeth. As such, it is one of the few bargains available in health care 122/.

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Approximately half of the American people have drinking water that is either naturally fluoridated or has had fluoride added.* Children who from birth have drunk fluoridated water have, on the average, 50 to 70 percent less teeth decay than those who have not 114, 115, 116, 117, 118, 119, 120 and 121/. Loss of first permanent molars can be reduced as much as 75 percent; and caries on the proximal surfaces of upper incisor teeth can be reduced 95 percent. The economic benefits of fluoridation vary with such factors as the age of the subjects when fluoridation was initiated, the total number of years they have been drinking fluoridated water, and the size of the city. A conservative estimate, based on number of tooth surfaces saved, is an annual saving in treatment costs of $11 to $16 per capita, resulting in an average cost-benefit ratio of approximately 1:50 after 12 to 15 years of fluoridation 122/. In other words, for every dollar spent on water fluoridation, 50 dollars are saved in treatment costs. One of the advantages of community water fluoridation is that it does not require active cooperation fromindividuals for its benefits to be conferred. Children in such communities receive fluoride from birth, which is expected to maximize the benefit. A recent report to Congress by the General Accounting Office stated that the U.S. Public Health Service was not actively promoting fluoridation 123/. Subsequently, the Public Health Service, through the Center for Disease Control, has increased its efforts to promote community water fluoridation. There is a need to educate the public on the benefits of fluoridation. A national survey taken in 1977 revealed that 76 million adults--about 51 percent of the adult population--do not know what fluoridation is. About 45 million adults served by public water systems do not even know that the water they drink is fluoridated 124/. The fluoridation of school water supplies is effective in rural communities that lack a central water supply. But because children do not attend school until some of their permanent teeth are partially or fully mineralized, the benefits of school water fluoridation are less than for community fluoridation. School water is usually fluoridated at levels higher than the concentration recommended for community fluoridation, because children consume only part of their daily intake of water at school. The maximum benefit reported has been a 10 to 40 percent reduction in caries 125, 126, 127, 128, 129, 130 and 131/. The approximate cost per person is $1.50 a year, with a cost-benefit ratio of 1:5.3 (one dollar spent for fluoridation saves $5.30 in dental costs). This figure varies

*A report that cancer mortality was higher in cities with fluoridated water than in those without fluoridation appeared in 1975 132 and 133/. However, subsequent analyses have repudiated these findings 134 and 135/. When the crude death rates for fluoridated and non-fluoridated cities were adjusted for demographic characteristics and for variables such as population density, median education and income level, and percentage of the population employed in manufacturing, no association was found between fluoridated water supplies and increased mortality 136/.

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with the size of the school; fluoridation is more efficient for larger schools and requires no individual compliance. Dietary supplements of fluoride, in tablet form, can effectively reduce caries. It has been estimated that a 50 to 70 percent reduction in caries results from ingestion of fluoride tablets from birth. When tablets are administered at school, the caries-inhibiting effect has been estimated at 20 to 40 percent 122, 120/. A six-year clinical trial of chewable fluoride tablets administered at school showed that children who chewed one tablet a day during the school year had 28 percent fewer cavities than a control group 388/. The cost-benefit ratio of tablets distributed at school is about 1:17.5 122/, or one dollar spent for tablets saves $17.50 in dental care costs. Administration of tablets at home is less effective for lack of parental compliance. Table 14 displays the cost-benefit comparison of community and school water fluoridation and distribution programs of fluoride tablets in a school setting. Table 14. ESTIMATED ANNUAL COST-BENEFIT RATIOS OF SYSTEMIC FLUORIDES a/ Estimated percent caries Cost per capita Saving per capita Method reduction Community Water Supply 50 $0.20 $10.00 Fluoridation School Water Fluoridation 40 1.50 8.00 Fluoride Tablets Distributed 35 0.40 7.00 at School

Costbenefit ratio b/ 1:50 1:5.3 1:17.5

a/ Estimates represent maximum benefits, which would not be attained until program has been operating for more than 12 years. b/ Assuming caries increment of 2.0 DMF/year in nonfluoridated community and cost of restoring a surface at $10.

Source: University of Michigan Workshop on Caries Prevention 137/. Table 15 shows the recommended dosages of dietary fluoride supplements adjusted for children's ages and content of fluoride occuring naturally in the drinking water.

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Table 15. RECOMMENDED DOSAGES OF DIETARY FLUORIDE SUPPLEMENTS, BY AGE AND LEVEL OF FLUORIDE IN WATER SUPPLY OF LOCALITY Fluoride Dosage in mg. Natural Fluoride Content as Percent of Optimal 0-2 Years 2-3 Years 3 Years and Older a/ Greater than 70% None None None 30% to 70% 0.125 0.25 0.5 0.250 0.50 1.0 Less than 30% a/ Dietary fluoride supplements should be continued until at least ages 12 to 14, or until all permanent teeth other than third molars have erupted.

Sources: Community Programs Section, National Caries Program, National Institute of Dental Research, National Institutes of Health (memorandum to Dental Public Health Professionals, 1979) Weekly fluoride mouthrinsing has proved to be an effective method of self-application when carried out in schools. More than 20 large-scale clinical trials have shown that frequent mouthrinsing with diluted fluoride solutions inhibits dental caries 138/. Caries reduction in these programs has ranged from 20 to 50 percent. Mouthrinsing in school can be done in the classrooms and can be supervised by properly trained teachers, aides, or volunteers. The Food and Drug Administration does not require professional dental personnel to supervise this activity. About 8 million children in the United States are participating in school fluoride mouthrinsing programs 139/. Assuming a conservative 25 percent caries reduction, the cost-benefit ratio of a weekly fluoride rinse in school has been projected at approximately $1 for each tooth surface saved, or about 1:10. If payment is made for supervision, the cost would increase to $1.60 per surface saved. Even in an optimally fluoridated community, a weekly mouthrinse at school combined with periodic applications of a fluoride gel tray resulted in 30 percent fewer new DMF surfaces 140/. However, this method requires much more organization than does systemically administered fluoride. Other methods of self-application of fluoride include supervised brushing with solutions and pastes, and the above-mentioned application of fluoride gel in trays customfitted to each child's mouth. These procedures are usually supervised by professional dental personnel, such as a dental hygienist, and are more complicated than the mouthrinse. Although brushing can be done less frequently than mouthrinsing (every two to six months depending on the type and concentration of fluoride used), its cost-effectiveness is less favorable because of

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the professional time required to supervise the procedure. The geltray technique has produced an 80 percent reduction in caries, when used daily, but the cost of producing the trays and the professional time required to supervise the application makes the total cost-benefit ratio unfavorable. Even if done in large groups in a school setting, the cost is an estimated $21.30 per surface saved 141/. Table 16 compares cost-effectiveness of various topical fluorides. Use of fluoride-containing dentifrices will reduce caries from 15 to 40 percent in areas with fluoridedeficient water 142, 143 and 144/. Studies have shown that supervised brushing at school with fluoride dentifrices does not provide more anti-caries protection than normal home use. More than 70 percent of all dentifrices sold in the United States contain fluoride. Because home use of these products is already widespread, it probably is not economical to provide fluoride dentifrices at public expense 145/. On the other hand, it may be worth while to encourage brushing with fluoride dentifrices as part of a broader program of preventive measures 146/. Table 16. ESTIMATED COST-EFFECTIVENESS OF TOPICAL FLUORIDE PROCEDURES Estimated percent reduction Cost per tooth surface saved Procedure Weekly mouthrinse 25 $1.00 Professional application of solution (multiplechair method) 25 to 40 2.60 to 4.40 Annual professional application of gel in preformed trays 40 4.40 Toothbrushing at home 20 10.00 80 21.30 Daily self-application of gel in custom trays

Source: University of Michigan Workshop on Caries Prevention, 1978 147/ Professionally administered fluoride treatments usually consist of a prophylaxis followed by exposure to a fluoride solution or gel for several minutes. Performed annually, this procedure can reduce caries

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from about 25 to 40 percent, according to various investigators 148, 149 and 150/. The cost, when the procedure is performed by a hygienist, has been estimated to be from $2.60 to $4.40 per tooth surface saved. Professional application of fluorides is a cost-effective preventive treatment for those who receive the treatment. If the goal of a public health program is to reach the maximum number of children, however, a less costly self-administered procedure may be desirable. For example, a weekly school mouthrinse that produces a 25 percent reduction in caries for a large number of children may be considered preferable to a professionally administered program, which, because of manpower and money constraints, would be available to a smaller number of childdren. Tooth sealants Adhesives have come into use recently to seal the biting surfaces of teeth. Although these surfaces represent only 12.5 percent of all tooth surfaces at risk for caries, studies of schoolchildren have shown that as much as 45 percent of carious activity occurs in the “pit and fissures” of these surfaces 151/. Several types of sealants have been tested with varying degrees of effectiveness. Teeth are usually carefully prepared by trained personnel in order for the adhesive to be bonded successfully with tooth enamel. Although a first-year reduction in caries of 80 to 100 percent has been reported with the use of sealants 152, 153, 154, 155, 156, 157 and 158/, the application is time-consuming and therefore relatively expensive. For maximum effectiveness, sealants must be applied soon after tooth eruption. Children must visit a dental professional at regular intervals to seal newly erupted teeth and to replace lost sealant. The results of clinical trials vary greatly, depending on the type of sealant used and how well it is retained on the teeth 159/. It is unrealistic to attempt to estimate a cost-benefit ratio, but this method might be cost-effective if performed by trained auxiliaries rather than dentists, and if done during the same visit as other preventive procedures. Plaque removal Theoretically, the regular removal of plaque should decrease dental caries, because the presence of plaque is necessary to initiate carious lesions. However, few studies substantiate this relationship. Experimental programs for mass control of plaque in the United States have tended to focus on gingival health or oral hygiene status as outcome criteria 160/. A Swedish study did monitor caries reduction 161, 162 and 163/. Schoolchildren in an experimental group were given regular prophylaxes, while those in a matched control group were not. At the end of four years, the control group had 15 times as much caries as those in the experimental group. The prophylaxes were performed once every two weeks during the first year and every three weeks the second .

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year. The interval was gradually increased to 8 weeks during the fourth year for younger children and 16 weeks for older children. In a similar study, children's teeth were deplaqued every three weeks for three years. This regimen produced a 51 percent decrease in new caries 164/. These studies have shown that the mechanical removal of plaque can successfully control caries; however, the frequency with which the procedure must be performed to be effective makes this method of caries prevention expensive. Further, some researchers suggest this procedure may remove the outer enamel that is rich in fluoride content. Therefore, it might well be undesirable from the standpoint of public health programs designed to reach large numbers of people. Diet Modification The annual per capita consumption of sucrose in the United States increased 15 percent between 1960 and 1977. Sucrose now constitutes between 16 and 25 percent of the calories in the average American diet. About 76 percent of the sugar consumed occurs naturally or is added to foods and beverages by processors; a growing proportion of that is consumed in the form of between-meal snacks. Only 24 percent of the sugar consumed in the United States is added to foods by consumers 165/. The consumption of sugars, particularly between meals, contributes to tooth decay. An experimental program in Sweden showed that discontinuing the practice of eating sticky sweets between meals could reduce caries as much as 90 percent 166/. A review of 17 studies points up the importance of the frequency of consumption of snack foods in causing caries 167/. In a recent symposium on caries prevention, three public health approaches to diet modification were suggested 168/. 1. Reduction of the availability, intake, and desire for sweets. 2. Fortification of sugars with anticaries nutrients like phosphates. 3. Substitution of refined sugars by less fermentable carbohydrate sweeteners or by other natural or synthetic sweetners. Positive clinical data supporting the second approach--fortification of sugars--do not seem to be available. With regard to the other alternatives, some actions have already been taken to reduce the availability and desire for sugar. Processors of baby food have eliminated some sugar from their products, and a campaign has been organized against advertisements for sweets on children's television. Another approach could be to teach nutrition in the public schools, the lessons being reinforced by private dental practitioners and their auxiliaries.

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There are several natural and artificial sweeteners that could be used as substitutes for sugar. Saccharin is the only synthetic sweetener available, but it has been shown to cause bladder cancer in animals, and so its carcinogenicity in man is suspected. Research is currently being conducted on the suitability and safety of a number of other sweeteners, although none will likely be ready for public consumption for several years. Percentage ingredient labelling on food packages would tell the consumer exactly what proportion of the food is sugar. Presweetened foods might be eliminated from government funded school lunch and breakfast programs. School boards or other official bodies could curtail the use of vending machines that dispense sugarrich foods in schools. In Alabama, an elementary school cannot receive state accreditation if it contains vending machines that dispense sweet foods 169/. There are many ways that the consumption of cariogenic food could be reduced. Discouraging the frequent consumption of sugar rich food may be, in the long run, an effective strategy for the primary prevention of dental caries, although extensive efforts would be required to achieve long-lasting change in eating habits. PERIODONTAL DISEASES Periodontal diseases are pathological conditions of the surrounding and supporting structures of the teeth. Periodontal diseases are almost as prevalent as dental caries in the American population. They affect nearly 75 percent of the adult population and are the most common cause of tooth loss in persons over 35 years of age 170/. Etiology The initiating factor for periodontal diseases is similar to that for dental caries: bacterial colonizations in dental plaque 171/. Although it is not known which of the many organisms in the mouth are responsible for the various forms of periodontal disease, a number of studies have found a direct relationship between the amount of bacterial plaque on teeth and the severity of gingivitis 172, 173, 174 and 175/. It is clear that the bacteria residing in the human gingival crevice can produce a variety of enzymes capable of destroying many of the constituents of human gingiva 176, 177, 178, 179, 180 and 181/. There is specific evidence from more recent studies that implicate various microorganisms as primary contributors to the formation of periodontal disease 182, 183 and 184/. However, studies so far have failed to show a direct relationship between periodontal diseases and either genetic or nutritional factors 185 and 186/. Hard deposits on teeth (calculus) have not been shown to cause inflammation by their mere physical presence 187 and 188/. A series of

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studies showed that the presence of bacterial plaque was more important histologically in the initiation of severe inflammation than mechanical irritation from calculus 189, 190, 191, 192 and 193/. Calculus is always covered by bacterial plaque, however, and by removing the calculus, the plaque is also removed. The incidence of various periodontal diseases is difficult to estimate because of uncertainties in separating the different clinical entities that are grouped under one general heading. In 1956, Russell 194/ developed the Periodontal Index (PI), which scores the clinical manifestations of the periodontal diseases on a scale of 0 to 8. Higher scores indicate gross pathology of bone destruction; lower scores signal more subtle clinical signs of early gingivitis. The PI score is a mean score for each individual, not an absolute count as is the DMF. Thus, a person can have one or more areas with advanced periodontal disease but show a low mean PI score. Another important measure in the assessment of periodontal disease is the Simplified Oral Hygiene Index (OHI-S) developed by Greene and Vermillion 195/ in 1964. The OHI-S is the sum of two component scores, the Simplified Debris Index (DI-S) and Simplified Calculus Index (CI-S). The PI and OHI-S measures have been used in the epidemiological data presented in this section. These data were obtained in the 1971-74 Health and Nutrition Examination Survey 216/ conducted by the National Center for Health Statistics. Epidemiology The incidence of periodontal diseases varies most noticeably with age and oral hygiene 197/. The presence of organisms in dental plaque probably explains the relationship between oral hygiene and periodontal diseases, but the relationship with age is not clearly understood. It would appear that the microorganisms in dental plaque provide a chronic irritation that eventually begins to break down the periodontal tissues. The gingival inflammation of children ages 6-11 is mostly associated with tooth eruption. Thirty-two percent of American youths aged 12-17 and approximately half of the adult population with at least one remaining natural tooth have some periodontal disease. Thirty-seven percent of adults have chronic disease with pocket formation between gum and tooth. Both income and education are inversely associated with high PI and OHI-S scores. Men have a mean score 40 percent higher than women, and black adults have an 80 percent higher periodontal index than whites. In summary, periodontal diseases are a major threat to oral health and account for a significant amount of pain, discomfort and loss of teeth in the adult population.

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Treatment The intent of the treatment of periodontal diseases is to interrupt, arrest, or reverse the progressively destructive process of the bacterial colonizations that are the precipitating causes of periodontal diseases. In more advanced diseases, an attempt is made to arrest the progression of the periodontal pockets which lead to the loss of the supporting bone. Treatments of more advanced clinical states of periodontal diseases are aimed at rearranging the forces on the periodontal attachment apparatus which consists of the root cementum, supporting bone, and the periodontal ligament (the connective tissue contents of the space between the bone and root cementum). The specific treatments and the order in which they are given will vary from patient to patient, but the stages in the process often include: 1. 2. 3. 4. 5. 6.

Thorough prophylaxis and the establishment of a program of oral hygiene in order to control or eliminate gingival inflammation; thorough root planing and gingival curettage. Reevaluation of the patient's ability to maintain oral hygiene as a condition for more extensive treatments. Restoration of carious lesions that are related specifically to gingival health. Extraction of teeth beyond treatment because of periodontal destruction. Periodontal surgery. Occlusal adjustment.

Extensive surgical therapy for advanced periodontal diseases is usually performed on patients who can maintain their oral hygiene and who understand the disease process which they are being motivated to control. Several studies in which comparisons were made between conservative treatment (curettage) and periodontal surgery raise some questions about the cost-effectiveness of periodontal surgery. Ramfjord, et al. 198/, report that in the short term (one to three years after treatment) curettage resulted in a slight gain of attachment, while surgery resulted in a slight loss of attachment. For the long term, there was no significant difference in attachment between the two therapies. In another analysis after 15 years, the subsequent loss of teeth was related more to the extent of pathology than the surgery performed 199/. Some investigators suggest that a diligent oral hygiene program that includes toothbrushing, flossing, irrigation, application of certain

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saturated salt solutions deep into the gingival sulcus, and periodic courses of systemic tetracycline can eliminate or greatly reduce potentially pathogenic bacterial populations 200/. Their findings suggest that this treatment abates or arrests further periodontal destruction. Prevention Plaque bacteria play a major role in the etiology of both dental caries and periodontal diseases. Since natural mechanisms do not adequately clean teeth, a combination of professional cleaning and personal oral hygiene practices (toothbrushing, flossing, water pressure devices and gingival stimulators) is recommended to control dental plaque. This combined approach can reduce the incidence of periodontal diseases by 90 percent 201 and 202/. But there are many gaps in the knowledge related to plaque control 203/. Plaque may form anew on teeth 24 hours after cleaning; it is not clear how often it must be removed to control or prevent disease. It has been shown in one study that subjects who removed all traces of plaque from teeth every two days can maintain healthy gingiva. However, the subjects' teeth and gums were in excellent condition at the beginning of the study and their teeth were checked after each brushing to be sure plaque had been completely removed 204/. There is additional evidence that supervised self-administered oral hygiene procedures are effective in reducing plaque and gingival inflammation 205/, and that plaque control is important for the success of periodontal treatment 205 and 206/. Teaching people to brush and floss their teeth correctly and motivating them to do it regularly without supervision has proved to be difficult. Formal classroom instruction in dental health for children generally has failed to produce long-term behavioral changes. The New York City Health Department recently terminated a 50year-old program of classroom instruction in dental health for elementary and junior high school children because it failed to reverse a 20-year decline in the number of children seeking or receiving dental treatment annually 208/. More encouraging results have appeared in studies of instruction and motivation techniques combined with professional dental care. In one three-year study 209/, an experimental group of young adults was given a professional prophylaxis at two, four, six, and nine months during the first year, at three-month intervals during the second year, and at four-month intervals during the third year. They were also instructed repeatedly about personal oral hygiene and periodontal disease, both individually and in groups. A control group was given annual examinations and told to continue with their usual oral hygiene practices.

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The oral hygiene score of the control group increased (worsened) at more than four times the rate of the experimental group. Gingival inflammation scores were significantly lower and loss of epithelial attachment was significantly less in the experimental group. A follow-up examination 32 months after the end of the original study found that subjects in the experimental group continued to show cleaner teeth, less gingival inflammation, and less detachment of tissues than subjects in the control group 210/. A future alternative to the mechanical cleaning of teeth may be the use of vaccines or antimicrobial agents to eliminate plaque, although clinical trials of antimicrobials so far have yielded ambiguous results 211, 212, 213, 214 and 215/. At present, however, it would seem that an organized and supervised program of activities aimed specifically at the prevention of periodontal diseases may be the most effective method of prevention. Such a program should consist of multiple components, each of which has some scientific evidence that would suggest its inclusion. The clinical objective of such a preventive program would be to facilitate the removal of bacteria, plaque, and calculus from the teeth. The high prevalence of periodontal diseases among youths provides support for the need for professional intervention to prevent periodontal diseases. Among youths 12 to 17 years of age, for example, 32 percent have periodontal disease and 6 percent of those show evidence of destructive periodontal disease 216/. Data from the National Nutrition Survey, primarily of low-income families, show that 55 percent of children in junior high school and 65 percent of all high school students have periodontal disease 217/. In seven cases of every 100 persons so afflicted, the disease had reached an advanced and destructive stage. Thus, because calculus is present in a fairly high proportion of youths, and because there is evidence of destructive (irreversible) periodontal diseases occurring, it would seem prudent to interfere with the progression of the disease in this age group by means of periodic, thorough oral prophylaxis. Because the need for such prophylaxis at specific intervals is not universal, this treatment might be limited to those with the greatest need. The literature on prevention suggests that a combination of professional cleaning and personal oral hygiene practices can reduce the incidence of the periodontal diseases. However, reliance on individual behavior alone to control the bacterial plaque associated with periodontal diseases has not been shown to be effective. Therefore supportive professional attention to remove calcified plaque and reinforce personal oral hygiene habits seem to be necessary components of a successful program to prevent periodontal diseases.

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MALOCCLUSION Although not as prevalent as dental caries or periodontal diseases, severe malocclusion is a handicapping condition for a substantial minority of the population. A malocclusion is considered to be seriously handicapping when the malposition of the teeth and jaws seriously inhibits the ability to chew and/or adversely affects social roles. The term malocclusion refers to “. . . that condition in which dental structures are not in acceptable equilibrium with each other or with the facial structures and/or cranium, thus interfering with or posing a potential threat to normal tissue development and maintenance, effective function, or a psychological problem” 218/. Etiology Malocclusion often follows loss of teeth due to poor hygiene. Untreated dental caries may cause premature tooth loss. The “space loss” resulting from lost tooth structure is considered to be one of the causes of malocclusion 219/. Malocclusion may also be related to childhood anxiety. Intensive and prolonged thumbsucking has been described by Moyers as “a direct cause of some of the worst forms of malocclusion” 220/. The National Health Examination Survey of children 6-11 years of age also found a relationship between thumbsucking and malocclusion 221/. The role of genetics in malocclusion is complex. Studies of twins indicate that heredity and environment are probably of equal importance in the etiology of malocclusion 222/. Epidemiology The Health Examination Survey indicated that orthodontic diagnosis, which includes evaluation of facial proportions and the relation of teeth to the underlying bone structure, is needed for approximately 2.5 million children and 10 million youths (about one out of every two youths in the U.S.) who have Treatment Priority Index (TPI) scores of 7 and above. The Treatment Priority Index combines selected major components of occlusion to obtain a weighted score, which ranges from 0 (ideal) to 10 (very severe malocclusion) 223/. The average TPI score for children and youths generally does not vary significantly with age, sex, race, family income, parents' education, or region of residence. Tooth displacement (crooked teeth) is probably the most widely recognized sign of malocclusion. Approximately two out of five children have crooked teeth, and one in 10 have tooth displacement scores of 4 or more, which the Health Examination Survey team assumed to be of critical severity. 224/

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In youths ages 12 to 17, tooth displacement is far more common than in younger children, because of the greater number of erupted teeth. More than 6 out of every 10 youths have tooth displacement scores of 4 or more. Approximately 17 percent of youths have either lingual or buccal crossbite 225/. The National Research Council Study of Seriously Handicapping Orthodontic Conditions estimated that use of criteria developed during the study “would probably identify approximately five percent of any population of children in this country as having a seriously handicapping orthodontic condition” 226/. The report, citing the National Center for Health Statistics, finds that an additional nine percent have a handicapping orthodontic condition for which treatment is “highly desirable.” Treatment The treatment of malocclusion is accomplished by a variety of minor and major tooth movement techniques. The objective of treatment, which can require up to 24 months, is to move the teeth into more functionally and esthetically acceptable alignment and occlusion. The full arch appliance is probably the most common orthodontic treatment technique currently used in the United States. This treatment entails placing of bands on each tooth and attaching a wide variety of brackets, pins, tubes, and wires to these bands in order to place tension on the appropriate teeth, thus causing them to move in a controlled fashion. In addition to the treatment of major malocclusion problems, there are many orthodontic treatment procedures that are applicable to minor tooth movement. Most of the appliances for minor tooth movement are either removable or use a technology that does not require the placement of bands on every tooth. Correction of oro-facial muscle imbalance is a relatively recent development that has emerged from the work of speech pathologists and cleft palate dental teams who were focusing originally on abnormal swallowing, speech defects, and tongue thrusting. Malocclusion is frequent in these cases. The successful treatment of malocclusion in these people is often dependent on the improvement or correction of these detrimental muscular forces. Prevention Prevention of malocclusions 227 and 228/ is unlikely because of the genetic factors in its etiology. However, some services are described by various authors as interceptive or palliative treatment. These services include 1) procedures to maintain or provide space for natural

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tooth movement at critical moments of growth and development, 2) the discouragement of thumbsucking, and 3) minor tooth guidance procedures. After a recent review of such procedures, Dunning concluded that, “Few of the techniques described . . . are within the usual range of the general practitioner” 229/. Perhaps the most clearly defined preventive orthodontic procedure is the use of a space maintainer on elementary school children. When a primary tooth is lost prematurely and the succeeding tooth is not expected to erupt for more than a year, the space should be maintained by an applicance. However, the best space maintainers are healthy primary teeth. Fluoride therapies and the timely restoration of primary teeth can lessen the need for space maintainers. SUMMARY AND CONCLUSIONS The literature shows that bacteria are associated with the etiology of both dental caries and periodontal diseases, with sugar as a necessary contributory agent in the development of dental caries. Bacterial colonizations in the form of dental plaque are directly associated with the initiation and progression of dental caries and the periodontal diseases. These bacteria act on sugars and other carbohydrates to produce acids, which initiate carious lesions in tooth enamel. Both dental caries and the periodontal diseases are nearly pandemic in the U.S. population. Two-thirds of the people of the United States need dental treatment. Thirty-three percent of elementary school children have two or more decayed teeth, and by age 11, more than 75 percent of all children have experienced tooth decay. By age 35, Americans, on the average, have lost five teeth and have 11 more affected by caries. Treatment early in life is essential to improved oral health during adulthood. Periodontal disease is most strongly associated with the presence of bacterial plaque due to poor oral hygiene and with increasing age, probably because long-term chronic irritation from the plaque eventually breaks down the periodontal tissues. The National Nutrition Survey found that 55 percent of junior high students and 65 percent of high school students have some degree of periodontal disease. Approximately 50 percent of adults with teeth have periodontal disease, and about 37 percent have chronic disease with pocket formation. Because of the substantial cost of treating the effects of dental caries and periodontal diseases, much attention has been paid to their prevention. Extensive literature on the prevention of dental caries shows four general strategies--plaque removal, diet modification, use of fluorides, and tooth sealants. Each of these preventive technologies

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can be effective under some circumstances, but the systemic fluorides are most easily applied on a community basis and topical flourides are effective in school-based programs. Plaque removal and diet modification entail a marked individual health behavior change; tooth sealants must be applied by a professional, are useful only for chewing surfaces of the teeth, and are less cost-effective than fluorides. A variety of cost-benefit analyses suggest that several of the fluoride strategies are highly cost-effective, providing the basis for the committee's recommendation of a foundation of community fluoridation and preventive care as essential to improvement of dental health. Analyses of dental caries, periodontal diseases, and malocclusions presented in this chapter underlie the recommendations relating to preventive services. These recommendations include a basic public system to assure the delivery of services to all children. The analyses also furnish a basis for emphasis on prevention for adults as a high priority in coverage of dental care services under an insurance program.

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THE SUPPLY OF DENTAL SERVICES

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Chapter 4 THE SUPPLY OF DENTAL SERVICES

A major concern in recommending the inclusion of dental services in a national health insurance program is the capacity of dental care providers to meet a potential increase in the demand for services. A sufficient supply of providers is important not only for a projected comprehensive national health insurance plan but also for limited plans that offer a specified set of services to a particular population. The supply of and access to dental services are influenced by a number of factors. The committee examined the current status and trends in dental providers, their productivity and the nature of various practice settings. Accordingly, Chapter 4 discusses the number of dentists, their specialization and distribution, the number and kinds of auxiliary personnel and the range of services they can deliver, the types of practice settings in which services are delivered, and conditions that influence productivity. Three types of expanded function dental auxiliaries are described, with reflections of some of the committee's discussion and debate. Capsule descriptions of private dental practice, hospital dentistry, and public programs and delivery systems are provided. The committee considered this information, especially in regard to the available data on productivity and the particular attributes of different practice settings. School-based settings, which lend themselves to the delivery of a preventive service for children and adolescents, are explored specifically. PRACTITIONERS Dentists In January of 1979, there were about 119,000 active dentists in the United States, of which 88 percent were general practitioners and 78 percent practiced alone. The average dentist in solo practice saw 67.5 patients a week and spent 33.5 hours a week in direct patient contact 230, 231 and 232/.

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As Table 17 shows, the total number of active dentists has increased since 1950. However, it was not until the last half of the 1960s that the rate of increase equaled the increase in population. Since then the rate of increase in the supply of dentists has exceeded growth of the population. The increase in the supply of dentists can be attributed mainly to federal policy initiatives. In the 1960s, legislation was enacted to provide funds for the construction of dental schools, whose number then grew from 47 in 1962 to 59 in 1976 233/. That increase was furthered by the Comprehensive Health Manpower Training Act of 1971, which mandated increases in the size of dental school classes as a condition for capitation grants from the federal government. Between 1960 and 1976, the number of dentist graduates increased from 3,233 to 5,336 per year 234, 235 and 236/. Several different projections have been made about the future supply of dentists through 1990 237 and 238/. The U.S. Bureau of Health Manpower estimates that there will be enough practitioners to meet the demand in 1990 even if third party dental insurance coverage is greatly increased 239/. Most dental students in the past have been white and male. More women are entering dental school today. In 1970-71, only 2.1 percent of entering dental students were women; by 1978-79, they made up 15.9 percent of the entering class and 21 percent of the senior class. Minorities have not fared as well. In the academic year 1971-72, about 8 percent of first year dental students were identified as minority. Blacks represented about 5 percent, Asians 2 percent, and Hispanics less than 1 percent. There was a negligible number of Native Americans. In 1978-79, minorities represented about 11 percent of the class, with some increase of Hispanics and Asians, but a relative decrease in representation of blacks. Geographic Distribution There is great variation in the distribution of dentists, both in terms of geographic regions and between metropolitan and rural areas. Although the national average ratio is about one dentist for every 1,900 persons, more than 85 percent of the counties in the United States have less than the average, and about 7 percent (218) have no dentist at all. In 1979, the ratio of dentists to population in the northeast and the west was about one and a half times that in the south. New York had 70.8 dentists per 100,000 population, the highest in the nation, while Mississippi was lowest with 30.7.

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Table 17. NUMBER OF ACTIVE DENTISTS AND DENTIST-TO-POPULATION RATIOS: SELECTED YEARS, 1950-79 Year Active Civilian Dentists Active Civilian Dentists per 100,000 Persons per Active Civilian Dentist Civilian Population 1950 75,310 49.8 2,008 1955 78,270 47.6 2,103 1960 84,500 47.0 2,127 1965 89,640 46.5 2,149 1970 95,680 47.1 2,123 1971 97,210 47.3 2,115 1972 98,860 47.7 2,097 1973 100,000 48.2 2,073 1974 103,030 48.9 2,044 1975 106,740 50.3 1,990 1976 110,000 51.4 1,944 1977 112,720 52.0 1,913 1978 115,450 53.1 1,883 118,330 54.0 1,851 1979*

Source: DHEW, Health Resources Administration 240, 241 and 242/ American Dental Association *Personal Communication with J.Ake 243/

49

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These data do not lead to clear conclusions about the number of dentists needed. However, some differences in dental practice associated with variation in ratios have been observed. Table 18 displays these differences by region. Dentists who practice in regions with lower ratios are more likely to have longer waiting periods for appointments, to report that they are “too busy to see all people requesting appointments,” and to have seen a greater number of patients. Table 19 shows utilization data by region; as expected, utilization is greater where the supply is greater. The ratio of dentists to population is greater in metropolitan areas. The national average is 56 dentists per 100,000 population for metropolitan areas. At the other extreme, there are only 26 per 100,000 in counties having a principal city of less than 5,000 people 244/. This distribution problem is reflected in data on Table 20. People wait longer for appointments in small cities than in large. Fewer dentists in large cities regard their practices as busy. The result is a difference in utilization: residents of metropolitan areas made 1.8 dental visits per person in 1977, while those who lived outside metropolitan areas (non-farm) made 1.2 visits 245/. The problem in the distribution of dentists is further exacerbated by the growth of dentist specialization. The dental profession recognizes eight specialties beyond general dentistry: dental public health, oral pathology, oral surgery, orthodontics, pedodontics, periodontics, endodontics, and prosthodontics. In 1979, 12.6 percent of all practicing dentists were specialists. The number of active specialists grew from 2,584 in 1953 to 15,003 in 1979 246/. This movement toward specialization in dentistry peaked in 1974 when new enrollees in dental specialty programs reached 1,282 or about 26 percent of their graduating class. But by 1978, new enrollment had dropped to the 1971 level of 1,217. This change represented a significant percentage drop because the 1978 graduating class was 37 percent larger 250/. It would appear that the total number of specialists (Table 21) is leveling off. The geographic distribution of specialists mirrors that of general dentists. For example, in 1976, 25 percent of all specialists were in California and New York, states that have only 18 percent of the total population 251/. Because specialists are dependent upon referrals from general practitioners, they must locate near general dentistry practices. The result is a continuation of the maldistribution problem, and specialty care is relatively inaccessible in many areas.

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a/ Average waiting time (in days) for new patient for a non-emergency appointment among dentists practicing along. b/ Percent of all dentists with average waiting time of 1 month or more for new patient for a non-emergency appointment. *Sample size too small for reliable estimate.

Source: American Dental Association 247/

Table 18. DENTIST/POPULATION RATIO AND SELECTED PRACTICE CHARACTERISTICS BY GEOGRAPHIC REGION Persons per active dentist Waiting time for non% of all dentists with % of all dentists reporting Geographic Region waiting time of 1 month emergency appointment a/ they are “too busy” b/ or more All Regions 1,905 6.8 7.9 11.0 E. South Central 2,614 9.5 * 16.3 W. North Central 2,414 9.1 14.8 14.6 South Atlantic 2,197 5.7 6.8 10.2 W. South Central 2,075 6.8 10.0 14.2 E. North Central 2,012 7.7 10.2 17.2 Mountain 1,862 5.6 * 9.9 Mid Atlantic 1,672 6.8 4.2 9.2 New England 1,594 7.1 5.4 8.0 1,557 5.1 5.0 4.1 Pacific 1,500 1,998 1,698 1,302 2,000 1,499 1,001 1,200 1,004 1,460

Median # of pts. among dentist practicing alone

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Table 19. UTILIZATION RATES BY REGION, 1977* % Population Making Visit In National Center for Health Statistics Preceding Year Region All Regions 49.7 Northeast 54.1 West 51.3 North Central 51.7 44.2 South

52

Average No. Visits for Population in Preceding Year 1.6 1.9 1.3 1.6 1.3

Source: National Center for Health Statistics, 1977 248/ * Weighted data not available Table 20. APPOINTMENT DELAY AND PRACTICE ACTIVITY, BY SIZE OF CITY, 1975 % With Average Waiting Time % Who Perceive Practice % Who Perceive Practice City Size to be Not Busy of 1 Month or More for Initial to be Too Busy Appointment All independent dentists 8.6 14.0 22.3 Under 2,500 20.1 25.0 12.9 2,500-25,000 15.2 21.0 17.9 25,000-100,000 6.5 12.0 23.1 100,000-1,000,000 5.1 10.1 25.1 3.1 8.7 27.0 Over 1,000,000

Source: American Dental Association 249/

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Pedodontists 1,106 1,225 --1,208 -1,781 1,981

Periodontists 929 1,114 --1,010 -1,911 2,144

Prosthodontists 654 702 --585 -891

Public Health 98 116 --67 -102

Note: The inconsistencies in the specialty data shown above stem from differences in reporting methods. The estimates through 1972 are felt to be overreported due to the inclusion of retired and deceased specialists. The 1975 and 1976 estimates may be underreported due to the use of reporting requirements that tended to reduce response rates. The 1977 estimates reflect an adjustment of the 1976 data and the inclusion of new graduates from residency programs. The 1978 and 1979 data were collected in the winter months of those years. These data do not include retired specialists which had been included in the 1977 estimates.

Source: American Dental Association 254, 255 and 256/; Personal Communication with J. Ake 257/

Table 21. TOTAL NUMBER OF SPECIALISTS AND SPECIALISTS BY TYPE, SELECTED YEARS Total Specialists Endodontists Oral Patholoogists Oral Surgeons Orthodontists Year 1968 9,705 439 89 2,262 4,128 1972 11,142 585 120 2,714 4,566 1974 11,825 ----1975 9,743 ----1976 10,728 625 64 3,086 4,388 1977 15,508 ---1978 15,003 926 73 3,502 6,040 16,595 1,098 96 3,849 6,437 1979

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Other problems have been associated with specialization. As in medicine, the fragmentation of services has fostered uncoordinated dental care in which the responsibility for the overall dental health of the patient becomes unclear, and basic dental services may not be provided. Further, the cost of basic services provided by a specialist often is greater. Dental Auxiliaries The present dental manpower team consists of the dentist supervising the dental assistant, the dental hygienist, and the dental laboratory technician. Most dentists employ at least a part-time auxiliary. More than 90 percent employ assistants, about 50 percent employ hygienists, and about 10 percent have technicians 252/. Table 22 shows the growth of the three auxiliary programs from 1967 through 1977. The sizes of the assistant and hygienist programs appear to be leveling off. The effects of auxiliaries on a dentist's productivity are shown in Table 23; the number of people an individual dentist can see can be greatly increased through the use of auxiliaries. Recently, however, the Bureau of Health Manpower, DHHS, predicted a decreased use of auxiliaries in private dental practices in the future. According to a simulated market analysis, there will be a relative oversupply of dentists and they will “economize” by substituting their own time for that of auxiliaries 253/. Dental Assistants The traditional duties of the assistant are assisting at the chairside in operations, preparing the patient for treatment, keeping the operating field clear, preparing filling materials, passing instruments, and handling general office duties. The training period may be one academic year, one calendar year, or two academic years, depending on the schools' policy. A high school diploma is a prerequisite 260/. The average monthly salary in 1976 was $558 (Table 24). There were 140,300 active dental assistants in 1977. The number of educational institutions (predominantly junior colleges) increased from 26 with 658 graduates to 284 with 6,502 graduates. Forty-eight states have at least one program. Dental Hygienists The traditional functions of the hygienist include the performance of prophylactic procedures, the exposure and processing of radiographs, the application of fluoride solutions, and the teaching of toothbrushing, flossing, and other preventive health measures.

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Source: ADA Annual Report on Dental Auxiliary Education 1977-78 258/

Table 22. FIRST-YEAR ENROLLMENT IN DENTAL AUXILIARY PROGRAMS, 1967-1977 Program Dental Assisting Percent Change from Previous Dental Hygiene Percent Change from Previous Year Year 1967 3,118 2,385 1968 3,625 16.3 2,870 20.3 1969 4,206 16.0 3,299 14.9 1970 4,841 15.1 3,852 16.8 1971 6,361 31.4 4,562 18.5 1972 6,671 4.9 4,815 5.5 1973 7,272 9.0 4,995 3.7 1974 7,858 8.1 5,118 2.5 1975 8,118 3.3 5,335 4.2 1976 8,325 2.5 5,598 4.9 8,234 -1.1 5,592 -0.1 1977 437 462 596 673 923 1,064 1,184 1,196 5,335 1,313 1,410

Dental Lab Technician

5.7 29.0 12.9 37.1 15.3 11.3 1.0 12.4 -2.4 7.4

Percent Change from Previous Year

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*Response rate inadequate for estimate.

Source: Survey of Dental Practice, 1977 259/

TABLE 23. AVERAGE NUMBER OF PATIENT VISITS PER WEEK BY DENTISTS IN GENERAL PRACTICE, WITH DIFFERENT NUMBERS OF AUXILIARIES, BY AGE OF DENTIST, 1977 Age of Dentists All Dentists Dentists with No Dentists with One Dentists with Two Dentist with Three Dentists with Four or Auxiliaries Auxiliaries Auxiliaries Auxiliaries More Auxiliaries All Ages 73 46 53 69 77 99 Under 40 73 47 41 62 75 98 40-44 85 59 55 71 78 98 45-49 82 70 57 65 85 104 50-54 72 * 50 69 78 89 55-59 70 59 53 75 72 83 60-64 62 49 59 56 * 84 53 28 42 63 68 90 65 and over

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There are 29,700 active dental hygienists in the United States. They are trained for a minimum of two academic years in 187 programs in 48 states. Some programs require other college courses and lead to baccalaureate degrees. One four year program admits students as freshmen. The trend in enrollment parallels that for dental assistants--a 250 percent increase between 1967 and 1977 261 and 262/. According to the 1977 Survey of Dental Practice, there is wide individual variation in the number of patients a hygienist treats 263/. The national average is 35 per week. Assuming an average fee of $15 per patient, a hygenist would produce a revenue of more than $2100 per month for a dentist, as compared with their median monthly salary of $947 in 1976 (Table 24). Dental Technicians The dental laboratory technician constructs dentures, crowns, and other oral appliances following a dentist's prescription. There are currently 41,600 active technicians. Two-year training programs are offered in twentyseven states. Between 1967 and 1977, the number enrolled in training increased 340 percent. Their median salary in 1976 was $996 a month. The number in training appears to be slowing in its rate of increase, but to a lesser extent than dental assistants and hygienists (Table 22). Expanded Function Dental Auxiliaries Expanded Function Dental Auxiliaries (EFDAs) usually are certified dental assistants or dental hygienists who have received extra training of six weeks to six months duration. This enables them to perform a wider range of reversible restorative procedures, such as placing restorations, carving and finishing amalgam, fabricating temporary restorations, and taking impressions. A number of studies conducted in military, university, and public health department settings have shown that the delegation of restorative procedures to EFDAs can result in appreciable increases in dentists' productivity with no significant reduction in the quality of the services. Patient acceptance has not been a problem. 266, 267, 268 and 269/. Dentists, however, have a variety of attitudes towards EFDAs and the kinds of functions they are willing to delegate. Younger dentists tend to accept them better than older dentists. To help train dentists in the efficient management of auxiliaries and to help them clarify role relationships, the DHHS introduced a program for Training in Expanded Auxiliary Management (TEAM) in the early 1970s. More than 30 schools received grants to instruct dental students. In recent years, both the demand for grants and the funding of the program have diminished.

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140,300 29,700 41,600

6,502 4,847 1,070

Source: American Dental Association, 264 and 265/

Assistants Hygienists Technicians

8,234 5,592 1,410

+18% +20% +47%

Table 24. SELECTED CHARACTERISTICS OF THREE TYPES OF DENTAL AUXILIARIES Total Number Number 1st Year Percent Change in Type of Dental Active Personnel Graduating in 1977 Enrollments in 1977 Total Enrollments Auxiliary 1972-77 Unfilled 1st Year Positions in Training Institutions, 1977 1,162 0 229 1-2 yrs. 2-4 yrs. 2-3 yrs.

Lenght of Training

$558 $947 $996

Median Monthly Salary, 1976

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Denturists Some dental technicians are dissatisfied with their working situation in most states and are seeking to be certified or licensed independently from dentists, and to be allowed to make dentures and deal directly with the public. They would like to be called “denturists,” and contend that they could save the patient time and money by eliminating the traditional procedure of sending dental impressions, models, bite blocks, and other items back and forth between the dentist's office and the laboratory. Some technicians would say that interaction with a dentist is totally unnecessary, while others think that patients should see a dentist initially to receive a certificate of oral health 270/. Most dentists argue that the knowledge they possess is needed for the diagnosis and construction of sound dentures, and that this requires the scientific knowledge base of a dental education. The American Dental Association is opposed to the legalization of independent denturists. Oregon is the only state in which denturists are licensed; that is the result of a 1978 statewide referendum in which 78 percent of the voters supported the denturists as independent practitioners who are subject to state administered education and licensing standards. The ADA believes that these provisions of the Oregon statute are insufficient to protect the health of the public. There are similar bills pending in at least 12 other states. The Council of State Governments has recommended that dental technicians be allowed to perform the extraoral and intraoral procedures required in the fabrication of removable prosthetic appliances and other devices, but that the fitting of the device should be done under the direct supervision of a dentist. Dental Nurses Dental nurses are not licensed in the United States. In general, experience in other countries has shown that dental nurses can make the clinical diagnoses of caries, administer local anesthesia, and restore (drill and fill) both permanent and primary teeth with silver amalgam, composite resins and stainless steel crowns. They can perform pulpotomies and extract deciduous teeth. They emphasize preventive dentistry by teaching oral hygiene, performing prophylactic topical flouride treatment, and placing space maintainers 271/. Pilot programs in the U.S. 272/ and experience in other countries can provide some insights into the potential for this type of dental

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training to perform preventive and restorative care, usually for school children 273/. This type of program has been in existence since 1921 in New Zealand 274/ and 1962 in Saskatchewan, Canada 275/. Similar programs have been developed in Great Britain, in the United States 276/,and in several developing countries. Training programs range from 1,600 to 2,000 or more hours, with several hundred hours in the biological sciences. In the American model, at Forsyth Dental Center, graduate dental hygienists took an additional 516 hours of basic sciences and ten weeks of didactic and preclinical training in cavity preparation and filling. An internship and an additional period of practice followed. The Forsyth experiment concluded in 1974 and the graduates are currently involved in TEAM programs. In Saskatchewan, dental nurses also take and interpret radiographs and perform both block and infiltration anesthesia 277/. They function in conjunction with a supervising dentist, but not under direct onsite supervision. When studied to examine the quality of their treatment, many dental nurses have compared favorably with dentists 278/. However, their licensure has been opposed by organized dentistry, which contends they are not a necessary type of dental care provider in the U.S. Although dental nurses are not specifically recommended in this report, the committee was not unanimous in this conclusion. A comment relevant to this issue is appended following Chapter 6. PRACTICE SETTINGS Although most dental care is provided in the offices of independent solo practitioners, there are many other practice settings and differing arrays of support services and organizational characteristics. Private Dental Practice: Solo and Groups The 1977 Survey of Dental Practice 279/ provides a recent description of the activities of private practitioners. About 78 percent are in solo practice and more than 90 percent are general practitioners. The remainder are specialists. They see an average of 67.5 patients a week in an average of 78.7 visits. They characteristically employ chairside assistants (91 percent) and nearly half (45 percent) employ dental hygienists. They differ from non-solo practitioners in a number of ways. They are older, work more hours a week, work more weeks of the year, and spend more of their time operating at the dental chair 280/. Of the 22 percent of dentists in non-solo practice settings, 13 ercent are in two-dentist practices, 6 percent in three- and four-

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dentist practices and 4 percent in practices of five or more dentists 281/. It is interesting to note that while they work less time than solo practitioners, the number of patients seen in an hour does not vary with the size of the group 282/. Ownership in a dental practice is associated with higher productivity. As more practices become incorporated (as are about 65 percent of practices with five or more dentists), many dentists work as employees. Non-owner dentists constitute 24.2 percent of two-dentist practices, 30.4 percent of three- and four-dentist practices, 53.3 percent of practices with five or more dentists. They are younger than owner dentists and make about half as much money. They also see 1.54 patients per hour as compared with the 1.73 visits per hour by owner dentists 283/. Relationships between productivity and methods of compensation are shown in Table 25. Hospital Dentistry The American Dental Association's Bureau of Economic Research and Statistics recently surveyed the 3,748 hospitals in the United states with dental departments 284/. This number is more than half of the total hospitals in the U.S. Among the 75 percent that responded, there was an average of 2,884 outpatient visits, 164 admissions, and 233 dental emergency visits per year, and a staff of nine full-time or part-time dentists. Children's hospitals had the largest staffs. Such departments commonly are under the direction of a dentist. Table 25. PATIENT VISITS PER HOUR FOR DENTISTS REPORTING IN THE SAMPLE BY METHOD OF COMPENSATION Method of Compensation Number of Dentists Total Visits per Hour Total 741 1.67 Practice Income Only 154 1.72 Fixed Salary Only 126 1.61 88 1.74 Fixed Salary Plus Equal Share of Practice Income Fixed Salary Plus Unequal Share of Practice Income 104 1.73 Equal Share of Practice Income Only 60 1.53 74 1.64 Unequal Share of Practice Income Only

Source: Nash, et al. 285/

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Inpatients are admitted and discharged by a dentist in most hospitals, and physical examinations are performed by the attending physician. Ninety percent of the hospitals in the study do oral surgery and nearly 70 percent provide operative (restorative) dentistry. The preventive maintenance services of dental hygienists are available to inpatients in only about 14 percent. Many of these hospitals are federal. Federal Delivery Systems The U.S. Public Health Service is responsible for the dental care of about 500,000 Native Americans, which occupies about 250 dentists in 47 hospitals, 135 ambulatory health centers, and 31 mobile units. Much of the work is contracted to private practitioners 286/. The Department of Defense and the Veterans Administration have separate systems of dental care. The armed forces dental services are located at military bases and employed 6,141 dentists in 1976 287/. The Veterans Administration dental services are located in 171 hospitals, 10 satellites, and six outpatient clinics and employ 777 dentists 288 and 289/. Federally funded Neighborhood Health Centers were developed by the Office of Economic Opportunity in the 1960s. They offer dental care as a component of comprehensive care. They operate under federal guidelines, but they are administered locally. The program was intended to serve 25 million low income people through 1,000 health centers at a projected cost of $3.35 billion. Public policy shifts in the early 1970s, however, arrested the growth of the centers. In 1976, there were about 125 centers serving 1.5 million people at a cost of $197 million 290/. Dental care accounted for 0.59 visits per enrollee as compared with 2.6 visits for medical care 291/. State and Local Programs Since 1940, many direct dental service programs have been organized and financed by state and local governments. Their services usually have been intended for children between ages five and fifteen, and their primary purpose has been to detect and treat dental caries in its early stages 292/. Of the 55 states and territorial health agencies or departments, 52 offered some type of dental care programs in 1975; two others incorporated dental services into other health programs. Table 26 shows the services provided in the various programs. Medicaid represents a partnership between the various states and the federal government for the financing of health care benefits.

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Dental services are allowed but not required by federal guidelines, therefore dental benefits vary from state to state, and many offer none 293/. Table 26. NUMBER OF STATES AND TERRITORIES PROVIDING DENTAL SERVICES BY TYPE OF SERVICE, FISCAL YEAR 1978 Type of Service Number of States and Territories Reporting Services Dental Services 52 Preventive 52 Restorative 40 Emergency 38 Screening 39 Prosthetic 20 Orthodontic 19 Dental Health Education 41 Nutrition Education 19 5 Hypertension Screening

Source: Association of State and Territorial Health Officials 294/ Other Practice Modes Most dental care in the United States is delivered in the settings that have been described. However, there are other models in this country and elsewhere that suggest options for the development of a dental health strategy in the U.S. Maricopa County, Arizona provides an example of a locally funded program. Its Bureau of Dental Health was established in 1966 to provide preventive, restorative, and educational services to poor children through age eight. Since that time its client group has been expanded to include poor children to age 14; its goal also has been broadened to the improvement of the oral health of all citizens. Restorative services are available in neighborhood primary health centers administered, funded, and staffed by the health department. Educational and preventive programs are offered to school children and through special education programs. Dental services are also available for high risk Maternity and Infant Care (M.I.C.) projects 295/.

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Several demonstration programs have been conducted in U.S. schools. In the late 1940s and early 1950s, the U.S. Public Health Service and the state health departments cooperated on programs in Woonsocket, Rhode Island, and Richmond, Indiana. Four series of treatments were given to children from kindergarten through the ninth grade. Each series included an examination, prophylaxis, topical flouridation, and the treatment of all dental defects except those requiring orthodontics. Dentists, dental assistants, dental hygienists and, in one case, a health educator were involved. More than 80 percent of eligible children received all four treatment series in both demonstrations. Oral health as reflected in the DMF was markedly improved, and the dentist time required to complete the fourth treatment was 55 to 75 percent less than the first 296 and 297/. One of the major objectives of the Richmond-Woonsocket programs was to encourage good oral health habits in the children and their parents. Dental health education was directed both to participants and nonparticipants in the schools through information media. A five year follow-up examination showed that both participants and non-participants received more dental care during those five years than they had previously. All had considerably better DMF scores than they had at the start of the program 298/. In Chattanooga, Tennessee, school children were treated in mobile dental clinics that went to the schools. During the years 1971 to 1975, approximately 2,250 children were treated twice a year. Average total costs per patient per year were $55.60 over the entire five-year period. There was an average annual decline in cost per patient of $7. More than three-quarters of this decline was due to changes in mix and amount of services needed. The remainder was due to increased efficiency associated with increased utilization. In this demonstration, mobile clinics were an effective and low cost method of providing dental care to school children 299/. School-based dental treatment programs have been instituted in many countries, some as a part of a more comprehensive national health program and others independently. Such programs in New Zealand, Australia, Sweden and Canada have recently been described 300 and 301/. In New Zealand, 98 percent of children receive services; in Sweden, 95 percent. Australia is moving rapidly toward a similar utilization rate. In the New Zealand and Australian programs, much of the routine treatment is performed by dental auxiliaries, including dental nurses. A dentist conducts the initial examination and follow-up examinations every two years. Services in the intervening years are provided by a therapist who performs a wide range of procedures, including routine operative dentistry with off-site supervision.

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Saskatchewan, Canada's central prairie province, started training dental auxiliaries to treat children in 1972, after a survey had shown that their dental health was poor. The two-year training program is similar to the New Zealand School Dental Nurse Program. Under the supervision of dentists, the nurses provide dental health education, prophylaxis, topical flouridation, restorative services using local anesthesia, and some surgical services including the extraction of primary teeth. More than 350 clinics have been established in elementary schools throughout the province. Each nurse can treat more than five hundred children a year. In 1976, the third year of the program, the costs were $83 per child, a 48 percent decrease from the first year. 302/ DENTAL PRACTICE PRODUCTIVITY The productivity of dental practice is important to this study because it indicates the efficiency of a practice in providing dental services. Comparisons among different types of dental practices enable the identification of factors that can increase productivity and thus increase the supply of dental services without increasing the supply of dentists. Dental practice productivity often is measured as patient visits per dentist hour and gross revenue per firm. Other measures for comparing dentists working in different settings include visits per hour and net income per year. These measures of productivity assume that dental visits are homogeneous, an assumption that will be discussed later. Many factors have contributed to an increased productivity of dentists over the past 25 years. Changes that have occurred in dental practice include improvements in instruments (such as high speed drills, evacuators, and ultrasonic cleaners), more efficiently designed facilities, standardization of procedures and instrument storage, more carefully planned scheduling systems, and the greater use of auxiliaries. Contemporary analyses of dental practice show that the factors most closely associated with productivity are dentist hours worked, size of practice, use of auxiliaries, use of capital, type of services rendered (casemix), dentist-population ratio in vicinity of practice, consumer demand in practice market area, and personal characteristics and preferences of dentists. Dentist Hours Worked and Size of Practice Statistically significant relationships have been shown between dentist hours worked and productivity 303 and 304/. Also the

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average number of weekly hours worked by the dentist decreases as the size of the practice increases (Table 27). Time at the chair in practice also decreases with the size of practice but at a slower rate. Correspondingly, the weekly average of visits per dentist was 16 percent less for solo dentists than for offices with five or more dentists. However, the number of visits per hour declines only five percent between solo practice and multiple dentists. The negligible differences in productivity suggested by visits per dentist hour are not borne out by figures on dental incomes, which reflect the amount of services rendered. Table 28 shows that the gross revenue minus expenses per dentist increases as the size of the practice increases. Dentists in a practice with five or more dentists generated about $26,000 more in revenue per dentist than did solo dentists. This difference may be bigger than it seems, because the average age of the dentist (and thus experience and income) is less as the size of practice is greater. Part of the explanation may be that average billings per dental visit are directly related to practice size; gross billings per visit were 30 percent higher for practices with five or more dentists than for solo practitioners. These higher billings may be the result of higher dental fees or differences in the nature of the services provided. However, data on a weighted average price index of dental services show that fees for dental service do not vary substantially by size of practice; prices of group practices are only about two to three percent higher than those of solo dentists 307/. Therefore, it would seem that some shifts in services provided are taking place. Table 29 shows that as the size of practice increases, the dentists deliver relatively more fixed prosthodontics, periodontics, endodontics, and orthodontic services. These services are more complex and bespeak a qualitative difference from services delivered by solo dentists. Productivity comparisons between solo and group dentists must adjust for this difference. One recent study of dental productivity that makes such adjustments for the complexity of the service produced found economies of scale in the dental practices studied. Practices with three to four dentists were found to be about 14 percent more productive than solo dentists. Those with five or more dentists were about 10 percent more productive than the three to four dentist practice 308/. Other studies have also found economies of scale in dental practice 309/. Use of Auxiliaries Perhaps the most frequently discussed, widely advocated, and thoroughly studied alternative for increasing the supply of dental services is the greater use of auxiliary personnel. The concept of increased productivity through the use of a trained dental assistant was discussed as early as 1925 310/. However, it was not until 1943 that a correlation was established between numbers of chairs and assistants, and the number of patients who could be treated per week 311/. A publication in the middle 1950s was the first to report actual procedures performed by the assistant 311a/. The five-year Richmond-Woonsocket study performed on a population of school children showed that an increase in productivity of 52 percent could be expected using one assistant, and 70 percent using two assistants.

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Average $84,480 39,346 30.54

Solo $80,828 42,777 26.13

Source: Scheffler, R.M. “Productivity and Economies of Scale in Dentistry: Some Empirical Evidence” 306/

Gross revenue per dentist Gross revenue per dentist less total expense per dentist Gross billings per dental visit

Table 28. FINANCIAL CHARACTERISTICS OF DENTAL PRACTICES

Source: Scheffler, R.M. “Productivity and Economies of Scale in Dentistry: Some Empirical Evidence” 305/

Table 27. TIME WORKED AND VISITS PER UNIT OF DENTIST, TIME BY SIZE OF PRACTICE Average Solo 2-3 Dentists Average Weekly Hours Worked 33.3 35.7 34.7 Average Weekly Chair Time 27.6 29.0 28.1 Average Visits per Week per Dentist 55.1 61.8 55.9 1.69 1.73 1.61 Average Visits per Dental Hour

2 Dentists $89,566 49,364 29.38

3-4 Dentists $91,667 48,136 31.81

3-4 Dentists 33.3 28.1 55.1 1.65

5 or more Dentists $106,296 56,627 34.70

5 or more Dentists 31.5 26.0 52.0 1.65

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THE SUPPLY OF DENTAL SERVICES 67

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The annual percentage increase in productivity per dentist over the 1950-1970 period has been calculated at 1.6 percent per year, with productivity measured in terms of patient visits 312/. This analysis led to a further conclusion that increased auxiliary use was the main contribution to these gains in dentist productivity. Another analysis of the same data shows that the mean number of visits per week increases by 12.5 visits with the addition of each auxiliary 313/. Dental practices with no auxiliaries average about 45 patients per week, whereas practices with 4 or more auxiliaries (including 1 dental hygienist) see 95 or more patients per week. Also, dental practices with two or more auxiliaries work six more hours delivering direct patient care each week, while spending only four more hours in the office than dentists with no auxiliaries 314/. A different measure of the productivity increases associated with dental auxiliaries is provided by the 1975 ADA Survey of Dental Practice 315/. As the number of full and part-time auxiliaries increases from none to five or more, both the median and mean gross and net incomes of the practice rise in almost direct proportion. The relationship between productivity in the dental office and use of auxiliaries has also been extensively studied using mathematical methods 316, 317, 318, 319, 320 and 321/. Taken together, the national data on dental practice, the experiments in actual clinical settings and the computer-assisted productivity analyses provide consistent results. The conclusion in all cases has been that the assistant, EFDA, and/or hygienist contributes substantially to practice output. However, it appears that there is no consensus on the optimal number of auxiliaries for a practice of a given size facing a given set of input prices and serving a given patient population. Also there is little documentation regarding the magnitude of the productivity of dental laboratory technicians, denturists, and dental nurses in the United States.

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Capital With respect to the role of non-labor inputs in augmenting the productivity of a dental practice, if capital is defined as the number of chairs in the practice, plus twice the number of operatory units, it has been estimated that a 10 percent increase in capital would be associated with a 2 percent increase in visits 322/. These results are consistent with an earlier finding 323/. Thus, the more providers generating patient visits (i.e. dentists, dental hygienists, preventive therapists, EFDA's, etc.) the more capital investment in operatories is needed. Casemix While there is little doubt that the mix of services offered by a practice affects both the volume of visits and the income generated, relatively few empirical studies of this have been made. This is primarily due to the lack of good casemix data in large sample. An activity analysis investigation of the productivity impact of expanded function auxiliaries used actual time per service data that were generated in a private practice. The study developed three alternative casemix specifications for this model dental practice: (1) a “general practice” mix basically reflecting the type of care rendered by a small suburban dental practice, (2) a “primary care” mix dominated by extractive and restorative care, and (3) a “cosmetic care” mix of services dominated by more elective procedures, such as bridges and endodontics 324/. Controlling for all other factors, the study found a sizable difference in the productivity potential of such a model practice across these three case mixes, regardless of the number of dentists assumed to be employed. Primary care had the least productivity potential while the cosmetic care practice had the greatest. The inability to adjust for casemix changes can clearly confound efforts to measure productivity change over time. If dental visits are becoming relatively more complex and time-consuming, observed visit rates may serve to understate gains in practice efficiency over time 325/. One report 326/ indicates that the casemix does shift somewhat as practice size increases. Table 29 shows that relatively more time is spent providing fixed prosthedontics as practice size increases. The amount of endodontics also increases substantially. In contrast, relatively less time is spent providing routine operative and preventive services. This shift in the relative mix of services does not necessarily mean, however, that patients in larger practices are not receiving preventive services; it could be simply a large increase in endodontic and fixed prosthetics services.

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Table 29. PERCENT OF DENTIST TIME SPENT IN RENDERING SERVICES, BY TYPE OF SERVICE AND SIZE OF PRACTICE, 1977 Practice Size (number of Dentists) Type of Services 1 2 3-4 5+ A. Diagnostic 13.5 10.3 8.9 11.0 B. Preventive 9.6 6.3 6.7 2.9 C. Operative 38.8 37.7 31.2 36.4 D. Removable Prosthodontics 6.9 6.3 7.1 6.5 E. Fixed Prosthodontics 18.2 23.8 30.5 25.5 F. Oral Srugery 5.9 4.4 3.7 3.5 G. Periodontics 1.9 2.0 1.7 2.5 H. Endodontics 4.6 7.7 8.3 9.7 0.6 1.6 1.8 2.1 I. Orthodontics

Source: Nash, et al. 327/ Dentist/Population Ratio The current evidence appears to indicate that the observed productivity of the dental firm is inversely related to the dentist/population ratio in its market area 328 and 329/. A recent study of the market for dental services found that the average number of visits per dentist increased as the number of dentists/population in an area decreased, controlling for a number of other factors that would affect this productivity measure 330/. Only one study suggested a positive relationship between productivity and the density of dentists in a market area 331/. An author of that study explained elsewhere that “greater demand apparently allows more efficient scheduling of patients from the producer's viewpoint and some substitution of patient waiting time for idle time of dentists, auxiliaries, and capital equipment 332/. Consumer Demand Considerations Many studies of the utilization of dental services discussed in Chapter 2 indicate that consumer demand is positively related to per capita income and educational attainment. Although these factors do not bear directly upon the ability of an individual dentist or practice to be efficient, they do influence the demand for services by the population, and, therefore, the rate of observed productivity. Numerous dental studies have documented the impact of fluoridated water on reducing the prevalence of caries over time. A first attempt by economists to assess the marginal impact of fluoridation on demand found that fluoridation had a negative effect on demand for care in several midwestern communities 333/.

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Fluoridation reduces the decay experience of the first half of life. Consequently more teeth are present, and, therefore, susceptible to periodontal disease. There also are more teeth available as abutment teeth for fixed prosthetic appliances and endodontic therapy. It would seem, therefore, that with a change in the kinds of services needed, there may be little reason to expect that the overall demand for services across an entire poplation would decrease. Dentist Characteristics Dentists' ages are the principle confounding characteristic that probably captures a number of influences. From a human capital standpoint, one might expect a dentist's technical efficiency to be inversely related to his age. On the other hand, to the extent that productivity increases with experience, one would expect older dentists to be relatively more efficient. From the perspective of work-effort decisions across the life cycle, one would expect younger dentists to work relatively longer hours in order to build up their practice size; likewise, one would expect dentist's demand for leisure to increase after some point, as income goals become realized. Recent empirical findings are consistent with these hypotheses 334, 335 and 336/. A statistically significant and strikingly similar relationship was found between the age of the dentist and practice productivity: productivity rose with age until about the midpoint of the dentist's career, then dropped as retirement neared. SUMMARY AND CONCLUSIONS There has been a substantial increase in the supply of dentists in the United States in recent years because of federal policy decisions. Although there now are some inequities in the geographic distribution of dentists, the current number and growth trend in the training of dentists strongly suggest that their supply will be adequate to meet the demand in 1990, even if third party dental insurance increases greatly. Productivity of private dental practice was emphasized because recommendations to cover treatment services for the entire population will, at least in the short term, necessarily be delivered largely in the settings in which dentists currently practice. Many factors affect dental practice productivity and thus the supply of services. Changes that have occurred in dental practice over the past 25 years include instrument improvements, more efficient facilities, standardization of procedures and instrument storage, more carefully planned scheduling systems, and increased use of

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auxiliaries. Because the supply of dental services can be more rapidly increased by adding various types of dental auxiliaries, the committee concluded that the supply of these auxiliaries can provide the flexibility needed for increases in the demand for services and that the supply of dentists, dental hygienists, dental assistants, and dental laboratory technicians seems adequate to meet any increase in demand for dental care that might result from the implementation of a properly designed health insurance program covering dental care services. Most dental care in the United States is currently provided in the offices of independent solo practitioners. There are many other practice settings and differing organizational arrangements. Included are solo and group practices, hospital dentistry, government programs, neighborhood primary health centers, and school-based programs. Demonstration projects with school-based dental care programs clearly show the potential of the school as a practice setting for the delivery of dental care to children. On the basis of the experience with the uses of dental hygienists and expanded function dental auxiliaries in providing preventive services in schoolbased preventive programs for children and adolescents, the committee recommends such auxiliaries be used to provide such care in the recommended school-based system.

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DENTAL CARE EXPENDITURES AND INSURANCE

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CHAPTER 5 DENTAL CARE EXPENDITURES AND INSURANCE

An understanding of the magnitude of current and past sources of funding and type of expenditures for dental care is required for projecting costs of a national program. This chapter examines patterns and trends in expenditures for different types of services. It also reviews developments in private dental insurance, including the characteristics of various financing and payment mechanisms. Cost sharing provisions, reimbursement methods, utilization review, and quality control are discussed for their potential effect on a national health insurance program. Expenditures for professional dental services in the United States rank fifth among expenditures for all personal health care services -- after hospital care, physicians° services, drugs, and nursing home care. Dental care expenditures have been increasing slightly more rapidly recently than expenditures for other personal health care services, amounting to $3.7 billion in 1968 and $13.3 billion ten years later. The 1968 dental expenditure figure represented 7.1 percent of all personal health care expenditures; by 1978 the proportion had risen to 7.9 percent 337/. Table 30 has historical data on dental care expenditures as compared with all personal health care expenditures. From 1940 to 1975 the proportion of health care expenditures spent on dental services decreased steadily. However, since 1975 this trend has been reversed. Dental Care Expenditures by Type of Service Estimates of national expenditures for different types of dental services have been derived from findings of the Research Triangle Institute (RTI) study of productivity in general dental practices in the U.S. The RTI data include the percent of charges for each type of service by general practitioners, who constitute about 88 percent of all practicing dentists. Professional judgment was employed to estimate similar distributions for the specialties. The weighted

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averages of these percentages were applied to national dental expenditure data for 1977, the year in which the productivity data were collected. The resulting estimates of expenditures by type of dental service are shown in Table 31 339/. Table 30. EXPENDITURES FOR ALL PERSONAL HEALTH SERVICES AND FOR DENTISTS' SERVICES, SELECTED YEARS 1929-1978 Dentists' Services Year All Personal Health Care (in Millions) Amount (in Millions) Percent of Total 1929 $ 3,202 $ 482 15.0 1940 3,548 419 11.8 1950 10,885 961 8.8 1960 23,680 1,977 8.3 1970 65,723 4,750 7.2 1975 116,297 8,237 7.0 1976 132,127 10,131 7.6 1977 149,139 11,650 7.8 167,911 13,300 7.9 1978

Source: Gibson, R.M., National Health Expenditure 338/ Expenditures for professionally administered preventive dental services (which include prophylaxis and the application of topical fluorides and teeth sealants) represented only 7.0 percent of the total dollars spent on dental services. Almost all--94 percent--of the expenditures for preventive services went for prophylaxis; most of the remainder was for fluoride treatments. In addition to expenditures for preventive services provided by dentists, American consumers also spent more than $1 billion in 1976 on oral hygiene products used at home 340/. Basic corrective dental treatment (Table 31) accounts for nearly one-half of total dental expenditures. Operative services are largely for the filling of teeth; about three-fourths of fillings are silver restorations. The remaining basic corrective services are for diagnosis, removable prostheses, and surgery (mostly extractions). These services are the first-line measures for treating dental disease. They generally imply the placement of conservative restorations or the extraction of teeth followed by a partial or full removable denture. The large percentage of reconstructive dental services shown in Table 31 for fixed prostheses reflects the high cost of crowns and bridges. Reconstructive crown and bridge services have become the nation's largest single expenditure for dental care, representing about 31 percent of all dental care expenses and 36 percent of the services provided by the general practitioners.

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Table 31. ESTIMATED EXPENDITURES FOR DENTISTS' SERVICES, BY TYPE OF SERVICE, 1977 Estimated Amount (in Thousands) Percent Distribution Type of Service Total 11,650,000 100 Preventive 815,500 7.0 Basic Corrective 5,626,950 48.3 Diagnostic 990,250 8.5 Operative 2,935,800 25.2 Removable Prostheses 1,001,900 8.6 Surgery 699,000 6.0 Reconstructive 5,207,550 44.7 Fixed Prostheses 3,588,200 30.8 Periodontics 233,000 2.0 Endodontics 757,250 6.5 629,100 5.4 Orthodontics

Source: Nash et al. 341/, adjusted according to ADA distribution of dentists by specialty. *Data do not include expenditures for the salaries of federal dentists. Percentage taken on 1977 expenditure to match existing data on practice. Several surveys have collected information on reasons for dental visits. Although it seems apparent that there has been a relative increase in extractions, it is difficult to determine changes in the amounts and types of services delivered. There seems to be, however, a major development in the period between the studies done in the 1950s and 1960s and those conducted more recently. The category “crowns and bridges” had not been used in previous studies, 342, 343 and 344/ but it represented the reason for 15.5 percent of all patient visits to general practitioners in 1977 345/. Other data from a later study show that 20 percent of dentists' time is spent providing crown and bridge services, and Table 31 shows that 30.8 percent of all expenditures are for crowns and bridges. This finding suggests that changes in dental practice philosophies and restorative technology, as well as the growth of payment plans, are having a substantial effect on the kinds of services provided. To date, no longitudinal studies have been performed to evaluate this substantial shift toward fixed prosthetic services. Dental Expenditures by Age Dental services for the adult population (ages 19 through 64) cost an average of $54.29 per person per year (Table 32). For the population under 19, the average dental expenditure is less than for adults, but is a larger proportion of total health expenditures

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for children and adolescents and represents 12.0 percent of their total personal health expenditures. In the over 65 age group, dental care expenditures represent only 2.5 percent of all private health care expenditures for this age group 346/. Table 32 indicates that no one age group accounts for a markedly disproportionate share of total dental expenditures, which are generally parallel to the proportion of the population in each age group. The somewhat higher per capita expenditures in the 19-64 age group probably reflects the higher reconstruction costs in adult dentistry. Table 32. NATIONAL DENTAL EXPENDITURES, BY AGE, FISCAL YEAR 1977 Dental Expenditures Age Amount* Percent Population Per Capita Distribution Distribution Expenditures Totals for All Ages Under 19 19-64 65 & Over

$10,020

100

100

$45.41

Percent of Total Health Care Expenditures 7.0

2,144 6,854 1,022

21.4 68.4 10.2

31.6 57.6 10.8

30.2 54.29 43.24

12.0 8.2 2.5

*In Millions

Source: Gibson and Fisher 347 and 348/ Public and Private Insurance of Dental Services Public expenditures for dental services as a percentage of total health expenditures are small and diminish with age. In the under-19 age group, public payments for dental care represent 4 percent of all health care payments, in the 19 to 64 age group it is 1 percent, and in the 65 and over age group it is 0.2 percent 349/. 2) Programs covering the costs of health services pay a substantially lesser portion of the expenditures for dental care in the United States than they do for hospital, physicians, or nursing home services. Funding for dental care services (Table 33) comes primarily from three sources: 1) private dental insurance, public programs, primarily Medicaid, and 3) direct, out-of-pocket payments from patients to dentists or dental organizations. The great bulk of these expenditures, some 77 percent, are out of pocket. Private insurance accounts for 19 percent and public programs only 4 percent.

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Source: Gibson 272/

Table 33. PERSONAL HEALTH CARE EXPENDITURES, BY TYPE OF EXPENDITURE AND SOURCE OF FUNDS, 1978 Total Hospital Physicians' Dentists' Other Drugs and Services Services Professional Care Drug Services Sundries Aggregate Amount (in millions) Total $167,911 $76,025 $35,250 $13,300 $4,275 $15,098 Direct Payments 55,317 7,533 12,013 10,213 2,233 12,667 Third-Party 112,594 68,491 23,237 3,087 2,042 2,431 Payments Private Health 45,363 26,724 13,779 2,548 1,030 1,131 Insurance Philanthropy 2,189 849 19 --40 --and Industrial Inplant Government 65,042 40,919 9,439 539 972 1,300 Federal 46,503 30,344 7,066 310 677 667 Medicare 24,918 18,275 5,548 --411 --Medicaid 10,234 3,820 1,145 247 220 628 Other 11,360 8,249 373 63 47 39 State and Local 18,539 10,574 2,374 229 295 634 Medicaid 8,131 3,034 909 196 174 499 10,409 7,540 1,464 33 120 135 Other Nursing Home Care

$15,751 7,179 8,572 108 106 8,358 4,715 396 4,038 281 3,643 3,208 435

Eyeglasses and Appliances

$3,879 3,478 401 44 --357 285 209 --76 72 --72

3,158 2,440 80 137 2,303 719 109 610

1,175

---

$4,333 --4,333

Other Health Services

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DENTAL CARE EXPENDITURES AND INSURANCE 77

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Dental insurance is a relatively recent phenomenon as compared with health insurance for other major medical services. The data in Table 34 indicates that private dental coverage has experienced substantial growth in recent years. Table 34. NUMBER AND PERCENT OF CIVILIAN POPULATION COVERED UNDER PRIVATE DENTAL INSURANCE PLANS, 1962-1978 End of Year Number (in Thousands) Percent of Civilian Population 1962 1,006 0.5 1965 3,100 1.6 1966 4,227 2.2 1967 4,679 2.4 1968 5,821 2.9 1969 8,510 4.2 1970 12,210 6.0 1971 15,348 7.5 1972 17,904 8.6 1973 22,008 10.5 1974 32,896 15.6 1975 34,477 16.2 1976 41,242 19.3 1977 49,747 23.1 60,000 27.3 1978 a/

Source: Carroll 351 and 352/ a/ American Dental Association 353/

The nation's major health care financing program, Medicare, does not cover out-patient dental care, and Medicaid entitlements for dental services for the poor are varied and limited. Indeed, many states have cut back on Medicaid dental care coverage in recent years. Thus, those dental services which are or will be covered by any third-party plans are more likely to be covered by private insurance plans. This trend seems likely to continue. Private Dental Insurance The late development of dental insurance is explained in part by the fact that dental disease has not been regarded as urgent or as life threatening as have some other diseases, and therefore the need to assure access to the services is not so pressing. A more important reason probably is that dental care does not satisfy the traditional insurance industry criteria for insurability. The traditional way to determine whether an event (such as treatment for an illness) constitutes an “insurable risk” requires that several conditions be met. First, the financial loss for any

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person occurs infrequently; thus pooling the risk spreads the costs. Second, the potential financial loss for any one person is large, so that spreading the risk provides an economic advantage to the insured that is of substantial value. Third, a person has limited ability to affect the frequency of the event insured against, therefore there is little likelihood that the person will cause the event that is insured against. Dental diseases do not satisfy these criteria. The cost of dental care is not major as compared with hospitalization, and individuals use wide discretion in deciding when to seek dental care and for what kind of treatment. These characteristics, combined with the absence of an adequate data base for predicting the volume of claims and the resulting benefit and administrative costs, led to a reluctance of the insurance industry to offer dental plans. Before 1940 there were fewer than 20 privately sponsored prepaid dental plans in the United States, and most of those were created to meet special problems of isolated industries 354/. By the 1950s the primary impetus for extending dental insurance coverage came from collective bargaining. Wage stabilization policies initiated during World War II and carried over into the Korean Conflict period bolstered the concept of nonwage fringe benefits, because they were exempt from controls. More recently the tax laws, which exclude the value of health insurance premiums paid by employers from workers' taxable income and allow individual deductions for employee contributions to health insurance premiums, have encouraged the expansion of health insurance. Once essential coverage for hospital and surgical care was achieved, unions began bargaining for employer-paid benefits for prescription drugs and dental care. Dental insurance is underwritten by dental service corporations, commercial insurance companies, Blue Cross/Blue Shield and independent plans. Some self insurance mechanisms also exist. Dental service organizations are sponsored by state dental societies that contract with groups of consumers to administer prepaid dental care plans. The first dental service organization was the Washington Dental Service, which evolved from 1954 labor-management negotiations 355/. Three years later the American Dental Association formally endorsed the concept of dental service corporations, and in 1965 the ADA established a national agency to coordinate the activities of state dental service organizations, which in 1969 became known as the Delta Dental Plans Association. By 1978 the Association was overseeing 44 such corporations in 47 states and the District of Columbia. They are non-profit organizations that reimburse member dentists on a fee-for-service basis, and allow freedom of choice for both patients and dentists 356/.

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The Continental Casualty Company was the first commercial firm to offer dental insurance. The availability of ADA statistics on utilization and fees made the plan possible, and Continental was guaranteed against losses by the employer. Blue Cross/Blue Shield began developing dental plans in 1965, and in some instances have assisted dental service corporations in administering their plans 357/. Remnants of earlier employer-sponsored dental clinics still exist, as do union-run clinics. However, commercial insurance companies dominate the dental insurance market today; dental service corporations and Blue Cross/Blue Shield are in distant second and third places, respectively (Table 35). Coverage under private dental insurance increased more than 300 percent between 1970 and 1977 (Table 34). Expenditures for dental care under private plans (Table 35) have grown from $778 million in 1974 to $2,548 billion in 1978 358/. The increases in both enrollment and expenditures have come largely from additional insurance underwritten by commercial insurance companies. Even so, in 1977 about 77 percent of all dental care expenditures were not covered and were paid out of pocket by patients 359/. In summary, private dental health insurance has grown rapidly, and if it continues to grow, 54.3 percent of all Americans would have some type of private dental insurance by 1990 360/. Publicly Funded Dental Care Of the $13.3 billion spent for dental services in 1978, only about a half-billion dollars (or 4 percent) were from public sources (Table 33). Between 1976 and 1978 private spending rose 33 percent (from $9.6 billion to $12.8 billion) while public spending rose only 11.6 percent (from $483 million to $539 million) 361 and 362/. The Medicaid program accounted for $444 million. The rest was spent under a variety of other federal, state, and local government programs. Table 36 identifies the sources of public funding of dental care in more detail. Public funding for dental services takes two major forms: (1) direct provision of services by dentists (or other dental personnel) employed by government agencies, and (2) reimbursement from public funds to privately practicing dentists who furnish services to government-sponsored patients. The federal programs in the first category include those of the Defense Department, which furnishes dental care to active members of the uniformed services; the Veterans Administration, which furnishes dental care to certain eligible veterans in its own facilities or finances it through the private sector; and the Public Health Service, which furnishes care to American Indians and several other entitlement groups.

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DENTAL CARE EXPENDITURES AND INSURANCE

Table 35. BENEFIT EXPENDITURES OF PRIVATE HEALTH INSURANCE FOR DENTAL CARE, SELECTED YEARS 1970-1978 Carrier 1970 1974 1975 1976 1977 1978 Total (Millions) $240.1 $778.4 $1,074.0 $1,609.3 $2,297.0 $2,548.0* Commercial Insurance Companies 147.0 332.2 525.0 1,078.5 1,531.5 Dental Service Corporations 54.0 340.0 362.0 285.0 228.4 Blue Cross-Blue Shield 3.8 53.5 131.0 176.6 237.4 Independent Plans Community (Consumer) 14.0 28.0 26.4 29.5 35.3 Employer- EmployeeUnion 20.0 22.4 27.2 37.6 232.7 (Labor-Management) 1.3 2.3 2.4 2.1 31.7 Private Group Clinic (Health Professional) *Distribution across carriers not available for this year. Source: Private Health Insurance; Selected Issues, Social Security Bulletin; Social Security Administration; U.S. Department of Health, Education, Welfare 363/

81

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Table 36. EXPENDITURES FOR DENTISTS' SERVICES, BY TYPE OF PUBLIC PROGRAM AND SOURCE OF FUNDS, CALENDAR YEAR 1978 Program and Source of Funds Dental Services (in millions) Total* $ 539 Federal 310 State and Local 229 Major Program Areas: Medicaid 443 Federal 247 State and Local 196 Other Medical Assistance 28 Federal 0 State and Local 28 Veterans Administration 44 Other Public Expenditures** 24 Federal 19 5 State and Local *Rounding may introduce errors. **Includes such programs as Defense Department Contract Spending, Maternal and Child Health, Vocational Rehabilitation, PHS and Other Federal Hospitals, Indian Health Service, and School Health. Source: Gibson 364/

Public expenditures for dental services is mostly in federal and state Medicaid programs, which are required under federal statute to provide dental services to eligible children as part of the EPSDT program (early and periodic screening, diagnosis, and treatment). Medicaid-eligible children under age 21 are furnished the treatment services found necessary in the screening process, and dental screening and dental care are among the required services. Dental care coverage for other Medicaid eligibles is optional under federal guidelines. In 1977, 36 states covered at least some dental services for adults 365/. Although Medicaid expenditures for dentists' services represent the great bulk of public expenditures for such services (and the proportion is slowly growing), total Medicaid expenditures are growing more rapidly than Medicaid expenditures for dental care. The rate of growth in total

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Medicaid spending between 1976 and 1978 was 24.5 percent while Medicaid dental expenditures increased only 16.6 percent. Several states have either eliminated or cut back on their coverage of dental care for adults. Medicaid dental expenditures in calendar year 1978 amounted to $443 million, of which $247 million were federal dollars. With total Medicaid in 1978 at 18.4 billion, only 2.3 cents of each Medicaid dollar went for dental care. Of the Medicaid dollar spent for services for the elderly, less than one penny goes for dental care 366/. Medicaid dental expenditures go mostly for children (52.3 percent) and adults in families with children (29.4 percent). Only 7.8 percent of Medicaid dental expenditures pay for services to the aged; another 11.1 percent is paid on behalf of the handicapped and disabled 367/.

Characteristics of Various Financing Systems Cost-Sharing Provisions Financing systems vary in such characteristics as cost sharing (co-payments and deductibles), reimbursement methods (fee-for-service and capitation), and such cost containment strategies as utilization services and quality control. Most private dental health insurance plans contain provisions requiring the patient to pay some part of the cost of the services covered. These cost-sharing provisions can take several forms. “Deductible” means that the patient must pay a pre-established dollar amount before the plan begins to pay. With “coinsurance” the patient is responsible for a certain percentage of costs above the deductible, typically 10 to 25 percent. With “copayment,” the patient pays a fixed dollar amount toward the cost of a specific service. (For example, in some drug plans, the patient may be responsible for the first one or two dollars of each prescription regardless of the total price of the prescription.) If the dentist can charge a fee greater than that covered by insurance, the patient may have to pay the difference. This aspect of dental third-party plans is discussed further under the section on reimbursement. Cost-sharing mechanisms are designed to hold down costs to the plan, first, by having the patient, rather than the plan, pay part of the costs of services furnished, and second, by inhibiting utilization. A study in 1973 found that plans covering only basic services were less likely to have cost sharing than comprehensive plans. Almost 85 percent of comprehensive plans had copayments or coinsurance; the rest had a deductible or benefit cap or both. Although the study did

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not distinguish between coinsurance and copayment, coinsurance is the dominant form; copayment as defined here is less common in dental plans 368/. Because comprehensive plans are more likely to have cost-sharing, and because comprehensive plans sponsored by employers and insured by commercial insurance companies account for most of the increase in dental coverage since 1973, it is likely that the proportion of plans with cost-sharing has increased substantially. Reimbursement Methods Providers of dental services are reimbursed most commonly on a fee-for-service basis. Salaries are frequently used to reimburse providers. Less commonly, a capitation reimbursement system provides an amount intended to cover certain specified services needed by an enrolled population for a stated time period. Fee-for-service reimbursement is of three forms 1) a usual, customary, and reasonable fee (UCR), 2) a fixed fee schedule, or 3) a table of allowances. The concept of usual, customary, and reasonable fees was developed by the dental profession, through the California Dental Service, to counter the unpopularity of the use of a fee schedule. It is widely used by the dental service corporations and Blue Cross/Blue Shield and is the favored reimbursement mechanism of organized dentistry 369/. With this approach, fees submitted by dentists for third party reimbursement are accepted if they fall within the customary range of 90 percent of the dentists in the state 370/. Fixed fee schedules have a set reimbursement for a particular procedure performed, regardless of what the dentist's regular charges might be. Medicaid programs traditionally have used fixed fee schedules; unlike commercial insurance, however, payment under Medicaid must be accepted by the dentist as payment in full. Although payment based on a fixed fee can control the costs for the insurance plan more effectively than UCR reimbursement, dentists who resent interference in the establishment of their fees may refuse to participate in fixed fee prepayment programs. Dentists with traditionally lower fees may prefer a fixed fee program, because it enables them to raise their fees to the established rate. A table of allowances lists the maximum amount an insurer will pay for a particular service. If the dentist's fee is higher than the listed allowance, the patient is held liable for the difference. The obvious distinction between this method of establishing fees and the UCR and fixed fee approaches is that the table of allowances protects only the third party payer.

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Under a capitation system, the dentist or dental service organization receives a periodic per capita payment based on an enrolled population. In return, the provider agrees to deliver a specific set of benefits. The sum required for the capitation payment is based on projections of the amount of covered care that will be delivered and the cost of providing that care. Capitation gives the provider organization an opportunity to plan and budget to meet the health care requirements of an identified population. It also provides an incentive for dentists to practice and encourage preventive dental care, because it is less expensive over time for a dental organization to provide preventive services than restorative and other more costly procedures. A study of two samples of patients receiving care from the same dentists on either capitation or fee-for-service arrangement found that patients received significantly more preventive services, fewer fillings, and experienced a more favorable modification in their DMF Index under the capitation arrangement 371/. However, these findings are not conclusive because most feefor-service patients were not insured. Capitation may also have undesirable effects, however, such as minimizing the number of patient visits or services provided or encouraging the provision of lower cost services. Capitation may lead to inadequate restorative care, particularly when beneficiaries of the system are (or are thought to be) transient, thus removing the incentive for the dental organization to place them on a program of maintenance care 372/. In assessing the effects of capitation payment on the cost and quality of the health care provided, it is often difficult to separate the influence of the payment method per se from the influence of the organization setting in which the care is provided. Capitation payment has traditionally been associated with closed panel prepaid group practice plans, or health maintenance organizations. The presumed advantages and disadvantages of capitation payment within a group practice of HMO context have been outlined by Corby 373/ as follows:

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DENTAL CARE EXPENDITURES AND INSURANCE

ADVANTAGES

1.

2.

3.

4.

5.

6.

86

DISADVANTAGES

Quality control. Consultation and peer review within group practices encourage the dentist to provide optimal dental care for the long term benefit of the patient, rather than the immediate benefit of earnings. Peer review is a condition for participation. Prevention. Health education and prevention become strong incentives because dental group practices are paid on the basis of how many patients have enrolled. Early maintenance is to the advantage of the dentist and patient. Capitation brings patients into a dental office who may never receive treatment if the service were not provided by an employer or union. It eliminates incentives for dentists to provide certain services over others. Excessive X-rays are eliminated, and pressure to provide crowns rather than fillings would be reduced. Claim forms are eliminated but not statements for services under co-payments schedules. Seasonal cash flow fluctuations may be less of a problem because capitation payment remains constant.

1.

2.

3.

4. 5.

6.

7.

It is conceivable that capitation programs could compromise a dentist's judgment of patient needs. The less treatment provided, the less overhead and the more profit. Lack of choice of dentist. Patients must receive treatment from a doctor listed as a provider. Capitation is best suited for group practices; the solo practitioner may find it much harder to to work as part of a network. Dentists' services are subject to audit and review by the third party payer.* Poor access to a dentist within the capitation network may discourage patient utilization. Dentists are responsible for seeing that patients come to the office at least once a year, depending on the contract. Substantial time may be required to bring patients up to maintenance level in the beginning of the program.* Renewal capitation contracts may call for a reduced payment to the provider-dentist.

*These disadvantages may also occur when dental health insurance pays for benefits on a fee-for-service basis.

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Utilization Review and Quality Control A variety of processes and programs other than third-party payer activities contribute to assuring the quality of dental care, including basic dental education, specialty training, licensure, and continuing education activities. The dental profession, usually through state and local dental societies, has created committees to deal with specific instances of questionable quality. Although these committees may have beneficial effects for individual patients who ask for assistance, they are not routine monitors of the quality and appropriateness of dental services. Many dental prepayment programs have instituted routine reviews of utilization and costs of the dental care for which they provide payment. Some of the programs are conducted in conjunction with dental societies. Most of the programs are concerned mainly with the necessity of services and levels of fees; nevertheless, they have some implications for the quality of care. Private plans and Medicaid usually require pre-treatment review of services proposed for their beneficiaries. The frequency with which prior authorization of benefits, prior determination of eligibility for benefits, and other types of pretreatment review are required by various payers is shown in Table 37. These data come from a 1976 survey of prepayment programs which had a low response and some definitional problems, but would be accepted by most experts as generally representative of current practice among insurers 374/. About 12 percent of the programs had no pretreatment review requirement. In meeting prior authorization or pretreatment requirements, dentists may be asked to submit treatment plans and radiographs for all proposed treatment costing more than a stated amount, typically $100 to $150. Although such claims constitute a small percent of the total of claims submitted, they usually include a high proportion of the more elective and expensive services and therefore represent a substantial portion of all costs paid by the plans. Insurance company dentists review the submissions and determine whether the services are justified. The cost-control measures are not without problems: costs are incurred by both the insurance company and the dentist for handling pretreatment claims and radiographs; the review annoys dentists who have their treatment plans questioned by people unfamiliar with their patients; the patient may be forced to pay out of pocket for denied care. Post-treatment reviews also are required by some insurers, as shown in Table 38. For every type of review, Medicaid and Delta dental plans were more likely to have requirements than were Blue Cross/Blue Shield and commercial insurance programs.

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The major ongoing review of the quality and utilization of health services is by the Professional Standards Review Organizations (PSROs), mandated by the 1972 amendments to the Social Security Act to review care provided to Medicare and Medicaid beneficiaries. At present, PSROs have limited relevance for dentistry, being mainly directed to acute hospital care. Accordingly, dental services now reviewed are oral surgery and some hospital-based periodontal surgery. PSROs are moving toward the review of ambulatory and long-term care, however, which may include services by the dental profession. Much work is under way to design and implement methods of monitoring and improving the quality of dental care. The ADA has recently issued a joint report of the Councils on Dental Care Programs, Hospitals and Institutional Dental Services, and the Bureau of Economic Research and Statistics, which describes 230 various systems employing a quality assurance program. It covers the categories of inpatient hospital review, ambulatory review, and third party carrier review, and assesses their data bases and associated strengths and limitations. The California Foundation of Dental Health has been funded by the W.K. Kellogg Foundation to examine the feasibility of developing quality measures for a peer review system that could be handled by a computer as a firstlevel screening mechanism. UCLA has also been funded by the W.K. Kellogg Foundation through the American Fund for Dental Health in order to develop an oral health status index which should prove to be useful in comparing the effectiveness of dental care plans. Educational institutions, in particular the universities of Kentucky and Washington, are experimenting with the introduction of quality assurance concepts and techniques in the basic dental curriculum 375/. The Division of Dentistry (DHHS) has supported a series of research projects, conferences, and workshops on quality assurance in dentistry. The interest in and need for quality assurance and utilization review methods are clear, even though much more research is required.

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Source: Praiss et al. 376/

Table 37. PRETREATMENT REVIEW REQUIREMENTS, BY PAPER GROUPS, 1976 Total Blue Cross and Blue Shield Requirement Number of Plans Total 111 28 Prior Authorization 79 20 Determination of Benefits 64 19 Other 23 7 None 14 3 Percent of Programs with Requirements Prior Authorization 71.2 71.4 Determination of Benefits 57.7 67.9 Other* 20.7 25.0 12.6 10.7 None *Includes checks of eligibility and patient liability for proposed services. Delta 24 16 17 4 2 66.7 70.8 16.7 8.3

Commercial 28 14 18 2 7 50.0 64.3 7.1 25.0

93.5 32.3 32.3 6.5

31 29 10 10 2

Medicaid

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DENTAL CARE EXPENDITURES AND INSURANCE 89

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Source: Praiss et al. 377/

Table 38. POSTTREATMENT REVIEW PROCEDURES USED, BY PAYER GROUPS 1976 Total Blue Cross and Blue Shield Procedure Number of Plans Patient Examination 111 28 Submission of Radiographs 60 10 Check Adherence to Treatment Plan 70 15 Provider Fee Audit 53 10 Review of Patient's Claim Record 84 18 Other 13 2 None 11 4 Percent of Programs using Procedure Patient Examination 54.1 35.7 Submission of Radiographs 79.3 75.0 Check Adherence to Treatment Plan 63.1 53.6 Provider Fee Audit 47.7 35.7 Review of Patient's Claim Record 75.7 64.3 Other 11.7 7.1 9.9 14.3 None Delta 24 19 16 19 23 4 1 79.2 91.7 66.7 79.1 95.8 16.7 4.2

Commercial 28 9 12 5 21 2 6 32.1 71.4 42.9 17.9 75.0 7.1 21.4

71.0 90.6 87.1 61.3 71.0 16.1 0.0

31 22 27 19 22 5 0

Medicaid

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DENTAL CARE EXPENDITURES AND INSURANCE 90

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Summary and Conclusions Dental care expenditures have been rising rapidly, reaching $13.3 billion in 1978, or 7.9 percent of all personal health care expenditures. Of this total, private insurance accounts for 19 percent, public programs 4 percent, and the remaining 77 percent are out-of-pocket outlays. Private dental insurance is a relatively late development compared with the growth in private medical insurance. In 1978, about 60 million persons, 27.3 percent of the population, were covered under private dental insurance plans. Ten years earlier, only 5.8 million persons were covered. Part of the reason for the late development of dental insurance is that dental care does not satisfy the traditional criteria for insurability. The portion of dental care funded from public sources is small and is decreasing. Consequently, the low income population covered by public programs is at risk of reduced access to dental care. The committee concluded that children in this special population group warrant access to basic dental services. Dental care costs are lower for children than for adults or the aged. However, children's dental care costs represent a higher percent of their total health care costs. The committee concluded that priority be given to cover children based on their long-range cost-effectiveness in improving oral health through prevention and early control of dental caries. Preventive dental services are estimated to represent only 7 percent of the total outlays for dental services. Reconstructive crown and bridge services have become the largest single expenditures for dental care, representing almost one-third of all dental care expenses. The trend in types of services rendered suggests a shift in expenditures toward higher technology reconstructive services for adults. The priorities for coverage of dental care recommended by the committee rank last the more expensive services for adults--periodontal treatment, restorations, crowns, and bridges. Cost-sharing mechanisms are designed to hold down costs to the insurance plan by requiring the patient to pay part of the cost when services are rendered. Such provisions, however, act as disincentives to use of services. Services that should have increased application because of their potential impact on health should not be discouraged with a cost-sharing mechanism. Thus, the committee recommends that cost-sharing not be applied to preventive dental services. Fee for service is the most common method of paying dentists. More recently, capitation payments have been applied to dental services under health maintenance organizations. A review of the advantages

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and disadvantages indicates that capitation payment methods appear to embody sufficient advantages to warrant their increased use in the financing of dental services. The committee therefore recommends that alternative prepaid delivery systems and capitation reimbursement systems be made an integral part of the central health program under national health insurance. The review of utilization and the control of quality are essential to the sound operation of an effective national health insurance program. Several types of quality assurance methods are currently in the development stage which show promise for improving the quality of dental care. The committee concluded that sound mechanisms of quality and utilization review for ambulatory dental care be included in a national health insurance program. The committee also recognized that the successful implementation of quality and utilization review mechanisms as well as the administration of national health insurance require the development of a sound management information system and therefore recommended that an information system be instituted as an initial component of a national health insurance program.

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Chapter 6 BENEFIT PRIORITIES AND THEIR ESTIMATED COSTS

Estimating expenditures for dental services under a national health insurance proposal is difficult in the current political and economic climate. Also, projecting such expenditures is hampered by the inadequacies that attend projecting costs of any national program and the inaccuracies that usually accompany initial estimates for new health programs. These problems notwithstanding, estimates of expenditures are required if there is to be a thorough national policy debate on the feasibility of dental benefits. This chapter presents the rationale and methods used by the committee to obtain cost estimates for the four benefit plans outlined in Chapter 1. To provide a broader view of potential dental care expenditures, the estimates are compared with projections of current expenditures and with estimates based on actuarial data. The four priorities of benefit plans are explained here in more detail and assigned estimated costs by procedure. The estimates of their costs are developed from national population-based measures of clinical needs for dental services, and are not the demand-based estimates commonly made from actuarial data on private dental insurance plans. The determination of the population's treatment needs was made by examiners who would not benefit directly from decisions to recommend the delivery of expensive high technology services rather than preventive and conservative treatment. The data to facilitate financially unbiased estimates of national dental needs were collected in the 1971-74 Health and Nutrition Examination Survey and have been discussed earlier in this report. PLAN PRIORITIES FOR COVERAGE OF DENTAL CARE Priority One has as its goal the reduction of the incidence and prevalence of dental disease in later life by instituting coverage of preventive services for children and adolescents. Preventive services for children reduce caries, although the degree to which caries are reduced is not completely clear when services are delivered with limited frequency.

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Priority Two emphasizes comprehensive services for children. There is need for treatment of decayed teeth in children, and much of it represents a backlog of neglect. Continued neglect of decayed teeth would lead to premature tooth loss. Orthodontic care in Priority Two has been limited to services for the five percent of adolescents who have seriously handicapping malocclusions. Lessened handicap could improve not only physical health, but also emotional well-being for adolescents to whom self-image is particularly important. Priority Three provides preventive services for adults 18 years and over. For young adults below the age of about 35, prevention is mainly directed at reducing the incidence of caries. It has been shown that the benefits of preventive services for children carry over to younger adults. The major question about the effectiveness of prevention for adults is the degree to which preventive services reduce periodontal diseases. The evidence is not clear. The clinical research mentioned in Chapter 3 strongly suggests that prevention will reduce periodontal diseases. However, there are few population-based studies to document reductions in periodontal diseases after preventive services are introduced. The optimal frequency of services required for presenting and controlling periodontal diseases is currently thought to vary for different individuals. Priority Four would provide diagnosis and treatment for adults. A major issue in treatment for decayed teeth in adults is the extent to which crowns are the treatment of choice. Crowns are very expensive, and their routine use could lead to large national expenditures if patients were treated according to current demand. The choice of this plan would represent a priority for making National Health Insurance dental benefits available to older members of the population and would thus include replacement (prosthetic) services for adults. There is considerable need for full dentures, partial dentures, and bridges, particularly among the elderly population. For the U.S. population as a whole, 10 percent of adults are estimated to need upper and/or lower dentures, and 6 percent need full dentures. Restricting consideration to adults with no teeth, almost one quarter of them need full dentures. Slightly more than one-third of edentulous adults have no dentures, defective dentures, or at least one absent or defective denture. These figures demonstrate a substantial need, largely among the elderly who have limited resources and opportunities to seek appropriate care. Replacement services, particularly for the elderly, improve their quality of life, nutrition, and self-esteem. However, the cost of a full set of dentures can vary greatly. At the present time, the fee for a complete set of full dentures, both upper and lower, in a private dental office is estimated at $660. But dentures also can be obtained for about $360 ($180 for an upper and $180 for a lower). The situation for bridges, also included in the replace

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ment package in Priority Four, is similar to that for crowns. Costs would rise sharply if services were delivered according to current demand. A MODEL FOR PROJECTING EXPENDITURES A need-based model for projecting expenditures has been developed for estimating the costs of various components of a comprehensive dental plan for national health insurance. Figure 1 shows the seven sets of variables used to project the total costs of each component. Need-based cost estimates of projected health care expenditures can only be made when there are valid and reliable measures of the national need for services available. In most instances such data are not obtainable for medical care. But for dental services, specific needs can be determined objectively. To project expenditures, the national estimates of dental treatment needs were translated into expenditures for each of the four coverage plans. Expenditures are based on fees charged in private dental offices. For FY 1980 an attempt is made to compare the projected expenditures based on needs with expenditures expected if the current financing mechanisms continue. Alternative projections based on the demand experience of the California Dental Service also are presented to help assess the validity of the estimates based on needs. All expenditures are presented in dollars for the year to which they refer. Inflation of dental fees for 1981-84 is taken to be the (geometric) mean of the inflation rates observed or projected for the period 1975-1980. Benefits and coverage are defined in detail by the services included under each of the four plans. The national data that make it possible to calculate the cost of meeting the population's dental treatment needs have been gathered in the Health and Nutrition Examination Survey (HANES) of the National Center for Health Statistics conducted during 1971-74. 378/ This survey documents dental treatment needs based on dental examinations for a sample of about 20,000 persons selected according to random sampling procedures. Each survey response is weighted so that, in aggregate, the sample reflects the U.S. population of noninstitutionalized individuals aged less than 75. A summary of estimates of U.S. dental treatment needs based on HANES is presented in Chapter 2, Table 1. The treatment needs for each benefit for each age group of interest in the U.S. have been estimated using HANES where available. In addition, more specific HANES data, such as measures of total number of teeth to be extracted, were used. The projected U.S. civilian population by age for each of the years 1980-84 379/ has been calculated and used in these cost estimates.

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Cost of Component = Sum of Age Specific Costs Total Cost of Plan = Sum of Component Costs

FIGURE 1: MODEL FOR PROJECTING DENTAL EXPENDITURES UNDER NATIONAL HEALTH INSURANCE

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In the case of needed restorations, the HANES survey may underestimate these needs, because there were no radiographs used in the dental examinations. Based on studies of examinations performed with and without dental radiographs, an adjustment of the HANES estimate of number of teeth to be filled resulted in an average increase of 36 percent. The services estimated to be required by the entire U.S. population were multiplied by the projected median price for each service. Prices largely were the fees in private dentists' offices reported in a 1975 survey by the American Dental Association 380/ and were inflated to give projected 1980 fees. The inflation rate was based on the Consumer Price Index (CPI) for dental services compiled by the Bureau of Labor Statistics. Thus, ADA median fees reported for 1975 were inflated by 47.3 percent to obtain a projected FY 1980 fees in terms of 1980 dollars. These fees are the prices indicated in the four dental plans computed in Table 39. For the Fiscal Years 1981, 1982, 1983, and 1984, expenditures are projected in terms of current dollars under the assumption of an annual inflation rate of 8 percent in dental fees from 1980 onwards. The (geometric) mean inflation rate for dental fees during the period 1974-1979 was 8 percent. An overhead that includes costs of administering the dental component of any national scheme and monies needed to ensure the quality of services rendered must be built into projected National Health Insurance costs. The California Dental Service Denti-Cal (Title XIX) program, which covers approximately 2.8 million persons, has an administrative cost of 6 percent 381/. According to Delta Plans Association this figure is below the usual administrative cost experienced by conventional insurance companies for dental programs 382/. But these data suggest that an administrative cost of 6 percent is realistic for an efficient organization. For a national program, one might expect further economies due to the large scale of operation. On the other hand, the extent of the quality assurance mechanisms in a national program have not been defined; an elaborate system to prevent the overutilization of dental services would be costly. Allowing for a moderately expensive quality assurance system, and assuming that a national program may not be able to achieve optimal efficiency in its administration, an administrative and quality control overhead of 10 percent seems reasonable. A review of private health insurance plans 383/ lists operating expenses as percent of premium income for private health organizations in 1976. Operating expenses and profits ranged from 5.0 percent to 46 percent of premimum income. For all private plans, the average figure was 12.8 percent. Excluding the category “individual policies” with an operating expense of 46 percent as being out of line with the other categories, the overall figure for operating expenses becomes 9.7 percent. An overhead of 10 percent rather than 6 percent was assumed to allow for unexpected contingencies and for additional quality control mechanisms.

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Table 39. DENTAL CARE SERVICES AND PROJECTED UNIT COSTS, BY PRIORITY PLAN, FY 1980 Priority Plan and Services PRIORITY ONE - Prevention services for children and adolescents a) Screening, prophylaxis (age 12-17 only), and fluoride application as appropriate b) Health education/plaque control c) Sealants: 4 per child at ages 6 and 12 PRIORITY TWO - Comprehensive services (excluding prevention) for children and adolescents from birth to 17 years, and orthodontic services for those with a seriously handicapping malocclusion a) Examination b) Radiographs Ages less than 7 years: 2 per year Ages 7-11 years: 4 per year Ages 12-17 years: 1 complete set every 3 yrears c) Space Maintainers d) Extractions e) Restorations Primary teeth 1 surface 2 surfaces 3 or more surfaces Permanent teeth 1 surface 2 surfaces 3 or more surfaces f) Crowns

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Amount $21.38 7.37 34.99 8.35 8.84 11.78 29.46 68.74 17.68 14.73 22.10 30.93 14.73 23.57 34.62 51.56

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g) Endodontic treatment Pulp capping, vital pulpotomy, and root canal therapy h) Treating handicapping malocclusions Diagnosis and treatment planning Initial appliances, fixed plus 18 months treatment PRIORITY THREE - Prevention services for adults a) Screening examination and prophylaxis PRIORITY FOUR - Comprehensive services (excluding prevention) for adults a) Examination b) Radiographs 1 complete set every 3 years c) Extractions d) Periodontal treatment Gingival curettage/quadrant Periodontal scaling and root planing (entire mouth) Periodontal surgery/quadrant e) Restorations 1 surface 2 surfaces 3 or more surfaces f) Crowns g) Endodontic treatment Pulp capping, vital pulpotomy, and root canal therapy h) Replacement services (bridges and dentures) Full dentures Upper arch - low cost Lower arch - low cost Partial dentures (including six months post-delivery care) Bridges Repair denture (full or partial) Reline denture (full or partial)

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123.25 73.65 1,502.46 19.15 8.35 29.46 20.62 29.46 58.92 110.48 14.73 23.57 34.62 226.21 123.25 209.95 209.95 368.25 773.33 28.24 91.33

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Expenditures derived under the need-based method would project the amounts required to alleviate the entire need for the specified services. In practice, not all members of the population needing services would utilize them even if they were available, and so specific utilization rates were assumed. Further, not all patients utilizing services would have all their needs met; there would not be 100 percent completion of services. The utilization rate and completion rate can be combined to form an overall rate, commonly referred to as the utilization rate. An adjustment for completion of services could contemplate 45 percent for adults and 55 percent for children regarding all services except full dentures and orthodontics), the rates experienced by the California Dental Service. For full dentures, a utilization rate of 97.4 percent is assumed for the projected expenditures. Although this rate is high, it appears to be the experience of England and Wales under the National Health Service 384/, and is supported by data from the Health Insurance Plan of Greater New York 385/. A utilization rate of 60 percent was assumed for orthodontic care of handicapping malocculsions. Although no evidence was available to justify the choice of any particular figure, the committee as a whole judged 60 percent to be reasonable. If other utilization rates are found more appropriate, the expenditures projected under the assumptions stated above should be adjusted to reflect alternative choices. Figure 1 and Table 39, respectively, summarize the model and costs per service used to compute expenditures. In Table 40, expenditures for each plan are projected for each of the years 1980-84. The utilization rates for the various services are assumed constant throughout the five years. However, needs may change as services are rendered. The need for preventive services for children and adolescents (Priority One) are assumed to remain constant, as are needs for comprehensive care for children (Priority Two) and for adults (Priority Four). Preventive services should reduce needs for comprehensive services in successive years, but the impact of increased prevention is not likely to be felt in the short term. Further, the impact will be dissipated if utilization rates are low, such as 45 to 55 percent, and reduction in need for comprehensive services may not be realized without behavioral changes on the part of the covered population. Some of the services in Priorities Two and Four cover a backlog of unmet needs that will not recur. However, with a fairly low utilization rate, the backlog may never disappear, in which case a reduction in expenditures because of fewer unmet needs might be overly optimistic. Further, incidence rates for dental conditions needing treatment may change in unknown ways as prevalence changes.

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Table 40. NEED-BASED PROJECTION OF EXPENDITURES FOR DENTISTS' SERVICES UNDER NATIONAL HEALTH INSURANCE, FISCAL YEARS 1980-84 Fiscal Years/Millions of Dollars 1980 1981 1982 1983 1984 Priority Plans Total* $20,011 $21,843 $23,834 $25,585 $27,897 PRIORITY ONE 702 747 797 858 923 PRIORITY TWO 3,398 3,653 3,935 3,817 4,184 Comprehensive services (excluding 2,807 3,015 3,246 3,512 prevention) for children and adolescents Orthodontic services handicapping 591 638 689 305 malocclusions PRIORITY THREE 1,643 1,802 1,973 2,160 2,358 Prevention services for adults PRIORITY FOUR 14,268 15,641 17,129 18,504 20,472 Comprehensive services (excluding prevention) for adults *Numbers may not total because of rounding. 336

3,808

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For orthodontic care in Priority Two, it is assumed that only children with a seriously handicapping malocclusion are eligible. The usual time for this treatment is at about twelve years of age, although the treatment might occasionally be made available at a younger age. Making this benefit available at a younger age would not change the aggregate cost projection. If the program were phased in during the first three years, children aged 11-17 in 1980 will receive needed care in 1980, 1981, or 1982, twelve-year olds becoming eligible in 1981 and 11-year-olds in 1982. The total need for the 11-17 age group, multiplied by 60 percent as a realistic utilization rate, is costed out and spread over the three fiscal years 1980, 1981, and 1982. For FY 1983 and FY 1984, expenditures are projected respectively for 10-year-olds (in 1980, becoming 13 in 1983) and 9-year olds (in 1980, becoming 13 in 1984), again assuming a 60 percent utilization rate. Thus, the steady state is reached in FY 1983 and expenditures for subsequent years would stay constant except for inflation and changes in the size of entering cohorts. For each year, projected expenditures include the entire course of orthodontic treatment. Replacement services in Priority Four would, in the first year, satisfy only part of the current need. For full dentures, it is assumed that current need could be met over a five-year period. During 1980-84, some new persons not currently needing full dentures would become needy, but to offset this some persons needing services would die, because the people most needing these services are elderly. The projected expenditures for full dentures do not necessarily correspond to the steady-state situation that would ulimately develop. Approximate calculations suggest future steady-state costs may be quite close (except for inflation and changes in population size of age cohorts) to the projected 1980-84 yearly expenditures. The remaining replacement services in Priority Four, partial dentures and bridges, were projected somewhat differently, separate expenditures being derived for incidence of new needs and backlog of unmet needs. Analysis of numbers of teeth needing to be replaced by partials and bridges for successive age cohorts in the HANES data (see Appendix II, Priority Four Incidence Calculations) allowed approximate estimates to be derived for the yearly incidence of new needs for partial dentures and bridges. Expenditures for treating these new needs were derived assuming estimated incidence rates applied to the projected population for each of the years 1980-84, and that the utilization rate would be 45 percent. The backlog was taken to be needs by the 1980 population, as predicted by HANES. Further, it was assumed that only 45 percent of the backlog would be treated as a result of the prevailing utilization rate. The backlog was then spread evenly over the five years 1980-84 and expenditures estimated accordingly.

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PROJECTED EXPENDITURES FOR FOUR DENTAL PLANS A summary of the projected expenditures for dentists' services based on a delivery system that is responsive to total population needs is given in Table 40 for each plan for each FY 1980-84. Table 41 gives detailed projections, for each covered benefit, of expenditures during FY 1980. All figures are in millions of dollars inflated to represent the actual buying power of the dollar for the appropriate year. The FY 1980 expenditures for dentists' services for the aggregate of all four plans is projected to be $20.3 billion dollars. The projected expenditures assume that service delivery would be in private dentists' offices under the fee-for-service mechanism. Other delivery mechanisms are possible in some cases. One is the delivery of preventive care to children in a school-based program by salaried dental hygienists as recommended in Chapter 1. The services in Priority One, which involve screening and prophylaxis (including fluoride application, plaque control, and dental health education) could be delivered by dental hygienists who travel to schools routinely. On the basis of one visit per child per year of school age (6-17 years), the operating expenditures in FY 1980 for Priority One excluding emergency costs would be about 0.18 billion dollars. For two visits per year, operating expenditures would double to approximately $.36 billion. These expenditures do not include costs for capital equipment during start-up. A school-based program offers substantial savings compared with the $670 million dollars projected for services delivered in dentists' private offices under a fee for service mechanism. However, a school program would have to be phased in slowly, perhaps over a period as long as seven years. It is estimated that nearly 8,000 dental hygienists would be required to staff a national program of one visit per year to each participating child. A feasible plan could begin with pilot programs in communities already fluoridated and build up to national coverage. At the 1980 rate of dental hygiene graduates, there would be no need for an increase in auxiliary education programs. DENTAL EXPENDITURES NOW AND IN A FUTURE NATIONAL PROGRAM Estimates of total national health expenditures are reported annually by the Health Care Financing Administration (previously by the Social Security Administration). Dentists' services in FY 1977 are estimated at $11.65 billion, but no itemization of these expenditures by types of dental care is published. However, recent estimates of percent of total charges by general practitioners that correspond to specific types of dental services are available from a study by Nash, et al. 386/. Charges for each of the categories--diagnosis, prevention, operative removable prosthetics, fixed prostethics, surgery, periodontics, endodontics, and orthodontics--were estimated and the estimates adjusted for charges made by specialists. These adjusted estimates were applied to the expenditures for dentists' services for FY 1980, projected under

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the assumption that there is no change in the present system, and that growth in expenditures to FY 1980 is similar to the pattern for the years FY 1975 to FY 1977. The itemization of services used by Nash, et al. 387/ was related to specific services in the four priority plans. A direct comparison of expenditures for dentists' services during FY 1980 between the current system and a system under national health insurance is given in Table 41. Care must be taken to interpret this table appropriately as the two columns of projected expenditures relate to different case mixes. The first column presents total expenditures for dentists' services in FY 1980 under the current utilization system. The second column gives a hypothetical distributon of expenditures in which services identified in the four plans are delivered according to population needs. Table 41. PROJECTED EXPENDITURES FOR DENTISTS' SERVICES UNDER CURRENT DENTAL CARE SYSTEMS COMPARED WITH EXPENDITURES UNDER NATIONAL HEALTH INSURANCE FY, 1980 Under Current Systems (in millions) Covered by the Four Plans When Delivery is Based on Need (in millions) Total* $17,677 $20,011 Diagnosis 1,503 1,952 Prevention 1,250 2,359 Operative 4,465 3,831 Removable Prosthetics 1,523 2,638 Fixed Prosthetics 5,445 4,084 Surgery 1,057 1,411 Periodontics 347 2,801 Endodontics 1,148 345 938 591 Orthodontics *May not add due to rounding

The projected expenditures under National Health Insurance do not account for all expenditures that would occur for dentists' services.

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Orthodontics under the current system includes services delivered in cases where the malocclusion is not severely handicapping. Under National Health Insurance, expenditures for orthodontics are solely for seriously handicapping malocclusions. Full dentures were included at a low-cost estimate in the projections for National Health Insurance expenditures and thus the figure of $2,638 million for removable prosthetics is not based on the same unit price as the figure of $1,523 million for projected expenditures under the current system. EXPENDITURE: DEMAND V. NEED-BASED PROJECTIONS Table 42 is a comparison of FY 1980 projected expenditures based on need and projections based on the demand experience of the California Dental Service (CDS). These latter projections were prepared independently by the staff of CDS and were determined by the demand experience of 195,000 employees, 140,000 employee spouses, and 200,000 children of employees. California dental fees were used in the calculation, but fee differentials among states were taken into account when projecting to national expenditures. The demand rates observed by CDS were applied to the projected 1979 civilian population of the United States. To obtain FY 1980 expenditure projections, the CDS estimates were increased by an additional 8.9 percent to account for inflation, and population-specific items are different in some cases. Priority Four shows particularly divergent projections. The difference is due mainly to the large discrepancy in expenditures for crowns. CDS projections reflect a much greater proportion of crowns as the treatment of choice rather than amalgam restorations. This suggests that expenditures for crowns could escalate sharply in a national program unless reimbursement for them was restricted. Expenditures for Priority Four also show differences for individual services. Bridges result in a greater total in the CDS projections, as might be expected from the CDS bias toward crowns. For dentures, the need-based estimate is somewhat higher. It would have been much higher if the same fees had been used as for CDS projections. Only low-cost prices were used for full dentures in the case of projections based on needs. The CDS projection for dentures is likely to be low because of the population served: workers and their families. The elderly are under-represented, although they have the greatest denture needs. As previously mentioned, the HANES data do not include persons over 74 years old, and thus even the need-based projections of expenditures may be low. Finally, the demand-based projections for Priority Four excludes the estimated amount of $1.1 billion for periodontal surgery. To permit a valid comparison of the two sets of estimates, the demand-based projections for Priority Four and the totals have been increased by this amount. A national health insurance program may alter demand and thus invalidate projections based on observed demand. However, need-

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based projections rely heavily on assumed utilization rates (taken to be 45 percent for adults and 55 percent for children), and thus any changes in these rates may change projected expenditures sharply. In any event, the greater of the two projections for individual services may give an upper limit for anticipated expenditures for dental services under national health insurance, although the need-based estimates would appear to provide a valid basis for comparing expenditures projected by other methods. Table 42. EXPENDITURES FOR DENTISTS' SERVICES BASED ON NEED AND DEMAND, FY 1980 Need-based Projections Demand-based Projections Priority Plan (in millions) Comprehensive Dental Benefits--Total $20,011 $22,945 1/ Priority One--Prevention for Children 702 955 3,398 2,090 Priority Two--Comprehensive Services for Children Services, excluding orthodontics 2,807 1,703 Orthodontics for seriously handicapping malocclusion 591 387 Priority Three--Prevention for Adults 1,643 2,497 14,268 17,431 1/ Priority Four--Comprehensive Services for Adults Crowns 1,682 4,987 All other services 7,603 7,344 1/ Bridges 2,345 3,312 2,638 1,788 Partial and full dentures 1/ To permit a valid comparison, Priority One and Priority Four and total figures for the demand-based projections are raised by $28 million and $1.1 billion, respectively, the amount estimated for sealants and periodontal surgery included in the needbased projections.

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SUMMARY AND CONCLUSIONS A model was developed for projecting expenditures for a comprehensive dental plan under national health insurance. This model was based on dental treatment needs identified in the National Health and Nutrition Examination Survey (HANES) conducted by the National Center for Health Statistics during 1971-74. Expenditures are based on fees charged in private dental offices and projected to 1980. Alternative projections also were developed based on the demand experience of the California Dental Service. Estimated expenditures for dental services in 1980 under the current dental delivery system amount to $17.7 billion. Projected expenditures for the proposed four priority plans using the need-based approach amounted to a total of $20 billion. Priority One, prevention for children and adolescents, was estimated at almost three quarters of a billion dollars. Comprehensive services for children and adolescents amounted to $3.4 billion. Priority Three, which covers prevention for adults 18 years and over, is estimated at $1.6 billion. The most costly part of the comprehensive proposed program is Priority Four, comprehensive services for adults, estimated at $14.3 billion. Based on the demand experience of the California Dental Service Corporation, projections of total expenditures of the four plans amount to almost $23 billion. The committee felt that the range of $20 billion to $23 billion is a reasonable measure of the costs of a comprehensive plan for dental benefits. The highest priority given to preventive services is justified not only by their impact on controlling dental disease but also by their relatively low costs. Crowns and bridges are two of the higher technology services for which the expenditures for current demand appear to be significantly greater than estimates based on need. This imbalance results in their lower priority for introduction, raises a need for reimbursement systems that can contain costs, and suggests the importance of sound mechanisms of quality and utilization review.

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BENEFIT PRIORITIES AND THEIR ESTIMATED COSTS 108

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1/ National Center for Health Statistics. Basic Data on Dental Examination Findings of Persons 1-74 Years, United States, 1971-74. Health and Nutrition Examination Survey (HANES). Vital and Health Statistics, Series 11, No. 214, 1979. 2/ National Center for Health Statistics. Current Estimates from the Health Interview Survey, 1977. Vital and Health Statistics, Series 10, No. 126, 1978. 3/ Newman, J.F. and Anderson, O.W. Patterns of Dental Service Utilization in the United States: A Nationwide Social Survey. University of Chicago, Center for Health Administration Studies, Research series 30, 1972. 4/ Koos, E.L. The Health of Regionville. New York: Columbia University Press, 1954. 5/ American Dental Association. Bureau of Economic Research and Statistics. A Motivational Study of Dental Care. JADA 56:566-4, 1953. 6/ Kriesberg, L. and Treiman, B.R. Socioeconomic Status and the Utilization of Dentists' Services. J Am Coll Dent 27(3):147-67, 1960. 7/ Suchman, E.A. and Rothman, A.A. The Utilization of Dental Services. NY St Dent J 31:151-58, 1965. 8/ Avnet, H.H. and Nikias, M.K. Insured Dental Care. New York Group Health Dental Insurance, Inc., 1967. 9/ Hochstim, J.R.; Athanasopoulos, D.A.; and Larkins, J.H. Poverty Area Under the Microscope. Am J Pub Hlth 58:1815-27, 1968. 10/ Nikias, M.K. Social Class and the Use of Dental Care Under Prepayment. Med Care 6:381-393, September-October 1968 . 11/ Okada, L.M. and Aparar, G. Dental Visits by Income and Race in Ten Urban and Two Rural Areas. Am J Pub Hlth 66:878-85, September 1976. 12/ National Center for Health Statistics. Edentulous Persons, United States, 1971. Vital and Health Statistics, Series 10, No. 89, 1974. 13/ See reference 1.

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14/ See reference 1. 15/ See reference 1. 16/ See reference 1. 17/ National Center for Health Statistics. Basic Data on Dental Examination Findings of Persons 1-74 Years, United States, 1971-74. Health and Nutrition Examination Survey (HANES). Vital and Health Statistics, Series 11, No. 214, 1979; and National Center for Health Statistics, Health and Nutrition Examination Survey, unpublished data. 18/ See reference 2. 19/ National Center for Health Statistics. Current Estimates from the Health Interview Survey, U.S., 1975. Vital and Health Statistics, Series 10, No. 115, 1975. 20/ National Center for Health Statistics. Dental Visits, Time Interval Since Last Visit, United States, July 1963-June 1964. Vital and Health Statistics, Series 10, No. 29, 1966. 21/ National Center for Health Statistics. Current Estimates from the Health Interview Survey, United States, 1969. Vital and Health Statistics, Series 10, No. 63, 1969. 22/ National Center for Health Statistics. Current Estimates from the Health Interview Survey, United States, 1973. Vital and Health Statistics, Series 10, No. 95, 1973. 23/ National Center for Health Statistics. Current Estimates from the Health Interview Survey, United States, 1973. Vital and Health Statistics, Series 10, No. 95, 1973. 24/ National Center for Health Statistics. Current Estimates from the Health Interview Survey, U.S., 1976. Vital and Health Statistics, Series 10, No. 95, 1973. 25/ See reference 20. 26/ National Center for Health Statistics. Volume of Dental Visits, United States, July 1963-June 1964. Vital and Health Statistics, Series 10, No. 23, 1965. 27/ National Center for Health Statistics. Dental Visits: Volume and tional Center for Health Statistics. Dental Visits: Volume and Interval Since Last Visit, United States , 1969. Vital and Health Statistics, Series 10, No. 76.

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28/ See reference 3. 29/ See reference 19. 30/ See reference 20. 31/ See reference 26. 32/ See reference 2. 33/ See reference 3. 34/ See reference 20. 35/ See reference 7. 36/ See reference 26. 37/ See reference 2. 38/ See reference 26. 39/ See reference 3. 40/ See reference 20. 41/ See reference 11. 42/ See reference 26. 43/ See reference 12. 44/ Salber, E.J.; Greene, S.B.; Feldman, J.J.; and Hunter, G. Access to Health Care in a Southern Rural Community. Med Care 14:971-986, December 1976. 45/ National Center for Health Statistics. Unpublished Data from the Health Interview Survey, Source P-7703, United States, 1977. 46/ Douglass, C.W. and Cole, K.O. Utilization of Dental Services in the United States. J Dent Educ 43:223-238, April 1979. 47/ See reference 9. 48/ See reference 44. 49/ See reference 3. 50/ See reference 26.

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51/ See reference 27. 52/ Young, W.O. and Striffler, D.F. The Dentist, His Practice, and His Community. 2nd ed. Philadelphia: W.B. Saunders, 1969. 53/ See reference 44. 54/ See reference 3. 55/ See reference 8. 56/ See reference 9. 57/ See reference 8. 58/ See reference 45. 59/ See reference 45. 60/ Haefner, D.P.; Kegeles, S.S.; Kirscht, J; and Rosenstock, I.M. Preventive Actions in Dental Disease, Tuberculosis, and Cancer. Pub Hlth Rep 82:451-459, 1967. 61/ See reference 20. 62/ See reference 5. 63/ See reference 4. 64/ Friedson, E. and Feldman, J.J. The Public Looks at Dental Care. JADA 57:325-335, 1958. 65/ See reference 8. 66/ See reference 10. 67/ Kegeles, S.S. Some Motives for Seeking Preventive Dental Care. JADA 67:90-98, 1963. 68/ See reference 6. 69/ House, D.R. Barriers to Access to Dental Care: An Economic Examination. Unpublished manuscript, 1978-79. 70/ Frazier, P.J.; Jenny, J.; and Bagramian, R.A. Parents' Descriptions of Barriers Faced and Strategies Used to Obtain Dental Care. J Pub Hlth Dent 34:22-38, 1974. 71/ See reference 67.

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72/ See reference 64. 73/ Tash, R.H.; O'Shea, R.M.; and Cohen, L.K. Testing a Preventive-Symptomatic Theory of Dental Health Behavior. Am J Pub Hlth 59:514-521, March 1969. 74/ See reference 6. 75/ Kriesberg, L. and Treiman, B.R. Preventive Utilization of Dentists' Services Among Teenagers. J Am Coll Dent 29:28-45, 1962. 76/ Bulman, J.S.; Richards, N.D.; Slack, G.L.; and Willcocks, A.J. Demand and Need for Dental Care: A Socio-Dental Study. London: Oxford University Press, 1968. 77/ Ramsdell, L.C. An Analysis of the Health Interests and Needs of West Virginia High School Students--A Report. J Sch Hlth 42:477-480, October 1972. 78/ See reference 6. 79/ O'Shea, R.M. and Gray, S.B. Dental Patients' Attitudes and Behavior Concerning Prevention. Pub Hlth Rep 83:405-410, 1968. 80/ Rayner, J.F. Socioeconomic Status and Factors Influencing the Dental Health Practices of Mothers. Am J Pub Hlth 60:1250-1258, July 1970. 81/ See reference 6. 82/ See reference 60. 83/ See reference 75. 84/ See reference 75. 85/ See reference 67. 86/ Kegeles, S.S. Why People Seek Dental Care: A Test of a Conceptual Formulation. J Hlth Hum Beh 4:166-173, Fall 1963. 87/ See reference 60. 88/ Rosenstock, I.M. et al. Public Knowledge, Opinion and Action Concerning Three Public Health Issues: Radioactive Fallout, Insect and Plant Sprays and Fatty Foods. J Hlth Hum Beh 7:91-98, Summer 1966. 89/ Kegeles, S.S.; Kirscht, J.P.; Haefner, D.P. Survey of Beliefs About Cancer Detection and Taking Papanicolaou Tests. Pub Hlth Rep 80:815-823, September 1965.

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90/ Kirscht, J.P.; Haefner, D.P.; Kegeles, S.S.; and Rosenstock, I.M. A National Study of Health Beliefs. J Hlth Hum Beh 7:248-254, Winter 1966. 91/ See reference 12. 92/ See reference 12. 93/ Darley, F.L. Diagnosis and Appraisal of Communication Disorders. Englewood Cliffs, New Jersey: Prentice-Hall, 1964 94/. Personal communication with T. McKiver, Department of Pediatric Dentistry, University of North Carolina Dental School, July 1977. 95/ Jensen, R. Anterior Teeth Relationship and Speech. Acta Radiol Supplement, 276, Stockholm, 1968, pp. 62-69. 96/ MacGregor, F.C. Some Psycho-social Problems Associated with Facial Deformities. Am Sociol Rev 16:629-38, 1951. 97/ Richardson, S.A.; Goodman, N.; Hastorf, A.H.; and Dornsbush, S. Cultural Uniformity in Reaction to Physical Disabilities. Am Sociol Rev 26:241-47, 1961. 98/ Berschied, E. and Walster, E. Beauty and the Best, Psych Today 5:42-46, 74, March 1972. 99/ Davis, F. Deviance Disavowal: The Management of Strained Interaction by the Visibly Handicapped. Soc Prob 9:120-32, Fall 1961. 100/ Goffman, E. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1963. 101/ Wictorin, L.; Hillerstrom, K.; and Sorensen, S. Biological and Psycho-social Factors in Patients with Malformation of the Jaws: A Study of 95 Patients Prior to Treatment. Scand J of Plast and Reconst Surg 3:138-43, 1969. 102/ Peters, J.P. et al. Sociological Aspects of Cleft Palate Adults: IV Social Integration. Cleft Pal 12:304-10, 1975. 103/ National Academy of Sciences. Seriously Handicapping Orthodontic Conditions. Washington, D.C.: National Academy of Sciences, 1976. 104/ Giddon, D.B.; Rude, C.M.; and Belton, D.E. Psychological Problems of the Physically Handicapped Patient. Int Dent J 25:199-205, 1975. 105/ Burnett, G.W.; Scherp, H.W.; and Shuster, G.S. Oral Microbiology and Infectious Disease. Baltimore: Williams and Wilkins Co., 1976. 106/ See reference 1.

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107/ See reference 1. 108/ National Center for Health Statistics. Decayed, Missing, and Filled Teeth Among Children, United States. Vital and Health Statistics, Series 11, No. 106, 1971. 109/ National Center for Health Statistics. Decayed, Missing, and Filled Teeth Among Youths, 12-17 Years. Vital and Health Statistics, Series 11, No. 144, 1974. 110/ See reference 108. 111/ See reference 1. 112/ See reference 1. 113/ See reference 1. 114/ Ludwig, T.G. The Hastings Fluoridation Project V--Dental Effects Between 1954 and 1964, NZ Dent J 61:175-179, 1965. 115/ Arnold, F.A.; Dean, H.T.; Jay, P.; and Knutson, J.W. Effect of Fluoridated Public Water Supplies and Dental Caries Prevalence. Pub Hlth Rep 71:652-658, 1956. 116/ Arnold, F.A.; Likins, R.C.; Russell, A.L.; and Scott, D.B. Fifteenth Year of the Grand Rapids Fluoridation Study. JADA 65:780-785, 1962. 117/ Ast, D.B. and Fitzgerald, B. Effectiveness of Water Fluoridation. JADA 65:581-587, 1962. 118/ Committee on Research into Fluoridation. The Fluoridation Studies in the United Kingdom and the Results Achieved After Eleven Years. London: HMSO, 1969. 119/ Murray, J.J. Fluorides in Caries Prevention. Bristol: John Wright & Sons, 1969. 120/ Carlos, J.P., ed. Prevention and Oral Health. Conference sponsored by the Fogarty International Center and National Institutes of Dental Research, Bethesda, Maryland. DHEW Publication No. (NIH) 74-707, 1974. 121/ The Present and Future Prospects for the Prevention of the Principal Oral Diseases. Report prepared by the staff of the Dental Research Institute, Forsyth Dental Center, Boston. In Healthy People: The Surgeon General s Report on Health Promotion and Disease Prevention. Washington, D.C.: Government Printing Office, DHEW Publication No. 79-55071A, 1979.

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122/ Burt, B., ed. The Relative Efficiency of Methods of Caries Prevention in Dental Public Health. Proceedings of a workshop at the University of Michigan, Ann Arbor, Michigan, June 5-8, 1978. 123/ General Accounting Office. Reducing Tooth Decay--More Empahsis on Fluoridation Needed. Report to the Congress of the United States by the Comptroller General. Washington, D.C.: General Accounting Office, April 1979. 124/ See reference 123. 125/ Horowitz, H.S.; Heifetz, S.B.; Law, F.E.; and Driscoll, W.S. School Fluoridation Studies in Elk Lake, Pennsylvania, and Pike County, Kentucky--Results After Eight Years. Am J Pub Hlth 58:2240-2250, 1968. 126/ Horowitz, H.S. Fluoridating School Water Supplies. In Internatonal Symposium on Fluoridation and Preventive Dentistry, pp. 79-87, Washington, D.C.: Public Health Service, 1969. 127/ Yacovone, J.A. and Lisanti, V.F. Effect of Part-time Exposure to Natural Water-borne Fluorides on the Incidence of Dental Caries. Arch Oral Biol 1:265-275, 1960. 128/ Bushel, A. and Smith, D.J. Newburgh-Kingston Fluorine Study X--Dental Findings for 17 Year Old Group After Nine Years of Fluorine Experience. NYJ Dent 25:215-218, 1955. 129/ Horowitz, H.S.; Law, F.E.; and Prtizker, T. Effect of School Water Fluoridation on Dental Caries, St. Thomas, V.I. Pub Hlth Rep 80:381-388, 1965. 130/ See reference 115. 131/ Heifetz, S.B.; Horowitz, H.S.; and Driscoll, W.S. Effect on School Water Fluoridation on Dental Caries: Results in Seagrove, N.E. after Eight Years. JADA 97:193-196, August 1978. 132/ Burk, D. and Yiamouyiannis, J. Fluoridation and Cancer. Congressional Record 121:7172-7176, July 21, 1975. 133/ Yiamouyiannis, J. and Burk D. Cancer From Our Drinking Water? Congressional Record 121:12731-34, December 16, 1975. 134/ Doll, R. and Kunlen, L. Fluoridation of Water and Cancer Mortality in the U.S.A. Lancet 1:1300-02, June 18, 1977. 135/ Hoover, R.N.; McKay, F.W.; and Farumeni, J.F. Jr. Fluoridated Drinking Water and the Occurrence of Cancer. J Nat Canc Inst 57:757-68, 1976.

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136/ Erickson, J.D. Mortality in Selected Cities with Fluoridated and Non-Fluoridated Water Supplies. NEJM 298:1112-16, May 18, 1978. 137/ See reference 122. 138/ See reference 122. 139/ See reference 122. 140/ Heifetz, S.B.; Franchi, G.J.; Mosley, G.W.; MacDougall, O.; and Brunell, J. Combined Anticariogenic Effect of Fluoride Gel-tray and Fluoride Mouthrinsing in an Optimally Fluoridated Community. Clin Prev Dent 1:21-28, January-February 1979. 141/ See reference 122. 142/ See reference 120. 143/ See reference 121. 144/ See reference 132. 145/ See reference 122. 146/ Horowitz, H.S.; Heifetz, S.B.; Meyers, R.J.; Driscoll, W.S.; and Korts, D.C. Evaluation of a Combination of Self-administered Fluoride Procedures for the Control of Dental Caries in a Nonfluoride Area: Findings After Four Years. JADA 98:219-223, February 1979. 147/ See reference 122. 148/ See reference 122. 149/ See reference 120. 150/ See reference 121. 151/ See reference 120. 152/ Bojanini, J.; Garces, H.; McCune, R.J.; and Pineda, A. Effectiveness of Pit and Fissure Sealants in the Prevention of Caries. J Preven Dent 3:31-34, November-December 1976. 153/ Brooks, J.D.; Mertz-Fairhurst, E.J.; Della-Guistina, V.E.; Fairhurst, C.W.; and Williams, J.E. A Comparative Study of the Retention of Two Pit and Fissure Sealants: One-year Results. J Preven Dent 3:43-46, September-October 1976. 154/ Buonocore, M.G. Adhesive Sealing of Pits and Fissures for Caries Prevention, With Use of Ultraviolet Light. JADA 80:324-328, February 1970.

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155/ Gourley, J.M. A Two-year Study of a Fissure Sealant in Two Nova Scotia Communities. J Pub Health Dent 35:132-137, Spring 1975. 156/ McCune, R.J.; Horowitz, H.S.; Heifetz, S.B.; and Cvar, J. Pit and Fissure Sealants: One-year Results From a Study in Kalispell, Montana. JADA 87:1177-1180, November 1973. 157/ Ripa, L.W. and Cole, W.W. Occlusal Sealing and Caries Prevention: Results 12 Months After a Single Application of Adhesive Resin. J Dent Res 49:171-172, February 1970. 158/ Rock, W.P. Fissure Sealants: Results Obtained with Two Different Bis-GMA Type Sealants. Oral Health 63:9-12, December 1973. 159/ See reference 122. 160/ Heifetz, S.B.; Bagramian, R.A.; Suomi, J.D.; and Segreto, V.A. Programs for the Mass Control of Plaque: An Appraisal. J Pub Hlth Dent 33:91-95, 1973 161/ Lindhe, J. and Axelsson, P. The Effect of Controlled Oral Hygiene and Topical Fluoride Application on Caries and Gingivitis in Swedish School-children. Comm Dent and Oral Epi 1:9-16, 1973. 162/ Axelsson, P. and Lindhe, J. The Effect of a Preventive Program on Dental Plaque, Gingivitis, and Caries in Schoolchildren--Results after One and Two Years. J Clin Periodont 1:126-138, 1974. 163/ Lindhe, J.; Axelsson, P.; and Tollskog, G. Effect of Proper Oral Hygiene on Gingivitis and Dental Caries in Swedish Schoolchildren. Comm Dent and Oral Epi 6:17-23, 1978. 164/ Hamp, S.E.; Lindhe, J.; Fornell, J.; Johansson, L.A.; and Karlsson, R. Effect of a Field Program Based on Systematic Plaque Control on Caries and Gingivitis in Schoolchildren after Three Years. Comm Dent Oral Epi 6:17-23, 1978. 165/ See reference 122. 166/ Gustafsson, B.E.; Quensel, C.E.; and Lanke, L.S. The Vipeholm Dental Caries Study: The Effect of Different Levels of Carbohydrate Intake on Caries Activity in 436 Individuals Observed for 5 Years. Acta Odont Scand 11:232-364, 1954. 167/ Bibby, B.G. The Cariogenicity of Snack Foods and Confections. JADA 90:121-132, January 1975. 168/ See reference 122. 169/ See reference 122.

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170/ Pelton, W.J.; Dunbar, J.B.; McMillan, R.S.; Moller, P.; and Wolff, A.E. The Epidemiology of Oral Health. Cambridge, Massachusetts: Harvard University Press, 1969. 171/ See reference 105. 172/ Socransky, S.S. Relationship of Bacteria to the Etiology of Periodontal Disease. J Dent Res (Suppl. to No. 2) 49:203-222, 1970. 173/ Arno A.; Waerhaug, J.; Lovdal, A.; and Schel, O. Incidence of Gingivitis as Related to Sex, Occupation, Tobacco Consumption, Toothbrushing, and Age. Oral Surg, Oral Med, Oral Path 11:587-595, 1958. 174/ O'Leary, T.J.; Shannon, J.L.; and Prigmore, J.R. Clinical Correlations and Systemic Status in Periodontal Disease, J So Calif Dent Assn 30:47, 1962. 175/ Ash, M.M., Jr.; Gitlin, B.N.; and Smith, W.A. Correlation Between Plaque and Gingivitis, J Periodont 35:424-429, 1964. 176/ Schultz-Haudt, S. and Scherp, H.W. Lysis of Collagen by Human Gingival Bacteria. Proc Soc Exp Biol Med 89:697-700, 1955. 177/ Dewar, M.R. Bacterial Enzymes and Periodontal Disease. J Dent Res 37:100-106, 1958. 178/ Gibbons, R.J. and MacDonald, J.B. Degradation of Collagenous Substrates by Bacteroides Melaninogenicus. J Bacteriol 81:614-621, 1961. 179/ Fullmer, H.M. and Gibson, W. Collagenolytic Activity in Gingivae of Man, Nature 209:728-729, February 1966. 180/ Beutner, E.H.; Triftshauser, C.; and Hazen, S.P. Collagenase Activity of Gingival Tissue from Patients with Periodontal Diseases. Proc Soc Exp Biol Med 121:1082-1085, 1966. 181/ Bennick, A. and Hunt, A.M. Collagenolytic Activity in Oral Tissues, Arch Oral Biol 12:1-9, 1967. 182/ See reference 121. 183/ Socransky, S.S. Microbiology of Periodontal Disease--Present Status and Future Considerations. J Periodont 48:497-504, 1977. 184/ See reference 172. 185/ Gorlin, R.J.; Stallard, R.E.; and Shapiro, B.L. Genetics and Periodontal Disease. J Periodont 38:5-10, 1967.

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186/ Nizel, A.E. Nutrition in Preventive Dentistry: Science and Practice. Philadelphia: W.B. Saunders Co., 1972 187/ The Etiology of Periodontal Disease. In World Workshop in Periodontics. Ramfjord, S.P.; Kerr, D.A.; and Ash, M.M. eds. Ann Arbor, Michigan: University of Michigan, 1966. 188/ Rovin, S.; Costich, E.R.; and Gordon, H.A. The Influence of Bacteria and Irritation in the Initiation of Periodontal Disease in Germfree and Conventional Rats. J Periodont Res 1:193-203, 1966. 189/ Waerhaug, J. Effect of Rough Surfaces Upon Gingival Tissue. J Dent Res 35:323-325, 1956. 190/ Waerhaug, J. Effect of Zinc Phosphate Cement Fillings on Gingival Tissues, J Periodont 27:284-290, 1956. 191/ Waerhaug, J. Observations on Replanted Teeth Plated with Gold Foil. Oral Surg, Oral Med, Oral Path 9:780-791, 1956. 192/ Waerhaug, J. Tissue Reaction on Metal Wires in Healthy, Gingival Pockets. J Periodont 28:239, 1957. 193/ Waerhaug, J. Histologic Considerations Which Govern Where the Margins of Restorations Should Be in Relation to Gingiva. D Clin N Amer 161, March 1960. 194/ Russel, A.L. A System of Classification and Scoring for Prevalence Surveys of Periodontal Disease. J Dent Res 35:350-359, 1956. 195/ Greene, J.C. and Vermillion, J.R. The Oral Hygiene Index: A Method for Classifying Oral Hygiene Status. JADA 61:172-179, August 1960. 196/ See reference 1. 197/ See reference 194. 198/ Ramfjord, S.P.; Knowles, J.W.; Nissle, R.R.; Shick, R.A.; and Burgett, F.G. Longitudinal Study of Periodontal Therapy. J Periodont 44:66-77, February 1973. 199/ Hirschfeld, L. and Wasserman, B. A Long-term Survey of Tooth Loss in 600 Treated Periodontal Patients. J Periodont 49:225-237, May 1978. 200/ Keyes, P.H.; Wright, W.E.; and Howard, S.A. The Use of Phase-contrast Microscopy and Chemotherapy in the Diagnosis and Treatment of Periodontal Lesions--An Initial Report. Quintessence Int 9:69-76, February 1978.

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201/ Sheiham, A. A Review of Methods of Prevention and Control of Peridontal Disease. Paper delivered at International Conference, Workshop on Research in the Biology of Periodontal Disease, Chicago, 1977. 202/ Knutson, J.W. Recent Developments in the Prevention and Treatment of Periodontal Disease. J So Calif Dent Assn 32:140-146, April 1964. 203/ See reference 160. 204/ Lang, N.P.; Cumming, B.R.; and Loe, H. Effect of Toothbrushing Frequency on Gingival Health. J Dent Res 51 (Supplement to No. 5):1313-1314, 1972. 205/ Lindhe, J. and Koch, G. The Effect of Supervised Oral Hygiene on the Gingivae of Children. J Periodont Res 2:215-220, 1967. 206 Nyman, S.; Linde, J.; Rosling, B. Periodontal Surgery in Plaqueinfected Dentitions. J Clion Periodont 4:240-249, 1977. 207/ Rosling, B.; Nyman, S.; Lindhe, J. The Effect of Systematic Plaque Control on Bone Regeneration in Infrabony Pockets. J Clin Periodont 3:38-53, 1976. 208/ Fisher, M.A. Symposium Comments. Hlth Ed Mon 2:242-244, Fall 1974. 209/ Suomi, J.D.; Greene, J.C.; Vermillion, J.R.; Doyle, J.; Chang, J.J.; and Leatherwood, E.C. The Effect of Controlled Oral Hygiene Procedures on the Progression of Periodontal Disease in Adults: Results after Third and Final Year. J Periodont 42:152-160, March 1971. 210/ Suomi, J.D.; Leatherwood, E.C.; and Chang, J.J. A Follow-up Study of Former Participants in a Controlled Oral Hygiene Study. J Periodont 44:662-666, November 1973. 211/ Loesche, W.J. Chemotherapy of Dental Plaque Infections. Oral Sci Rev 9:65-107, 1976. 212/ Spolsky, V.W.; Bhatia, H.L.; Forsythe, A.; and Levin, D. The Effect of an Antimicrobial Mouthwash on Dental Plaque and Gingivitis in Young Adults. J Periodont 46:685-690, November 1975. 213/ Lobene, R.R. and Soparkar, P.M. The Effect of an Alexidine Mouthwash on Human Plaque and Gingivitis. JADA 87:848-851, October 1973. 214/ Muller, E.; Schroeder, H.E.; and Muhlemann, H.R. The Effect of Two Oral Antiseptics on Early Calculus Formation. Helv Odont Acta 6:42-45, October 1962.

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215/ Hofbeche, J.D.; Ruljancich, M.K.; and Reade, P.C. A Clinical Trial of the Efficacy of a Cetylpyridinium Chloride-based Mouthwash I: Effect on Plaque Accumulation and Gingival Condition. Aust Dent J 20:397-404, December 1975. 216/ See reference 1. 217/ Greene, J.C. The Case for Preventive Periodontics. J Dent Child, 42:24-27, January-February 1975. 218/ See reference 170. 219/ See reference 170. 220/ Moyers, R.E. and Jay, P. eds. Orthodontics in Mid-century. St. Louis, Missouri: C.V. Mosby, Co., 1959. 221/ National Center for Health Statistics. An Assessment of the Occlusion of the Teeth of Children 6-11 Years. Vital and Health Statistics, Series 11, No. 130, November 1973. 222/ Morris, A.L., Chairman, National Research Council Study of Seriously Handicapping Orthodontic Conditions. Washington, D.C.: National Academy of Sciences, 1976. 223/ See reference 103. 224/ See reference 221. 225/ See reference 221. 226/ See reference 103. 227/ Dunning, J.M. Principles of Dental Public Health (3rd ed.). Cambridge: Harvard University Press, 1979. 228/ Finn, S.B. Clinical Pedodontics (3rd ed.). Philadelphia: W.B. Saunders, 1967. 229/ See reference 227. 230/ American Dental Association. Bureau of Economic Research and Statistics The 1977 Survey of Dental Practice. Chicago: American Dental Association, 1978.

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231/ U.S. Department of Health, Education, and Welfare, Bureau of Health Manpower. Dental Manpower Fact Book .DHEW Publication No. (HRA) 80-21, March 1979. 232/ American Dental Association. Bureau of Economic and Behavioral Research Manpower Resource Book, 1979. Chicago: American Dental Association, 1979. 233/ See reference 232. 234/ U.S. Department of Health, Education, and Welfare, Public Health Service. A Report to the President and Congress on the Status of Health Professions Personnel in the United States. DHEW Publication No. (HRA) 78-93 , 1978. 235/ American Dental Association. Council on Dental Education Dental Education in the United States, 1976. Chicago: American Dental Association, 1976. 236/ See reference 232. 237/ See reference 234. 238/ U.S. Department of Health, Education, and Welfare Bureau of Health Manpower. Forecasts of Employment in the Dental Sector to 1995. DHEW Publication No. (HRA) 79-6, 1979. 239/ See reference 238. 240/ See reference 234. 241/ See reference 231. 242/ Lobene, R.R.; Berman, K.; Chaisson, L.B.; Karelas, H.A.; and Nolan, L.F. The Forsyth Experiment in Training of Advanced Skills Hygienists. J Dent Ed 38:369-379, 1974. 243/ Personal Communication with James Ake, Division of Manpower Analysis, Bureau of Health Manpower, Department of Health, Education, and Welfare, 18 January 1980. 244/ See reference 234. 245/ See reference 45. 246/ See reference 232. 247/ See reference 230 248/ See reference 45.

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249/ American Dental Association. Bureau of Economic Research and Statistics The 1975 Survey of Dental Practice. Chicago: American Dental Association, 1977. 250/ U.S. Department of Health, Education, and Welfare Bureau of Health Manpower . Facts on Dental Manpower Compiled by the Division of Dentistry, 1978. 251/ Schoen, M.H. Dental Care Delivery in the United States. In International Dental Care Delivery Systems, J.I. Ingle and P. Blair, eds. Cambridge: Ballinger Publishing Co., 1978. 252/ See reference 230. 253/ See reference 238. 254/ American Dental Association. Bureau of Economic Research and Statistics Facts About States for the Dentist Seeking a Location .Chicago: American Dental Association, 1973. 255/ American Dental Association. Bureau of Economic Research and Statistics Facts About States for the Dentist Seeking a Location .Chicago: 1976. 256/ American Dental Association. Bureau of Economic Research and Statistics Distribution of Dentists in the U.S. by State Region, District, and County. Chicago: American Dental Association, 1976. 257/ See reference 243. 258/ American Dental Association. Council on Dental Education. Annual Report on Dental Auxiliary Education, 1977-78. Chicago: American Dental Association, 1978. 259/ See reference 230. 260/ See reference 258. 261/ See reference 258. 262/ U.S. Department of Health, Education, and Welfare. National Center for Health Statistics. Health Resources and Utilization Statistics, 1976. DHEW Publication No. (PHS) 79-1245, 1978. 263/ See reference 230. 264/ See reference 230. 265/ See reference 258.

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266/ Kilpatrick, K.E.; MacKenzie, R.S.; and Delaney, A.G. Expanded Function Auxiliaries in General Dentistry: A Computer Simulation. Hlth Serv Res 7:288-300, Winter 1972. 267/ Lipscomb, J. and Scheffler, R.M. Impact of Expanded-duty Assistants on Cost and Productivity in Dental Care Delivery. Hlth Serv Res 10:14-35, Spring 1975. 268/ Douglass, C.W.; Gillings, D.B.; Moore, S.; and Lindahl, R.L. Expanded Duty Dental Assistants in Solo Private Practice. J Am Col Dent 43:144-163, July 1976. 269/ Douglass, C.W. and Lipscomb, J. Expanded Function Dental Auxiliaries: Potential for the Supply of Dental Services in a National Dental Program. J Dent Educ 43:556-567, September 1979. 270/ Council of State Governments National Task Force on State Dental Policies. J Dent Educ 43 (Part 2):91-94, October 1979. 271/ Lewis, M.H. Saskatchewan Dental Plan Report. Regina, Canada: Province of Saskatchewan Department of Health, August 1975. 272/ See reference 242. 273/ Ambrose, E.R.; Hord, A.B.; and Simpson, W.J. A Quality Evaluation of Specific Dental Services Provided by the Saskatchewan Dental Plan, Final Report. Regina, Canada: Province of Saskatchewan Department of Health, February 1976. 274/ Redig, D.; Dewhirst, F.; Nevitt, G.; and Snyder, M. Delivery of Dental Services in New Zealand and California. J So Cal Dent Assn 275/ See reference 241. 276/ See reference 242. 277/ Keenan, G.W. The Saskatchewan Dental Nurse: An Expanded Duty Auxillary. J Can Dent Assn 6:344-345, 1975. 278/ See reference 242. 279/ See reference 230. 280/ See reference 230. 281/ See reference 230. 282/ See reference 230.

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283/ Nash, K.D.; Douglass, C.W.; Lipscomb, J.; Scheffler, R.; and Wilson, J. Economics of Scale and Productivity in Dental Practices. Volume 1. Final Report. Research Triangle Institute. DHEW Contract N. 231-75-043, 1978. 284/ Milton, B.B. and Barkholder, N.A. Survey of Hospital Dental Department. The New Dentist 9:22-23, 1979. 285/ See Reference 83. 286/ Dental Program Budget Justification Package: FY 1980 Budget. Dental Services Branch, Indian Health Services, Health Services Administration, DHHS. 287/ See reference 251. 288/ See reference 251. 289/ Marcus, M. and Drabek, L. V.A. Dental Manpower Requirements. Los Angeles, Calif: UCLA School of Dentistry, 1976. 290/ Davis, K. and Schoen, C. Health and the War on Poverty: A Ten-Year Appraisal. Washington, D.C.: The Brookings Institution, 1978. 291/ U.S. Department of Health, Education, and Welfae, Health Resources Administration. Neighborhood Health Centers Summary of Project Data. Report 15, Second Quarter, 1976. 292/ Geiser, E.G. and Menz, F.C. The Effectiveness of Public Dental Care Programs. Med Care 14:189-198, March 1976. 293/ See reference 290. 294/ Comprehensive HPRS Report: Services, Expenditures, and Programs of State and Territorial Health Agencies, FY 1978. Washington, D.C.: The Association of State and Territorial Health Officers, Health Program Reporting System, March 1980. 295/ Annual Report, Maricopa County Department of Health Services. Statistics Prepared by the Maternal and Child Health Department, Maricopa County, Arizona, 1978. 296/ Law, F.E.; Johnson, C.E.; and Knutson, J.W. Studies on Dental Care Services for Children. Pub Hlth Rep 70:402-409, April 1955. 297/ Waterman, G.E. and Knutson, J.W. Studies on Dental Care Services for Schoolchildren. Pub Hlth Rep 69:274-254, March 1974.

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298/ Galagen, D.J.; Law, F.E.; Waterman, G.E.; and Spitz, G.S. Dental Health Status of Children 5 Years after Completing School Care Programs. Pub Hlth Rep 79:445-454, May 1964. 299/ Doherty, N. and Paturzo, D. Costs of Dental Care in Mobile Clinics. J Pub Hlth Dent 37:266-274, Fall 1977. 300/ Ingle, J.I. and Blair, P. eds. International Dental Care Delivery Systems. Cambridge, Massachusetts: Ballinger Press, 1978. 301/ Dunning, J.M. and Dunning, N. An International Look at School-based Children's Dental Services. AJPH 68:664-668, 1978. 302/ See reference 273. 303/ Boulier, B.L. Two Essays in the Economics of Dentistry: A Production Function for Dental Services and an Examination of the Effects of Licensure. Unpublished Ph.D. dissertation, Princeton University, 1974. 304/ Maurizi, A. Economic Essays on the Dental Profession. Iowa City Iowa: College of Business Administration, University of Iowa, 1969. 305/ Scheffler, R.M. Productivity and Economies of Scale in Dentistry: Some Empirical Evidence. Northwestern University Dental Conference Summary, 1979. 306/ See reference 305. 307/ See reference 283. 308/ See reference 305. 309/ Kushman, J.; Scheffler, R.M.; Minars, L.; and Mueller, C. Non-Solo Dental Practice: Incentives and Returns to Size. J Econ Bus 31:1, 1979. 310/ Johnson, D.N. The Possibilities of Professional Service Through Cooperation Between the Dentist and His Assistant. JADA 12:44-48, January 1925. 311/ Klein, H. Civilian Dentistry in Wartime. JADA 31:648-661, May 1974. 311a/ Waterman, G.E. The Richmond-Woonsocket Studies on Dental Care Services for Children. JADA 52:676-684, June 1956. 312/ Feldstein, P.J. Financing Dental Care: An Economic Analysis. Lexington, Mass.: D.C. Heath, 1973.

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313/ U.S. Department of Health, Education, and Welfare. Bureau of Health Manpower. Dental Manpower Factbook. Table C-4 , Patient Visits by Number of Auxiliaries and Dentists Age, 1979. 314/ U.S. Department of Health, Education, and Welfare, Bureau of Health Manpower. Facts on Dental Manpower. Chart II-7.1 , Dentists Hours by Number of Auxiliaries and Type of Work. (Prepublication Sheets, 1978) . 315/ See reference 249. 316/ See reference 266. 317/ Marcus, M. Task Analysis in Dentistry: Computer Application, Final Report. School of Dentistry, University of California at Los Angeles, 1975. 318/ Marcus, M.; Van Baelen, A.; and Forsythe, A. Dental Productivity: A Perspective. Inquiry 12:204-215, September 1975. 319/ See reference 267. 320/ Redig, D.; Snyder, M.; Nevitt, G.; and Tocchini, J. Expanded Duty Dental Auxiliaries in Four Private Dental Offices: The First Year's Experience. JADA 88:969-984, May 1974. 321/ See reference 268. 322/ See reference 303. 323/ See reference 304. 324/ Lipscomb, J. Legal Restrictions on Input Substitution in Dentistry: An Activity Analysis Approach. Working paper. Duke University Institute of Policy Sciences, October 1977. 325/ See reference 305. 326/ See reference 283. 327/ See reference 283. 328/ See reference 303. 329/ Kushman, J.; Scheffler, R.M.; Miners, L.; and Mueller, C. Non-Solo Dental Practice: Incentives and Returns to Scale. Manuscript from Department of Agriculture Economics, University of California at Davis, 1977. 330/ See reference 324.

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331/ Scheffler, R.M. and Kushman, J.E. A Production Function for Dental Services: Estimation and Economic Implications. So Econ J 44:25-35, July 1977. 332/ See reference 329. 333/ Upton, C. and Silverman, W. The Demand for Dental Services. J Hum Resour 7:250-261, 1972. 334/ See reference 303. 335/ See reference 329. 336/ See reference 314. 337. Gibson, R.M. National Health Expenditures, 1978. Hlth Care Finan Rev 1:1-36, Summer 1979. 338/ See reference 337. 339/ See reference 283. 340/ Summary of 1974 Sales of Drugstore Products, Oral Hygiene Products. Drug Topics. Marketing Guide 1975. 341/ See reference 283. 342/ See reference 26. 343/ Moen, B.B. and Poetsch, W.E. More Preventive Care, Less Tooth Repair. JADA 81 : July 1970. 344/ National Center for Health Statistics. Data from the National Health Survey. Vital and Health Statistics, Series B, No. 15, 1957-58. 345/ See reference 283. 346/ Gibson, R.M. and Fisher, C.R. National Health Expenditures Fiscal Year 1977. Soc Sec Bull 4:3-20, July 1978. 347/ See reference 346. 348/ Gibons, R.M. and Fisher, C.R. Age Difference in Health Care Spending Fiscal Year 1977. Soc Sec Bull 42:3-16, January 1979. 349/ See reference 348. 350/ See reference 337.

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351/ Carroll, M. Private Health Insurance Plans in 1976: An Evaluation. Soc Sec Bull 41:3-16, 1978. 352/ Carroll, M. and Arnett, R. III. Private Health Insurance Plans in 1979: Coverage, Enrollment, and Financial Experience. Hlth Care Finan Rev 1:3-22, Fall 1979. 353/ Leadership Bulletin, February 12, 1979. Chicago: American Dental Association. 354/ Report to State of California, Department of Finance. A Study of Dental Care Benefits for State Employees. Sacramento, Calif.: Wyatt Co., December 30, 1976. 355/ See reference 227. 356/ See reference 227. 357/ Delta Dental Plan Association. Dental Prepayment and Insurance: Stakes Get Higher. JADA 89:525, September 1974. 358/ See reference 348. 359/ See reference 337. 360/ See reference 238. 361/ See reference 337. 362/ See reference 346. 363/ See reference 352. 364/ See reference 337. 365/ Medicaid Services, State by State. Department of HEW, Social and Rehabilitation Service, Medical Services Administration, Division of Program Monitoring. Memorandum, February 24, 1977. 366/ Fischer, C.R. Differences by Age Groups in Health Care Spending. In Health Care Financing Review 1:65-90, Spring 1980. 367/ See reference 366. 368/ Survey of Dental Benefit Plans, 1973. Department of HEW, Public Health Service, Health Resources Administration, Bureau of Health Manpower, DHEW Publication No. HRA (79)29, 1979. 369/ Milgrom, P. Regulation and the Quality of Dental Care. Germantown, Maryland: Aspen Systems Corporation, 1978.

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370/ Bernhart, M. California Dental Service--Pacesetter for Prepayment. JADA 89:838-841, October 1974. 371/ Rosen, H.M.; Sussman, R.A.; and Sussman, A.B. Capitation in Dentistry: A Quasi-experimental Evaluation. Med Care 15:3, March 1977. 372/ Dunning, J.M. Dental Care for Everyone. Cambridge, Mass: Harvard University Press, 1976. 373/ Carby, C. Capitation--Is It a Threat? 374/ Praiss, I.L.; Tannenbaum, K.A.; Gelder-Kogan, E.; and Hale, C. Changing Patterns and Implications for Cost and Quality of Dental Care. Inquiry 16:131-401, Summer 1979. 375/ See reference 369. 376/ See reference 374. 377/ See reference 374. 378/ See reference 1. 379/ See reference 299. 380/ American Dental Association, Bureau of Economic Research and Statistics. Dental Fees Charged by General Practitioners and Selected Specialists in the United States, 1975. JADA 94:Febuary 1977. 381/ Delta Dental Plans Association. Statement on National Health Insurance. Proposed for Delta National Children's Dental Care Program. Chicago, Illinois. 382/ See reference 381. 383/ Carroll, M.S. Private Health Insurance Plans in 1976: An Evaluation. Soc Sec Bull 41:3-16, September 1978. 384/ Gray, P.G.; Tood, J.E.; Slack, G.L.; and Bulman, J.S. Adult Dental Health in England and Wales in 1968. London: HMSO, 1970. 385/ Nikias, M.K.; Fink, R.; and Shapiro, S. Comparisons of Poverty and Non-poverty on Dental Status, Needs, and Practices. J Publ Hlth Dent 35:237-259, Fall 1975. 386/ See reference 283.

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REFERENCES 132

387/ See reference 283. 388/ Driscoll, W. S., Heifetz, S. B., and Karts, D. C. Effect of Chewable Flouride Tablets on Dental Caries in Schoolchildren: Results after Six Years of Use. JADA 97:820-824, November 1978.

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APPENDIX 1

133

APPENDIX 1 STATISTICAL NOTES HEALTH AND NUTRITION EXAMINATION SURVEY The Health and Nutrition Examination Survey (HANES) is a continuing nationwide sample survey conducted by the National Center for Health Statistics in which data are collected through standardized physical examinations, tests, and measurements. Information from the examination is supplemented with personal and demographic characteristics and medical history on illnesses, injuries, impairments, chronic conditions, utilization of health resources, the need for medical and dental care, and other health topics. From the examination and history data, information is obtained on the total prevalence of selected health conditons, known and previously unknown or undiagnosed. The content of the HANES program is revised periodically and selected components added and deleted to meet current needs for health data of this type. For this survey two to four years are required to obtain a large enough sample of examinees for reliable national estimates. The universe for HANES is the civilian noninstitutionalized population of the United States. Members of the Armed Forces, U.S. nationals living in foreign countries, and people living in institutions during the reference period are excluded. The 1971-1974 HANES program is based on a multistage stratified probability sample of loose clusters of persons in land-based segments in which 65 primary sampling units were selected from the approximately 1,900 geographically defined units into which the United States was divided. Approximately 28,000 persons ages 1-74 years were selected in the sample of whom nearly 21,000 came into the examining location for examination. The initial response rate for the medical history, personal and demographic data was about 95 percent; the final response rate for this examination, about 76 percent. National estimates are based on a four-stage estimation procedure involving inflation by the reciprocal of the probability of selection of the individual examinee, a non-response adjustment, ratio adjustment and postratification. Since the HANES estimates shown in this report are based on a sample of the population, they are subject to sampling error. The standard error of selected percentages of persons needing dental treatment is given in Table I. For more detailed information on the HANES design, limitations of the data and sampling errors of the national estimates, see: National Center for Health Statistics, Basic Data on Dental Examination Findings of Persons 1-74 Years, United States, 1971-1974, by James E. Kelly,

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APPENDIX 1

134

D.D.S., and Clair R. Harvey, Vital and Health Statistics, Series 11-No. 214, DHEW Pub. No. (PHS) 79-1662. Public Health Service, Washington, D.C., U.S. Government Printing Office, Nov. 1978. HEALTH INTERVIEW SURVEY The Health Interview Survey (HIS) is a continuing nationwide sample survey conducted by the National Center for Health Statistics in which data are collected through personal household interviews. Information is obtained on personal and demographic characteristics, illnesses, injuries, impairments, chronic conditions, utilization of health resources, and other health topics. The household questionnaire is reviewed each year and supplemental topics are added and deleted. For most topics, data are collected over an entire calendar year. The universe for HIS is the civilian, noninstitutionalized population of the United States. Members of the Armed Forces, U.S. nationals living in foreign countries, and people who died during the reference period are excluded. The survey is based on a multistage probability cluster sample of 376 primary sampling units selected from approximately 1,900 geographically defined units in the first stage and 12,000 segments containing about 42,000 eligible households. National estimates are based on a four-stage estimation procedure involving inflation by the reciprocal of the probability of selection, a non-response adjustment, ratio adjustment, and poststratification. Since the HIS estimates shown in this report are based on a sample of the population, they are subject to sampling error. Table II shows the standard errors of aggregates of persons and dental visits, and table III shows standard errors of percentages of persons. For more detailed information on the HIS design, limitations of data, and sampling errors of the estimates, see: National Center for Health Statistics, Current Estimates from the Health Interview Survey, United States, 1977, by L.J. Howie and T.F. Drury, Vital and Health Statistics, Series 10-No. 126, DHEW Pub. No. (PHS) 78-1554, Public Health Service, Washington, D.C., U.S. Government Printing Office, Sep. 1978.

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APPENDIX 1

135

Table I. STANDARD ERROR FOR PERCENTAGE OF PERSONS AGED 1-74 YEARS WITH NEED FOR DENTAL TREATMENT, BY AGE AND TYPE OF SERVICE Specific dental treatment needed

Total

1-5 yrs

Both Sexes

6-11 yrs

12-17 yrs

18-64 yrs

65-74 yrs

Standard error

General (at least one of the following)...

1.31

1.05

2.15

1.71

1.79

2.02

Removal of debris and calculus............

2.56

0.61

2.82

3.55

3.21

3.06

Gingivitis treatment..

1.30

0.01

0.33

1.18

1.90

2.64

Periodontal disease treatment...........

0.42

0.02

0.09

0.43

0.95

0.92

Severe malocculusion treatment...........

0.18

0.07

0.89

0.75

0.09

-

Fixed bridges and/or partials............

0.93

-

0.11

0.81

1.63

0.97

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APPENDIX 1

136

Table II. STANDARD ERRORS OF ESTIMATES OF AGGREGATES Standard error in thousands Size of estimate in thousands

Population

Number of dental visits

70...............................

15

...

100..............................

18

...

500..............................

40

...

1,000............................

57

303

5,000............................

125

677

10,000...........................

174

958

20,000...........................

237

1,355

50,000...........................

325

2,147

100,000..........................

550

3,047

200,000.............................

...

4,338

250,000.............................

...

4,865

300,000.............................

...

5,346

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APPENDIX 1 137

Table III. STANDARD ERRORS, EXPRESSED IN PERCENTAGE POINTS, OF ESTIMATED PERCENTAGES FOR POPULATION ESTIMATES Estimated percentages

Base of Percentages Shown in Thousands 2 or 98 5 or 95 10 or 90 25 or 75 50

500.................. 1.1 1.8 2.4 3.5 4.0

1,000................ 0.8 1.2 1.7 2.5 2.9

2,000................ 0.6 0.9 1.2 1.8 2.0

5,000................ 0.4 0.6 0.8 1.1 1.3

10,000............... 0.3 0.4 0.5 0.8 0.9

20,000............... 0.2 0.3 0.4 0.6 0.6

30,000............... 0.1 0.2 0.3 0.5 0.5

50,000............... 0.1 0.2 0.2 0.4 0.4

100,000.............. 0.0 0.1 0.2 0.2 0.3

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APPENDIX 1 138

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APPENDIX 2 INDIVIDUAL COMMITTEE MEMBERS' COMMENTS ON THE REPORT

ALVIN L. MORRIS, D.D.S., PH.D. While I approve the report and its conclusion, there are two areas with which I am sufficiently concerned that comments appear in order. In the committee's zeal for providing basic preventive and educational services in or through the nation's school systems, it has produced a report that will be interpreted by many as recommending an exclusion of the private sector, or more specifically the dental practitioners of the nation, from participation in the delivery of Priority One services: prevention for children and adolescents. The report recommends, “however, no payment would be provided by public insurance programs for such services outside the school based program.” In my opinion, that recommendation is basically flawed for the following reasons. 1. Regardless of how dental services are provided and financed, ultimately the nation will be dependent upon the dental profession to make a national dental health care program a reality. To exclude preventive services for children and adolescents from the practice of dentistry under a national plan would have unfortunate consequences. It would use the power of funding mechanisms to reorient dental practice away from the current emphasis on prevention in which the profession takes justifiable pride. In the presence of a school based preventive program, patients should be provided the choice of receiving preventive services from dentists in the community. Under the national plan, reimbursement for such services should be at the per capita cost level of providing school based services. 2. The recommendation ignores the reality that not all school systems will introduce preventive dentistry programs regardless of how a national health plan is written. Some school boards and administrators will opt not to put forth the effort to implement such programs. Some will have other priorities for their efforts. In some communities the anti-fluoridationists will influence what occurs. In such communities, dental practitioners will be the only source of preventive services for children.

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3. The recommendation appears in conflict with one appearing later in the committee report that states “alternative prepaid delivery systems and capitation reimbursement systems be made an integral part of a dental health program under national health insurance.” I believe that the delivery of preventive services by practicing dentists should be an available alternative to school based programs. I do agree that the school based approach is the preferred alternative. My second area of concern is the absence of emergency services under Priority One. While acknowledging potential difficulties in administering such a benefit, I do not accept them as insurmountable. The case for including emergency services can be made adequately, in my opinion, on the basis of the alleviation of suffering. However, another compelling argument can be mounted. If the reduction of tooth loss is a primary goal of preventive dentistry, treating dental pain, including mild pain, is a preventive service of highest order. Consistent with the committee's emphasis on prevention and for humanitarian reasons, emergency services should be included in Priority One. Comment has concurrence of: I. Lawrence Kerr, D.D.S. President, American Dental Association Private Practitioner Harold Hillenbrand, D.D.S Executive Director Emeritus American Dental Association

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COMMENT UWE E. REINHARDT, PH.D. Thanks mainly to the untiring efforts of the committee's staff, led by Chester Douglass, and to the patient and able chairing of the committee by Dorothy Rice, this report now stands as a solid contribution to policy analysis in the area of dental care. I concur in the findings of the report and endorse its recommendations as far as they go. There are two issues, however, that might have been examined more thoroughly in the report: (1) the issue of health-manpower substitution in dentistry and (2) the structure of the market for dental care. Both issues bear directly on the quality and cost of dental care and thus on the problem of access to dental care. Both issues also touch upon such delicate matters as the quality of dental care, professional prerogatives, and professional incomes, and it is unlikely that a committee as diverse as ours would have reached a consensus on those issues. I would be remiss in my social responsibility as an economist, however, were I to endorse the report without further comments on them. Indeed, to do so might be viewed by my peers as “economic malpractice.” For the busy reader, the arguments to be woven further on in this comment can be distilled into ten succinct propositions and three recommendations. These may strike the reader as provocative. For that reason I have gone to unusual length to amplify them in additional Sections II to V.* Proposition 1 Our current statutes governing the assignment of tasks among the various members of the dental-care team are probably too conservative. Experience in other countries suggest that in the United States the delegation of tasks from relatively expensive dentist manpower to less expensive non-dentist manpower could be pushed beyond currently permissible limits without impairing the quality of dental care.

*Available from Office of Communications at the Institute address on p. ii. Request “Reinhardt Comment” and send $1.25 to cover duplication and postage.

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Proposition 2 In assessing the merits of any new type of health manpower, such as extended-function dental nurses or physician extenders, it is not enough to inquire whether this manpower is needed to meet a shortage of dentists or physicians. From society's viewpoint, the deployment of expanded-function dental nurses, for example, might be desirable even if there were an ample supply of dentists. After assuring themselves on the issue of quality, the consumers' essential next question is what impact the new type of manpower will have on the prices of health services. Another way of looking at the matter is to inquire what set of economic lifestyles consumers are willing to support by their use of health services: predominantly the elevated economic lifestyles of physicians and dentists, or relatively more of the less elevated lifestyles of lower-skilled health workers. Proposition 3 In an era of relatively flush health-care budgets, such as the 1970s, the question raised in Proposition 2 might be academic. In the highly constrained budget environment of the 1980s, the question becomes increasingly important and will therefore be raised more often in debates on health policy. Proposition 4 The quality of the care dispensed by a dental-care system has two distinct dimensions: 1. the technical quality of the services actually delivered by the system (the microquality); and 2. the percentage of the population adequately served by the system (the macroquality). By international standards, the American dental-care system probably deserves a high grade on its microquality and a low grade on its macroquality (as is susggested by the “substantial unmet need for dental care” identified by the committee). Proposition 5 Even if it were demonstrable that more extensive task delegation within dental care might, in some instances, lower the microquality of dental care--a result not to be taken for granted--society might, nevertheless countenance or even actively seek a trade-off of microfor macroquality to serve a greater number of persons without having to allocate greater financial resources.

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Proposition 6 Trade-offs such as that alluded to in Proposition 5 have important consequences for individual consumers. As a general principle decisions on them should not, therefore, be left mainly in the hands of health professionals (or of economists, for that matter). Where feasible, consumers should be offered ample opportunity to tradeoff dollars for quality in dental care. This freedom of choice should be offered consumers at least so long as our society refuses to make dental care of homogeneous quality accessible to all citizens, regardless of ability to pay, perhaps through a comprehensive universal dental care program of the type adopted by some nations in Europe. Proposition 7 Current statutory restrictions on task delegation in dental care serve to enforce an economic structure that hampers the ability of market forces to constrain dental care prices and expenditures. Proposition 8 Not only do the current statutes on task delegation in health care unduly limit the consumer's options-leaving some consumers priced out of adequate health care altogehter--but also these statutes favor physicians an dentists in the distribution of the economic opportunities offered by the health-care sector. In particular, these statues reserve the right to professional entrepreneurship mainly to physicians and dentists, forcing the other members of the health-care team into administrative and economic dependence on the licensed professional entrepreneurs. Probably unintentionally, but quite effectively nevertheless, the arrangement has limited the enterpreneurial possibilities for women and members of minorities, who have traditionally been underrepresented in the ranks of the professional entrepreneurs and overrepresented among those relegated by the statues to the subordinate ranks of salaried health workers. Thus one may question our current licensure laws in health care not only on grounds of economic efficiency, but also on grounds of fairness. Proposition 9 Although there are compelling technical reasons for governmental restrictions on the practice of medicine and dentistry, economists increasingly have come to believe that our current licensure laws are being urged on society as much to protect the economic position of particular health care providers as to assure consumers of effective

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qualtiy control 1/. Economists have come to take this view partly because of the health professions' rather selective and seemingly self-contradictory objections to alternative means of quality assurance, such as strict, periodic relicensure rather than one-time licensure for life. The nine propositions suggest the following recommendations: Recommendation 1 Because the United States is unlikely soon to make adequate dental care available to all Americans through a national dental insurance or dental care plan, policymakers should critically review the existing statutes on licensure in dentistry and explore ways to make added dental services available at lower prices through bolder delegation of tasks from dentists ot non-dentists, especially to expanded-function dental auxiliaries and nurses. Recommendation 2 Because the cost savings from more extensive task delegation in dental care are more likely to flow through to consumers in a highly competitive market structure, every effort should be made to maintain and to heighten competitive pressures in the dental care market. This strategy might include experimentation with an expanding of the right to independent entrepreneurship--from dentists alone to dental hygienists, to expanded-function dental auxiliaries and nurses, and to denturists. Recommendation 3 To preserve competition in the market for dental care, any public dental care program--such as the schoolbased program recommended by the committee--should be subject to vigorous and fair competition from the private sector. This principle, for example, suggests a voucher system for the proposed school-based program. Under this system, parents who prefer to have their children treated in a private practice would be entitled, for every child, to an annual, non-transferable voucher equal to the average annual pre-capita costs experienced by the relevant school-based program. Without such a voucher system, the public program would have an unfair advantage over the private sector.

1/ For a succinct statement and analysis of this thesis, see Paul J. Feldstein, Health Care Economics (1979), Chapter 9 on “The Political Economy of Health Care.”

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Opponents of proposals to increase competition in health care sometimes argue that lack of consumer sovereignty alone makes a mockery of such proposals. How, they ask, can price competition possibly play a meaningful role in markets in which consumers receive services whose quality they cannot possibly assess and for which they may not even pay at point of service? This is, indeed, a troublesome question to which enconomists do not have consensus on an answer. I do not believe, however, that the lack of consumer sovereignty is equally severe along the entire spectrum of health services from routine well-patient care to intensive acute care. Indeed, with all due respect for the dental profession, I would accompany my present missive on competition with Proposition 10 The degree of consumer sovereignty and the degree of cost-sharing by patients in the markets under discussion in this comment are likely to be such as to make the case for competition compelling.

I am not concerned in this comment with the delegation and competitive marketing of root canals or of similarly complex procedures. The focus is on much simpler routine procedures, such as prophylaxes and amalgam restorations of the sort now performed by dental nurses in New Zealand and Saskatchewan. Consumers purchase these services repeatedly and have ample occasion to exchange with acquaintances information about the perceived quality and the prices of such services rendered by particular providers in their community. After a decade of intense empirical research on health care markets, economists have come to the conclusion that for such routine primary care services competitive markets tend to work pretty much as would be predicted by classical economic theory. In the separately available amplification of these remarks, I begin with some exposition of the basic economics of health manpower substitution (Section II). Thereafter, in Section III, I comment on the technical feasibility of task delegation in dental care, illustrating my comments with some remarkable data on the performance of expanded-function dental nurses in the Canadian Province of Saskatchewan. In Section IV, the focus shifts to the market structure in dental care, in particular to the constraints imposed upon this structure by our licensure laws. Section V recommends proposed changes in the organization of dental care in the United States. The comment concludes with Section VI.

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COMMENT MAX H. SCHOEN, D.D.S., DR. P.H. I concur in the findings and recommendations contained in the Final Report of the Committee on the Study of Alternative Dental Care Provisions in a National Health Care Policy. However, although concurring, I feel that the recommendations are not strong enough. In essence, the data show that the two major dental diseases, caries and periodontal disease, are chronic diseases which affect the vast majority of the population. With minor exceptions the effects are irreversible. Caries incidence peaks during adolescence and periodontal disease increases steadily as one ages. Both can either be prevented or controlled through the use of existing measures. Most caries can be prevented through the combined use of systemic fluoride, topical fluoride, sealants and dietary control. As stated in the report, these measures are best carried out through water fluoridation and mass therapy delivered at schools to virtually all children. However, the data also show that there is a considerable amount of untreated disease in the child population. Studies also have demonstrated that dental health education, unless tied to continuing therapy, is of limited value at best. Therefore, I believe the recommended program would be strengthened considerably if it included school-based treatment for disease as well as prevention. Such public treatment programs should be instituted first in areas of greatest need, as evidenced by large percentages of untreated caries. Once the disease became less of a mass problem, the desirability of school-based treatment programs could be reconsidered, although a public treatment component should be retained to guarantee access to the underserved. While the figures for Denti-Cal (California's dental Medicaid program which uses private practice) are encouraging, they are far from optimal and still leave a large reservoir of unmet need. At present, there is no measure similar to water fluoridation which can be applied to the prevention and control of periodontal disease. However, studies have shown that the disease can be prevented or controlled by frequent prophylaxis which includes deep scaling, root planing and gingival curretage. I believe the only way this will be applied to the vast majority of our populataion is through organized programs, with a major public component.

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Hygienists, functioning independently, can be located where people are: at their places of work, at the schools (where many already will be for the children's program) and at community health centers. Here too, the constant reinforcement of therapy appears to have a major beneficial impact upon personal oral hygiene or home care. This aspect of the program would be reinforced further by concurrent inclusion of that part of the recommendations urging treatment of existing disease and rehabilitation. In order to be more effective, all of these components must be part of an organized public program. While I support a National Health Service as being the best way to deal with dental disease, I recognize it is unrealistic to propose its implementation and the phase-out of private practice at this time. But it is not truly unrealistic to have a comprehensive national dental program now, even if composed of a variety of components. The nature of the two major dental diseases cries out for such a coordinated approach. The study shows that total manpower is not a major problem, although there are difficulties with its distribution and the appropriate use of ancillary personnel. Total cost estimates, regardless of method of calculation, are not exorbitant and even then do not consider any saving from the prevention or control of disease. The problem is that an organized program with large public components is not politically expedient and I write this concurrence to point this out. A plan which would result in much less dental disease and the sequellae of disease in very few years could be phased in over a brief period of time if it were politically expedient. The committee's report, after describing how disease and consequent tooth loss can be minimized, does not follow through fully enough on the approporiate measures. Comment has concurrence of: Melvin A. Glasser, LL.D. United Auto Workers, International Union

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COMMENT LOIS K. COHEN, PH.D. While the report as it stands contributes to a general understanding of some of the available policy options, I personally feel that several significant aspects of past “evaluated” experience have been omitted from the analytic portions of the project. Consequently, options which might reflect these considerations have not been presented. The research literature which assesses the outcome of oral health status among populations covered by various types of nationally developed dental care delivery systems has not been comprehensively considered in this report. Policy issues raised in the volume, International Dental Care Delivery Systems (eds. J.I. Ingle and P. Blair, Cambridge, Mass: Ballinger Publishing Co., 1978), the product of an IOM forum to consider dental service policy alternatives, address several points of relevance to the current report. One of these relates to the family and the organization of dental care systems. Systems which cover family units can be contrasted to systems which deliver care separately to children and their parents or other adults. Another issue suggests that there may be a culture of dentistry which could be more influential in its total effect than would any single component of that cultural fabric. No single variable, such as a school-based program in and of itself, can be the entire answer to the problem of unmet need in a given society. Rather it would appear that a constellation of factors which maximizes availability of care, access, appropriateness of the service package, and acceptability to consumers as well as providers ought to be considered. For want of a better term, this holistic approach in contrast to a segmented one could be subsumed under the rubric of a culture of dentistry. An additional point is that nowhere in the literature discussed in the volume on international care or elsewhere in the domestic literature, is there any evidence that dental emergencies when covered by a third-party program, are abused by “over-utilization.” Family There is considerable literature on the importance of the family as a determinant of dental service utilization. In a recent review, A Decade of Dental Service Utilization: 1964-1974, (U.S. Dept. of Health and Human Services, HRA 80-56, 1980), family resource variables appear to act as enabling factors making utilization of services possible. The role of individual family members such as the mother, furthermore, has been shown to be significantly related to perceived need for care and actual visits to the dentists, in addition to the employment of optional personal oral hygiene practices--such as toothbrushing (e.g. Rayner, J.F. “Socioeconomic Status and Factors

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Influencing the Dental Health Practices of Mothers,” American Journal of Public Health, 60, July 1970; Metz, A.S. and Richards, L.G. “Children's Preventive Dental Visits: Influencing Factors,” Journal of the American College of Dentists, October 1967; Lambert, C., College and University Press, 1967). Freeman, H.E., et.al. The Clinic Habit, New Haven, Connecticut This literature seems to parallel findings from the study of the utilization of other ytpes of health services, reinforcing the strong relationship between the child's behavior and that of the mother or relevant “social others.” While this literature was discussed in committee deliberation, its failure to be included in the Final Report is reflected in the committee's ultimate recommendations. A school-based preventive program for children which omits significant links to the family ignores one of the most prominent sets of findings emerging from the health services and social science literature of the past fifteen or more years. There are several ways to enhance a school-based program so that it might efficiently link itself to the family. One way is to assure that services for children could be provided in the same setting and/or by the same provider as is the case for other family members. The fact that 110,000 or more dentists in this country predominantly provide care in the private sector suggests that links to the private sector would seem sociologically more sound than would severing private practitioners from the reimbursement scheme as proposed under “Priority One.” The committee did consider reimbursing the private practitioner at the rate which would be applicable for the same service delivered in the school setting. That proposal, ultimately rejected in the final report, still stands as one viable option for establishing a link with the family's usual custom of receiving care. Another option is to include some services for adults in the same setting and by the same type of practitioner as is provided for children. Emergency service is one category of services which could be utilized creatively to form a transitional link between children and parents and other adult role-models. Culture of Dentistry The mystery of why tooth loss patterns do not always bear a close relationship to oral disease rates suggests that much more is happening in the interaction between consumers and providers of dental services than merely the expected delivery of “appropriate” services. Consumers can and do demand extractions in some cultures. Providers extract more teeth than perhaps are warranted in some situations. The flavor of expected behaviors noted by voluminous social survey data obtained from public samples as well as professional samples suggests that the U.S. ought not ignore the multi-factorial nature of oral health utilization, let alone oral health status. Planning service delivery, no doubt, is an imperfect

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process. However, if we are aware that certain cultural factors appear to be important determinants of health service utilization and health status, then it would appear incumbent on us to try to integrate into our plans what appear to be logical and necessary elements to enhance optimum outcome. In this case, aside from linking the school population to family patterns of care, the American cultural expectation with regard to the delivery of quality oral health services is that private sector dentistry is capable and, in fact, does fill that need on most occasions. To ignore the predominant mode of delivery in the first level of plan, in my view, is to ignore the prevailing supportive structures in the current cultural context. How much further we could advance toward the goal of better health for all, if we could use to advantage the incentives and strengths of the current system. Should changes in the system be necessary, evolutionary progress toward that end would seem to make more sense than any potentially disruptive approach, such as one which removes the private sector and places an entirely new school-based system in operation. Politically radical, the approach of “Priority One” does not seem to make for a sensible social strategy. An additional sociological point that I cannot resist stating relates to the gradual removal of responsibilities from the family to other social institutions, a process long in progress since the Industrial Revolution. The school has been a popular place to transfer such responsibilities and this institution has suffered attempting to accomplish their traditional educational tasks with the extra burdens of providing recreational, safety, health and other functions assigned to them. Recognizing this burden on the schools, it would seem logical to retain as much control as possible for health care in the family, if not for the reason that the family is already the primary socialization influence on the child. I am not against school-based programs, but I feel uncomfortable pulling out from all the possible policy options available only one organizational model existing internationally, ignoring essential and critical links to existing supports in the culture, namely the family and the private sector of dentistry. In the quest for rapid solutions, we may fail, as the New Zealand lesson tries to teach us, to achieve long-term success--oral health for all which includes adults. New Zealand is now experimenting with rectifying problems it has with its fine schoolbased system by recently supplementing the school service with preventive technologies, by working closer with the private sector to correct deficiencies in the transition from school to private office care, and to make more compatible the existing separate modes of delivery for the different age groups in the population.

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Emergency Services Given the specific nature of the definition of dental emergencies, it would seem unlikely that abuse of these services would lead to the provision of comprehensive dental care. Moreover, there is nothing in the literature of which the committee is aware that would suggest abuse. On humanitarian grounds and in the absence of contradictory evidence, it would appear that the provision of emergency dental services would be appropriate. Linking minimal service provision of this sort to the system which delivers care to children also could reinforce the idea of the maintenance of a similar delivery mode for all. Though a minor link, nonetheless, this could minimize yet another potential constraint or source of confusion created by heterogeneous systems for different population groups. In summary, while I agree with much of the committee report, and am particularly delighted with the reliance on a “needs-based” approach to planning, I believe that all options were not considered sufficiently and that those related to a school-based program for children and emergency services could have been improved upon in the light of data from the dental health services and socio-dental research literature.