Third, the options for increasing the capacity of the current dental safety net system also need to be explored. Based on the judgments of informed administrators and policy experts, these estimates are expected to assist planners from organized dentistry and public agencies in developing effective strategies for increasing the capacity of the safety net system to provide more care to lower-income populations.

	METHODS

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Data sources. Being underserved is a relative concept and usually is based on national surveys of utilization rates, but the national reports conflict and present widely different utilization rate estimates for different family income groups. In a thoughtful assessment of this problem, Macek and colleagues⁴ concluded that the best estimate of the number of people visiting the dentist one or more times annually comes from the Medical Expenditure Panel Survey conducted by the Agency for Healthcare Research and Quality.⁵ Accordingly, we use the utilization data from that survey in this report.

Current capacity. The data on the current capacity of the dental safety net system come from several sources, including government reports, published data from the American Hospital Association, American Dental Education Association and oral communications with staff members from these organizations. Because of the paucity of data regarding some safety net sectors, we use available information to estimate the number of visits or patients treated. These estimates are imprecise and probably overestimate the system’s capacity. As noted above, they do provide order-of-magnitude approximations and are intended to inform policy-makers who are concerned with improving the oral health of underserved populations.

	RESULTS

TOP ABSTRACT METHODS RESULTS SAFETY NET EXPANSION OPTIONS DISCUSSION CONCLUSIONS REFERENCES

 
Underserved population. Table 1 shows the percentage of the population with one or more dental visits, the mean expense per visit and the source of payment according to family income in the year 2000.⁵ The data indicate that there were only minor differences in utilization between the 82.5 million people in the poor, near-poor and low-income populations. Only 27.8 percent (weighted average) of these three low-income groups (22.9 million people) saw a dentist during the year. In contrast, the middle-and high-income populations had decidedly higher utilization rates (40.4 percent and 53.5 percent, respectively).

Safety net system capacity. The primary components of the dental safety net for the noninstitutionalized, underserved population are clinics located in community health centers, community hospitals, public and parochial schools, public health departments, dental schools and other social service agencies.

Community health centers. There are many types of community health centers, and one useful way of grouping them is based on their primary source of financial support. First are public sector clinics that are funded in part by the federal government. There are several types of these clinics, but we group them in this report under the term "federally qualified health centers" (FQHCs). Second are public and voluntary sector clinics operated by state, county and municipal governments, hospitals, civic organizations and dental societies. These clinics do not receive any direct federal subsidy, and we refer to them in this report as "health centers" (HCs).

In 2004, the federal government supported 914 FQHCs for underserved populations (Dr. Jay Anderson, chief dental officer, Bureau of Primary Health Care, Division of Community and Migrant Health, Health Resources and Services Administration, Rockville, Md., oral communication, 2005). Of these centers, 603 (66 percent) provided dental services directly and about 108 referred patients to contracted private practitioners. The latter arrangement is used by FQHCs with and without dental clinics. The 2.15 million people receiving dental care in these clinics averaged 2.3 visits per person in 2004. Some 1,586 full-time equivalent (FTE) dentists and 547 FTE dental hygienists provided care in these facilities.

No national database is available regarding HCs. Therefore, to estimate the number and capacity of HCs, we used data from a 2001 survey of safety net clinics in Illinois.⁶ The state had 50 percent more HCs than FQHCs. Thus, on a national basis, we estimate that there are 904 HCs (50 percent more than the 603 FQHCs) available to treat the underserved. However, the authors indicated that HCs had fewer FTE dentists and chairs than FQHCs and treated 30 percent fewer patients.⁶ Projecting these state data nationally, we estimate that the 904 HCs treat about 2.2 million patients per year.

Community hospitals. Of the 4,927 general community hospitals in the United States in 2002, about 200 have accredited dental residency programs that are organizationally independent of a dental school. (Many hospitals without dental residents offer emergency dental services for control of pain and infection. Patients who use these services are not included in this analysis.) Table 2 presents the number of accredited non–dental-school—based dental residency programs and residents by type of program in 2002/2003.⁷ (Approximately two-thirds of all accredited non–dental-school—based programs are sponsored by hospitals; other programs are sponsored by medical schools, branches of the military and/or government agencies.) The majority of residents were in general dentistry and oral and maxillofacial surgery.

School-based dental clinics. A national survey conducted in 2001 reported that 300 public and parochial elementary and high schools had dental clinics in which dentists provided restorative and other curative services to children.⁸ No data are available regarding the number of under-served patients treated in these schools. To obtain an estimate, we made the following assumptions: one FTE dentist is employed per school clinic; all treated children come from families in the under-served population; dentists work 160 days per year and treat seven patients per day; and patients average 1.5 visits per school year. Under these assumptions, an upper-boundary estimate of the number of patients treated in the schools is about 220,000. A much larger number of schools offer screening and preventive services provided by dental hygienists and dentists; we did not include these programs in our analysis.

Dental schools. Dental school residents and students primarily treat patients from lower-income families. In contrast, patients treated in dental school–based faculty practices primarily come from middle- and high-income families. Thus, estimates of low-income patients treated in dental schools are based on services provided by students and residents. Dental schools reported that students provided 2,915,058 patient visits in 2001/2002.⁹ On the basis of discussions one of us (P.R.) had with dental school clinic directors in 2005, we estimate that the mean number of visits per patient per year is 13. On this basis, students treat about 224,000 patients annually.

The number of patients treated by residents is not available, but if we assume that dental school and hospital residency programs are similar, the estimated number of lower-income patients treated by the 3,105 dental-school–based residents in 2001/2002 was 1.5 million. When we combine the number of lower-income patients treated by students and residents, we estimate that dental schools treated some 1.7 million patients in 2001/2002.

Table 3 presents a summary of these estimates. If we assume a target of 33.3 million people, the safety net system has the capacity to treat 22 percent of them.

	SAFETY NET EXPANSION OPTIONS

TOP ABSTRACT METHODS RESULTS SAFETY NET EXPANSION OPTIONS DISCUSSION CONCLUSIONS REFERENCES

Community health centers. Ideally, all 914 FQHCs should provide dental services. Unfortunately, the substantial expansion of FQHCs seen in the past several years has come to an end (Dr. Jay Anderson, oral communication, 2005). In 2005, only 10 FQHC dental facilities were constructed. With the current budget deficit and demands on the federal budget, a 2 percent annual increase in the number of FQHC dental clinics probably is realistic for the foreseeable future (Dr. Jay Anderson, oral communication, 2005).

In addition to increasing the number of FQHCs offering dental services, FQHCs could increase their productivity. A recent study conducted in Connecticut showed that dentists in private practice and in FQHCs were equally productive with the resources available to them.¹⁰ The difference was that private practices had more operatories and employed more staff members than did the FQHCs, and, therefore, they were able to treat 50 percent more patients per day.

Because of federal funding constraints, it is unlikely that FQHC and private practice dental facilities and staffing will ever be equal. However, some improvements in facilities and staffing are possible, and, even though federal resources are constrained, a 25 percent increase in the number of FQHC patient visits may be realistic. If the number of FQHC dental clinics increased by 20 percent during the next 10 years and productivity increased by 25 percent, the additional number of patients treated annually would be about 1 million.

The data on HCs are so limited that it is difficult to assess the feasibility of expanding the capacity of this segment of the safety net. With the cutbacks in dental Medicaid funding in many states,¹¹ it is unlikely that this segment of the dental safety net will expand significantly within the next 10 years.

Community hospitals. Major constraints limit the expansion of hospital-based dental residency programs. First, federal support for dental residents through the graduate medical education (GME) program has declined during the past five years.¹² Second, many states have reduced Medicaid coverage for adults or for certain services, making it more difficult for hospital dental programs to generate the clinical revenues needed to cover their expenses.¹³ Third, the number of dental school graduates seeking advanced clinical training in a specialty or in general dentistry has increased minimally (15 percent) in the last 10 years.¹⁴ For these reasons, it will be difficult to expand hospital programs and, in turn, increase the number of underserved patients receiving dental care in hospital outpatient clinics.

If GME funds were restored to general practice residency (GPR) and advanced education in general dentistry (AEGD) programs, one policy option for expanding the capacity of community hospitals (or dental schools) to care for the under-served would be to require one year of residency training to be eligible for state or regional licensing examinations.¹⁵ Delaware currently requires one year of residency training and a clinical examination,¹⁶ and, beginning in 2007, New York will require a one-year residency in lieu of a clinical examination.¹⁷ In addition, several states offer a one-year residency program as an option for state licensing (Lois Haglund, American Dental Association, oral communication, May 2006).

To illustrate, perhaps one-half of all dental school graduates would be required to undergo one year of residency training within the next 10 years, and they would receive GME or some other public support during the year of training.

Under these conditions, about 1,800 more dental school graduates would participate in a one-year general dentistry residency program (GPR or AEGD), because dental specialty residency programs are unlikely to expand enrollment.¹⁴ On the basis of previous estimates of the number of underserved patients treated in dental residency programs, an additional 887,000 patients would receive care in this scenario. We assume that 50 percent of these additional patients would be treated in hospitals and 50 percent in dental-school–based general dentistry residency programs.

School-based delivery systems. Schools have many advantages in delivering basic dental services to disadvantaged children. The major constraints on expanding these programs are finding the money, space and other resources needed to build dental operatories in elementary and high schools, recruit dentists and other clinical staff and, most importantly, generate adequate revenues to cover operating expenses. With these formidable challenges, it is unrealistic to expect significant growth in school-based delivery systems. Therefore, we assume that the number of low-income children receiving primary dental care in this setting will change minimally, if at all, within the foreseeable future.

Substantial evidence suggests that senior students practicing in well-run, patient-centered community clinics and practices increase their productivity by a factor of three or four.

Dental schools. Under the current model of clinical dental education, schools will have to expand class size or residency programs to increase the number of underserved patients treated. With the decline in state support experienced in the past 10 years, most state-supported schools are not in the position to expand class size significantly because of limitations in space and the number of faculty and administrative staff members. From 1992 to 2002, first-year dental student enrollment increased from 4,072 to 4,448 students (Dr. Richard Weaver, associate director, Center for Educational Policy and Research, American Dental Education Association, oral communication, 2005). About one-half of the increase in the number of students was due to the formation of two new schools rather than growth in enrollment of existing schools. (Three new schools are in the planning stage and are likely to open within the next 10 years. However, the impact of these schools on the access issue will be limited, because it will be many years before enrolled students graduate and begin their residency training.)

Another possibility is to change the traditional model of dental education and require senior dental students to spend more time in patient-centered community clinics and practices treating underserved patients. Patient-centered care means that the primary goal of the community facility is patient care, and any educational activities in the clinic must not detract from achieving this goal. Substantial evidence suggests that senior students practicing in well-run, patient-centered community clinics and practices increase their productivity by a factor of three or four. Specifically, instead of treating two patients per day in dental school clinics, students average about five to seven patients per day in community clinics.¹⁸

To reach an estimate of the impact of all senior dental students from the existing 56 dental schools in the United States spending 60 days providing care in community clinics to underserved patients, we made the following assumptions: the schools average 80 students in the senior class, students treat an average of seven patients per day in community clinics and two in dental school clinics, all patients treated in either setting come from under-served populations, and patients average 13 visits per year in dental school clinics and 2.3 visits in community clinics.

Under these assumptions, senior dental students would treat an additional 600,000 under-served patients per year (that is, 60 days per year x seven patient visits per day x 4,600 students/2.3 visits per patient = 840,000 patients. The 600,000 additional patients treated is determined by subtracting 168,000 from 840,000. The 168,000 figure is based on the assumption that seniors care for 75 percent of the 224,000 patients treated annually by junior and senior dental students.).

We believe that the feasibility of having all senior dental students spend 60 days in community clinics or practices treating underserved patients is reasonably good. Fifteen (27 percent) of 56 dental schools now participate in the national Pipeline, Profession, and Practice: Community-Based Dental Education program, sponsored by the Robert Wood Johnson Foundation and The California Endowment.¹⁹ This program requires seniors to spend 60 days in community rotations by 2007, the final year of the project. In addition, according to anecdotal information we have received, many other schools are expanding their community-based educational programs. The long-term sustainability of the Pipeline model of dental education will depend on the program’s impact on school finances and the educational performance of students.

Table 3 presents our estimates of the number of patients who could be treated annually in an expanded safety net system during the next several years. In total, 9.9 million people have the potential to receive care, an increase of 2.5 million people (34.4 percent) from the current system.

	DISCUSSION

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Limitations. This report has significant limitations because of the lack of available data and the many assumptions we made to estimate the number of low-income patients treated in dental safety net clinics. To obtain more precise estimates, researchers need to collect data on this important component of the dental care delivery system.

The primary finding of this analysis is that, at best, the current dental safety net system cares for about 7.4 million patients annually. Although the current safety net system plays a significant role, it has limited capacity relative to the size of the entire underserved population of 82.5 million people and our target utilization rate of 33.3 million people visiting a dentist annually. The most important components of the dental safety net are FQHCs, HCs and dental schools. These three delivery organizations account for 83 percent of the system’s capacity.

Because the current safety net system cares for about 7.4 million patients per year, and the national Medical Expenditures Panel Survey⁵ indicates that about 22 million underserved people obtain care annually, this suggests that 60 to 70 percent of the underserved who obtain care must do so in private dental practices. One study of the dental safety net system at the state level supports this estimate. Beazoglou and colleagues¹⁰ analyzed Medicaid claims from Connecticut and found that 69 percent of children obtained care in the offices of private practitioners.

The potential for expanding the capacity of the safety net is substantial. During a 10-year period, another 2.5 million lower-income people could obtain care if FQHCs increased in number by 20 percent and improved their productivity by 25 percent; if 50 percent of dental school graduates received one year of residency training before licensure; and if all dental schools required senior students to spend 60 days in patient-centered community clinics and practices providing care to the underserved.

Improved productivity of FQHCs. The single most important strategy for increasing the capacity of the dental safety net is improving the productivity of FQHCs. Beazoglou and colleagues¹⁰ found that FQHCs in Connecticut treated one-half the number of patients that private practitioners treated. (This difference may not be representative of other states, because nationally, FQHCs average about 35 percent more patient visits than those in Connecticut.) This large productivity difference in Connecticut was the result of FQHCs’ having fewer operatories and allied health staff per dentist and not because FQHC dentists did not work as hard as private practitioners. Their study strongly suggests that a modest increase in the number of operatories and support staff could have a substantial and positive effect on the number of patients treated annually in FQHCs.

Residency training. A second strategy for treating more low-income patients is to require more dental school graduates to complete one year of residency before entering practice. In 2003, the American Dental Association passed a resolution supporting a postgraduate year in an accredited residency program as an optional substitute for traditional state or regional licensing examinations.²⁰ Several states also adopted this approach, and as of 2007, two states will have required one year of residency training.^15–17

Thus, momentum seems to be building among the states, and within the next 10 years, we believe that it is likely many more states either will require dental students to undergo residency training or offer it as an option. Currently, about 35 percent of dental school graduates receive additional clinical training in accredited residency or graduate programs.¹⁴ Thus, hundreds of graduates who now enter private practice, the armed forces and other areas of practice after dental school might seek residency training. Because the specialties are unlikely to expand their programs, most of the new resident positions would be in general dentistry (in hospitals or dental schools).

Patient-centered delivery systems. The third promising strategy to reduce disparities is to require senior dental students to spend more time in patient-centered delivery systems providing care to underserved populations. Increasing evidence indicates that this community experience improves the quality of dental education while reducing the cost.²¹ More schools are implementing community rotations as they struggle with economic problems resulting from slow-growing or reduced state budgets, rapidly increasing educational expenses and private practitioner incomes growing at twice the rate of clinical faculty salaries.

The long-term solution to reducing disparities in access to care and oral health must include the private sector delivery system.

If the dental safety net expands in this way during the next several years, the total capacity of the system would be about 10 million patients per year. Considering that the target now is 33.3 million people, and this number is likely to increase modestly during the next several years with growth of the population, the expanded safety net system could care for about 30 percent of the underserved population at best.

These estimates suggest that the long-term solution to reducing disparities in access to care and oral health also must include the private sector delivery system. In fact, some evidence suggests that the best strategy for increasing access to dental care is providing the underserved with adequately funded (public or private) dental insurance versus expanding the dental safety net system.²² Cunningham and Hadley²² recently examined this issue empirically with respect to medical care, and their analysis indicated that almost all access measures were better for low-income people with high insurance coverage versus access to community health centers. The authors concluded that expansion of insurance coverage should be viewed as the main tool for removing financial barriers to care and increasing utilization. They also noted that safety net expansion is a complementary and an important strategy in geographical areas that have difficulty attracting private practitioners, even when the population has adequate insurance coverage. These conclusions are especially relevant for dentistry, because the current dental safety net system has such limited capacity.

It is beyond the scope of this report to assess what changes in publicly financed dental insurance are necessary to increase significantly the participation of private practitioners in caring for low-income Americans. Clearly, making fees more competitive and streamlining administrative processes are part of the solution.

A related issue is the capacity of the private sector dental work force to care for another eight to 10 million new patients. If phased in during a five-year period, the additional number of patients should not be a problem, because dentists’ productivity is increasing,²³ and they have considerable flexibility in scheduling recall appointments.²⁴ This flexibility probably explains the ability of private practitioners in 22 rural counties in Michigan to treat thousands of new patients receiving Medicaid in just 12 months, once this program was turned over to a private insurer that paid dentists competitive fees.²⁵ The greater challenge is convincing federal and state legislators to adequately fund public dental insurance.

	CONCLUSIONS

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In this article, we provide an upper-boundary estimate of the capacity of the dental safety net system to provide care to the 82.5 million lower-income people in the United States. If 33.3 million low-income people received dental care annually, this would reduce access disparities between low- and middle-income populations.

Although the data have limitations, the current safety net system appears to care for about 7.4 million people annually. Most care is delivered in FQHCs, HCs, community hospital dental residency programs and dental schools. The dental safety net has the potential to expand by about 34.5 percent during the next 10 years, which would enable a total of 10 million patients to receive treatment annually. The increased capacity is a function of greater FQHC productivity, increases in the number of FQHCs offering dental services, more dental school graduates receiving residency training and senior dental students spending more time in patient-centered community clinics and practices providing care to underserved patients.

Even with an expanded safety net, the majority of underserved patients would continue to receive care in private practices. Thus, a long-term reduction in access-to-care and oral health disparities requires greater participation by the private practice community in caring for the under-served. Some evidence suggests that this is the most effective way to expand access. Safety net clinics have an important role to play in geographical areas in which the availability of dentists in private practice is limited, even when the population has adequate purchasing power. The capacity of the private dental system to treat eight to 10 million new patients is not a major concern, in our view. The biggest challenge is convincing the American people and their elected representatives that oral health is important to overall health and that more low-income citizens should have access to basic dental care services.