oral health report 2021

The 2021 report on oral health in America: Directions for the future of dental public health and the oral health care system

Affiliations.

• 1 Dental Public Health, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada.
• 2 School of Dentistry, University of Detroit Mercy, Detroit, Michigan, USA.
• 3 American Dental Association, Health Policy Institute, Chicago, USA.
• 4 Prevention and Public Health Sciences, University of Illinois Chicago College of Dentistry, Chicago, Illinois, USA.
• 5 Division of Pediatric and Public Health, UNC Adams School of Dentistry, Chapel Hill, North Carolina, USA.
• PMID: 35611708
• DOI: 10.1111/jphd.12521

In the two decades between Oral Health in America: A Report of the Surgeon General and Oral Health in America: Advances and Challenges much good happened but intractable challenges persist. Inequity in oral health status, utilization, and access to care continue to negatively affect the health and economic wellbeing of Americans and their families, local, state, and federal health care systems, and American society overall. To move the nation forward, we argue that: more emphasis is needed in prevention; access to care must be improved to mitigate inequity; newer understandings of oral disease must be leveraged in the service of health and health care; the value that oral health brings to economic wellbeing must be elucidated; better policy choices must be made in all of the above; and more effective oral health care leaders in driving policy change must be trained.

Keywords: dental care; health inequities; health policy; healthcare policy; oral health; public health dentistry.

© 2022 American Association of Public Health Dentistry.

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News Release

Tuesday, December 21, 2021

Report details 20 years of advances and challenges of Americans’ oral health

Despite important advances in the understanding and treatment of oral diseases and conditions, many people in the U.S. still have chronic oral health problems and lack of access to care, according to a report by the National Institutes of Health. Oral Health in America: Advances and Challenges , is a follow-up to the seminal 2000 Oral Health in America: A Report of the Surgeon General . The new report, which is intended to provide a road map on how to improve the nation’s oral health, draws primarily on information from public research and evidence-based practices and was compiled and reviewed by NIH’s National Institute of Dental and Craniofacial Research (NIDCR) and a large, diverse, multi-disciplinary team of more than 400 experts.

The report updates the findings of the 2000 publication and highlights the national importance of oral health and its relationship to overall health. It also focuses on new scientific and technological knowledge – as well as innovations in health care delivery – that offer promising new directions for improving oral health care and creating greater equity in oral health across communities. Achieving that equity is an ongoing challenge for many who struggle to obtain dental insurance and access to affordable care.

“This is a very significant report,” said NIH Acting Director Lawrence A. Tabak, D.D.S., Ph.D. “It is the most comprehensive assessment of oral health currently available in the United States and it shows, unequivocally, that oral health plays a central role in overall health. Yet millions of Americans still do not have access to routine and preventative oral care.”

The newly issued report provides a comprehensive snapshot of oral health in America, including an examination of oral health across the lifespan and a look at the impact the issue has on communities and the economy. Major take-aways from the report include:

• Healthy behaviors can improve and maintain an individual’s oral health, but these behaviors are also shaped by social and economic conditions.
• Oral and medical conditions often share common risk factors, and just as medical conditions and their treatments can influence oral health, so can oral conditions and their treatments affect other health issues.
• Substance misuse and mental health conditions negatively affect the oral health of many.
• Group disparities around oral health, identified 20 years ago, have not been adequately addressed, and greater efforts are needed to tackle both the social and commercial determinants that create these inequities and the systemic biases that perpetuate them.

“This is an in-depth review of the scientific knowledge surrounding oral health that has accumulated over the last two decades,” said Rena D’Souza D.D.S., Ph.D., director of NIDCR, which oversaw and funded the project’s three-year research program. “It provides an important window into how many societal factors intersect to create advantages and disadvantages with respect to oral health, and, critically, overall health.”

The COVID-19 pandemic emerged while the report was being written. The science around SARS-CoV-2 continues to come into focus in real-time, and, although data were only starting to surface about the oral implications of the disease, the authors included a preliminary analysis of it to assess initial impacts.

The authors make several recommendations to improve oral health in America, which include the need for health care professionals to work together to provide integrated oral, medical, and behavioral health care in schools, community health centers, nursing homes, and medical care settings, as well as dental clinics. They also identify the need to improve access to care by developing a more diverse oral health care workforce, addressing the rising cost of dental education, expanding insurance coverage, and improving the overall affordability of care.

“Although there are challenges ahead, the report gives us a starting point and some clear goals that offer reasons to be hopeful, despite those challenges,” added D’Souza. “It imagines a future, as I do, in which systemic inequities that affect oral health and access to care are more fully addressed, and one in which dental and medical professionals work together to provide integrated care for all.”

Scientists and public health professionals will use the report to identify areas of scientific inquiry and research as well as develop and implement programs that ultimately will improve the oral health of individuals, communities, and the nation.

To view or download the report, please visit the NIDCR website at https://www.nidcr.nih.gov/oralhealthinamerica .

Questions about the report? Email  [email protected]  or call NIDCR at 1-866-232-4528.

About the National Institute of Dental and Craniofacial Research:  NIDCR  is the nation’s leading funder of research on oral, dental, and craniofacial health.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov .

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by Kimber Solana

December 22, 2021

Original Article

ADA commends NIH report, Oral Health in America: Advances and Challenges

Comprehensive report outlines key findings, call to action to improve nation's oral health.

Good oral health is important for the overall health and well-being of individuals of all ages, their families, communities and the nation, according to a newly released report from the National Institutes of Health.

That was among the key findings of Oral Health in America: Advances and Challenges, a wide-ranging report that provides a “comprehensive picture of the state of oral health in America,” according to Rena D’Souza, D.D.S., Ph.D., NIH National Institute of Dental and Craniofacial Research director, during a Dec. 21 webcast announcement on the release of the report.

“And while progress has been made in some areas over the last 20 years, much work remains,” Dr. D’Souza said.

The ADA commended the federal agencies that worked on the report, which was produced by the National Institute of Dental and Craniofacial Research of the National Institutes of Health.

“Oral health is an integral part of overall health, and dentists are leading the way in scientific advancements and clinical treatments that help improve patient health,” said ADA President Cesar R. Sabates, D.D.S. “I am excited to see the progress that has been made and to work in an interdisciplinary fashion to address the challenges that remain, particularly when it comes to improving public health.”

Among the key findings of the 790-page report include:

• Through research and policy changes over the past 20 years, substantial advances have been made in the understanding and treatment of oral diseases and conditions, yet many people of all ages and demographic backgrounds still have chronic oral health problems and lack access to care.
• Healthy behaviors can improve and maintain individuals’ oral health; these behaviors are shaped by social and economic conditions in which people are born, grow, work and live.
• Oral and medical conditions often share common risk factors, and just as medical conditions and their treatments can influence oral health, so can oral conditions and their treatments affect other health issues.
• The COVID-19 pandemic has challenged the nation’s health care system, including oral health providers. With those challenges came new ways of ensuring safety during provision of dental care, of treating disease, and recognizing that oral health cannot be separated from overall health.

The report also included several calls to action to help improve the nation’s oral health, such as policy changes to help reduce or eliminate social, economic and other systemic inequities that affect oral health behaviors and access to care; and strengthening the oral health workforce by diversifying the composition of the nation’s oral health professionals.

“And now we need the broad oral health community to translate this knowledge into action in improving the future of oral health for all," said Bruce Dye, D.D.S., scientific editor and co-director of the report and associate editor of The Journal of the American Dental Association, during the webcast. "The most important story to take away from this report is that good oral health for all is within reach.”

The 2021 report is a follow up to the seminal report on the nation's oral health that Surgeon General David Satcher released two decades ago.

“That original report, which was considered a milestone in public health, firmly established oral health as being intrinsically linked to overall health and well-being,” said Dr. D’Souza.

Dr. Sabates noted that he was proud of the ADA experts who were directly involved in the report, including the ADA’s Health Policy Institute and the ADA Science & Research Institute, which offered notable contributions of vital data and oral health research. In addition, Dr. Sabates said the ADA looks forward to reviewing the full report in depth to identify opportunities for the future.

“The ADA remains committed to advancing research, education, practice resources and advocacy on behalf of dentists and the public to continue to improve oral health in the U.S.,” Dr. Sabates said.

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• Summary of Recommendations
• USPSTF Assessment of Magnitude of Net Benefit
• Practice Considerations
• Supporting Evidence
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• Article Information

USPSTF indicates US Preventive Services Task Force.

eFigure. US Preventive Services Task Force (USPSTF) Grades and Levels of Evidence

• USPSTF Recommendation: Oral Health in Children and Adolescents Aged 5 to 17 Years JAMA US Preventive Services Task Force November 7, 2023 This 2023 Recommendation Statement from the US Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening and preventive interventions performed by primary care clinicians for oral health conditions, including dental caries, in children and adolescents aged 5 to 17 years (I statement). US Preventive Services Task Force; Michael J. Barry, MD; Wanda K. Nicholson, MD, MPH, MBA; Michael Silverstein, MD, MPH; David Chelmow, MD; Tumaini Rucker Coker, MD, MBA; Esa M. Davis, MD, MPH; Katrina E. Donahue, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Li Li, MD, PhD, MPH; Gbenga Ogedegbe, MD, MPH; Lori Pbert, PhD; Goutham Rao, MD; John M. Ruiz, PhD; James Stevermer, MD, MSPH; Joel Tsevat, MD, MPH; Sandra Millon Underwood, PhD, RN; John B. Wong, MD
• USPSTF Review: Screening and Prevention for Oral Health in Children and Adolescents JAMA US Preventive Services Task Force November 7, 2023 This systematic review to support the 2023 US Preventive Services Task Force Recommendation Statement on oral health screening and prevention in children and adolescents summarizes published evidence on the benefits and harms of screening, referral, behavioral counseling, and preventive interventions for oral health in asymptomatic children and adolescents aged 5 to 17 years. Roger Chou, MD; Christina Bougatsos, MPH; Jessica Griffin, MS; Shelley S. Selph, MD, MPH; Azrah Ahmed, BA; Rongwei Fu, PhD; Chad Nix, MSc; Eli Schwarz, DDS, MPH, PhD
• Aligning Prevention Evidence Gaps With Prevention Research JAMA Viewpoint November 7, 2023 This Viewpoint describes the development of tools to communicate actionable steps to address research needs and gaps for USPSTF recommendations that have insufficient evidence to make definitive guidance. Wanda Nicholson, MD, MPH, MBA; Michael J. Barry, MD; Carol M. Mangione, MD, MSPH
• A Call for More Oral Health Research in Primary Care JAMA Editorial November 7, 2023 Michael S. Reddy, DMD, DMSc; Rena N. D’Souza, DDS, MS, PhD; Jennifer Webster-Cyriaque, DDS, PhD
• Patient Information: Dental Caries in Adults, Adolescents, and Children JAMA JAMA Patient Page November 7, 2023 This JAMA Patient Page describes oral health, particularly care of the teeth and prevention of tooth and gum disease, and discusses the pros and cons of screening for dental caries by primary care clinicians. Jill Jin, MD, MPH
• USPSTF Review: Screening and Prevention for Oral Health in Adults JAMA US Preventive Services Task Force November 14, 2023 This systematic review to support the 2023 US Preventive Services Task Force Recommendation Statement on oral health screening and prevention in adults summarizes published evidence on the benefits and harms of screening, referral, behavioral counseling, and preventive interventions for oral health in asymptomatic adults 18 years or older. Roger Chou, MD; Shelley S. Selph, MD, MPH; Christina Bougatsos, MPH; Chad Nix, MSc; Azrah Ahmed, BA; Jessica Griffin, MS; Eli Schwarz, DDS, MPH, PhD
• Review of Common Oral Conditions JAMA Review March 26, 2024 This review discusses diagnosis and first-line treatment options for dry mouth, oral candidiasis, and recurrent aphthous ulcers. Eric T. Stoopler, DMD; Alessandro Villa, DDS, PhD, MPH; Mohammed Bindakhil, DDS, MS; David L. Ojeda Díaz, DDS; Thomas P. Sollecito, DMD

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US Preventive Services Task Force. Screening and Preventive Interventions for Oral Health in Adults : US Preventive Services Task Force Recommendation Statement . JAMA. 2023;330(18):1773–1779. doi:10.1001/jama.2023.21409

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Screening and Preventive Interventions for Oral Health in Adults : US Preventive Services Task Force Recommendation Statement

• Editorial A Call for More Oral Health Research in Primary Care Michael S. Reddy, DMD, DMSc; Rena N. D’Souza, DDS, MS, PhD; Jennifer Webster-Cyriaque, DDS, PhD JAMA
• US Preventive Services Task Force USPSTF Recommendation: Oral Health in Children and Adolescents Aged 5 to 17 Years US Preventive Services Task Force; Michael J. Barry, MD; Wanda K. Nicholson, MD, MPH, MBA; Michael Silverstein, MD, MPH; David Chelmow, MD; Tumaini Rucker Coker, MD, MBA; Esa M. Davis, MD, MPH; Katrina E. Donahue, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Li Li, MD, PhD, MPH; Gbenga Ogedegbe, MD, MPH; Lori Pbert, PhD; Goutham Rao, MD; John M. Ruiz, PhD; James Stevermer, MD, MSPH; Joel Tsevat, MD, MPH; Sandra Millon Underwood, PhD, RN; John B. Wong, MD JAMA
• US Preventive Services Task Force USPSTF Review: Screening and Prevention for Oral Health in Children and Adolescents Roger Chou, MD; Christina Bougatsos, MPH; Jessica Griffin, MS; Shelley S. Selph, MD, MPH; Azrah Ahmed, BA; Rongwei Fu, PhD; Chad Nix, MSc; Eli Schwarz, DDS, MPH, PhD JAMA
• Viewpoint Aligning Prevention Evidence Gaps With Prevention Research Wanda Nicholson, MD, MPH, MBA; Michael J. Barry, MD; Carol M. Mangione, MD, MSPH JAMA
• JAMA Patient Page Patient Information: Dental Caries in Adults, Adolescents, and Children Jill Jin, MD, MPH JAMA
• US Preventive Services Task Force USPSTF Review: Screening and Prevention for Oral Health in Adults Roger Chou, MD; Shelley S. Selph, MD, MPH; Christina Bougatsos, MPH; Chad Nix, MSc; Azrah Ahmed, BA; Jessica Griffin, MS; Eli Schwarz, DDS, MPH, PhD JAMA
• Review Review of Common Oral Conditions Eric T. Stoopler, DMD; Alessandro Villa, DDS, PhD, MPH; Mohammed Bindakhil, DDS, MS; David L. Ojeda Díaz, DDS; Thomas P. Sollecito, DMD JAMA

Importance   Oral health is fundamental to health and well-being across the life span. Dental caries (cavities) and periodontal disease (gum disease) are common and often untreated oral health conditions that affect eating, speaking, learning, smiling, and employment potential. Untreated oral health conditions can lead to tooth loss, irreversible tooth damage, and other serious adverse health outcomes.

Objective   The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate screening and preventive interventions for oral health conditions in adults.

Population   Asymptomatic adults 18 years or older.

Evidence Assessment   The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults.

Recommendations   The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement)

See the Summary of Recommendations figure.

The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms to improve the health of people nationwide.

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

The USPSTF is committed to mitigating the health inequities that prevent many people from fully benefiting from preventive services. Systemic or structural racism results in policies and practices, including health care delivery, that can lead to inequities in health. The USPSTF recognizes that race, ethnicity, and gender are all social rather than biological constructs. However, they are also often important predictors of health risk. The USPSTF is committed to helping reverse the negative impacts of systemic and structural racism, gender-based discrimination, bias, and other sources of health inequities, and their effects on health, throughout its work.

Oral health is fundamental to health and well-being across the life span. 1 , 2 Dental caries (cavities) and periodontal disease (gum disease) are common and often untreated oral health conditions that affect eating, speaking, learning, smiling, and employment potential. 1 - 4 In the US, oral health disparities are shaped by inequities in the affordability and accessibility of dental care and other disadvantages related to social determinants of health (eg, living in an underserved rural area). 1 , 2 , 4 Dental caries and periodontitis disproportionately affect persons living in poverty; Asian, Black, Hispanic/Latino, Native American/Alaska Native, and Native Hawaiian/Pacific Islander adults; pregnant persons; adults with disabilities; adults 65 years or older or living in institutional settings; adults living in rural and urban underserved areas; adults without insurance or with public insurance; and adults experiencing homelessness. 1 , 2 Untreated oral health conditions can lead to tooth loss, irreversible tooth damage, and other serious adverse health outcomes. 1 , 5

Due to a lack of evidence, the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults.

Due to a lack of evidence, the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults.

See Table 1 for more information on the USPSTF recommendation rationale and assessment and the eFigure in the Supplement for information on the recommendation grade. See the Figure for a summary of the recommendation for clinicians. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual. 6

This recommendation applies to asymptomatic adults aged 18 years or older.

Dental caries refers to a multifactorial disease process resulting in demineralization of the teeth. 7 , 8 Periodontal disease refers to inflammation of the gingival tissue, or gingivitis, which affects the hard and soft tissue that supports the teeth and can progress to periodontitis involving bone loss. 1 , 9 Oral health conditions for this recommendation statement refer to clinical health outcomes focused on the presence and severity of dental caries, dental caries burden (number of affected teeth), presence and severity of periodontal disease, tooth loss, and morbidity, quality of life, functional status, and harms of screening and treatment related to these conditions. 1 The USPSTF focused on dental caries and periodontitis as the most common oral health conditions and the most potentially amenable to primary care interventions.

For the purposes of the review, screening included clinical assessments (eg, physical examination) and standardized risk prediction tools or a combination of approaches by primary care clinicians to identify adults who have existing oral health conditions or adults who might benefit most from interventions to prevent future negative oral health outcomes due to increased risk. 1 Interventions that were reviewed focused on preventing future dental caries and included counseling and health education toward reducing the burden of bacteria in the mouth, decreasing the frequency of refined sugar intake, and promoting resistance to caries in the teeth through use of fluoride, dental sealants, silver diamine fluoride solution, 1 , 10 and xylitol. 1 The USPSTF found insufficient evidence to recommend for or against screening or preventive interventions for oral health conditions in the primary care setting for adults and suggests primary care clinicians use their clinical expertise to decide whether to perform these services.

In deciding whether to routinely screen or deliver interventions for oral health conditions, primary care clinicians should consider the following.

Dental caries is the most common condition in adults worldwide; more than 90% of US adults are affected by dental caries, and an estimated 26% have untreated dental caries. 1 , 2 Untreated dental caries can lead to serious infections and tooth loss. 1 , 8 An estimated 42% of US adults older than 30 years have periodontal disease, increasing to nearly 60% at age 65 years or older. 1 , 11 Untreated periodontitis can contribute to destruction of tissues that support the teeth and is the leading cause of tooth loss in older adults. 1 , 9 , 12 , 13

Older adults are more likely to have medical conditions or use medications causing xerostomia (dry mouth), which contributes to oral health conditions. 1 , 14 Frequent intake of dietary sugars in foods and beverages, suboptimal fluoride exposure, oral hygiene practices (eg, lack of toothbrushing and flossing), tobacco use, unhealthy alcohol use, and methamphetamine use increase the risk of oral health conditions. 1 According to 2009-2016 National Health and Nutrition Examination Survey data, people who smoke have a higher incidence of periodontal disease (62%) compared with adults 30 years or older overall (42%). 1 , 11

Social determinants of health (nonbiological factors) associated with increased risk of oral health conditions include low socioeconomic status, lack of dental insurance, and living in communities with dental professional shortages, affecting access to dental care. 1 For older adults, physical limitations and loss of dental coverage upon retirement can increase barriers to dental care. 5

Potential screening approaches in primary care (eg, oral clinical assessments or standardized risk assessment instruments) to identify persons with early untreated dental caries or periodontal disease or persons at increased future risk are noninvasive and would seem unlikely to cause serious harms, but evidence is lacking. Health education and counseling to encourage routine oral hygiene and reduce modifiable risk factors (eg, frequent intake of refined sugars or tobacco use) are also noninvasive.

The USPSTF found little evidence on current practices in primary care for routine screening or performing interventions to prevent dental caries or periodontitis in adults. In its review of the evidence, the USPSTF found that preventive interventions are generally performed in dental settings by dental professionals. There are well-known significant barriers to providing oral health services in the primary care setting, including variable clinician access and familiarity with interventions. 1 Primary care clinicians may need additional training and specific equipment to deliver screening and preventive interventions, have reimbursement challenges, and encounter administrative obstacles to making dental referrals and linking patients to dental care. 1 The USPSTF recommends oral fluoride supplements starting at age 6 months for children younger than 5 years with water sources deficient in fluoride and administration of varnish to the primary teeth of all children younger than 5 years after tooth eruption. 15 It is unknown how frequently fluoride is administered in older children and adults.

The Health Resources and Services Administration’s oral health factsheet ( https://www.hrsa.gov/sites/default/files/hrsa/oral-health/oral-health-2016-factsheet.pdf ) and report on Integration of Oral Health and Primary Care Practice ( https://www.hrsa.gov/sites/default/files/hrsa/oral-health/integration-oral-health.pdf ) emphasize optimal collaborations between primary care clinicians and oral health professionals.

The US Department of Health and Human Services’ Report of the Surgeon General ( https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf ) and the National Institutes of Health’s report Oral Health in America: Advances and Challenges ( https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf ) comprehensively describe the importance of oral health to overall health and highlight advances and challenges toward improving oral health in the US.

The Community Preventive Services Task Force recommends fluoridation of community water sources to reduce dental caries ( https://www.thecommunityguide.org/findings/dental-caries-cavities-community-water-fluoridation ).

The USPSTF has issued recommendations on screening and interventions to prevent dental caries in children younger than 5 years 15 ; screening for oral cancer 16 ; interventions for tobacco smoking cessation in adults, including pregnant persons 17 ; and screening and preventive interventions for oral health in children and adolescents aged 5 to 17 years. 18

The USPSTF commissioned a systematic evidence review 1 , 19 to evaluate the benefits and harms of screening and preventive interventions for oral health conditions in adults. The USPSTF previously addressed counseling to prevent dental and periodontal disease (1996). Concurrently, the USPSTF commissioned a systematic evidence review to evaluate the benefits and harms of oral health screening and preventive interventions in children and adolescents aged 5 to 17 years 20 ; this recommendation is addressed in a separate statement. 21

The USPSTF found limited evidence on available and appropriate screening instruments or clinical risk assessments to identify adults with oral health conditions in the primary care setting. The review identified 6 studies (n = 1281) of self-reported questionnaires on perceived dental health designed to distinguish between persons with and without periodontitis, but most questionnaires included whether there was a history of periodontitis, making them less relevant for screening in asymptomatic persons or those with previously unrecognized oral periodontitis. 1 , 19 The questionnaires demonstrated moderate discrimination (area under summary receiver operating characteristic curve, 0.79 [95% CI, 0.75-0.83]). 1 , 19 The evidence review did not identify any questionnaires designed to identify adults with dental caries.

The single primary care study 22 (n = 86) evaluating the accuracy of clinical examination to identify dental caries found high specificity for dental caries and periodontitis (range, 0.80-0.93) but low sensitivity for periodontitis (0.56 [95% CI, 0.38-0.74] and 0.42 [95% CI, 0.24-0.56] for 2 examiners) and variable sensitivity for dental caries (0.33 [95% CI, 0.12-0.62] and 0.83 [95% CI, 0.52-0.96]). 1 , 19

The review found no evidence on the accuracy of risk assessment tools to identify adults at increased risk of future oral health outcomes.

For evidence on whether screening prevented negative oral health outcomes in adults in the primary care setting, the review identified a single study in pregnant persons 23 (n = 477) that compared no screening with a dental screening approach involving 2 questions and an optional oral cavity visual inspection by midwives. There were no statistically significant group differences in number of decayed teeth or filled teeth, and measures of periodontitis and birth outcomes in both groups were similar. 1 , 19 , 23

The same single study 22 (n = 477) evaluating screening vs no screening in pregnant persons did not report examining harms of screening. 1 , 19

The USPSTF sought evidence on interventions implemented in a primary care setting that could prevent a broad collection of oral health conditions; however, the evidence review identified studies focused on dental caries interventions performed by dental health professionals in a dental setting. The USPSTF also sought evidence on the effectiveness of oral health behavioral counseling in a primary care setting to prevent oral health outcomes but found no such evidence. 1 , 19

The following discussion focuses on preventive medications. Studies often had significant methodological limitations (eg, high attrition, unclear randomization, or uncertain applicability to the US) and did not report analysis by race, socioeconomic status, or other important social determinants of health. Studies inconsistently reported community water fluoridation levels or whether participants received oral health education, precluding evaluation of the effectiveness of these factors on oral health outcomes. The review did not find evidence evaluating the effects of interventions on nonoral health outcomes such as cardiovascular or cognitive outcomes, quality of life, or functional status. 1 , 19

The review found no evidence on fluoride interventions provided by primary care clinicians. Five trials (n = 971) in adults reported on the effects of topical fluorides (varnish or gel/solution) applied by dental professionals to prevent dental caries. 1 , 19 In the single randomized clinical trial 24 (n = 104) of older adults in residential and nursing homes, application of fluoride varnish (sodium fluoride 22 600 ppm) every 3 months was associated with a statistically nonsignificant reduction in dental caries at 1 year (mean difference in new active dental caries or fillings, 0.7; P  > .05), but at 2 and 3 years, group differences were statistically significant (mean difference, 1.8; P  < .001 and mean difference, 1.6; P  < .001, respectively). 1 , 19 In addition, fluoride varnish was associated with decreased risk of developing new dental caries (relative risk, 0.25 [95% CI, 0.10-0.63]), translating to a number needed to treat of 3.1 (95% CI, 2.1-7.7). 1 , 19 A nonrandomized cluster trial 25 (n = 232) of older adults in long-term care facilities found no group differences in dental caries burden (based on DMFT/DFT [Decayed, Missing, and Filled Teeth/Decayed, Filled Teeth] score) at 1 year (adjusted mean difference, −0.04 [95% CI, −0.10 to 0.03]). 1 , 19 The 3 additional trials of other topical fluoride approaches (sodium fluoride 2% solution, stannous fluoride [30%] paste followed by aqueous solution, and acidulated phosphate fluoride [1.2%] at varied time frames) obtained inconsistent results. 1 , 19

The review found no studies on the effectiveness of sealants vs no sealants to prevent dental caries in primary care. Two trials (n = 178) evaluating light-cured resin-based sealants in young adults applied by dental professionals were of limited quality and yielded imprecise results. 1 , 19 Three trials (n = 590) examined the effectiveness of silver diamine fluoride solution to reduce dental caries or fillings in older adults. 1 , 19 Fluoride exposure (ie, oral health behaviors) was reported in 1 study and not reported in 2 studies. 1 , 19 In older adults, evidence suggests that silver diamine fluoride may be more effective than placebo to reduce new root dental caries or fillings (mean difference, −0.33 to −1.3 at 24 to 30 months). 1 Silver diamine fluoride may also reduce likelihood of developing new root dental caries (adjusted odds ratio, 0.4 [95% CI, 0.3-0.7] and relative risk, 0.19 [95% CI, 0.07-0.46] in 2 randomized clinical trials; n = 478). 1 , 19 No evidence was found evaluating the effects of xylitol to prevent dental caries or periodontitis. 1 , 19

The review found very limited evidence on the harms of interventions. Of the 9 studies reviewed assessing preventive interventions, 1 trial evaluating fluoride varnish or silver diamine fluoride (vs placebo) stated “no major side effects or discomfort was reported.” 1 , 19 , 24 Eight other trials did not report examining for harms. 1 , 19

A draft version of this recommendation statement was posted for public comment on the USPSTF website from May 23, 2023, to June 20, 2023. Some comments suggested that a recommendation supporting primary care screening and preventive interventions could expand dental care access and positively impact oral health disparities. The USPSTF is committed to advancing health equity and to the provision of equitable clinical preventive services to improve health. The USPSTF carefully considers evidence of benefits and harms, makes recommendations when supported by sufficient evidence, and makes recommendations on primary care–relevant services. However, based on the evidence, the USPSTF cannot recommend for or against oral health screening or preventive interventions for adults in the primary care setting. Primary care clinicians should use their clinical expertise to decide whether to perform these services. The USPSTF is calling for additional research to fill critical evidence gaps on this topic. Several comments agreed that the evidence is too limited to make a recommendation for or against primary care–feasible oral health screening or preventive interventions in adults.

See Table 2 for research needs and gaps related to screening and preventive interventions for oral health in adults.

The US Department of Health and Human Services’ Report of the Surgeon General (2000) and the National Institutes of Health’s update (2021) emphasize the importance of integrating oral health into primary care medical settings, primarily focusing on counseling, coordination, and referral. 2 , 14 The National Academy of Medicine’s (formerly the Institute of Medicine) and the Health Resources and Services Administration’s report Advancing Oral Health in America (2011) recommends strategic action for prioritization of oral health within US Department of Health and Human Services agencies and in its partnerships with other stakeholders. 5

The American Dental Association (2013) recommends professionally applied 2.26% fluoride varnish or 1.23% fluoride gel in adults at elevated risk of developing dental caries. 26 The American Academy of Family Physicians (2018) recommends that primary care clinicians educate patients about risks and benefits of fluoride use. 27 The American College of Obstetricians and Gynecologists (2013) recommends routine counseling about the importance of oral health care during pregnancy and maintaining good oral health habits throughout the life span. 28

Accepted for Publication: September 30, 2023.

Published Online: November 7, 2023. doi:10.1001/jama.2023.21409

Corresponding Author: Michael J. Barry, MD, Informed Medical Decisions Program, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 ( [email protected] ).

The US Preventive Services Task Force (USPSTF) members: Michael J. Barry, MD; Wanda K. Nicholson, MD, MPH, MBA; Michael Silverstein, MD, MPH; David Chelmow, MD; Tumaini Rucker Coker, MD, MBA; Esa M. Davis, MD, MPH; Katrina E. Donahue, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Li Li, MD, PhD, MPH; Gbenga Ogedegbe, MD, MPH; Lori Pbert, PhD; Goutham Rao, MD; John M. Ruiz, PhD; James Stevermer, MD, MSPH; Joel Tsevat, MD, MPH; Sandra Millon Underwood, PhD, RN; John B. Wong, MD.

Affiliations of The US Preventive Services Task Force (USPSTF) members: Harvard Medical School, Boston, Massachusetts (Barry); George Washington University, Washington, DC (Nicholson); Brown University, Providence, Rhode Island (Silverstein); Virginia Commonwealth University, Richmond (Chelmow); University of Washington, Seattle (Coker); University of Maryland School of Medicine, Baltimore (Davis); University of North Carolina at Chapel Hill (Donahue); The University of Texas Health Science Center, San Antonio (Jaén, Tsevat); University of Virginia, Charlottesville (Li); New York University, New York, New York (Ogedegbe); University of Massachusetts Chan Medical School, Worcester (Pbert); Case Western Reserve University, Cleveland, Ohio (Rao); University of Arizona, Tucson (Ruiz); University of Missouri, Columbia (Stevermer); University of Wisconsin, Milwaukee (Underwood); Tufts University School of Medicine, Boston, Massachusetts (Wong).

Author Contributions: Dr Barry had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The USPSTF members contributed equally to the recommendation statement.

Conflict of Interest Disclosures: Authors followed the policy regarding conflicts of interest described at https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/conflict-interest-disclosures . All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings.

Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.

Role of the Funder/Sponsor: AHRQ staff assisted in the following: development and review of the research plan, commission of the systematic evidence review from an Evidence-based Practice Center, coordination of expert review and public comment of the draft evidence report and draft recommendation statement, and the writing and preparation of the final recommendation statement and its submission for publication. AHRQ staff had no role in the approval of the final recommendation statement or the decision to submit for publication.

Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We thank Sheena Harris, MD, MPH (AHRQ), who contributed to the writing of the manuscript, and Lisa Nicolella, MA (AHRQ), who assisted with coordination and editing.

Additional Information: Published by JAMA®—Journal of the American Medical Association under arrangement with the Agency for Healthcare Research and Quality (AHRQ). ©2023 AMA and United States Government, as represented by the Secretary of the Department of Health and Human Services (HHS), by assignment from the members of the United States Preventive Services Task Force (USPSTF). All rights reserved.

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Oral Health in America

Important, but insufficient, gains have been achieved in access to and delivery of oral health care since the 2000 US surgeon general’s report on oral health in America. Access to care has increased for children and young adults, but considerable work remains to meet the oral health care needs of all people equitably. The National Institutes of Health report, Oral Health in America: Advances and Challenges, reviews the state of the US oral health care system, achievements made since 2000, and remaining challenges. In this article, the authors highlight key advances and continuing challenges regarding oral health status, access to care and the delivery system, integration of oral and systemic health, financing of oral health care, and the oral health workforce.

Public insurance coverage has increased since 2000 but remains limited for many low-income, minority, and older adult populations. The oral health care workforce has expanded to include new dental specialties and allied professional models, increasing access to health promotion and preventive services. Practice gains made by women and Asian Americans have not extended to other minority demographic groups. Oral health integration models are improving access to and delivery of patient-centered care for some vulnerable populations.

Conclusions and Practical Implications

Coordinated policies and additional resources are needed to further improve access to care, develop dental insurance programs that reduce out-of-pocket costs to lower-income adults, and improve the integration of oral and medical health care delivery targeting a common set of patient-centered outcomes. Dental care professionals need to fully participate in meaningful and system-wide change to meet the needs of the population equitably.

The 2000 surgeon general’s report, Oral Health in America, revealed stark disparities and inequities in oral disease burden and health care access in the United States. 1 In 2003, the surgeon general issued a call to action to address these challenges. 2 Numerous federal and state government programs, professional organizations, and private practices created initiatives to increase the capabilities and diversity of the oral health care workforce, expand collaborations between dental and medical providers, expand dental science and technology, and improve access to care. The 2021 National Institutes of Health report, Oral Health in America: Advances and Challenges, 3 describes advances toward these goals over the past 20 years, along with challenges. The report details the unequal burden of oral health conditions across population groups and highlights promising new directions for health care delivery.

The purpose of the oral health care system is to meet the oral health needs of the entire population. Yet it does not meet the needs of the population at this time, despite advances made since the 2003 call to action. A 2018 guest editorial in The Journal of the American Dental Association described the US dental care system as stuck in a low-level equilibrium, 4 in which the supply of oral health care services matches the effective demand for services, given existing service prices and available community income and financing. The equilibrium is low because there is substantial unmet demand among groups priced out of the system, and the system appears unable to accommodate this unmet demand. Populations with insufficient access to oral health care include adults with no private or public dental insurance; people who are frail or have complex health care needs; people who are lesbian, gay, bisexual, or transgender; people living in Health Professional Shortage Areas; and people living in long-term care facilities. 3

The report highlighted 10 messages that are critical to oral health care practice ( Figure 1 ) and important changes in oral health and access to care, along with barriers that remain unaddressed. Our article highlights key elements of the report, including advances in funding and delivery of oral health care for children, strengthening of the insurance backbone allowing some additional Americans to get oral health care, efforts to improve integration with the medical system, some diversification of the workforce as well as additional practice models, and the continuing challenges in access to oral health care. Funding, medical care integration, workforce, and access are interrelated features of oral health care delivery, and addressing each of these is necessary to creating a well-designed system that equitably meets the needs of the population.

Summary messages for dental practice. HPV: Human papillomavirus. Source: National Institutes of Health. 3

Overall, oral health status has improved somewhat since 2000. 5 The average number of missing permanent teeth has fallen from nearly 6 to less than 3. 6 Edentulism has declined to 2% among working-age adults and 17% among adults aged 65 through 74 years. 6 There has been no improvement in the prevalence of caries and untreated caries. Caries prevalence is similar across income and racial or ethnic groups. However, more than 40% of people who are in low-income groups have untreated caries compared with 9% among those in groups that are not low income, and untreated caries prevalence is 36% among Blacks and 23% among Hispanics compared with 18% among non-Hispanic Whites. 7 Racial disparities persist even after controlling for income.

Nearly 60% of adults 65 years and older have periodontal disease. 8 The prevalence of any periodontitis is higher among low-income and racial or ethnic minority populations than higher-income or White and non-Hispanic populations. Older Americans also have higher prevalence than younger people of medical comorbidities that affect oral health, including hypertension, heart disease, and dementia. 9 , 10 Oropharyngeal cancer prevalence is also increasing, despite reductions in cigarette smoking, primarily owing to the increasing prevalence of human papillomavirus infection. 11

Access to Care and Oral Care Delivery

The percentage of Americans with an annual oral health care visit increased from 2000 through 2018, particularly among children younger than 18 years (from 74% in 2000 to 86% in 2018). 12 Race or ethnicity and income-level differences seen in 2000 were largely erased by 2018. Annual visit rates among older adults increased from 57% in 2000 to 66% in 2018, but rates did not change among adults aged 18 through 64 years (66% in 2018). Differences also persisted across race or ethnicity and income groups for all adults older than 18 years: in 2018, less than one-half of older adults living below 200% of a federal poverty guideline had a dental visit.

Access to comprehensive oral health care continues to be one of the biggest challenges within the oral health care system and a key driver of oral health care inequity. Many Americans regularly seek care for nontraumatic dental conditions in hospital emergency departments that are not equipped to provide comprehensive or definitive oral health care. 13 Most patients seeking care in the emergency department are uninsured, qualify for Medicaid, 14 or are unable to find a dental office that accommodates their work schedule. 15 Others simply cannot afford the high deductibles and co-payments of private dental insurance programs. 16 , 17

During the first year of the COVID-19 pandemic, it became evident that dentistry was not viewed as an essential health care service. Dental practices were largely closed to nonemergency care. The American Dental Association leadership responded, assuring Americans, “Dentistry is an essential health care service because of its role in evaluating, diagnosing, preventing or treating oral diseases, which can affect systemic health.” 18 As of 2018, 75% of oral health care services were diagnostic or preventive, and 12% were restorative. 19

Practice setting

As of 2018, 91% of active dentists worked in private practice settings. The remainder practiced in dental schools, military and Veterans Administration clinics, community and other public health practices, and hospitals (Health Policy Institute, American Dental Association, unpublished data, August 26, 2019). As of 2021, 46% of private practice dentists were in solo practice. Although solo practice remains the most common setting, group and corporate practices are becoming more common, with over 10% of dentists affiliated with a dental support organization (DSO). 20

Private Practices

Private practices typically serve patients who are privately insured or able to self-pay for care; less than 40% of dentists accept Medicaid or Children’s Health Insurance Program (CHIP) payments. Private practices are located predominantly in highly populated, affluent regions. This results in more than 600 Health Resources and Services Administration–designated dental Health Professional Shortage Areas nationwide; many are rural areas with a combined population of more than 34 million people. 21 , 22 Rural populations also have longer travel times to providers and lower rates of insurance coverage 22 ; together, these factors make rural residents less likely to use preventive services and more likely to use emergency care. Racial or ethnic disparities in dental outcomes are also larger in rural areas. 23 , 24 , 25

Safety Net Clinics

Safety net clinics, including dental schools and federally qualified health centers (FQHCs), serve as care delivery sites for millions of adults and children who are uninsured or enrolled in public insurance. From 2001 through 2020, the number of people obtaining oral health care at FQHCs increased from 1.4 million to 5.2 million; in 2017, one-third of these patients were younger than 18 years. 26 Of these, 88.5% were Medicaid or CHIP beneficiaries. Although all FQHCs are required to provide dental services, some rely on referral mechanisms. 27

DSOs provide centralized practice management and group-purchasing services to affiliated dentists. A 2017 survey of 47 DSOs found that 61% of affiliated dentists had patients who were Medicaid or CHIP beneficiaries, and 43% cared exclusively or almost exclusively for Medicaid and CHIP beneficiaries. 28 Thus, DSOs have become a substantial contributor to the dental safety net.

School-Based Oral Health Programs

School-based oral health programs, whether stand-alone or integrated with other health services, improve access to oral health care for students, deliver preventive services, improve oral health literacy, and connect students and families to a dental home. However, scope-of-practice laws in many states limit the effectiveness of school-based programs by requiring either an on-site dentist or a dentist’s prior examination for students to receive services in these efficient settings. Other challenges for these programs include getting consent forms signed and returned and avoiding interference with existing dentist-patient relationships.

Oral Health Integration

The separation of oral health care from the broader health care system began with the compartmentalization of dental and medical education, which led to distinct delivery, coding, and payment systems. 29 Recognizing the relationships between many oral and systemic health conditions and their treatment, in 2003 the surgeon general called for integration of oral and general health care to meet the needs of the population. 2 After this call to action, numerous models were developed, many following the road map provided by the federal Oral Health Strategic Framework, with financial support from the Health Resources and Services Administration. 30 , 31

The Integration of Oral Health and Primary Care Practice 32 and the Oral Health Delivery Framework 33 models focus on improving access to care by providing risk assessment, caries prevention, patient education, and referrals for patients in smaller towns receiving services in safety net settings, using interprofessional practice collaborations. 27 , 34 , 35 , 36 Oral Health Delivery Framework sites successfully integrated oral health screenings and fluoride varnish application into medical visits, followed by a dentist referral.

Commercial insurers and health systems have used integration to provide patient-centered care, improve patient health, and reduce costs. 34 , 37 Insurers have used integration to provide dental examinations and prophylaxis to pregnant women, children, and adults with medical comorbidities. 38 , 39 , 40 Health systems that combine care delivery and coverage have used clinic colocation, shared clinic workflows, and fully integrated electronic health records to facilitate integration of care and improved quality measures 41 ; fully integrated dental offices were found to double care-gap closure for older adults compared with nonintegrated offices. 42

Despite progress, barriers at multiple levels limit more widespread integration of oral and medical health care delivery. 34 , 43 Clinical barriers include perceived limits to scope of practice between dental and medical providers, inadequate cross-discipline training, concerns about patient acceptance, and limited demonstration of clinical effectiveness. 34 Technical barriers include lack of time and facility space and incompatibility of electronic records systems. 34 Federal policies to increase access to care and implement quality measures associated with integration of oral and general health care for children were set in place by the Patient Protection and Affordable Care Act (ACA), 44 but integration and access to care efforts for adults have lagged owing to the exclusion of comprehensive adult dental benefits in most Medicaid programs and absence of a universal, comprehensive Medicare dental benefit. 45 , 46

Insurance Coverage and Financing

The percentage of Americans covered by dental insurance grew from 55% in 2009 to 80% in 2019. These increases in coverage resulted primarily from the expansion of Medicaid and CHIP and benefits extension for young adults to age 26 years in 2010 after the passage of the ACA. 47

From 2011 through 2014, 56% of people with private dental insurance had a dental visit in the past 12 months compared with 33% of those with public insurance and 26% of those with no insurance. Among children with Medicaid and CHIP coverage, use of dental services nearly doubled from 2009 (28%) through 2020 (50%). 48 However, the ACA’s successes have not reached all underserved populations. 49 Extending benefits to young adults (aged 19-25 years) in 2010 accounted for most of the increase in annual dental visits. 50 Use increases may have been limited by dentist supply constraints, low rates of Medicaid acceptance, and poor oral health literacy. 49 Furthermore, many of the improvements since 2010 largely reversed negative trends seen from 2000 through 2010. For example, data show improvements in rates of delayed or nonreceipt of needed oral health care from 2000 through 2018 for children and young adults, but rates have not improved for adults overall and have doubled for older adults ( Figure 2 ).

Delay or nonreceipt of needed oral health care during the past 12 months due to cost, by selected age group: United States, 2000-2018. Source: National Center for Health Statistics. 12

Cost continues to be a major barrier to receiving oral health care. Unlike medical insurance, under which 89% of costs are covered by insurance and preventive services are fully covered, dental out-of-pocket costs can exceed 40% for insured patients. 51 Financial barriers play a larger role in access to oral health care than for any other type of health care; almost 25% of adults with incomes below the federal poverty guideline deferred needed oral health care because of cost in 2014 and 2015. 16 Furthermore, the Centers for Medicare & Medicaid Services accounted for 37% of medical care spending but only 10% of dental care spending in 2019. 51 This stark difference suggests that the oral health care needs of many vulnerable populations are not addressed adequately by current programs.

Most adults who qualify for Medicare and Medicaid lack dental insurance. Medicare offers essentially no dental benefit, although Medicare recipients may purchase dental benefits from a Medicare Advantage (MA) plan, if one is available. In the past 20 years, enrollment in MA plans increased from approximately 7% to 34% (covering ≈ 22 million people). 52 Approximately two-thirds of MA enrollees have a dental benefit; this increased coverage and access has benefited primarily higher-income older adults, increasing disparities in oral health care delivery. 53 As of 2019, 19 states and the District of Columbia provided extensive adult dental benefits under Medicaid, 15 provided limited benefits, 12 provided emergency-only benefits, and 4 offered no benefits. 54 Lack of dental insurance has been shown to transfer unmet oral health care costs to the medical system through patients’ higher use of emergency and urgent-care services.

The Dental Workforce

In 2022 in the United States, there are more than 200,000 active dentists, or approximately 61 dentists per 100,000 residents, ranging by state from 41 per 100,000 in Alabama through 104 per 100,000 in the District of Columbia. 55 There are also approximately 194,000 dental hygienists, 312,000 dental assistants, and 30,000 dental laboratory technicians. 56 , 57 , 58 Most dentists (80%) are in general practice, with the remainder spread between 12 dental specialties, including new specialties of dental anesthesiology (2019), oral medicine (2020), and orofacial pain (2020). 55 Since 2000, the supply of dentists has increased by 23%. The largest increases have been among pediatric dentists (103%) and endodontists (42%), whereas the number of dental public health specialists fell by 14%.

The 2003 surgeon general call to action sought efforts to increase the diversity of the dental workforce to better reflect the demographics of dental patients. 2 Such efforts have had some success over the past 20 years. The number of women enrolling in dental schools has increased substantially; women now make up approximately one-half of dental school graduates and are expected to make up one-half of active dentists by 2040. 59 Efforts to increase the racial and ethnic diversity of the dental workforce have had less success. There is a higher percentage of practicing dentists who are White or Asian than in the general population, whereas Black and Hispanic dentists are underrepresented. 60 Since 2000, there have been modest increases in dental school enrollments among Hispanics. Enrollment rates from other historically underrepresented races and ethnicities (HURE) have remained stagnant, despite increases in the number of applicants. HURE graduates also incur higher educational debt on average than non-HURE graduates; thus, education costs may be a disincentive to apply or enroll. 61

The call to action identified the need for improved access to primary oral health care for low-income and racial or ethnic minority populations. 2 Allied dental care professionals, such as hygienists and dental therapists, can facilitate care for vulnerable populations who face barriers in seeking care. 62 , 63 In many states, scope-of-practice laws restrict these providers from caring for patients in accessible settings. 64 Efforts to change these laws have had limited success. Thirteen states now allow dental therapists to practice, but they are active only in 5 states. 62

Moving Forward

The 2021 Oral Health in America report showed that although important advances were made in oral health care workforce development, delivery, and financing over the past 20 years, these advances have been insufficient to solve the problems of cost and access to oral health care services. 3 We highlight 3 strategies discussed in the report that could help advance dental practice toward equitably meeting the oral health care needs of the US population.

Strategy 1. Make dental care services an essential benefit for private and public insurance

The dental financing model does not afford all Americans equal access to oral health care and diminishes oral health’s value in the overall health care system; payment reform is necessary to increase access and quality of care and reduce health disparities. 4 Although there have been improvements for children, increases in dental insurance coverage over the past 20 years have largely bypassed Medicare beneficiaries, Medicaid-eligible adults, and insured people who cannot afford the high out-of-pocket costs of their plans. Including oral health care in comprehensive health coverage can increase oral health care access and reduce overall health costs. 65 The US economic recovery depends on a healthy workforce, and oral health is an essential component of health.

Major financing reform of medicine in the United States has come largely through publicly funded programs. To bring about insurance reform in oral health care, insurers, working with public and private purchasers, dental and dental hygiene groups, and public health professionals at the state and federal levels, must identify and implement payment reform pilot programs to show the value of such reforms for improving the US population’s oral and general health.

Many have supported integrating a Medicare dental benefit into Medicare Part B outpatient medical coverage 53 , 66 to further promote the integration of medical and oral health care, adoption of oral health care quality measures, and participation of dental practitioners in accountable care organizations. Means testing could be used to reach at least low-income enrollees. However, a means-tested benefit, beyond existing tests to set premiums and co-payments, could leave services unaffordable to some enrollees and could limit dentists’ enrollment as Medicare providers, thereby increasing the burden on resource-constrained safety net providers. 53

In addition to establishing an essential dental benefit for adults, federal and state policy makers could support patient demand and provider acceptance and reduce out-of-pocket costs by increasing reimbursement rates for publicly funded dental benefits.

Strategy 2. Incorporate dental or oral health care services demand into workforce planning

The 2003 call to action suggested incorporating the future demand for oral health care services into workforce planning. Others have repeated these calls. 67 , 68 There is no estimate of the optimal number of general dentists, specialists, or allied dental providers for the population. It is not known whether the current workforce size meets the current demand for care, but it is clear that expanding dental coverage will increase demand for services and exacerbate any existing supply constraints, particularly for primary oral health care.

The US population is aging and becoming more urban and racially and ethnically diverse. 69 These trends are likely to exacerbate existing inequities in access to oral health care services associated with inadequate insurance coverage, place-based limits on dental services, and lack of diversity in the oral health care workforce. Policy makers and dental education administrators will need to be forward thinking to align the capabilities and demographic characteristics of the oral health care system workforce with the future demand for care. The complex care needs of an aging population would support the establishment of federally supported dental specialty and hygiene training programs in geriatric oral health and patients with special health care needs with clinical training incorporated into assisted living and other long-term care facilities.

Strategy 3. Increase the integration of oral and medical care delivery

Oral health integration is a key strategy for improving oral health care access, quality, and outcomes. Increasing prevalence of medical comorbidities will increase the importance of medical-dental integration to effectively manage patient care needs. A newly established partnership between the Centers for Disease Control and Prevention and the National Association of Chronic Disease Directors should help create a national medical-dental integration framework. 70 2019 updates to the patient-centered dental home concept include integration of standardized definitions and performance measures, which may help integrate care for defined populations. 71 Additional models of care delivery, even in rural settings, are showing promise. 72

To achieve the promise of oral health integration and better align oral and medical health care delivery, interprofessional partnerships between dental and medical practitioners are needed. In addition, the long-standing system-level barriers that perpetuate the separation of dental and medical professions, education, care, and payment systems need to be addressed. 73 Dental and medical education share a common scientific foundation. Integrating dental and medical education programs and internships could improve cross-disciplinary knowledge and create champions for oral health integration into primary care. 74 , 75 , 76 Oral health care and payment systems also need to focus more on oral health outcomes and less on procedures. 4 Some integrated health systems already have adopted quality measures for oral health, but change is slow among independent dental providers. 77 The use of a common dental and medical diagnostic coding system would support the extension of quality measures.

The lack of interoperability of electronic dental and medical records is a major barrier to communication and integration. 41 , 78 Independent dental practices depend primarily on patient self-reported health status and treatment history. A 2019 comparison of parent-reported health information in children’s dental records and their actual medical records showed substantial reporting errors. 79 Enabling web-based access to patient medical charts, such as through the Care Everywhere website, 80 would improve the accuracy of information available to dental providers, informing treatment decisions. It also may improve communication between dental and medical providers. Policy makers should support efforts to provide online access to patients’ medical charts.

Conclusions

The US oral health care system requires major changes to meet the needs of the population equitably. The opportunities described in the Oral Health in America report and highlighted above are mutually dependent. Public and private stakeholders need to coordinate a meaningful and systemwide approach to eliminating barriers and inequities in oral health care access, reducing costs, and improving oral health outcomes for Americans.

Biographies

Dr. Fellows is a senior investigator, Kaiser Permanente Center for Health Research, Portland, OR.

Dr. Atchison is a professor, School of Dentistry and Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA.

Dr. Chaffin is the chief dental officer, Delta Dental of Iowa, Johnston, IA.

Dr. Chávez is the director, Pacific Center for Equity in Oral Health Care, and a professor, Department of Diagnostic Sciences, University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, CA.

Dr. Tinanoff is a professor, Department of Orthodontics and Pediatric Dentistry, University of Maryland School of Dentistry, Baltimore, MD.

This article has an accompanying online continuing education activity available at: http://jada.ada.org/ce/home.

Disclosures. None of the authors reported any disclosures.

ORCID Numbers. Jeffrey L. Fellows: 0000-0001-8839-2851; Norman Tinanoff: 0000-0002-6810-7432.

The authors thank Neon Brooks for her substantive and timely editing of manuscript drafts and Kelly Jewell for her administrative help organizing citations.

Any statements or conclusions presented in this article are those of the authors.

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Elektrostal

Elektrostal Localisation : Country Russia , Oblast Moscow Oblast . Available Information : Geographical coordinates , Population, Area, Altitude, Weather and Hotel . Nearby cities and villages : Noginsk , Pavlovsky Posad and Staraya Kupavna .

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Elektrostal Demography

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PEKIN, Elektrostal - Lenina Ave. 40/8 - Restaurant Reviews, Photos & Phone Number - Tripadvisor

• Victor Mukhin

Victor M. Mukhin was born in 1946 in the town of Orsk, Russia. In 1970 he graduated the Technological Institute in Leningrad. Victor M. Mukhin was directed to work to the scientific-industrial organization "Neorganika" (Elektrostal, Moscow region) where he is working during 47 years, at present as the head of the laboratory of carbon sorbents.     Victor M. Mukhin defended a Ph. D. thesis and a doctoral thesis at the Mendeleev University of Chemical Technology of Russia (in 1979 and 1997 accordingly). Professor of Mendeleev University of Chemical Technology of Russia. Scientific interests: production, investigation and application of active carbons, technological and ecological carbon-adsorptive processes, environmental protection, production of ecologically clean food.   

Title : Active carbons as nanoporous materials for solving of environmental problems

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Oral Health Surveillance Report, 2019

This surveillance report provides national estimates for selected measures for oral health status during 2011–2016, examines changes since 1999–2004, and highlights disparities in oral health by certain sociodemographic characteristics. Measures include the prevalence and severity of dental caries in primary and permanent teeth (for those aged 2 years or older), the prevalence of dental sealants on permanent teeth in children and adolescents (aged 6–19 years), and tooth retention and edentulism (total tooth loss) among adults (aged 20–64 years) and older adults (aged 65 years or older). This report, which provides estimates from 2011 to 2016, builds on findings of earlier data briefs or studies that also examined oral health status and disparities among specific populations in the United States. 7,9,11,20,21

Selected Findings

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• Oral Health Surveillance Report 2019 (Print-friendly) pdf icon PDF - 5.1 Mb
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Suggested Citation: Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016 . Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2019.

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