Convened November 18–19, 2024

Advancing Oral Health Across the Lifespan
Proceedings of a Workshop—in Brief

Oral health is essential to general health and well-being, but an epidemic of oral diseases is affecting populations of all ages. To explore innovative practices and models for advancing oral health across the lifespan, the National Academies of Sciences, Engineering, and Medicine’s Board on Health Care Services hosted a hybrid workshop on November 18-19, 2024.¹ Topics touched on during the workshop included the myriad factors that impact oral health across the lifespan including policy, payment models and insurance coverage, infrastructure, data systems, workforce, education and training, preventive care, disparities, continuity and coordination of care, and community engagement.

INTRODUCTION

An estimated 108 million people in the United States see a medical care provider each year but not a dentist, and roughly 27 million people visit a dentist but not a medical care provider (Vujicic and Fosse, 2022). To Anita Glicken (National Interprofessional Initiative on Oral Health), this represents 108 million missed opportunities for primary care providers to engage their patients in preventive oral care, education, and screening, and to refer them to dentists for identified disease. She further noted the untapped potential of the dental profession to contribute to screenings, management, and co-management of chronic oral diseases. In addition, access to dental care remains problematic, with over 57 million Americans living in areas with dental professional shortages and over 67 million lacking dental coverage (CDC, 2024).

IMPROVING ORAL HEALTH: A GLOBAL PERSPECTIVE

Marko Vujicic, American Dental Association Health Policy Institute, said he believes the world is on the verge of a golden age for health care policy. The World Health Organization (WHO), for example, has highlighted the significance of oral health to overall health and the substantial unmet need for oral health care. WHO has issued a global strategy and action plan on universal coverage for oral health by 2030. In the United States, children, but not adults, are covered by core health insurance programs under the Affordable Care and Patient Protections Act. However, the Child Health Insurance Program (CHIP) is a separate insurance program for children that offers dental health coverage.

There is a strong economic argument for investing in oral health, said Vujicic, including the impact of poor oral health on employment and productivity. Vujicic and his colleagues calculated that productivity losses resulting

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¹ The workshop agenda and presentations are available at https://www.nationalacademies.org/event/43388_11-2024_advancing-oral-health-across-the-lifespan-a-workshop (accessed December 13, 2024).

from unmet oral health care needs cost the global economy $323 billion annually, not including additional costs incurred by the medical care system.

“The high level of unmet oral health care needs is rooted in health policy choices,” he said, adding that the lack of mandatory adult coverage for dental care in the United States is a prime example. Vujicic said surveys have shown that people know dental health is important for their overall health, but they cannot afford dental care. However, he is optimistic that momentum is changing sides on dental coverage for adults, given the value propositions that should help persuade policy makers.

OVERVIEW OF AMERICA’S FEDERAL ORAL HEALTH POLICIES AND PROGRAMS

Michael Johnson, U.S. Public Health Service (USPHS), presented on the Oral Health Coordinating Committee’s (the Committee) role to assist the USPHS in meeting its responsibilities to promote the oral health of the U.S. public across federal agencies and between the public and private sectors. The Committee comprises 14 federal agencies. Its Oral Health Strategic Framework 2024–2029 is under review by the Office of the Surgeon General. Evidence is needed, he said, in order to change policy.

Natalia Chalmers, Centers for Medicare & Medicaid Services (CMS), said Medicare, by law, generally cannot pay for most dental services. For beneficiaries enrolled in Medicare Advantage, dental services can be offered as a supplemental benefit. Starting in 2025, states are permitted, but are not required, to submit applications to update their essential health benefits benchmark plans to include adult dental coverage effective plan year 2027.

Though the Medicare statute generally prohibits payment for most dental services, Chalmers said an exception is when a dental service is inextricably linked to, and substantially related and integral to the critical success of, a covered medical service. CMS has implemented a process for the public to present evidence to CMS for instances where dental services are inextricably connected to covered medical services. Through that process, Medicare has identified clinical scenarios under which payment may be made for oral evaluations and necessary treatments for patients with a variety of conditions, including organ transplantation, cardiac valve replacement, head and neck cancer, and undergoing chemotherapy. In 2025, Medicare may provide payment for certain dental services for Medicare beneficiaries receiving dialysis for end-stage renal disease.

Chalmers explained that half of the child beneficiaries in Medicaid and the CHIP did not see a dentist, despite availability of this insurance coverage. Human-centered design initiatives with Medicaid beneficiaries identified several barriers to accessing dental care, such as lack of childcare and transportation. Chalmers said a comprehensive national oral health strategy could address some of these barriers by meeting people where they are to improve coordination of care, as can happen at federally qualified health centers (FQHCs) that offer dental and medical services.

To advance the oral health policy agenda, CMS has created a first-of-its-kind cross-agency workgroup that works across Medicare, Medicaid, and Marketplace. The goal, said Chalmers, is to align understanding of the role of oral health in all CMS programs and for all its beneficiaries.

Gina Thornton-Evans, Centers for Disease Control and Prevention (CDC), said one critical role for CDC’s Division of Oral Health is to fund state oral health programs that monitor the burden of disease, examine associations with chronic conditions and oral health outcomes, increase access to evidence-based preventive dental services, and increase awareness of infection prevention and control guidelines. CDC relies on its national partners to support the states in these efforts and provide technical assistance, resources, and surveillance and evaluation support. Her division also funds Good Health and Wellness Programs in Indian Country across 27 Native American tribes and in U.S. territories.

The Division of Oral Health, said Thornton-Evans, leads state and national data collection to monitor oral disease burden, related risk factors, and access to preventive dental services. Collaborative work includes examining dental visits and smoking status with the CDC Office of Smoking and Health; the incidence, trends, stage at diagnosis, and five-year relative survival of oral and pharyngeal cancers with the Georgia Department of Public Health; and the effect of the COVID-19 pandemic on

dental care provider availability and access to care among Medicaid beneficiaries with CMS.

The goal of the National Institute of Dental and Craniofacial Research (NIDCR) is to “advance fundamental knowledge about dental, oral, and craniofacial health and disease and to translate these findings into prevention, early detection, and treatment strategies to improve oral health for everyone, for every community across the full lifespan,” said Jennifer Webster-Cyriaque, National Institute of Dental and Craniofacial Research (NIDCR). NIDCR’s Data-Driven Science Hub is a knowledge base for dental, oral, and craniofacial research and integrate molecular- to population-level data with overall health data. The idea is to facilitate evidence-based interventions without requiring randomized, controlled trials and to provide data for NIDCR’s signature initiatives.²

In the public health area, NIDCR is part of a trans-National Institutes of Health effort to establish a primary care-focused, disease-agnostic clinical research network. This effort includes establishing a more comprehensive understanding of the different factors or barriers that impact oral health. This will help identify upstream interventions to improve oral health. It also creates the opportunity to study whole-person health, chronic comorbid conditions, and oral health as a modifiable risk factor. To deploy the interventions this research generates, NIDCR established its Community-Based Participatory Research Consortium to combine collaborative, community-based intervention projects with data mining to evaluate population-based strategies to reduce oral health disparities.

Both NIDCR³ and the CDC’s Division of Oral Health⁴ fund dental public health training programs. These programs increase the size of the dental health workforce, and its involvement in research and amplifies the effects of its existing dental practice-based network.

OVERVIEW OF STATE-LEVEL ORAL HEALTH POLICIES

Despite progress over the past 25 years in increasing access to dental care, institutional barriers still impede access to quality care for all Americans. Mary Foley, Children’s Health Insurance Program Dental Association, highlighted that addressing these barriers requires preserving the nation’s public health infrastructure, advancing integration by using technology, improving data collection to monitor health outcomes, and containing costs. Foley noted the need to move beyond one-size-fits-all programs to develop and implement programs that meet the specific needs of individuals.

Preserving the nation’s public health infrastructure, said Foley, requires breaking down silos and integrating the efforts of over a dozen agencies that address public health today. Infrastructure and policy need to be integrated at the state level, too, she said, adding that state Medicaid programs have failed to connect their Medicaid beneficiaries to the public health and social services agencies that address social risk factors. “We do not believe that dentists should have to find meals or housing for their patients,” said Foley. “We believe these services need to be identified and addressed at the systems level.”

Foley said the move to managed care in Medicaid presents an opportunity to arrange these services using the initial health assessment that federal law requires for Medicaid beneficiaries. Managed Medicaid plans have the infrastructure and staff to coordinate medical, dental, and social services and be accountable for them, she said, noting that health care integration at the provider level also offers the opportunity for collaboration when connected through technology.

Foley noted the need to enhance data collection to improve health outcomes and acknowledged the data initiative Webster-Cyriaque discussed would do just that. She added that the new International Classification of Disease, tenth edition, service provision codes for dental procedures will allow examination of a person’s status when they first arrive for care and their oral health outcome is after receiving care. She also said an increase in Medicaid reimbursement rates in California did not change care provider enrollment, though it has helped sustain practices that see Medicaid beneficiaries.

Oral Health Ohio is a state coalition that advocates for systems to prioritize oral health to close gaps across the lifespan. Marla Morse, Oral Health Ohio, emphasized

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² https://www.nidcr.nih.gov/news-events/nidcr-news/2023/nidcr-primed-move-ahead-impact-institute-awards-14-million-tackle-unsolved-clinical (accessed March 6, 2025).

³ https://www.nidcr.nih.gov/grants-funding/grant-programs (accessed March 21, 2025).

⁴ https://www.cdc.gov/oral-health-funded-programs/funding/oral-health-program-funding.html (accessed March 21, 2025).

how policymakers need to hear from a variety of voices to create effective oral health policies. Toward that end, Morse’s organization held conversations with various communities and used that input to develop a state oral health plan that addresses oral health from birth to old age. “By examining oral health across life stages, we can better understand what I am going to call the cliffs as people [progress] through different stages of their lives,” said Morse. For example, certain children, such as those in foster care or with a disability, are at risk of losing oral health coverage when transferring from a pediatric to an adult system. Another cliff occurs when people turn 65 and lose a dental benefit their commercial insurance may have provided.

Morse said a broad coalition elevated the importance of oral health to policymakers, resulting in a 93 percent increase in payment for most dental services, which marked the first dental fee increase in Ohio in over 20 years. Her organization is also building a comprehensive approach to tele-dentistry to provide oral health care across the lifespan.

Scott Darius, Florida Voices for Health, said his statewide health advocacy organization’s main function is capturing health care stories from Floridians and sharing them with lawmakers, the media, and communities.

Florida Voices for Health’s theory of change, he said, is to listen to the stories of people who have given up on trying to use these systems, which encourages them to return. These stories also help provide context to policymakers for the quantitative data, which often has limited ability to create a comprehensive picture of the challenges faced by their constituents. Getting the right storytellers in front of the right legislators helped get an increase in Medicaid reimbursement rates in 2023.

Darius said the effect of poor oral health is felt across demographic groups, political ideologies, and socioeconomic status, creating the opportunity to organize across communities and engage decision makers. He hopes his organization’s network, through storytelling, can create and share a cohesive narrative that transforms public health in the United States. Darius also noted how networks, such as OPEN Communities,⁵ allow states to collaborate and borrow ideas from one another.

One in four people in the United States have a disability, and a greater proportion of people in households experiencing disability rate their oral health as fair to poor compared with those in households not experiencing disability (Carequest Institute for Oral Health, 2022). John Kemp, Lakeshore Foundation, explained how individuals with a disability have a higher prevalence and severity of oral disease compared to the general population while also facing significant barriers to accessing care. One barrier relates to the lack of training of care providers regarding disability. For example, Kemp stated that over 80 percent of U.S. physicians believe people with a disability have a worse quality of life than individuals without a disability (Iezzoni, et al., 2021). Only in 2018 did the American Dental Association (ADA) update its ethics code to prohibit denying care for patients with disabilities. A second barrier is the gap in insurance and coverage for people with disabilities. Medicaid coverage for oral health care is inconsistent across states, and many children with disabilities lose coverage upon reaching adulthood.

Several potential solutions are on the horizon for advancing oral health care access, said Kemp. A growing number of dental schools, for example, are training students to provide oral health care for people with disabilities. Incentives for professionals to serve communities with inadequate access and improvements in reimbursement policies to account for the additional time needed to treat people with special health care needs are also promising mechanisms for change. Finally, efforts to advocate for all state Medicaid programs to cover comprehensive oral health for adults are producing change.

SUPPORTING ALL INDIVIDUALS TO IMPROVE THEIR ORAL HEALTH

Lisa Holderby-Fox, University of South Carolina, said community health workers (CHWs) are front-line health workers with a close understanding of the communities they serve, which are often where they live. They have shared the same struggles as their community members and function as intermediaries between the community and health care and social systems. CHWs are not medical or oral health care practitioners, but they are information sources, liaisons, and facilitators who help community members find solutions to their access challenges, such as finding transportation options.

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⁵ https://communities.openoralhealth.org/s/ (accessed February 07, 2025).

CHWs, said Holderby-Fox, improve the quality and cultural competence of service delivery, and they are the most diverse component of the public health workforce. CHWs build individual and community capacity by increasing health knowledge and self-sufficiency through outreach, community education, informal counseling, social support, and advocacy. CHWs have embraced core competencies that include outreach, communication skills, facilitating access to services, and health literacy. CHWs also engage in continuing education, which is where they receive training in oral health, and have embraced the Smiles for Life Front Line Health Worker curriculum. Currently, though, there is no national credential for CHWs.

Dentists and university dental programs are not addressing the upstream causes of disparities in oral health care. To do so, Elisa Chavez, University of the Pacific, suggested the dental community needs to work with local organizations, reach out to patients who cannot come to the dental office, and increase dental students’ awareness about the challenges these populations face. “Unless there are opportunities for them to see the problems firsthand, it is hard for them to grasp just talking about the problem in a lecture,” said Chavez. Chavez said opportunities exist for educational and practice outreach via screening and service events, providing extramural rotations to underserved areas, creating loan repayment programs for service, and increasing and focusing recruitment efforts to attract a diverse workforce.

To address the shortage of dental hygienists, her institution created a remote dental hygiene program that California’s Dental Hygiene Board has now approved. The idea, said Chavez, is to create cost-effective opportunities for capable people who cannot or do not wish to leave their communities for dental education. Using community health centers as clinical educational sites can increase the capacity for patient care and develop future care providers who are committed to and know the community and are more likely to remain there to serve the community, which increases capacity. This program will provide students with the prerequisite training they need to eventually become registered dental hygienists in alternative practice, a designation for dental hygienists with specialized training to provide dental care outside of a dental office.

Chavez said recognizing dental schools as part of the safety net would help reduce costs of dental education and help better leverage schools as a community resource. Medicaid, for example, pays for about 80 percent of the procedures at her institution, which is also where many individuals who do not qualify for Medicaid but have limited resources receive their dental care, including specialty services.

Maria Ryan, Colgate-Palmolive Co., said supporting patients and their communities to improve their oral care and access to oral health services requires getting oral health on the global health agenda, something she is working on by participating in the Global Health Equity Network,⁶ World Economic Forum,⁷ and Oral Health Affinity Group.⁸ The latter issued a report in May 2024 calling for action in four areas:

• Adopt health financing policies that improve coverage, access and affordability of oral health care services.
• Promote health care service delivery models that integrate oral health care services into primary, secondary, and tertiary care.
• Develop innovative health and oral health workforce models, including training and remuneration, that allow for flexibility in addressing oral health needs.
• Implement policies that promote upstream interventions focusing on prevention, health promotion and healthy behaviors, versus costly downstream treatment of oral disease.

It is also important, she said, to address low oral health literacy and promote self-care, something Ryan’s company’s Bright Smiles, Bright Futures^® program has been doing for over 30 years.⁹ In 2021, Colgate-Palmolive launched the Know Your OQ™ program,¹⁰ a free, inter-

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⁶ https://initiatives.weforum.org/global-health-equity-network/home (accessed February 7, 2025).

⁷ https://www.weforum.org/ (accessed February 7, 2025).

⁸ https://initiatives.weforum.org/global-health-equity-network/home (accessed February 7, 2025).

⁹ https://www.colgatepalmolive.com/en-us/community-impact/bright-smiles-bright-futures (accessed February 7, 2025).

¹⁰ https://www.knowyouroq.com/ (accessed February 7, 2025).

active assessment¹¹ people can take to learn their oral health quotient¹² and get information and resources to learn about oral health and how to improve their score. Her team has learned that people will act if taught why oral health is important; the preventive strategies they can take, such as why fluoride is helpful for preventing caries; the signs and symptoms of oral disease; and the places they can receive oral health care.

Improving the oral health of communities requires partnerships to create the right programs and products, said Ryan. Her company, for example, partnered with the Care Center for Persons with Disabilities Personalized Care Suite at the University of Pennsylvania to develop and test a smartphone app that successfully engages younger users and helps them establish good brushing habits.

Paul Glassman, California Northstate University, said dental practices are sophisticated, high-cost surgical suites that are costly to operate and not necessary to deliver the care most people need. In many communities, there are too few dentists. These dentists have limited capacity to serve everyone, so working harder to get people to dental practices will not solve the access problem. One strategy Glassman has taken is to develop a virtual dental home using dental hygienists and geographically distributed, tele-health connected teams in residential facilities, schools, and nursing homes.

Using the Smart Scan system developed by Dental.com, which uses artificial intelligence to analyze photos school staff takes of children’s mouths and a remote dentist to issue a final assessment, Glassman and his collaborators have shown they can identify children who need care without requiring an on-site oral health professional.

Glassman’s team also worked with CHWs and home visiting agencies to perform oral health assessments in the home for children up to age five. CHWs working directly with families provide effective education and support for adopting mouth-healthy habits, and in California, they can apply fluoride varnishes during home visits. Expanding the oral health system in this way and integrating it with educational systems, social service systems, care delivery systems, and CHWs will have a larger effect than focusing on integrating oral health care with primary care or other parts of the health care system, he said.

Glassman’s team also developed a program to shorten the wait time for people with disabilities who require sedation or general anesthesia to receive care. This program integrates oral health services with social service systems to bring dental services to these individuals where they live.

Cristin Kearns, University of California, San Francisco, highlighted how the sugar industry conducted a decades-long campaign to minimize or ignore dietary sugar as a cause of tooth decay and health conditions, such as type 2 diabetes and heart disease. It was only in 2015 that WHO endorsed a limit on sugar consumption.

Kearns said no U.S. age group meets the goal of limiting added sugar to less than 10 percent of daily caloric intake, raising the question of why dental organizations are not advocating for and implementing evidence-based sugar-reduction policies. She asserted that dental caries prevention should be understood as an important health issue.

During the discussion following the presentations, several workshop participants suggested reaching children through Head Start programs and including oral health questions in social determinants of health screens, particularly those conducted by CHWs and home health workers. Other participants noted the importance of reaching children as young as possible to forestall developing serious and expensive dental disease and of promoting good oral health through many avenues. For example, the Women, Infants, and Children program was identified as an opportunity to provide oral health information to pregnant women and young children.

INCREASING ACCESS TO ORAL HEALTH CARE

Shenam Ticku, Harvard School of Dental Medicine, discussed the 100 Million Mouths Campaign¹³ for integrating oral health into primary care training. In 2016, research from the HRSA-funded Center for Integration of Primary Care and Oral Health showed that most primary

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¹¹ Available at https://www.knowyouroq.com (accessed December 13, 2024).

¹² Oral health quotient is a score from a questionnaire developed by Colgate-Palmolive that tests an individual’s understanding of how oral health, physical health, and mental well-being are connected.

¹³ https://cipcoh.hsdm.harvard.edu/one-hundred-million-mouths-campaign (accessed February 25, 2025).

care curricula included only one to three hours of oral health content, with most training programs acknowledging that their graduates were not competent in oral health. The exceptions were programs with an oral health education champion and formal relationship with a dental school, residency, or hygiene program (Ticku et al., 2020).

This finding, said Ticku, led to an effort to recruit and train an oral health champion in every U.S. state. These individuals engage with primary care training programs in their state, including those for nurse practitioners and physician assistants, and develop oral health champions in each program. Starting with six states in 2020, the program now has champions from various disciplines in 26 states across the nation (Ticku et al., 2023).

Ticku said the program recruits approximately six champions a year. Training starts with a two-day, four-hour workshop and includes discussions on how to approach a primary care training program, make the case for oral health, and evaluate the oral health curriculum. At monthly meetings, champions share best practices and discuss barriers and challenges while the campaign provides technical assistance.

Once trained, the champions engage with primary care training programs to include a sustainable oral health curriculum. Ticku said to date the 26 champions have engaged with more than 130 programs affecting over 9,000 learners.

Karlynn Sievers, Intermountain Health, discussed Smiles for Life,¹⁴ an oral health curriculum developed by family physicians to ensure integration of oral health into primary care. This free, web-based curriculum comprises nine modules that cover the relationship of oral and systemic health; child, adult, and geriatric oral health; acute dental problems; oral health during pregnancy; caries risk assessment; silver diamine fluoride application; and the oral exam. There are pre- and post-tests and no-cost continuing education credits for several professions.

Sievers said the program now reaches a wide range of health care professionals, including medical assistants, midwives, pharmacists, CHWs, and dentists. As of 2023, over 230,000 practitioners have registered for the course since 2010, with approximately 25,000 new registrants annually. Smiles for Life plans to provide content that professional schools can use more easily to increase oral health education and find better ways to reach professionals who want more education on oral health.

John Pournoor, Government Analytica, suggested three phases to transforming public health policy, each lasting decades. According to Pournoor, the first phase emphasizes deciding who the health system will cover, ensuring access for those covered, providing sufficient funding, and deciding on covered services. The second phase involves managing health expenditures. The third phase encourages patient autonomy, makes services more patient centered, and ensures consistent quality improvement.

In Minnesota, Pournoor and his colleagues are taking a three-pronged strategy by amplifying the voice of those in favor of a public policy change on issues of oral health care, having those in favor advocate with those who are neutral regarding change, and using public value arguments, data, case studies, and testimonials to counter those against the change. By telling the right story, bipartisan support in the state legislature has resulted in millions of dollars to address dental care deserts in the state.

THE ROLE OF PUBLIC AND PRIVATE PAYERS IN IMPROVING ACCESS AND AFFORDABILITY OF ORAL HEALTH CARE

Scott Hinchee, Altair ACO, described how his Minnesota-based accountable care organization provides services to people with disabilities. Ten of its fifteen member organizations provide the home and community-based services that help those with disabilities live more successfully in their communities, and five member organizations support people’s health with a core focus on people with disabilities, including a dental clinic, its newest member. Part of Altair’s charge is to establish a value-based path that reflects person-centered care.

Hinchee said advocating for an outcome tied to a value-based payment requires measuring the outcome. Toward that end, Altair partnered with Minnesota’s Department of Human Services to analyze Medicare and Medicaid claims data for more than 20,000 people its member organizations serve. These data will enable

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¹⁴ https://www.smilesforlifeoralhealth.org (accessed February 25, 2025).

Altair to see how its services affect people’s health by assessing their use of health care services throughout the system. One challenge going forward will be to ensure the balance between quality outcomes and sustainable system-wide budgets.

Cherag Sarkari, Liberty Dental Plans, said his company’s sustainable, value-based reimbursement model for dental care focuses on preventive service, rewards care providers for health outcomes, and improves patients’ overall long-term health. Clinicians in the program administer a caries risk assessment upon a patient’s voluntary enrollment in the program and every 12 months afterward to determine if a patient’s oral health risk scores have improved. This assessment is an evidence-based approach that measures outcomes correlated with patient risk stratification and aims to eradicate dental disease. The payment model encourages care providers to spend more time with patients to identify underlying risk factors that contribute to poor oral health and reimburses them for additional services, such as motivational counseling, that they provide to moderate and high-risk patients.

Sarkari said this model disrupts the “drill, fill, and bill” mindset, promotes preventive dentistry, and engages patients to take an active role in their own oral health care. The program launched in 2019 as a pilot focused on the child Medicaid population. Over its first six months, more than half the participating patients showed significant improvements in their caries risk profile. Children had a 4 percent reduction in fillings and a 28 percent decrease in root canals and pulpotomies. The company expanded the plan nationally in 2021 and began a pilot program targeting seniors in Ohio. As of August 2024, 45 percent of enrolled patients reduced their caries risk scores, the use of preventive services increased, and restorative and surgical services decreased.

Peter Fuentes, MetLife, explained his company focuses on the commercial space with a value-based model that emphasizes proactive care and limits disease and risk. This program identifies dentists who focus on improved health outcomes for at least 12 patients and designates them as MetLife SpotLite on Oral Health awardees. Any patient can then enter their Zip code into the MetLife provider directory and find one of the 17,000 SpotLite dentists in their area.

This program, said Fuentes, increases care provider satisfaction with network participation, reduces disease and risk for disease for patients by aligning patient and provider objectives, and brings quantifiable benefits for employers. The average cost per member per visit is $165 for SpotLite dentists versus $188 for all others. Over its first year of operation, 80 percent of SpotLite patients received preventive care versus 70 percent for all others, and only 17 percent of patients with SpotLite dentists required restorative care compared to 25 percent for other dentists.

Natalia Chalmers, CMS, said nationally, dental care accounts for approximately 4 percent of U.S. healthcare spending, with CMS spending $26 billion for dental services in 2022, up from $16 billion in 2018. While out-of-pocket spending for medical care is approximately 9 percent, they average 40 percent for dental care, which can vary based on dental coverage. Roughly 60 percent of Medicaid beneficiaries are in managed dental care programs compared to 72 percent in medical managed care.

Chalmers explained that the CMS Center for Medicare and Medicaid Innovation (CMMI) tests alternative payment models that include payment incentives for care providers for taking novel approaches to delivering cost-efficient, high-quality care. CMMI evaluates each model for its impacts on quality of care and changes in spending under the programs. She said that moving to a value-based model takes time, resources, and investments in education and technology. Currently, the majority of dental practices still follow a fee-for-service model.

Richard Berman, University of South Florida, said the best approach would be to focus on one specific customer segment, whether it is people with disability, Medicare beneficiaries, or rural Medicaid beneficiaries. The next step is to assemble a homogeneous group of key partners and identify their particular problem; test one of the new, cost-effective, high-quality models in a demonstration project; and then reward the participating dentists financially, Berman said.

The ensuing discussion session included several comments from workshop participants on incentives to increase dentists’ participation in Medicaid and reward value-based care, though several workshop participants noted the importance of better defining value and developing metrics to measure it. Several participants called for federal reform that would mandate all state Medicaid plans to cover adult oral health care, raise reimbursement, and reduce administrative burden, and for Managed Care Organizations (MCOs) to take a more active role in connecting their members to dental clinics.

Several participants noted that dieticians and nutritionists are a good source for providing oral health advice and called for working more closely with the public health community. One participant commented there was once a vibrant public health dentistry service, but cuts in federal funding have greatly reduced its reach and effectiveness.

ORAL HEALTH CARE FOR DIFFERENT POPULATIONS

Annaliese Cothron, American Institute of Dental Public Health (AIDPH), said her nonprofit’s work is based on community participatory research, with community members as equal partners in a research process they help design. AIDPH focuses on groups that often have limited access to dental care, such as veterans, rural communities, people with disabilities, and LGBTQ+ individuals. Few data exist on the oral health of the latter group, said Cothron, and dental schools do not focus on this population.

Cothron said of the 9 million veterans who receive health care from the Veterans Health Administration (VHA), only 2.2 million are eligible for VHA dental care, with just over 600,000 receiving dental care. Veterans self-report visiting the emergency department at a higher rate than non-veterans, and they self-report high rates of dental pain and tooth loss. Those with dental pain have lower productivity in the workplace.

Cothron offered several suggestions, including:

• Collect data on clinical outcomes for these populations in surveillance systems;
• Fund research, education, and advocacy to address gaps in resources and knowledge; and
• Proactively protecting the current public health infrastructure.

Brett Weber, Community Catalyst, described how Tribal communities face severe shortages of care providers, and people seeking care through their tribe’s oral health system often have to wait several months to receive care. One solution that Tribes have implemented is the development of a workforce of dental therapists, based off approaches that have been implemented in New Zealand. Dental therapists have a more limited scope of practice than a dentist, but can perform restorative and preventive care, exams, oral health education, fill cavities, pull baby teeth, and pull permanent teeth in limited circumstances. They must graduate from a three-academic-year dental therapy program standardized by the Commission on Dental Accreditation.

This solution, which encourages people in Tribal communities without good access to dental care to become the providers their communities need, said Weber, originated in tribal communities and was not imposed on them. Dental therapists work in a dental office under a dentist’s supervision, providing routine care so the dentist can focus on complicated procedures. Dental therapists often see children at school to make them feel more at ease, which Weber said is an important outcome.

Weber said tribes employing dental therapists report shorter wait times for an appointment, more preventive care, fewer invasive procedures, and more revenue coming to the dental practice, particularly in Medicaid expansion states and those with adult Medicaid dental benefits. Currently, dental therapists work in five states and are authorized in some settings in nine additional states. Alaska, Washington, and Minnesota offer accredited education programs, with others in development.

When Russell Dunkel, Wisconsin Department of Health Services, became dental director for the sole Wisconsin facility that only treats individuals with special health care needs, he was surprised by the number of patients who had received no dental care for 20 years or more. Today, years later, the wait time to get an appointment at this clinic is close to two years, and the wait time for oral surgery is 3.5 years, partly because of limits place on operating room time for dental procedures. Barriers

to care include a shortage of dental health professionals trained to treat individuals with special needs and who will accept Medicaid, along with challenges associated with special patient care for those who require higher levels of sedation or hospitalization.

Dunkel and his colleagues have developed trainings, clarified state Medicaid policies, and increased reimbursement rates to encourage dentists and dental anesthesiologists to become Medicaid providers. He is also exploring use of the dental procedure code for dental case management to reimburse for the desensitizing visits some individuals may require before receiving any treatment. Another approach has been to have dentists establish a relationship with a FQHC, for example, and list that as their primary Medicaid service location to minimize calls into their main office.

Other ideas Dunkel discussed included establishing training centers that would offer online trainings that dentists and staff could take at their convenience and opening special needs clinics through dental schools to provide both junior and senior dental students opportunities to get more exposure to treating patients with special health care needs. He noted that many dentists may have the clinical experience but lack the behavioral management experience or confidence to work with individuals with special health care needs.

In the ensuing discussion, one participant said her school’s dental assistant training program recruits from FQHCs, and she called for making it easier for FQHCs to provide such training. Another participant noted that the Commission on Dental Accreditation recently expanded its definition of a sponsoring organization to include community sites. One workshop participant suggested thinking about how to reinvest the $2.4 billion spent annually on emergency department dental care into FQHCs that can deliver much higher levels of care.

DENTISTRY IN 2035: WILL YOU BE THE DISRUPTOR OR THE DISRUPTED?

Joel Oxman, 3M, retired, challenged the workshop participants to think about what they can do to thrive and not just survive going forward. He said innovation starts with curiosity, particularly regarding understanding who one’s customers are and what they need. Innovation also requires considering megatrends affecting health care, such as the aging population, the pace of technology change, business model disruption and consolidation, and the shift from treatment to value-based prevention. Oxman noted that as patients demand more choice, greater value, and better access, it could lead to undoing the divide between dentistry and medicine. Integrating the two will require a new mindset, clinical practice models, and payment models, along with improved shared information systems and outcomes measurement.

Oxman said a major electronic health record company has developed an integrated medical-dental record. For payment models, a survey of health care executives found that 96 percent believe embedding dental benefits in medical plans is already happening or will happen eventually.

ENHANCING ORAL HEALTH RESEARCH AND INNOVATION

Teresa Dolan, Overjet, said the dental care system runs on archaic infrastructure with siloed, unstructured data, creating unnecessary administrative burden and hindering patient care. She believes part of the solution is to build AI-powered, interoperable data systems that automate administrative workflows; incorporate additional data on social determinants of health, risk indicators, and treatment plans; augment evidence-based clinical decision making; and track the progression of disease.

Dolan said her company works with both payers and care providers to develop a system that uses the best available science to determine what is medically necessary and what treatments the patient should receive. Such a system could produce more consistent and faster reviews of claims, which would save payers billions of dollars annually. For patients, it could identify issues earlier and address lack of patient acceptance of care that results in adverse outcomes. Overjet is also developing and validating an AI-enabled composite oral health score. Besides enabling outcome-based monitoring in clinical practices, such a system could better enable consumers to engage in their own oral health and provide a metric for value-based care.

Eric Tranby, CareQuest Institute for Oral Health, said health data are not easily accessible, there is no common data model in oral health, and the data are often incomplete. This is unfortunate, he said, because there

are questions that better data could answer, such as the effect of a policy on outcomes and cost of care or the size and profile of underserved populations. Such data need to integrate oral, medical, environmental and social data; represent the payer, care provider, and patient landscape; and contain payment and outcome metrics. Above all, he said the analysis of these data should be presented in a way that is accessible and understandable via a platform that is scalable, sustainable, and minimizes administrative burden.

Flavia Teles, University of Pennsylvania, discussed the Center for Innovation and Precision Dentistry, a partnership between the schools of engineering and dentistry that combines innovative research and development with training. One project, for example, developed a low-cost treatment that destroys the biofilm that causes caries using a nanomedicine approved for treating iron-deficiency. One of her projects uses AI to improve detection of periodontitis and identify which individuals need more aggressive treatment. This system uses a limited amount of clinical data—one saliva sample tested for one cytokine.

Alonso Carrasco-Labra, University of Pennsylvania, said practice guidelines enable the efficient translation of evidence into practice and should be conceived as implementation tools. He added that the lack of clinical guidelines for treating oral health problems is a barrier to integrating medicine and dentistry.

Oral health, said Carrasco-Labra, needs to adopt medicine’s well-established methods for developing guidelines for coordination of care that manage conflicts of interest and evaluate societal and patient values and preferences. He noted that only 6 of the 13 guidelines produced by ADA are up to date and reflect new data. While development of oral health guidelines with a broad group of key partners has been limited, using this approach results in guidelines that span dentistry and medicine. One example is a clinical practice guideline for pharmacologic management of acute dental pain developed in collaboration with the American College of Emergency Physicians.

Carrasco-Labra listed several misconceptions about guidelines, including:

• There is not enough evidence to create evidence-informed clinical or public health guidelines;
• Guidelines are too expensive and take too long to develop to be helpful in informing clinical and public health decisions promptly; and
• Guidelines are written statements published in peer-reviewed journals that clinicians often do not read and do not often play a role in informing population-level decision making.

In the ensuing discussion, Glassman offered several suggestions for how to use the innovations the speakers discussed to better reach the entire population:

• Allow and pay for geographically distributed systems to integrate oral health using tele-dentistry to complete most examinations and provide comprehensive care.
• Allow and pay for CHWs to perform risk assessments, collect data that facilitates dentists’ decisions, and perform basic preventive procedures such as fluoride varnish and silver diamine fluoride that can be done without extensive professional training.
• Connect these services in a fully interconnected care, referral, and tracking systems.

Rebecca Fein, American Dental Association, added that such systems should be interoperable to avoid exacerbating digital disparities.

Ray Bridgewater, Assembly of Petworth, stated how coalition building across different populations is essential to achieving desirable outcomes, and that it is important to foster trust between communities and funders.

POTENTIAL FOR SYSTEM TRANSFORMATION THROUGH NATIONAL ALIGNMENT, ORGANIZING, AND ACTIONS

Robert Weyant, University of Pittsburgh, opened a discussion among the session moderators by noting there needs to be better connectivity among workshop participants, perhaps through a Listserv, to exchange ideas and keep abreast of advances and system changes. Hawazin Elani, Harvard School of Dental Medicine, noted the growing interest in innovative payment systems, patient-centered outcomes, and data collection to measure health care outcomes, though more work on risk

adjustment for these payer models is needed to achieve a sustainable value-based health care system.

Michael Helgeson, Apple Tree Dental, highlighted the importance of interoperable information that works for patients, providers, researchers, and payers to accelerate translation of new knowledge into practice, and for tailoring benefits or guidelines for specific populations across the lifespan. Jessica Lee, University of North Carolina Adams School of Dentistry, raised the importance of creating a system that includes employing providers at all levels of care and locations to improve access to care and reach people earlier in order to change the paradigm to value-based payment for continuous enrollment. One challenge for value-based care is keeping patients enrolled long enough to determine if the system works. She also called for strengthening Medicaid, while Astha Singhal, University of Florida College of Dentistry, called for expanding Medicaid’s dental coverage to include all adult beneficiaries.

Hugh Silk, University of Massachusetts Medical School, called for tapping into partnerships between the oral health system and businesses interested in the oral health of their employees and communities. Additionally, Silk suggested new funding streams to address oral health in the community. For example, to deploy mobile care and reach the over 60 million people who lack medical and dental care. He noted the important role CHWs and dental therapists can play in increasing outreach and capacity and of the need to increase training opportunities to bring more people into the oral health field.

Elizabeth Mertz, University of California, San Francisco, said “We know what needs to be done; we just need to do it.” To overcome key barriers, she said that dentistry needs an expanded workforce, which includes other service professionals, that can meet the needs of different populations. Additionally, she said there is no empirical evidence to support limiting the scope of practice for dental hygienists and dental therapists.

Anita Glicken asked the workshop participants to think about what is needed to advance all the ideas identified in the workshop. “The work’s going to have to happen afterward—the preparation and the collaborations.” She stated that the workshop created the energy to mobilize action and catalyze change. “I really have faith that this is going to move forward,” she concluded.

REFERENCES

equity. Annals of Family Medicine 21(Suppl 2):S86 S91. https://doi.org/10.1370/afm.2930.

Vujicic, M., and C. Fosse. 2022. Time for dental care to be considered essential in US health care policy. American Medical Association Journal of Ethics 24(1):E57-63. https://doi.org/10.1001/amajethics.2022.57.

DISCLAIMER This Proceedings of a Workshop—in Brief has been prepared by Austen Applegate, Tracy Lustig, and Joe Alper as a factual summary of what occurred at the meeting. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution. Members of the planning committee included Anita Glicken (Chair), National Interprofessional Initiative on Oral Health and the University of Colorado Anschutz Medical Center; Hawazin Elani, Harvard School of Dental Medicine and Harvard T.H. Chan School of Public Health; Michael Helgeson, Apple Tree Dental; Jessica Lee, University of North Carolina Adams School of Dentistry; Elizabeth Mertz, University of California, San Francisco; Hugh Silk, University of Massachusetts Medical School; Astha Singhal, University of Florida College of Dentistry; Patrick Smith, American Board of Dental Public Health and University of Illinois-Chicago College of Dentistry; Robert Weyant, University of Pittsburgh School of Dental Medicine.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Scott Darius, Florida Voices for Health, and Nancy Chapman, Oral Health Alliance. Leslie Sim, Health and Medicine Division, The National Academies of Sciences, Engineering and Medicine served as the review coordinator.

SPONSORS This workshop was supported by the American Academy of Pediatric Dentistry, American College of Dentists, American Dental Association, ARCORA, CareQuest Institute, Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, Colgate, Delta Dental Foundation, Gary and Mary West Foundation, Henry Schein, Inc., National Institute of Dental and Craniofacial Research, Santa Fe Group, The Henry Schein Cares Foundation, and United Concordia Dental.

STAFF Austen Applegate, Chidinma Chukwurah, Tracy Lustig, and Sharyl Nass, Board on Health Care Services, and Patricia Cuff, Board on Global Health, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine.

For additional information regarding the workshop, visit https://www.nationalacademies.org/our-work/advancing-oral-health-across-the-lifespan-a-workshop#sectionWebFriendly.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2025. Advancing oral health across the lifespan: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/29096.

Health and Medicine Division Copyright 2025 by the National Academy of Sciences. All rights reserved.