Although many issues impact dental public health and the care dental professionals provide in the United States today, routinely accessing dental care is one of the most important.1-4 The utilization of dental services is an important hypothesis because when people access dental care, in essence, they are utilizing dental care. However, access to care is multidimensional in definition and all aspects are important to fully understand dental care utilization (Figure 1).
Figure 1. Access to Care Influences.
First, if individuals do not have access to dental care, they may wait to access care only when pain or infection forces them to a dental clinic or even an emergency room setting. This will ultimately affect their health and their quality of life. One reason may include the fact that in many states dental hygienists are restricted to providing care only under the supervision of dentists.15 This may decrease the availability many have to preventive dental care outside of a dental clinic. These trends are changing and more states, than ever, have direct access to their dental hygienists, as depicted with the states that have moved from gray (restricted access to dental hygienists) to red (direct access to dental hygienists) (Figure 2). The American Dental Hygienists’ Association (ADHA) defines direct access as the ability of a dental hygienist to initiate treatment based on their assessment of a patient’s needs without specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship.15
Figure 2. The Progression of Direct Access to Dental Hygienists.15
Key: Direct Access States are depicted in red.
Additionally, since more individuals qualify for public funding, more dental clinics have opened, that specifically market to this population or promote services to those with Medicaid funding. Although, in some areas of the country, access to care for those utilizing Medicaid insurance may be limited by the number of providers accepting Medicaid reimbursement. Additionally, the increase in dentists and dental hygiene graduates will result in an increase in the supply of dental providers.16,17
Another trend in regards to access to care is the continued focus on problems residents in rural communities have when accessing dental care. The US Census Bureau reported trends suggest more of the population is moving away from rural areas into urban areas. This means that rural communities will most likely continue to have access issues, but this should affect less and less of the population as rural residents continue to decrease.
It has long been suggested the main problem with care is the inability to access dental care in the US. However, although that may be part of the issue, there is another compelling concept to discuss. Although many would agree that all have a need for preventive dental care, not all individuals are accessing this care. Studies suggest that even when individuals have dental coverage, not all individuals utilize or access dental care.5-9
The decision to seek care is also an issue. Although reasons populations may not access care include barriers which are multifactorial (Figure 3), an overwhelming reason includes societal values regarding oral health and dental care. Values are complicated in nature and absolutely affect a population accessing care. Some suggest changing values is the single most difficult barrier to change. First, a population must have knowledge (education) that dental disease can be prevented and the positive effects that are available with routine, preventive dental hygiene care. Without basic literacy in health prevention, a population would likely not access dental care. Educating populations on dental care is not too difficult to do and dental health education is a primary function of dental providers. However, education alone does not result in dental care utilization.
Figure 3. Barriers to Care.
The next step is for the patient to seek care. The patient must find an office, schedule an appointment, arrive at the clinic and pay for the services. All of these take time and effort and financial resources. In order for an individual to visit a dental provider, especially for routine, preventive dental care, there must be motivation to do so. The individual must value this service.
The most viable solutions concerning access to care issues begin with improving the value placed on oral health. Americans need to decide whether they value preventive care enough to practice prevention daily and whether they value this care enough to provide funding for this care (publicly) and/or to pay for these services (privately).18 Values are derived from a mixture of cultural influences. Populations can have cultural influences from their environment, geographic origin(s), faith, race, ethnicity, education or family income level, to name a few. Education can influence behavior, because without knowledge of prevention, many would not practice prevention. Resources affect care because, without financial means (the Department of Health and Human Services sets annual poverty guidelines for eligibility for public funded programs) or transportation, many could not receive dental services (Figure 4).
Figure 4. Influences on Behavior Change.
So, many individuals may lack access to care for different reasons needed to obtain dental care services, or some simply do not value dental care until pain presents.