Review
A crisis exists in the oral health care delivery system for children in the United States, a crisis that is the result of a complex group of circumstances. Many dentists do not provide care for children in their practices. Many who do provide care for children do not accept insurance provided by Medicaid and the Children's Health Insurance Program. Yet, in 2014, the majority of US children will be eligible for public funding for their dental care at a fee level that many private practitioners reject. The American Dental Association has argued that the problem of access to care could be resolved by dentists if only reimbursement fees for children with public insurance were increased. However, the evidence to support this claim is scant, and increased fees are not realistic to expect considering the nation's budgetary problems. The burden of dental disease is greater among children from economically disadvantaged families in which the stressors of living in poverty frequently reduce dental care to a lower priority. Furthermore, barriers such as transportation, distance, and child care all have a negative impact on economically disadvantaged children receiving care.
In spite of the barriers, dentistry, as a privileged profession granted a virtual monopoly to practice, has the social and moral obligation to address the problem of access to care, particularly for children. Forty years ago, in 1972, James Dunning, distinguished public health dentist and dean of the Harvard School of Dental Medicine, advanced a solution that is relevant to access today. He said, "Any large scale incremental care plan for children, if it is to succeed, must be brought to them in their schools." The school-based programs in the 6 countries we have reviewed in this article have documented the effectiveness of dental therapists caring for children in schools. The literature has indicated that dental therapists provide quality care. Participation rates of elementary school children in the international school-based programs cited are between 82% and 98%. These rates contrast starkly with those for the US private practice model, in which approximately 50% of elementary school children are seen by a dentist in any 1 year, with a lower rate of 40% for children with public insurance. In New Zealand, almost 60% of children aged 2 to 4 years were seen by a school-based dental therapist in 2009, whereas in the United States only 28% of children aged 2 to 4 years had a dental appointment in 2007.
The oral health of children in countries with school-based programs is better than that of children in the United States. In New Zealand, 51.6% of children aged 12 to 13 years in 2009 were caries-free; the DMFT was 1.3. In Hong Kong, 62% of children aged 12 to 13 years were caries-free in 2001; the DMFT was 0.8. In Singapore, the DMFT of children aged 12 years was 0.7. In the United States, 42.7% of children aged 12 to 15 years were cariesfree in 2004; the DMFT was 2.55.
Countries with school-based programs staffed by dental therapists have a better record of caring for their children than does the United States. The DMFT of Hong Kong children was 0.8, with 0.6 of the index being filled teeth. Malaysia reported 97% of its elementary school children receiving care were rendered orally fit. Singapore reported that 89% to 96% of elementary school children were dentally fit. In New Zealand, 81.7% of elementary children with caries have had the affected teeth restored. John Walsh, dean of New Zealand's dental school at the University of Otago, compared and contrasted the ratio of filled to unfilled teeth and designated this ratio a "care index." The care index for New Zealand children in 1964 was 72%, versus 23% for the US children, indicating their higher levels of untreated decay. In 1994, the care index in the United States had improved to 72.3% for children at 300% of the federal poverty level but was only 48.7% for children at 100% of the poverty level. In 2004, the index was 77.1% for elementary school children, aged 5 to 11 years. The index falls with increasing levels of poverty; for children at 100% of poverty the care index was 67.5%. Walsh claimed that the care index provides a convenient measure of the effectiveness of a country in treating dental caries. He suggested that the extent to which a nation meets the needs of its children is largely dependent on the degree of cooperation that exists between the dental profession and the government. In addressing the American College of Dentists in 1964, Walsh said, "The worthiness of a society can be evaluated in terms of its concern for and care of the health of its children." He went on to quote President John F. Kennedy: "Children may be the victims of fate; they must never be the victims of neglect."
The cost of dental care for children in the United States exceeds by several times that of cited international school programs. If publically funded, school-based clinics staffed by dental therapists existed in the United States, not only would access to primary dental care be available for essentially all children, versus the approximately one half of children who receive annual care currently, but the cost of dental care for children would be significantly reduced.
Such savings in costs can be partially explained by the salaries or incomes of the practitioners providing care. Dental therapists' annual salaries are, for New Zealand, US $30 000 to $45 000; South Australia, US $60 000 (C. Klempster, personal communication, August 2012); and Hong Kong, US $60 000 (E. C. M. Lo, personal communication, August 2012). In Malaysia, salaries of therapists are approximately 50% of those of dentists (N. Jaafar, personal communication, August 2012). These salaries are in contrast to the 2009 incomes of general dentists and pediatric dentists in the United States: $212 920 and $312 660, respectively.
A public school–based system of care does not exist in the United States, and capitalization and training costs are not included in the preceding cost savings estimates. However, the costs of capitalizing an infrastructure for such a system would be recovered rapidly were such an investment to be made, with significant savings in the cost of dental care for children over the long term. With the majority of America's children now eligible for primary dental care through Medicaid/CHIP, it is prudent that these funds be expended as economically as possible in publically funded school-based programs. Ultimately, the cost of ensuring oral health for US children will depend on comprehensive public health programs of prevention, which school-based dental therapists could effectively lead.