Comparison of the University of Iowa's community-based and University-based pediatric dental clinics

Transcription

1 University of Iowa Iowa Research Online Theses and Dissertations Summer 2011 Comparison of the University of Iowa's community-based and University-based pediatric dental clinics Deise Cruz Oliveira University of Iowa Copyright 2011 Deise Oliveira This thesis is available at Iowa Research Online: Recommended Citation Oliveira, Deise Cruz. "Comparison of the University of Iowa's community-based and University-based pediatric dental clinics." MS (Master of Science) thesis, University of Iowa, Follow this and additional works at: Part of the Other Dentistry Commons

2 COMPARISON OF THE UNIVERSITY OF IOWA S COMMUNITY-BASED AND UNIVERSITY-BASED PEDIATRIC DENTAL CLINICS by Deise Cruz Oliveira A thesis submitted in partial fulfillment of the requirements for the Master of Science degree in Operative Dentistry in the Graduate College of The University of Iowa July 2011 Thesis Supervisor: Professor Michael J Kanellis

3 Graduate College The University of Iowa Iowa City, Iowa CERTIFICATE OF APPROVAL MASTER'S THESIS This is to certify that the Master's thesis of Deise Cruz Oliveira has been approved by the Examining Committee for the thesis requirement for the Master of Science degree in Operative Dentistry at the July 2011 graduation. Thesis Committee: Michael J Kanellis, Thesis Supervisor Gerald E Denehy Deborah S Cobb Deborah V Dawson

4 To my parents, Clementino da Cruz and Varlene Rodrigues da Cruz To my husband, Cristiano Oliveira, for their unconditional love, support, encouragement, and unfailing belief that I was capable of attaining this goal. ii

5 ACKNOWLEDGMENTS With the deepest gratitude I wish to thank my husband, Cristiano Oliveira, for understanding my love for Dentistry. To my family, for their love, support and understanding my constant absence. I would also like to acknowledge and express my enormous gratitude to my research committee chairman, Dr. Michael J Kanellis, for providing feedback and continual support through this project. It was a pleasure to work with you! I express my appreciation to Dr. Deborah Cobb, Director of the Operative Dentistry graduate program, because through her insight and support I was able to pursue a combined degree program; Master in Operative Dentistry and Master in Dental Public Health, and for this I am extremely grateful! I would like to express my appreciation to my thesis committee members, Dr. Gerald Denehy, Dr. Deborah Cobb, and Dr. Deborah Dawson for generously sharing their wisdom with me. Also, I would like to express my appreciation to Mrs. Colleen Kummet who was essential to this project since the beginning. I would like to acknowledge Dr. Marcela Hernandez, Dr. Richard Burke Jr. and Dr. Raymond Kuthy for their participation in this project process. This thesis would not be accomplished without all these professional s contributions. It was an honor for me to work with you all. Thank you very much! iii

6 TABLE OF CONTENTS LIST OF TABLES... VI vi CHAPTER I INTRODUCTION... 1 CHAPTER II REVIEW OF LITERATURE... 3 Dental Caries Disease... 3 Bacterial Factors... 5 Dietary and Other Factors in Dental Caries Etiology... 7 Summary of Dental Caries Dental Practice in the United States American Dental Schools Post-doctoral Education Dental Workforce in the United States Access to Dental Care Access to Dental Care for Children in the United States Barriers to Access and Utilization of Dental Care for Underserved Populations Lack of Transportation Lack of Dental Insurance Dental Care Providers Dental Care Resources for Underserved Populations Funding: Medicaid and other resources Learning-Service Community Partnership Model Muscatine Center for Social Action (MCSA) Muscatine Pediatric Dental Clinic (MPDC) Learning-Service Community Partnership Model: Strengths and Limitations Pediatric Dentistry Program Evaluation CHAPTER III MATERIALS AND METHODS Introduction Parental Satisfaction Survey Research Questions Hypotheses Research Design Study Population Inclusion and Exclusion Criteria Survey Instrument Variables Statistical Methods and Data Analysis Comparison of Patients and Procedures at MPDC and The University of Iowa s Pediatric Dentistry Clinic at the College of Dentistry Research Questions Hypothesis Research Design Study Population and Data Collection Statistical Methods and Data Analysis iv

7 Institutional Review Board (IRB) CHAPTER IV RESULTS Introduction Patient Satisfaction Response Rate and Univariate Analyses Survey Respondent Patients Clinic Patient s Satisfaction Bivariate Analyses MPDC and The University of Iowa Pediatric Dentistry Clinic Comparison of Clinics CHAPTER V DISCUSSION Overview Satisfaction Survey Response Rates Satisfaction Survey Demographic Differences Satisfaction Survey Principal Findings MPDC and The University of Iowa Pediatric Dentistry Clinic Demographic Differences Comparison of Clinics-Principal Findings Study Strengths Study Limitations Relevance of this Study Future Directions CHAPTER VI CONCLUSIONS APPENDIX A INTRODUCTORY LETTER APPENDIX B QUESTIONNARIE APPENDIX C INDEPENDENT AND DEPENDENT VARIABLES Dependent Variables Independent Variables APPENDIX D TABLES REFERENCES v

8 LIST OF TABLES Table D 1 Response Rate Overall (N=100%)* Table D 2 Descriptive Statistics for Number and Percent of Respondents by Child s Age Table D 3 Descriptive Statistics for Number and Percent of Respondents by Zip Code Area Table D 4 Descriptive Statistics for Number and Percent of Parents Respondents by Child s Gender Table D 5 Descriptive Statistics for Number and Percent of Parents Respondents by Child s Race Table D 6 Descriptive Statistics for Number of Hispanic Children Table D 7 Descriptive Statistics for Primary Language Spoken at Home Table D 8 Descriptive Statistics for Respondent Relationship with the Child Table D 9 Descriptive Statistics for Number and Percent of Parents Respondents by Reason for Appointment Table D 10 Descriptive Statistics for Number and Percent of Parents respondents by Length of Waiting Time for Today s Dental Appointment Table D 11 Descriptive Statistics for Number and Percent of Parents Respondents by First Heard Pediatric Dentistry Clinic at MCSA Table D 12 Descriptive Statistics for Reasons for Choosing the MPDC Table D 13 Descriptive Statistics for Treatment with Another Dentist not from MPCD Table D 14 Descriptive Statistics by Dentist Last Visit Table D 15 Descriptive Statistics for Dental Insurance Table D 16 Descriptive Statistics for Number and Percent of Parents Respondents by Child s Frequency of Dental Visits Table D 17 Descriptive Statistics for Number and Percent of Parents Respondents by Child s Overall Dental Table D 18 Descriptive Statistics for Number and Percent of Parents Respondents by Child s Overall Medical vi

9 Table D 19 Descriptive Statistics for Number and Percent of Parents Respondents by Distribution of Income Table D 20 Descriptive Statistics by Patient Satisfaction Table D 21 Descriptive Statistics for Number and Percent of Parents Respondents by Overall Satisfaction Table D 22 Descriptive Statistics for Most Positive Points at MPDC Table D 23 Descriptive Statistics for Points for Improvement at MPDC Table D 24 Bivariate Analyses of the MPDC Satisfaction Survey (p-value) Table D 25 Descriptive Statistics and Bivariate Analyses of the Comparison Between Muscatine Clinic and UI Pediatric Dentistry Clinic vii

10 1 CHAPTER I INTRODUCTION The Muscatine Pediatric Dentistry Clinic (MPDC) at the Muscatine Center for Social Action (MCSA) was established January 4th, It is a partnership between the MCSA and The University of Iowa s Department of Pediatric Dentistry. MPDC operates Tuesdays (care provided by senior dental students) and Thursdays (care provided by pediatric dentistry residents). Students and residents are supervised by a pediatric dentistry faculty member. MPDC s mission is to provide dental care to low income children residing in Muscatine and Louisa counties, in Iowa. Care includes diagnostic, preventive, restorative, and emergency services. MPDC targets a population that has been traditionally underserved by local dentists including Medicaid-enrolled children and low income children without dental insurance. MPDC offers dental students the opportunity to gain experience treating children with the ultimate goal of increasing the number of practicing general dentists who serve pediatric populations. MPDC completed 6 years of operation on January 4th, The main goals of this study were to describe patient characteristics, clinical activities and parental satisfaction at the Muscatine clinic and to compare characteristics of the Muscatine clinic to those of the University of Iowa s pediatric dentistry clinic at the College of Dentistry. Clinical activities and patient profile variables for MPDC were reported for the entire fiscal year year. Variables include patient age, gender, type of insurance, number of dental procedures completed, type of treatment received, and number of visits per patient. A satisfaction survey was given to the parent of each patient presenting to the MPDC clinic between November 16 th, 2009 and January 17 th, 2010.

11 2 Two broad research questions were addressed in this study: 1) Are parents satisfied with MPDC and the treatment provided to their children? 2) Are there are differences in the population served and treatment provided at the Muscatine clinic and the University of Iowa pediatric dentistry clinic at the College of Dentistry? The results of this study provide information that contributes to a fuller understanding about the population served by MPDC, the treatment received, and parental satisfaction with the clinic. It also compares characteristics of the Muscatine clinic to the University of Iowa s pediatric dentistry clinic at the College of Dentistry. The results of this study may help guide MPDC staff and the University of Iowa s Department of Pediatric Dentistry in future decision-making regarding clinic activities and dental school curriculum.

12 3 CHAPTER II REVIEW OF LITERATURE As a service-learning community partnership model, MPDC provides an innovative approach to increasing dental students experience treating children that will hopefully translate into more general dentists feeling comfortable providing care to children. In addition, this partnership improves access to dental care for underserved populations in Muscatine and Louisa County, Iowa. This service-learning community partnership is composed of The University of Iowa s College of Dentistry and a community agency, the Muscatine Center for Social Action (MCSA). The learning and service components of this program are mutually beneficial. In accordance with the definition of service-learning community partnership models 1, this chapter is divided into eight sections: dental caries disease; dental practice in the U.S.; access to dental care; barriers to access to dental care for underserved populations; dental care resources for underserved populations; learning-service community partnership models (LSC-M); LSC-M strengths and limitations; and pediatric dentistry program evaluation. Dental Caries Disease Dental caries was relatively rare until the 1600s 2. The disease was first diagnosed in Europe and spread to North America because of an increase in sugar consumption. The diagnosis process at that time was symptomatic decay and the treatment was tooth extraction because it was thought to be gangrene. The first truly scientific theory regarding dental caries was defined by Dr. W.D. Miller in It was the chemico-parasitic theory which indicated that dental caries is the decomposition of the tooth structure caused by bacterial acids present in the dental plaque 3. However, because of technology limitations

13 4 at that time, Miller was not able to determine the specific pathogens for dental caries. Thus, the surgical model continued to drive dentistry: the clinical symptoms were addressed by tooth extraction or restoration. The preventive approach, avoiding bacterial contamination, the cause of the disease, was never addressed 3. Later, based on Miller s theory, dental caries was recognized as an infectious disease requiring a susceptible host, cariogenic bacteria, and a diet with refined carbohydrates 4. As a result of a combination of all these factors, demineralization of the tooth structure may occur. Although dental caries is classified as an endemic, preventable and curable disease by the National Institutes of Health 5, dental caries continues to have high prevalence rates in the United States. According to the National Health and Nutrition Examination Survey 6, dental caries is the most prevalent, costly, and chronic childhood disease. It is related to tooth loss among the elderly population and might be implicated in severe health consequences in these individuals. In addition, the NHANES survey found that 94% of adults in the U.S. had dental caries experience. NHANES is an ongoing surveillance system that provides data for a representative sample of the U.S. population over the age of 2 years. Data from the NHANES indicated that, among children aged 2-11 years, 41% had dental caries experience in their primary dentition 6.Children in this age group that had caries experience were more likely to be from low income families, have special health care needs, or be an ethnic minority. Continuing the NHANES report, 42% of children and adolescents between the ages of 6 and 19 years and approximately 90% of adults presented with dental caries experience 6. Comparing data from the NHANES and NHANES , the most recent survey findings,

14 5 suggest that there has been a decline of dental caries experiences in the permanent dentition and in edentulism rates. However, dental caries experience was not reduced in the primary dentition. Bacterial Factors Dental caries and periodontal diseases are a result of specific bacterial species that form the dental plaque. The dental plaque is a multi-species biofilm which adheres to the teeth surfaces. Normally, a healthy mouth presents with numerous bacteria species in the plaque. However, plaque per se is not odontopathic 7. Dental caries is a multifactorial infectious disease. The dental caries process starts with acid formation by specific bacterial species in the dental plaque. The bacterial acid, in contact with the tooth structure, will cause demineralization of the hard tissue. Dental caries occurring in the enamel begins with demineralization and can lead to dentin and pulpal involvement. Dental caries occurring in the cementum is classified as root caries 8. Mutans streptococci were first identified in dental caries in humans in 1924 by Clarke 9. Studies have shown that the bacteria most commonly associated with caries are basically caused by mutans streptococcus (Streptococcus mutans and Streptococcus sobrinus) and Lactobacilli species 9. Mutans streptococci (MS) are believed to be more involved in the dental caries initiation process, while lactobacilli species are responsible for the disease progression 10. In the remainder of this chapter, MS will be used to denote the specific organism and this group of closely related organisms. Regarding patients caries risk development, individuals who present with more than 10 6 colony forming units (CFU) per ml saliva of mutans streptococci 11 or 10 3 CFU/ml or more of lactobacilli 12 are considered to be at high risk for caries.

15 6 In the 1970 s many studies reported the presence of no mutans streptococci (MS) in newborns mouth 9. Köhler & Bratthall 2 analyzed the amount of MS in 36 children (aged 4-5 years old) and their respective parents (34 mothers and 31 fathers). This study showed a positive quantitative correlation between mothers and their children regarding amount of MS; however, no correlation was found with fathers. Children classified as free of dental caries presented with less than 10 3 CFU/ml of MS. In addition, this study identified that more than 50% of the children were infected with MS by 4 years of age and children s mothers were identified as the main transmitter of MS. A 1993 study conducted by Caufield and colleagues 13 monitored the oral bacterial levels of 46 mother-child pairs from infancy until the children turned 5 years of age. Thirty-eight children of the 46 children were identified with MS colonization (mean age of colonization was 26 months). This study investigated the vertical transmission of MS between mother and child which means the mother-to-child transmission of the MS. However, in 8 children (17%) MS was not detected during the study period. Caufield s study 13 was the first to report a window of infectivity period for infants. For the majority of children in the study, the period of initial MS infection was found to be between 19 and 31 months. A prospective cohort study by Alves and colleagues 14 investigated nonfamilial sources of transmission of MS in 119 children from 28 day-care centers in Brazil. The purpose of this study was to track the transmission of MS from child to child, caregiver to child and mother to child. MS levels were determined for all participants at baseline. Only 5.6% (N=9) of children were detected to have MS at this point in time (age range 5 to 13 months). MS infection rates at later intervals were: 15.6% (N=22) at 6 months, 32.1% (N=42) at one year; and 40.3% (N=48) at 18 months. Among the 40.3% of children that were colonized with MS by 18 months of age, 47.9% (N=23) were identified with dental caries. In addition,

16 7 50% (N=23) of the children-mother pairs matched genotypes. The highest level of MS was found among caregivers; however, none of their genotypes matched those of the children for whom they were responsible. In 7 day-care centers, at least 2 children had similar genotypes of MS. Four pairs of children among the 19 day-care centers had MS with identical DNA profiles. The study findings confirmed the existence of MS transmission among non-familial sources, also referred to as horizontal transmission. Dental caries is a multifactorial infectious disease and MS transmission is one of the factors. Other factors include dietary sugars, eating frequency, fluoride, plaque, and saliva composition and flow. These are discussed below. Dietary and Other Factors in Dental Caries Etiology Warren and colleagues 15 investigated factors associated with caries crosssectionally in children aged 6 to 24 months as part of a longitudinal cohort study. The study population included 212 mothers with children recruited from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic sites in southeastern Iowa. A survey instrument was given to mothers asking for detailed information about their child s diet habits, oral hygiene, and family socioeconomic status. Each child also received a dental exam using d1, d2-3 criteria 16. Saliva samples of mother and child pairs were collected in order to determine salivary Mutans Streptococcus (MS) levels. At the time of the exam 187 children were dentate, and 23 of these children had d (1) or d (2-3) carious lesions. Warren and colleagues 15 found that plaque accumulation, MS levels, children s age, and family SES are factors associated with dental caries in young children. In a follow-up study, Warren and colleagues 15 performed longitudinal analyses with the same population of children. In this study, participants were

17 8 examined at baseline, and after 9 and 18 months. Of the 128 children (60%) who remained in the study after 18 months, the study findings showed that the prevalence of d(1) level caries increased from 9% to 77% while d(2-3) level caries prevalence increased from 2% to 20%. The authors also found that high consumption of sugary foods and early MS colonization are factors that are predictive of dental caries experience in young children. Marshall and others 17 studied the relationship between dental caries lesions and children s dietary habits. The study population was 5 year-old children enrolled in the Iowa Fluoride Study (n = 634). The participants dietary habits were assessed using a 3-day food diary answered by their parents every year during the 5 year study period. Children were examined for dental caries at a mean age of 4.8 years (range years). Study results suggested that higher consumption of sugary foods or 100% juice as snacks and soda pop at meals was associated with increased dental caries experience among young children. However, high consumption of sugary food or carbohydrates at meals, instead of at snack time, was associated with decreased experience of dental caries among young children. Margolis & Moreno 18 investigated dental plaque composition of 5 populations recruited from the Boston area. Specifically plaque composition was measured before a 10% sucrose rinse and at 7, 15, 30, and 60 min after the rinse. Participants were placed in two groups: caries-free (CF) (DMFS equals zero) and caries-positive (CP) (DMFS greater than 10). Results showed that high ph values plaque were found in CF groups and low ph and high lactic acid concentration were found in CP group. In conclusion, Margolis and Moreno 18 suggested that dental caries experience might be related to low salivary ph and high lactic acid concentration.

18 9 Psoter et al. (2006) investigated the relationship between Early Childhood Caries (ECC) and social and demographic factors including ethnicity/race, household income and parents education level. The study population was composed of 5,171 Arizona pre-school children at the age of 5 who were examined in February, 1994 and September, 1995 by 5 calibrated examiners. The total number of clinical examinations was 3,850. Survey information was collected before the execution of exams. Psoter and colleagues demonstrated that ECC is associated with low income and low parental education level; however, it did not find an association between caries and minority ethnicity/race group (African American, Mexican American, and Hispanic). Other caries predictors were also identified by Dye et al. 19. The authors analyzed the association between dental caries occurrence and dietary habits in children aged 2 to 5 years-old in the United States. This study used data collected during the third National Health and Nutrition Examination Survey (NHANES III) from 1988 to Information on eating habits was collected from parents in a 24-hour recall database. The study population included 4,236 children. Dye and colleagues results 19 showed that children who skipped breakfast or who did not eat five servings of fruits and vegetables daily presented with more caries experience than the others. Dye and colleagues 19 suggested that young children with poor eating habits are more likely to experience caries than other children without such habits. Finally, Dini and others 20 investigated the association between dental caries experience, socio-demographic factors, breast-feeding and oral hygiene in children aged 3-4 years at daycares in Sao Paulo, Brazil. The study population included 303 children from 26 kindergartens. Socio-demographic information was collected from the parents before dental examination of their children. Study findings showed that of the 80% of the children who received milk with added

19 10 sugar in their bottles, 46% were diagnosed with dental caries lesions. Of the children with dental caries, 17% presented with a more advanced stage of the disease. Children who presented with extensive dental caries were those fed formula by bottle, or breast-fed after 2 years of age. Dini and colleagues 20 suggested that dental caries experience is associated with prolonged breastfeeding and prolonged use of a bottle containing formula. Summary of Dental Caries Dental caries is an infectious bacterial disease that results in tooth destruction by acid formed in the dental plaque by certain resident bacteria in the presence of sugar. Dental caries risk factors for children include frequent and prolonged exposure to cariogenic foods, lack of fluoride exposure, moderate to high plaque accumulation and inappropriate salivary properties. Dental caries lesions are usually treated by tooth restorations. Thus, the next section will describe dental practice in the United States. Dental Practice in the United States The American Dental Association (ADA) is the largest dental organization in the United States. The association is highly organized and promotes the public image of dentistry 21. According to the ADA 22 dentistry is a unique profession that offers many career options combining science and technology with helping people enhance and maintain their oral health, quality of life, appearance and self-esteem. Demand for dental care continues to grow due to the increasing number of older adults keeping their teeth longer, and increased awareness of oral health care. Dentists treat a diverse group of patients: the healthy; the ill; the young; the elderly; the disadvantaged and those with special needs. Dentistry is a professional career that offers the flexibility to balance professional and personal lives because it offers the opportunity to be your own

20 11 boss. A dentist s average income is considered in the highest 5% of U.S. income according to the U.S. Census Bureau. The practice of dentistry in the United States occurs through private and public dental practices, academic institutions, industry, and the Armed Forces 23. By far, private dental practice is the largest component of the dental health care system, with public delivery systems making up only a small proportion of the system. American Dental Schools In 1840, Horace Hayden and Chapin Harris established the world's first dental school, the Baltimore College of Dental Surgery and originated the Doctor of Dental Surgery (DDS) degree. This marked the first formal education in dentistry in the United States 24. During the 1800s, dental schools were largely proprietary; in other words, they were not affiliated with major universities and were private for-profit institutions. In the early 1930s the last proprietary school was abolished and all dental schools became affiliated with major universities in the U.S. 24. As of 2010, there were 58 fully accredited dental schools in the U.S 22, 25, 26. The most current information from the ADA reports that in 2011, there are 61dental schools in 36 States and Puerto Rico 26. The 61 dental schools include 3 new dental schools in the process of initial accreditation. Dental educational programs in the U.S. lead to a Doctor of Dental Surgery (DDS) or a Doctor of Dental Medicine (DMD) degree, typically after four years of education. The DDS and DMD are equivalent degrees. In 2004, 37 dental schools awarded the D.D.S. degree and 19 awarded the D.M.D. which was first used by Harvard Dental School 24.

21 12 Post-doctoral Education After graduation from dental school, dentists who seek additional training might continue their education in a specialty or other advanced program. The ADA recognizes nine specialties: Dental Public Health; Endodontics; Oral and Maxillofacial Pathology; Oral and Maxillofacial Radiology; Oral and Maxillofacial Surgery; Orthodontics; Pediatric Dentistry; Prosthodontics; and Periodontics 22. Advanced education programs include: Postgraduate General Dentistry (PGD); General Practice Residency (GPR); and Advanced Education in General Dentistry (AEGD). Generally, GPRs are hospital-based and AEGDs are dental school-based. GPR-trained dentists are more likely to be on a hospital staff and to treat medically compromised patients 27. Academic dental institutions are the foundation of the U.S oral health care system. Dental schools provide dental education programs (pre-doctoral), specialty training (post-doctoral) and advanced dental education programs. The mission of academic dentistry includes education, research, and patient care 28. Dental Workforce in the United States Dental care delivery in the United States involves private and government entities such as private and public dental practices, academic institutions and the Armed Forces. As stated previously, most dental care is provided in private dental practices 21. The practice of dentistry has improved for dentists: working hours have decreased and remuneration has increased. However, the pattern of practice for dental professionals does not necessarily meet the needs of the nation. For this reason, Mertz and O Neill 29 addressed this issue in their paper called The growing challenge of providing oral health care services to all Americans. It is a systematic review of the literature that addressed and updated information about

22 13 oral health care in the U.S. This study compared the dental professional and physician workforce. The authors found that the number of dentists is much smaller than the number of physicians and that the dentist workforce has increased at a slower rate compared to the population increase. In addition, most of the dentists were middle-aged (40 55 years of age), male and had little ethnic diversity. Compared to physicians, dentists were also more likely to be in solo practice 29. According to the 2006 ADA Distribution of Dentists in the U.S. by Region and State 25, there were 179,594 professionally active dentists (clinical practitioners, dental school faculty or staff, armed force dentists, governmentemployed dentists at the federal, state, or local levels, interns and residents, and other health or dental organization staff members) in the U.S. Of these, 164,864 were in active private practice. Thus, private practitioners represent approximately 91.5% of the population of active dental practitioners 25. Between 2006 and 2008 there was an increase of 2,180 dentists in the U.S. By 2008 there were 181,774 active dentists. Of those, 167,769 (92.3%) were private practitioners. 25 Among 179,594 professionally active dentists in 2006, 80.8% were male and 19.7% (35,444) were female. By ,867 (21.4%) of all active dentists were female. The mean age of all professionally active dentists in the U.S in 2006 was 49.4 years old. Also in 2006, solo dentists comprised 63.1% of all private practitioners, 20.0% worked with one other dentist and 16.9% worked with two or more dentists 25. Some advantages of private practice are choice of practice location, good income, autonomy and high status in the community. Disadvantages include overhead costs, equipment maintenance and ongoing compliance with regulatory agencies. 21.

23 14 In 2008, 79.1% (143,783) of responding dentists were general dentists and 20.9% (37,991) were specialists. Among those 37,991 specialists, 26.6% were orthodontists, 18.5% oral surgeons, 15.3% pediatric dentists, 13.5% periodontists, 12.5% endodontists, 8.7% prosthodontists, 3.7% public health dentists, 1.0% oral pathologists and 0.3% oral radiologists 26. The ADA Future of Dentistry report predicted that the number of professionally-active dentists will be 182,255 in 2010 and 189,295 in Projections through 2020 indicate that male active private practitioners will decline in 2020, whereas the number of female active private practitioners will increase from 19.2% in 2006 to 30% in Access to Dental Care Access to dental care for children continues to be one of the major public health issues in the United States Approximately 17 million of U.S. children do not have a dental visit each year, which represents one in five children among 1 to 18 years-old 31. Factors founded to be associated with disparities in the literature about oral health include gender, income, age, and race/ethnicity. Thus, these factors were found to be related to caries risk in young children in the U.S. by the Oral Health in America: A Report of the Surgeon General 32. The children at poverty or minority status are more likely to be at risk for oral health diseases 32. Among 6 U.S. children, one lives in poverty 33 ; in addition, half of the population under 5 years of age belongs to minority groups 34. The low SES and younger children were more likely to have dental caries than non-low SES and older children in the United States 6, 35. Accordingly to the 2000 Oral Health in America: A Report of the Surgeon General 32, it was identified that disparities exist in oral health and in access to care for vulnerable populations, including children. This report mentioned that

24 15 some dental educational factors such as declining of dental school applicant pool, shortages of faculties, and an overcrowded curriculum could influence disparities. The projections showed that the student/faculty ratio is expected to decline which may reduce the variety of dental students experiences, including experience with treatment of pediatric patients. Also, dentist/population ratio is projected to decline. Approximately 49 million of U.S. population lives in one of the 4,230 areas with shortage of dentists. 36 Therefore, the shortage of dental providers combined with low reimbursement rates from Medicaid reduces even more the access to care for the 17 million children who do not have care each year in the U.S. 37 Among states that report information about dentist participation in Medicaid, 23 reported that fewer than half of the states dentists saw at least one Medicaid patient during It is important to mention that the Current Commission on Dental Accreditation (CODA) standards do not require pediatric patient care in the dental school curriculum in the U.S.; however, only the dental education entities have the responsibility to graduate future dentists with training in pediatric patients 39. With the health care reform law in 2010, it is estimated that dental access to care is projected to increase for 5.3 million more children in 2014 due to extension of dental insurance 40. Access to Dental Care for Children in the United States Accordingly to the 2000 Oral Health in America: A Report of the Surgeon General 32, by improving access to care for children in the U.S. we will improve oral health and reduce disparities in the U.S.

25 16 Based on the state of Iowa, 11.5% of children less than 5 years-old were Hispanic children in Even though Hispanics habitants represents only 4% of the total population in the state of Iowa, these individuals constitute the highest concentration of any other race or ethnic group of preschoolers in the state of Iowa 34. Barriers to Access and Utilization of Dental Care for Underserved Populations The Oral Health in America: A Report of the Surgeon General 32 stated in 2000 that oral health means much more than healthy teeth Oral health is integral to general health. You cannot be healthy without oral health. Oral health and general health should not be interpreted as separate entities 32. Thus, individuals should have access to dental care otherwise neglecting of oral disease can impact systemic health and quality of life of the population. Note that oral diseases can be prevented by early diagnosis or treated by early intervention, avoiding the disease progress. Even though the incidence and prevalence of oral diseases has decreased in the U.S. population in the last 50 years, certain segments of the population such as rural populations, racial and ethnic minorities, and elderly populations have been left behind 32. For instance, the oral health of Hispanics is relatively poor, due to lack of access to care. Regarding Hispanic adult populations, Ramos-Gomez and colleagues in found that Hispanic adults had 40% more untreated caries lesions than white. In addition, based on the Children's Dental Health Project 42 ; Hispanic children in pre-school had 2.5 times more dental caries than white children in the U.S. and 27% of Hispanics reported having a dental visit compared with 48% of non-hispanic Whites 42.

26 17 Lack of Transportation Lack of transportation is a very important barrier when it comes to dental access to care for Hispanic populations. Many Hispanics rely on public transportation and it can be an issue in rural areas where it is not the main transportation type, like small cities in Iowa 43. Therefore, elderly, woman, and children are the populations most affected, because they rely on other family members for their transportation to the dentist 43. A study by Maserejian et al in a showed that Hispanics underutilized free dental services because of lack of transportation. Lack of Dental Insurance Flores and Tomany-Korman 45 investigated the presence of disparities in dental and medical health, and access and use of health services among minority children in the US. The data from this study was part of the telephone survey of the National Survey of Children s Health ( ) which interviewed parents of children 0 to 17 years old (n=102,353). Based on their findings the authors reported that Hispanic children had the highest prevalence of being uninsured (21%) compared with whites (6%), African Americans (7%), and Native Americans (15%). Hispanic children were two times more likely to be uninsured compared to white children. Fisher and Mascarenhas 46 investigated differences between uninsured patients for dental and medical care. Their findings showed that 36% of children lack dental insurance compared to 14% who lack medical insurance. Regarding the access to dental care among Hispanic groups in the United States, from data reported that persons without dental insurance are 39% less likely to receive dental care than those with dental insurance 47.Therefore, lack of dental insurance impacts children s dental access

27 18 to care, especially preventive services. As mentioned previously, it is estimated that with the health care reform law in 2010 dental access to care should increase for 5.3 million more children by 2014 due to expansion of dental insurance 48. Wall and Brown 49 reported that Hispanics were the racial/ethnic group with the lowest levels of private dental insurance and dental visits. In addition, Wall and Brown study 50 reported that Mexican-Americans were the Hispanic subgroups with the lowest level of dental visits and lack of dental insurance. Dental Care Providers Maserejian et al 44 investigated the underutilization of dental services among underserved populations in Massachusetts. The authors found that the underutilization of dental services was associated with financial barriers, as well as cultural and social environment factors related to individuals oral health values. Regarding the issues related to access to care for low-ses children, the most important problem is that even when children have dental coverage through Medicaid, relatively few dentists will accept them as patients due to low reimbursement, high patient failure rates, and documentation requirements 38, 46. Dental Care Resources for Underserved Populations In 1990, the state of Iowa had approximately 17,000 children from immigrant parents living in the state. This represented 2% of the total child population in Iowa 34. In later study, in , The Henry J. Kaiser Family Foundation 40 reported an increase of 5% of children from immigrant parents living in the state. Thus, in children of immigrant represented 7% of children population in Iowa 40.

28 19 Funding: Medicaid and other resources Undocumented immigrants often do not seek medical or dental care due to being afraid that health providers will report their immigration status to the U.S. government 51. The welfare reform law of 1996 eliminated or restricted the eligibility for Medicaid and other federal public benefits to undocumented immigrants. Thus, undocumented children are not eligible to receive Medicaid or Hawk-I benefits 52, 53. Eighty five percent of immigrant families are mixed status (families composed of both citizens and noncitizens). In most cases the children of immigrant parents are eligible to receive health services but parents do not seek care because of the confusion and fear that the law has created 38, 47. Huang and colleagues in reported that children of immigrants were four times more likely to lack health insurance than children from US-born parents and approximately two times more likely to not have a dental visit in the past year. In the state of Iowa, there is a relatively high concentration of Hispanics residing in Muscatine and Louisa County. The U.S Census reported that 11.9% of Muscatine County residents were Hispanic. If unofficial Hispanic habitants are included, this would put the Hispanic population in Muscatine County at approximately 17-18% of the total population. Learning-Service Community Partnership Model As a service-learning community partnership model, MPDC provides an innovative approach to increasing dental students experience treating children and might help to increase the workforce of dentists willing to treat children. In addition, this partnership improves dental care access for underserved children residing in Muscatine and Louisa County.

29 20 This service-learning community partnership consists of The University of Iowa College of Dentistry and a community agency, the Muscatine Center for Social Action (MCSA). This service-learning community partnership is mutually beneficial. Muscatine Center for Social Action (MCSA) The primary mission of the Muscatine Center for Social Action (MCSA) is to provide shelter, basic health care, and vocational and educational support services to the homeless and near homeless of Muscatine County 55, 56. Muscatine has significant poverty indicators. The 2000 Census reported that 30% of those living in Muscatine live with incomes of two times the poverty level or below 57. In 2001, Muscatine County had an average food stamp participation rate of 6,481/100,000. (Iowa s rate was 4,604.9) 57. The number of children in the Muscatine Schools who were eligible for free or reduced price meals in 2001, was 35% (1,882 of 5,375 children enrolled) compared to a 28.7% rate for most of east-central Iowa. Both Muscatine County and Louisa County have among the highest percentage of Hispanic population in Iowa. The U.S Census reported that 11.9% of Muscatine County residents are Hispanic. The total number of Hispanics in Muscatine County is likely much higher, as the Diversity Service Center of Iowa reports that as many as one-half of adult Hispanics in the Muscatine area are in the United States illegally 57. Medicaid and Hawk-I assistance is not available for people who are undocumented. With the high Hispanic population in the county, it is likely that many eligible families are not enrolled in Medicaid, thereby limiting their access to health care.

30 21 Muscatine County had 3,910 Medicaid enrolled children in FACITS 2001 documented a Medicaid enrollment rate for the county at 10, per 100,000, higher than the state rate of 8, per 100,000. The Muscatine community presents high indices for teenage pregnancy, out-of-wedlock births, and various forms of abuse, addiction, and violent crime. The community of Muscatine far exceeds state rates for these negative indicators which directly affects oral health as well 55, 56, 58. At present, there are 12 practicing dentists in Muscatine County (a dentist to population ratio of 1:3,559). The comparative Iowa rate for 2001 was 1:2,041. Further, there is not a full time pediatric dentist in either Muscatine or Louisa County. The Iowa Department of Public Health declared Muscatine County a dentally underserved area on November 1, At that time there was only one dentist in the county that accepted new Medicaid patients and dental vouchers from the Iowa Department of Public Health for urgent restorative care for children. A 1990 report by the National Health and Education Consortium reported that, any health problem such as hunger, poor vision or hearing, increased blood lead levels, dental caries, and child abuse can interfere with the learning process. Dental caries can affect children's growth, increase absences from school, because difficulty concentrating during the learning process, and result in significant pain and infection. In addition, dental caries increases the demand on the public health system for emergency care 37. In the state of California 59, approximately 500,000 children from 5 to 17 years of age were absent at least one school day in 2007 due to dental problems or a toothache. Another study conducted in Minneapolis 60, reported more than 10,000 emergency room visits related to toothache or other dental concerns in a year study of seven hospitals in the Minneapolis. This represented a total cost of approximately $4.5 million in treatment of toothaches or abscesses.

31 22 The 2009 Iowa Oral Health Survey measured the oral health status of third grade children (8-9 years-old) in Iowa 61. The Oral Health Bureau with the Iowa Department of Public Health (IDPH) developed and implemented an open-mouth survey of third grade students during the spring of The purpose of this survey was to track the oral health status of Iowa children in order to evaluate the current public health program and policy planning. A computerized random sample of 1,850 school children was invited to participate in the survey. Schools with school-based sealant program were excluded 61. The open-mouth survey was performed by dental hygienists employees or contracted of the state s Title V child health centers. Oral health indicators included the presence of restorations, sealed permanent molars, and/ or cavitated lesions. The participation rate was 65% (1,206 students). The results indicated that 49.2% of children had at least one sealant on a permanent first molar, 46.7% had at least one restored tooth, 50% of 3rd grade children in Iowa had caries experience, and 30% had untreated dental decay. The majority of children were White (88%). Hispanics made up 5.4% of the study group and African Americans made up 4.1% 61. Dental caries continues to affect more than 50 percent of school-aged children 59. Children from low socioeconomic status families, as well as minorities are at higher risk for caries and are less likely than others to receive dental care 62, 59. This is also true for Muscatine and Louisa counties. Of recent Muscatine County School aged children who received a dental exam through the School-Based Dental Sealant Program provided by Unity Public Health, more than 50 percent did not have a dentist. In addition over 75 percent of the children had dental caries that required follow-up. Unity Public Health provides dental vouchers from the Iowa Department of Public Health for children who qualify for Title V funding. Between October 1, 2001 and September 30, 2002, Unity Public Health issued 65 vouchers that totaled $5, dollars for urgent restorative

32 23 dental care. This figure was the total allotment that Unity Public Health received from the State Department of Public Health. Many more children needed urgent restorative work, but without a payment source, were unable to receive the needed dental care 57. Based on these indicators the MCSA Board of Directors and staff searched for ways to respond to the medical and dental needs of the uninsured and homeless of Muscatine County. In 2002, MCSA established a partnership with the University of Iowa School of Nursing, this partnership still going on. Through this partnership two nursing students provide educational classes about general health and nutrition along with direct care to people residing at the MCSA shelter. Further, the MCSA board of directors considered establishing a Free Health Clinic ; however Muscatine County Community Services expressed financial concern that the need would be greater than the available resources. In 2002, the MCSA Board of Directors learned of the potential benefit of a partnership with a FQHC (Federally Qualified Health Care), Community Health Care in Davenport, Iowa. By definition, FQHCs are publicly funded, non-forprofit, consumer-directed health care corporations, which provide high quality, cost-effective and comprehensive primary and preventive care, to medically underserved and uninsured people. In 2003, MCSA s Health Steering Committee conducted a survey of households in Muscatine in an effort to identify unmet health care needs in the community. Survey questions included: 1) Do you see a doctor when you need one? 2) Do you see a dentist when you need one? 3) How are your prescriptions paid? 4) Where does your family go for medical help? and 5) How are your medical bills paid? The survey included approximately 22.5% of households in Muscatine. Survey results indicated that 17.6% of households in Muscatine County did not see a dentist and 11.4% did not see a doctor when they needed

33 24 one 58, 63. The MCSA Board of Directors made a formal request to Davenport Community Health Center Board to consider a satellite clinic in Muscatine. At approximately the same time, the University of Iowa College of Dentistry, through the Department of Pediatric Dentistry, expressed an interest in establishing a satellite dental clinic in Muscatine to expand opportunities for their senior dental students to provide dental care to children. The MCSA Steering Committee welcomed the opportunity to collaborate with the College of Dentistry in an effort to bring affordable pediatric dental care to the Muscatine community. An agreement was made between MCSA and the College of Dentistry to staff a University of Iowa satellite pediatric dental clinic in the lower level of MCSA. The clinic opened in January Muscatine Pediatric Dental Clinic (MPDC) The two primary program objectives of MPDC include increasing access to care for low-income children in Muscatine and Louisa County, and providing community-based experience in treating children to senior dental students from the University of Iowa, College of Dentistry 64. Clinic operation hours at MDPC are Tuesdays and Thursdays from 9:00 AM 12:00 noon and 1:00 PM 4:00 PM. Approximately eighteen patients plus emergencies are scheduled daily. Children eligible for treatment in the clinic include children ages 0-12 years of age that reside in Muscatine or Louisa County. Adolescents with emergency needs are also accommodated. MPDC staffing consists of senior dental students, residents and faculty members from the Department of Pediatric Dentistry at the University of Iowa, College of Dentistry. The staff also includes dental assistants and a bilingual receptionist. All patients seen at MPDC become registered as patients of the College of Dentistry.