Research Briefs

• U.S. adults face access barriers to primary care due to high rates of chronic disease and an insufficient number of physicians. Dentists could fill the primary care void by offering chronic disease diagnosis and monitoring in their dental offices.       
• Expert stakeholders in the dental, medical, and public health fields in Massachusetts opined that dentists trained in systemic care could serve patients who do not have access to physicians and relieve the overburdened primary care industry while lowering health care costs.
• Reforms needed to expand the primary care scope of dentistry include changes to dental school curriculum, increased interprofessional collaboration between physicians and dentists, and implementation of governmental supervision.  

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• This report presents the number of programs, total enrollment, and graduates from advanced dental education programs in 11 disciplines, from 1975 to the present.      
• Total enrollment has increased in every discipline, with the exception of oral and maxillofacial pathology.
• The number of graduates has increased in every discipline, with the exception of periodontics.
• The number of programs has increased in six disciplines and decreased in five.

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• We update our earlier estimates of the future supply of dentists in the U.S. by revising some of our assumptions. We continuously monitored key dentist labor market decisions in recent years and concluded these changes were enough to warrant a revised analysis.    
• Under what we consider to be the most probable scenario, the per capita supply of dentists in the United States is projected to increase through 2037 even after adjusting for expected changes in hours worked and patient visits due to dentist age and gender composition.
• Understanding the future evolution of the total supply of dentists contributes only partially to the central policy question of whether the dental workforce will be able to meet population needs. The issue of provider adequacy is far more complex and further research is needed.    

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• Total dental expenditures were $124B in 2016. This was a 3.3% increase from 2015, after adjusting for inflation.
• Per capita total dental expenditures also increased in 2016, for the second year in a row.
• Dental expenditures increased in 2016 for all sources of financing (e.g. out-of-pocket, insurance, CMS programs). The breakdown of expenditure by source of financing was largely unchanged in 2016. However, CMS programs saw a slight increase.
• Total U.S. dental expenditures have increased for two straight years after being flat for several years.

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• Wisconsin, Washington and California had the lowest Medicaid reimbursement rates for both adult and child dental care services among states that provide dental services via fee-for-service.
• There is considerable variation across states in Medicaid fee-for-service reimbursement rates.

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• After adjusting for inflation, average fees for dental procedures have increased over time, especially for the three most often performed endodontic procedures.
• Reimbursement rates from third-party payers have increased slowly from 2005 to 2014, or have decreased in some cases. The difference between fees charged by dentists and reimbursement rates through third-party payers appears to be increasing over time.
• Despite a small rebound from 2014-2015, specialist dentist incomes have been stagnant. This is possibly due to declining dental care use for complex specialty procedures or changes in reimbursement rates.

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• Out of five types of dental specialists (oral surgeons, endodontists, orthodontists, periodontists, and pediatric dentists), oral surgeons are consistently the highest earning dental specialists while periodontists are the lowest earning dental specialists.
• Among the five specialist types studied in this brief, orthodontists have the lowest self-reported busyness levels while oral surgeons have the highest self-reported busyness levels.
• Among the five specialist types studied in this brief, a greater percentage of pediatric dentists work in dental service organization (DSO) affiliated practices while a lower percentage of periodontists work in DSO affiliated practices.

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• General practitioner and specialist dentists' average earnings did not change significantly in 2015.
• Dentists were slightly busier in 2015 but there is still significant unused capacity in the dental care system.
• Looking forward, 2016 data are likely to provide a better sense of whether the dental care economy is turning around or whether a "new normal" is entrenched.

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• National dental care expenditures were $117.5 billion in 2015.
• Taking into account both inflation and population growth, national dental expenditures rose between 2014 and 2015, reversing a multi-year trend.
• Research suggests that Medicaid expansion under the Affordable Care Act may have increased demand for dental care and public dental expenditures. This is an important area of future research.

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• From 2013 to 2014, the percentage of working-age adults lacking dental benefits dropped and the percentage with private dental benefits coverage increased.
• The percentage of children lacking dental benefits continued to fall in 2014 and is now at its lowest level since 1999, the first year that data became available.
• It is still too early to tell whether increases in dental benefits coverage will boost dental care utilization, particularly among working-age adults.

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• Dental care utilization among working-age adults did not change in 2014.
• Dental care utilization continued to increase among elderly adults in 2014 and is at its highest level since the Medical Expenditure Panel Survey began tracking dental care utilization in 1996.
• Although not statistically significant, dental care utilization increased 2 percentage points in 2014 among working-age adults with public insurance. This might signal the early impact of Medicaid expansion under the Affordable Care Act, but further research is needed.

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• Endodontists are consistently the second-highest earning dental specialists.
• Endodontists' incomes were hit the hardest by the impact of the Great Recession and, along with pediatric dentists, are the only dentists to see definitive signs of post-recession income recovery.
• Endodontists' self-reported busyness levels are among the lowest of all dentists. General practitioner dentists tend to perform at least two-thirds of the most common endodontic procedures.
• Endodontists are among the least likely dentists to work in corporate dental practice.

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• We update our estimates of the future supply of dentists in the U.S. by incorporating expected shifts in average age and gender composition. These shifts will impact hours worked and volume of patients seen, an aspect we did not address in our earlier modeling.
• Under what we consider to be the most probable scenario, the per capita supply of dentists in the United States, adjusted for hours worked and patient visits, is projected to increase through 2035.
• Understanding the future evolution of the total supply of dentists contributes only partially to the central policy question of whether the dental workforce will be able to meet population needs. The issue of provider adequacy is far more complex and further research is needed.

Read the full Research Brief. (PDF)

• More than one in three adults ages 19 through 64 with private dental benefits do not have a single dental claim within the year.
• Fees paid to dentists through private dental benefits plans are significantly lower than market fees. This leads to substantial differences in total dental spending estimates based on "market" versus "actual" fees.
• For the majority of adults, total copayments, coinsurance and premiums exceed the “market” value of dental care.

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• Large group dental practices, measured in terms of employee size, grew from 1992 to 2012. In 2012, large group dental practices accounted for 3.9 percent of dental practice employees, while very small dental practices accounted for 80.7 percent of dental practice employees.
• Large group medical practices, measured in terms of employee size, also grew from 1992 to 2012. In 2012, large group medical practices accounted for 29.6 percent of medical practice employees, while very small medical practices accounted for 33.6 percent of medical practice employees.
• The drivers of consolidation of dental and medical practices are very different; medical practice is not a good model for dental practice.

• In a tertiary health care setting, physicians reported they were dissatisfied with the referral system to dentists, the coverage of dental care services for patients, and their ability to distinguish a worrisome oral lesion from a variant of normal.
• More than half of worrisome lesions were referred to physician specialists instead of dentists specifically due to the lack of a referral system.
• Efforts to improve the referral system to dentists, facilitate the creation of an electronic referral system, and promote dental education for physicians could increase both physician and dentist satisfaction and the quality and efficiency of care for patients.

• Average annual per-patient dental expenditures in the U.S. were $685 in 2013. 
• Average expenditures for patients in the 90th percentile were $1,624. Expenditures at this level and above could represent a financial burden to dental patients.
• Contributing to this burden are out-of-pocket expenditures which, as a percentage of the total expenditure, are higher for dental services compared to other sectors of the health care system.
• Patients with high dental expenditures represent a relatively small percentage of the U.S. population, and the services they receive are not usually required annually.

• More than one in four children ages 1 through 18 with private dental benefits do not have a single dental claim within the year.
• Fees paid to dentists through private dental benefits plans are significantly lower than market fees. This leads to substantial differences in total dental spending estimates based on "market" versus "actual" fees.
• For the majority of children, total copayments, coinsurance, and premiums exceed the “market” value of dental care.

Read the full Research Brief. (PDF)

• As of September 2015, 22 states did not provide any dental benefits to adults in their Medicaid programs beyond emergency procedures.
• We estimate that it would cost between $1.4 and $1.6 billion per year to provide dental benefits to Medicaid adults in these 22 states. The state shares represent between 0.4 and 2.1 percent of total Medicaid spending depending on the state.
• Providing dental benefits to Medicaid adults may lead to enhanced savings for states in other areas, such as hospital emergency department spending. Further research is needed in this area.

• Most accountable care organizations (ACOs) are not responsible for dental care as part of their ACO contract. Nine percent of the largest commercial contracts and 25 percent of Medicaid contracts hold providers responsible for the cost and quality of dental services.
• The top reason ACOs report for excluding dental care is a lack of integrated health information technology. The perceived potential for cost savings associated with dental care is the top motivation among ACOs that include or plan to include dental care.
• Despite research suggesting that integration of dental care may benefit patients, financing and delivery of dental care remains disconnected from other health services, even among ACOs working to improve overall population health. Integration of dental care may present an opportunity for improved accountability for total health, yet to date, there is little incentive for ACOs to facilitate access to these services.

• The number of emergency department (ED) visits for dental conditions in the United States fell from 2012 to 2013, the first decline since the early 2000s.
• There were per-capita declines among all age groups except adults ages 50 to 64. The largest per-capita decline was among young adults ages 19 to 25.
• Looking forward, there are substantial opportunities to reduce ED visits for dental conditions through targeted referral programs and enhanced coverage for preventive dental services among vulnerable populations.

• General practitioner dentists' earnings declined slightly in 2014. This represents a continuation of a multi-year trend. For specialist dentists, earning trends are more volatile.
• Low dentist busyness levels and low wait times indicate additional capacity is available in the dental care system.
• With five full years of data since the beginning of the economic recovery, it is clear that dentist earnings are not rebounding.
• Looking forward, given that dental spending is expected to remain sluggish while supply of dentists is expected to increase, the prospects for dentist earnings remain unclear.

• National dental care expenditure was $113.5 billion in 2014.
• Taking into account both inflation and population growth, national dental expenditure remained flat between 2013 and 2014, continuing a multi-year trend.
• The establishment of health care insurance marketplaces as well as Medicaid expansion under the Affordable Care Act could impact demand for dental care and dental expenditure. This is an important area of future research.

• In 2013, and for the first time since 2007, dental care utilization did not decline among working-age adults
• Dental care utilization continued to increase among children in 2013 and is at its highest level since the Medical Expenditure Panel Survey began tracking dental care utilization in 1996.
• The Affordable Care Act has the potential to alter dental care utilization patterns. The establishment of health insurance marketplaces as well as Medicaid expansion could increase dental benefits coverage and demand for dental care.

• More children had dental benefits in 2013 than in 2012, a continuation of a trend that began in 2000. The percentage of children lacking dental benefits is at its lowest rate since the Medical Expenditure Panel Survey began tracking dental insurance coverage in 1999
• The percentage of young adults ages 19-25 with private dental benefits continued to increase in 2013, a trend that began in 2010 and is partly a result of the Affordable Care Act.
• The Affordable Care Act has the potential to alter dental benefits coverage patterns. The next release of the Medical Expenditure Panel Survey will provide important insights.

• Cost barriers to dental care fell significantly in 2014, continuing a trend that began in 2010. This decline is now in its fourth year, reversing the increase that occurred from 2000 to 2010. Young adults and low-income adults had the largest decline in cost barriers to dental care from 2013 to 2014.
• Cost barriers for dental care remain significantly higher than for other types of health care services.
• More research is needed to assess whether the Affordable Care Act, namely Medicaid expansion, is affecting dental benefits coverage and cost barriers to dental care.

• In all forty-seven states and the District of Columbia where we have reliable data, dental care utilization among Medicaid-enrolled children increased between 2005 and 2013. This resulted in a significant narrowing of the gap in dental care utilization between Medicaid-enrolled children and children with private dental benefits.
• Most states experienced a drop in dental care utilization among adults with private dental benefits between 2005 and 2013. In contrast, most states saw an increase in dental care utilization among children with private dental benefits.
• While dental care utilization for Medicaid children continues to “catch up” to children with private dental benefits, a very large gap remains among adults. Policymakers ought to focus on reforms to Medicaid if access to dental care issues for adults are to be addressed.

• We examined career satisfaction among dentists working in two types of large group practice: those affiliated with a dental management organization, and those completely owned and operated by dentists.
• Dentists working in large group practices affiliated with dental management organizations were less satisfied with certain aspects of their practice, such as income and feeling emotionally drained, but were most satisfied with others, such as weekends off and reported fewer hours spent on nonclinical tasks, compared to dentists working in practices that were dentists owned and operated.
• As dental practice structures evolve, it is important to continue studying the implications for both dentists and patients.

• From 2002 to 2012, market share increased for dental firms with 20 employees or more, while dental firms with fewer than five employees experienced a decline in market share.
• During the same period, very large dental firms - those with 500 employees or more - also saw increases in the number of establishments, number of employees and annual receipts.
• Market penetration of very large firms varies by state, from a low of none in seven states to a high of seven percent of the Florida market.

• In 2015, all medical plans offered through Covered California include embedded pediatric dental benefits. This represents a significant change from 2014, when no medical plans were embedded.
• We estimate that this policy change led to about a $7 increase in child medical plan monthly premiums. It also resulted in a slight and statistically insignificant decline in child stand-alone dental plan (SADP) premiums. Potential declines in SADP premiums will have to be monitored in the coming years.
• While the California experience suggests that child dental benefits obtained via embedded medical plans are less costly than SADPs with respect to monthly premiums, further research is needed to examine differences in deductible arrangements, total out-of-pocket costs, and provider networks.

• Most accountable care organization (ACO) contracts do not include dental services. However, over time, the share of commercial ACO contracts that include dental services has increased.
• ACOs that do include dental services are more likely to include a federally qualified health center or community health center and are much more likely to have contracts with Medicaid.
• Looking forward, more research is needed to understand how ACOs approach the decision on including dental services.

• The number of emergency department (ED) visits for dental conditions in the United States continues to rise. In 2012, ED dental visits cost the U.S. health care system $1.6 billion, with an average cost of $749 per visit.
• Emergency department use for dental conditions has declined among young adults ages 19 to 25, has remained relatively flat among children and has increased for other age groups. The share of ED dental visit costs paid for by Medicaid has also increased.
• Looking forward, there are substantial opportunities to reduce ED visits for dental conditions through targeted referral programs and enhanced coverage for preventive dental services for adults  through Medicaid.

• There is an upward trend in the share of medical plans with embedded dental benefits in the health insurance marketplaces.
• While pediatric dental benefits are an essential health benefit under the Affordable Care Act, many plans do not offer first dollar coverage for preventive dental services.
• Medical plans with embedded pediatric dental benefits are more likely than stand-alone dental plans to provide first dollar coverage for preventive services.
• Information on dental benefits is much more transparent in the 2015 Federally-Facilitated Marketplace compared to 2014.

• Centers for Medicare & Medicaid Services’ projections for health care spending growth tended to overestimate actual growth in spending during the period 1999 to 2012. The accuracy of spending growth projections also decreased with the projection horizon.
• Centers for Medicare & Medicaid Services’ spending projections for dental care appear to be more accurate than projections for prescription drug expenditures, but not as accurate as projections for other components of health care.

• National dental care expenditure was $111 billion in 2013, roughly the same as the previous year when adjusted for inflation.
• Taking into account both inflation and population growth, national dental expenditure fell slightly between 2012 and 2013.
• With four full years of post-Great Recession data, it is clear that dental spending is not rebounding and has, instead, very likely entered a "new normal."

• Dentists' earnings are not rebounding despite several years of economic recovery since the Great Recession.
• Low dentist busyness levels and decreased wait times indicate additional capacity is available in the dental care system.
• Given that dental spending is expected to remain sluggish while the supply of dentists is expected to increase, the prospects for dentist earnings remain unclear.

• Due to the Affordable Care Act, the Medicaid market for dental care will grow significantly in many states. Even in many states electing not to expand Medicaid eligibility, there will still be a large influx of adults and children into Medicaid.
• In an overall stagnant dental care sector, driven by declining dental care use among middle- and high-income adults, Medicaid represents one of the few market segments with expanding demand for dental care.
• Translating expanded Medicaid dental benefits coverage to expanded access to dental care and ultimately, improved oral health, will require significant reforms to Medicaid programs. States can draw on a significant body of evidence to guide reforms.

• From 2003 to 2013, Medicaid reimbursement rates for pediatric dental care services have not kept up with inflation in most states. In contrast, most states have seen increases in inflation-adjusted private dental insurance charges.  
• States that have implemented reimbursement increases along with other Medicaid program reforms have seen significant gains in provider participation and access to dental care. The impact of fee changes in the private market has been studied less.
• As Medicaid continues to expand, policy makers ought to examine the extent to which key enabling conditions are in place to translate expanded coverage to expanded access to care.  Adequate provider reimbursement is one of these enabling conditions.

• Cost and low perceived need are the top reasons why adults indicate they do not intend to visit a dentist in the next 12 months. This is true among adults of all ages and income levels.
• Other important reasons for not visiting a dentist include lack of time, difficulty traveling to a dentist, anxiety, and difficulty finding a dentist that accepts Medicaid.
• The prominence of "no need" as a reason for forgoing dental care may be driven by improvements in oral health, changes in oral health literacy, or a significant shift in the value proposition of dental care.  Further research is needed in this area.

• Since Fiscal Year 2012, per-capita outpatient dental emergency department visits have decreased in Maryland. The decline can be attributed to reduced visits among children and adults ages 21-40.
• The decrease in outpatient dental emergency department visits among children could be attributed to reforms Maryland has instituted in its pediatric Medicaid program since 2007.
• As the majority of expenditure for outpatient dental emergency department visits is financed by Medicaid, an effective statewide emergency department diversion program could save Maryland Medicaid up to $4 million per year.

• We project the supply of dentists in the U.S. by modeling various sources of outflows from and inflows to the dentist workforce. The model, while conceptually straightforward, has the potential to generate numerous alternative scenarios.
• Under what we consider to be the most probable scenario, the per capita supply of dentists in the United States is projected to increase through 2033. Total inflows to the dentist workforce are expected to exceed total outflows, and the net gain is expected to exceed the growth in the U.S. population.
• Understanding the future evolution of the total supply of dentists contributes only partially to the central policy question of whether the future supply of dentists is sufficient. The issue of provider adequacy is far more complex and further research is needed.

• From 2003-2004 to 2011-2012, the percentage of the population reporting they needed dental care but could not get it declined.  In both time periods, non-elderly adults were most likely to indicate being unable to obtain needed dental care.
• Among a group of eleven types of barriers to receiving needed dental care, financial barriers were mentioned most often. The level of financial barriers was highest among low-income non-elderly adults.
• Barriers related to the availability of a dentist were reported by a very small percentage of the population. The percentage indicating such “supply-side” barriers fell from 2003-2004 to 2011-2012.
• The results suggest strongly that financial factors are by far the most important reason the population foregoes needed dental care. Looking forward, due to the large numbers of children and adults expected to gain dental coverage under the Affordable Care Act, it is important to monitor access to dental care.

• In 2013, the average Medicaid fee-for-service reimbursement rate was 48.8 percent of commercial dental insurance charges for pediatric dental care services.
• In 2014, the average Medicaid fee-for-service reimbursement rate was 40.7 percent of commercial dental insurance charges for adult dental care services in states that provide at least limited adult dental benefits in their Medicaid program.
• From 2003 to 2013, for pediatric dental care services, Medicaid fee-for-service reimbursement relative to commercial dental insurance charges fell in 39 states and rose in seven states and the District of Columbia.
• The available evidence strongly suggests that increasing Medicaid reimbursement rates for dental care services, in conjunction with other reforms, increases provider participation and access to dental care for Medicaid enrollees.

Read the full Research brief. (PDF)

• From 2011 to 2012 dental care utilization increased among children and decreased among working-age adults
• Changes in dental care utilization patterns from 2011 to 2012 represent the continuation of multi-year trends.
• Dental care utilization in 2012 was at its highest level among children and at its lowest level among working-age adults since the Medical Expenditure Panel Survey began tracking dental care use in 1996. 

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• More children had dental benefits in 2012 than in 2011. The increase represents a continuation of more than a decade-long trend. The percentage of children lacking dental benefits is at its lowest rate since the Medical Expenditure Panel Survey began tracking dental insurance coverage in 1999.
• Among adults, 2012 did not bring any major changes in dental benefits patterns except for a noticeable increase in private dental benefits coverage for adults ages 19-25.
• The Affordable Care Act has the potential to alter dental benefits coverage patterns among the U.S. population.

Read the full Research brief. (PDF) 

• The percentage of the population reporting cost as a barrier to receiving needed dental care fell in 2013. This decline is now in its third year, reversing the increase that occurred from 2000 to 2010.
• The largest decrease in cost barriers to dental care was among adults ages 21-34.  The percentage reporting cost barriers declined from 17.1 percent in 2012 to 14.8 percent in 2013.
• Despite improvements in affordability over the last few years, cost still remains the most critical barrier to obtaining needed dental care.

Read the full Research brief. (PDF)

• There is often confusion among Medicaid enrollees when it comes to the availability of dental benefits in Medicaid, particularly for adults.
• The majority of adults rate oral health as important. Adults with private health insurance are slightly more likely to rate oral health as important compared to adults with Medicaid. There is no difference in reported oral health importance between Medicaid-enrolled children and children with other forms of health insurance.
• Medicaid-enrolled adults report higher rates of average, poor and bad self-perceived oral health status compared to adults with other forms of health insurance. However, there is no difference in reported oral health status between Medicaid-enrolled children and children with other forms of health insurance.
• Among Medicaid-enrolled adults and children, the main reasons for not visiting a dentist include many dental services not being covered by Medicaid and difficulty finding a dentist that accepts Medicaid.

Read the full Research brief. (PDF)

• Young adults are the most likely of any age group to face financial barriers to dental care. Their dental care use has declined over time and they account for most of the increase in emergency room visits for dental conditions.
• The take-up rate of dental benefits within the newly established health insurance marketplaces is, on average, 21.2 percent for adults and 20.1 percent for children. Adults ages 26-34 are by far the most likely age group to purchase dental benefits.
• Policymakers should consider improving information transparency on adult dental benefits options within health insurance marketplaces. This will improve the shopping experience for young adults, who indicate strong interest in acquiring dental benefits.

Read the full Research brief. (PDF)

• There is a general lack of knowledge among Americans on how dental insurance is addressed within the Affordable Care Act.
• When asked about preferences for medical and dental plans, the majority of adults indicate they prefer a dental plan that costs less and has limited provider choice. In contrast, for medical plans, the majority of adults indicate they prefer a plan that costs more and has a broader choice of providers.
• Young adults and low-income adults have the strongest preference for less costly dental plans that have a more limited choice of providers.
• Just over one percent of adults and two percent of children obtained dental insurance through the health insurance marketplaces.
• Among those who shopped for dental insurance in the health insurance marketplaces, key reasons for not purchasing a plan include plans being too expensive, inability to find plans that cover services of interest, and the lack of a requirement to purchase dental insurance.

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• Based on triage status, dental emergency department (ED) visits were less likely than nondental ED visits to be categorized as immediate or urgent and more like to be categorized as semi-urgent or non-urgent.
• About two-thirds of dental ED visits occurred outside of normal business hours. Also, a dental ED visit was more likely to occur outside of normal business hours than a non-dental ED visit.
• The triage status of dental ED visits and arrival time at the ED did not vary by primary payer.
• The majority of dental ED visits can be diverted to a dental office. The savings from diverting these ED visits, estimated to be up to $1.7 billion per year, could be used to fund Medicaid premiums, preventive dental visits or other more cost-effective interventions.

Read the full Research Brief. (PDF)

• The final 2014 take-up rate of stand-alone dental plans in the health insurance marketplaces has not improved much since February 2014.
• Overall, the 2014 take-up rate of dental benefits for children appears low when compared to the objectives of the Affordable Care Act. Although further analysis is needed based on full enrollment data, our ongoing analysis of marketplace enrollment continues to suggest that the lack of a true mandate for pediatric dental benefits within the health insurance marketplaces is having important consequences.
• The final 2014 take-up rate of dental benefits for children in states where dental benefits are only available through stand-alone dental plans is only 26.1 percent, emphasizing that the lack of a true mandate for pediatric dental benefits is impacting consumer behavior.
• Because data are not available on the number of children obtaining dental benefits through medical plans, it is impossible to determine the total number of children and adults who obtained dental benefits through the health insurance marketplaces.

Read the full Research Brief. (PDF)

• The take-up rate of stand-alone dental plans in the newly established health insurance marketplaces through February 2014 varies considerably from state to state. Idaho has the highest take-up rate for children and Alabama the highest for adults.  
• Overall, the take-up rate of stand-alone dental plans for children is low when compared to the objectives of the Affordable Care Act. Although further analysis is needed based on full enrollment data, early results suggest the lack of a true mandate for pediatric dental benefits within the health insurance marketplaces is having important consequences.
• Due to data limitations, it is unclear whether consumers are purchasing dental benefits primarily through stand-alone dental plans or medical plans with embedded dental benefits. 

Read the full Research Brief. (PDF)

• There is considerable variation across states in how dental benefits are offered within the newly established health insurance marketplaces. In some marketplaces, pediatric dental benefits can be purchased only through stand-alone dental plans, while in others all medical plans include embedded pediatric dental benefits.
• There is limited information available to consumers on many key attributes of dental plans within the marketplaces, making it challenging to make meaningful comparisons and fully informed decisions.
• Stand-alone dental plans and medical plans with embedded dental benefits differ in several ways, including out-of-network coverage, deductible arrangements, and premiums. 
• Further research is needed to study the implications of alternative marketplace set ups on consumer purchasing decisions and, ultimately, access to dental care.

Read the full Research Brief. (PDF)

• The number of group practices in the United States is increasing; they are expanding and changing in character and structure. Understanding the evolution of group practices has been difficult because past discussions and research have suffered from a lack of specificity, and the information gathered was less insightful.
• A classification system for group dental practices is needed that would allow studies to be done and comparisons made in a more useful manner and allow a better understanding of contemporary dental group practice.
• Six basic types of group practice are identified and described.

Read the full Research Brief. (PDF)

• Approximately 8.3 million adults are eligible to gain Medicaid dental benefits in 2014. This is a result of expanded Medicaid eligibility and increased enrollment efforts, two key aspects of the Affordable Care Act. An estimated 2.9 million are eligible to gain extensive benefits with an additional 5.4 million eligible to gain limited benefits.
• In the few states that are expanding Medicaid eligibility and provide extensive dental benefits, a significant increase in demand is expected for dental care among Medicaid adults. In these states, policy makers ought to ensure that the enabling conditions are in place to ensure the Medicaid population can access dental care.
• If all states were to expand Medicaid eligibility, this would further increase the number of adults with Medicaid dental benefits by 2.7 million. The impact of states enhancing their current adult dental benefit within Medicaid, however, would be far greater.

Read the full Research Brief. (PDF)

• National dental care expenditure reached $111 billion in 2012, roughly the same as the previous year when adjusted for inflation.
• Taking into account both inflation and population growth, there was little change in national dental expenditure from 2011 to 2012, continuing a trend that began in 2008. Dental spending has not rebounded since the end of the Great Recession.

• Dental spending began to slow in the early 2000s, well before the onset of the Great Recession.  While overall health spending also began to slow in the early 2000s, the slowdown in the dental sector was much more pronounced.
• There were also no significant changes in inflation-adjusted per-patient dental expenditure from 2010 to 2011, continuing a trend that began in 2009. The elderly continue to have the highest level of per-patient dental expenditure.

Read the full Research Brief. (PDF)

• Among children with commercial dental benefits, dental care utilization ranges from 30 percent to 74 percent across the states.  Indiana and Oregon had the lowest percentage of children utilizing dental services, while Vermont and Massachusetts had the highest.   
• In Texas, Oklahoma, Hawaii and Oregon, dental care utilization rates were higher among children in Medicaid than children with commercial dental benefits.
• Among children with commercial dental benefits, the low utilization rate for dental care services in many states highlights the need to better understand oral care seeking behavior for this population. The wide variation in the dental care utilization gap between Medicaid and commercially-insured children also highlights how some state Medicaid programs have had remarkable success in improving access to care for low-income children.

Read the full Research Brief. (PDF)

• Dentists’ earnings remain sluggish despite being three years removed from the Great Recession.
• Low dentist busyness levels and reduced patient wait times indicate additional capacity is available in the dental care system.
• The coming years are a period of major transition in the dental care sector and the prospects for dentist earnings remain unclear.

Read the full Research Brief. (PDF)

• More children had dental benefits in 2011 than in 2010. The continued expansion since 2000 was primarily due to Medicaid and SCHIP, which mandate dental benefits for children.
• By contrast, more working-age adults are going without dental benefits compared to 2000, although there was no significant change between 2010 and 2011. More adults are in Medicaid compared to a decade ago, but adult dental benefits within Medicaid programs, on average, have eroded since 2000.
• Among the elderly, the percent with private dental benefits remained steady from 2000 through 2010, but there has been an uptick in 2011, which may reflect the increasing demand for dental care among this age cohort.

Read the full Research Brief. (PDF)

• From 2003 through 2011, dental care utilization declined steadily among working-age adults. The trend is occurring regardless of dental benefits status and income level.
• For children, dental care utilization increased considerably in the early 2000s but has held steady from 2003 through 2011. The increase in utilization was driven entirely by gains among lower income groups.
• Among the elderly, dental care utilization has steadily increased since 2000, driven primarily by gains among individuals with private dental benefits.

Read the full Research Brief. (PDF)

• The percentage of the population indicating cost as a barrier to receiving needed dental care fell from 2010 to 2012, a reversal of the increase that occurred from 2000 through 2010.
• Despite the decrease in the percentage of the population indicating cost as a barrier to dental care over the last few years, cost barriers in the dental sector remain high relative to other parts of the healthcare sector.
• Low-income, non-elderly adults reported the highest level of cost as a barrier, as well as the biggest increase from 2000 to 2010.  This increase could be associated with a corresponding erosion in dental benefits among this age group during the same period.
• Possible explanations for the decrease in financial barriers to dental care from 2010 to 2012 include the economic recovery, a flattening of prices of dental services, as well as recent increases in public health insurance coverage.

Read the full Research Brief. (PDF)

• Total per-capita dental expenditures are expected to grow in the next thirty years, but at a much lower rate than the past few decades. This could suggest the emergence of a ‘new normal’ in terms of dental spending.
• Adults 60 years of age and over are expected to account for a greater share of total dental expenditures.
• The sluggish dental expenditure growth expected in the coming decades combined with an expansion of dental school enrolment could potentially lead to challenging economic conditions for practicing dentists.  But further research is needed in this area.

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• Emergency department (ED) visits for dental conditions are increasing, driven primarily by a larger share of dental visits taking place in EDs rather than dental offices.
• Decreases in private dental insurance coverage among young adults combined with significant reductions in adult dental Medicaid programs have created a financial barrier that could have led to a substitution of dental ED visits for dental office visits.
• Unfortunately, the Affordable Care Act does not address increased dental utilization in EDs or generate effective solutions to increase access to dental care in office settings.
• Several programs have demonstrated success in reducing ED use for non-traumatic dental conditions.  These programs should be expanded.
• Without further interventions from policy makers, dental ED visits are likely to increase in the future, straining the health care system and increasing overall health care costs.

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• Approximately 8.7 million children are expected to gain some form of dental benefits by 2018 as a result of the Affordable Care Act (ACA), an increase of 15% relative to 2010. This will reduce the number of children without dental benefits by about 55%.
• Although 17.7 million adults are expected to gain some level of dental benefits as a result of the ACA, almost all of this increase is in Medicaid which varies significantly state to state on adult dental benefits policy. As a result, only 4.5 million of adults are expected to gain ‘extensive’ dental benefits through Medicaid. An additional 800,000 will gain private dental benefits through health insurance exchanges. Combined, this will reduce the number of adults without dental benefits by about 5%.
• There is likely to be significant pressure on Medicaid providers within the dental care delivery system. The ACA is expected to generate an additional 10.4 million dental visits per year through Medicaid by 2018.

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• Dental care is not generally included as a core component within today’s Accountable Care Organizations (ACOs). Where dental services are incorporated, it is mainly only at the level of facilitated referral or co-location.
• One key reason is that existing ACOs focus on Medicare populations and Medicare does not include dental benefits. There is also a perception that most dental providers and plans are accustomed to providing care according to frequency limits defined by dental insurance policies rather than a patient’s dental risk profile.
• ACOs could help bridge the gap between oral and general health care, improve coordination of care, and help reduce overall health care costs. They also provide an opportunity to re-examine the role of oral care providers within the health care team. Since dental care for children is an essential health benefit under the Affordable Care Act, the most immediate opportunities are with the pediatric population. 

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• More children had dental benefits in 2010 than in 2001. This gain was primarily due to Medicaid and SCHIP, which mandate dental benefits for children.
• By contrast, more adults went without dental benefits in 2010 than did in 2001. Although more adults had Medicaid over that period, adult dental benefits within Medicaid programs, on average, eroded during the 2000s.
• Looking forward, a combination of factors, including the Affordable Care Act, will lead to an increase in dental benefits coverage for children. However, there will likely be continued erosion of dental benefits for many groups of adults.

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• Traditional estimates of dental practice expenses have not included owner dentist salaries as a practice expense.
• When owner dentist salaries are included as a cost, practice expenses average about 90% of gross billings.
• Taking into account the actual collection rate on gross billings, practice expenses (including owner salaries) are, on average, about 97% of gross billings collected.

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• From 2000 to 2010, inflation-adjusted per-patient dental expenditure was flat among children but increased among adults, especially among the elderly and higher income adults.
• In 2010, per-patient dental expenditures were higher among the elderly than among those in younger age cohorts, and the highest level of expenditures was among the upper-income elderly.
• Due to the aging of the baby boomers, the percent of the population over the age of 65 will grow and dental expenditures among this segment of the population could buoy up the dental economy for years to come.

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• Adjusting for inflation and population growth, national dental expenditure has been flat since 2008 after decades of steady growth. It has not rebounded since the end of the Great Recession.
• Dental spending began to slow in the early 2000s, well before the onset of the Great Recession.
• While overall health spending also began to slow in the early 2000s, the slowdown in the dental sector was much more pronounced.

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• From 2000 to 2010, dental care utilization among low-income children increased in 47 states. For low income adults, utilization declined or remained flat in almost every state.
• Only two states – Massachusetts and Virginia – experiences an increase in utilization for both low-income adults and children.
• Significant reductions in adult dental benefits in Medicaid programs are one important factor explaining the decline in utilization among low-income adults.

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• From 2000 to 2010, dental care utilization increased among children and declined among adults. The decline among adults began in the early-2000s.
• For children, the increase in utilization was driven entirely by gains among lower income groups. In contrast, utilization declined for all adult income groups, but most severely for poor adults.
• Financial barriers to care are growing for adults and are one important factor in explaining the decline in dental care utilization.

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• Dentist incomes have been stable since 2009. The average annual GP dentist income was $192,392 in 2011.
• Incomes began to decline in the mid-2000s, several years before the start of the Great Recession.
• There are important differences in dentist earnings by location, gender, and type of employment arrangement that warrant further analysis.

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