cost of delay web

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State Dental Policies Fail One in Five ChildrenThe Cost ofDelay

FEBRUARY 201


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The Pew Childrens Dental Campaign works to promote policies that will help millions o children maintain

healthy teeth, get the care they need and come to school ready to learn.

A special thanks to the W.K. Kellogg Foundation and DentaQuest Foundation or their support

and guidance.

PEW CENTER ON THE STATES

Susan K. Urahn, managing director

PEW CHildRENS dENTAl CAmPAigN

Shelly Gehshan, director

Team Leaders: Team Members: Design and Publications:Andrew Snyder Jill Antonishak Evan PotlerLori Grange Jane L. Breakell Carla UrionaMichele Mariani Vaughn Libby DoggettMelissa Maynard Nicole Dueert

Kil Huh

Amy KatzelLauren LambertMolly LyonsBill MaasMarko MijicMorgan F. Shaw

ACKNOWlEdgmENTS

This report beneted rom the eforts and insights o external partners. We thank our colleagues at the

Association o State and Territorial Dental Directors and the National Academy or State Health Policy and

Amos Deinard with the University o Minnesota or their expertise and assistance in gathering state data. We

also thank Ralph Fuccillo and Michael Monopoli with the DentaQuest Foundation and Albert K. Yee with theW. K. Kellogg Foundation or their guidance, eedback and collaboration at critical stages in the project.

We would like to thank our Pew colleaguesRebecca Alderer, Nancy Augustine, Brendan Hill, Natasha

Kallay, Ryan King, Mia Mabanta, Laurie Norris, Kathy Patterson, Aidan Russell, Frederick Schecker and

Stanord Turneror their eedback on the analysis. We thank Andrew McDonald or his assistance with

communications and dissemination; and Jennier Peltak and Julia Hoppock or Web communications support.

And we thank Christina Kent and Ellen Wert or assistance with writing and copy editing, respectively.

Finally, our deepest thanks go to the individuals and amilies who shared their stories with us.

For additional inormation on Pew and the Childrens Dental Campaign,

please visit www.pewcenteronthestates.org/costodelay.

This report is intended or educational and inormational purposes. Reerences to specic policy makers or

companies have been included solely to advance these purposes and do not constitute an endorsement,

sponsorship or recommendation by The Pew Charitable Trusts.

2010 The Pew Charitable Trusts. All Rights Reserved.

901 E Street NW, 10th Floor 2005 Market Street, Suite 1700

Washington, DC 20004 Philadelphia, PA 19103


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February 2010

Dear Reader:

Most Americans dental health has never been betterbut that is not true or an estimated 17 million

children in low-income amilies who lack access to dental care.

A 2000 report by the U.S. Surgeon General called dental disease a silent epidemic. Ten years later,

too little has changed. Our reporta collaboration o the Pew Center on the States, the DentaQuest

Foundation and the W.K. Kellogg Foundationnds that two-thirds o the states are ailing to ensure

that disadvantaged children get the dental health care they need. Our report describes the severe

costs o this preventable disease: lost school time, challenges learning, impaired nutrition and health,

worsened job prospects in adulthood, and sometimes even death.

The good news? This problem can be solved. At a time when state budgets are strapped, childrens

dental health presents a rare opportunity or policy makers to make meaningul reorms without

breaking the bankwhile delivering a strong return on taxpayers investment. Several states are

demonstrating the way orward with proven and promising approaches in our areas: preventive

strategies such as school sealant programs and water fuoridation; improvements to state Medicaid

programs to increase the number o disadvantaged children receiving services; workorce innovations

that can expand the pool o providers; and tracking and analysis o data to measure and drive progress.

Pew believes investing in young children yields signicant dividends or amilies, communities and

our economy. We operate three campaigns aimed at kidsocused on increasing access to high-

quality early education, dental health care and home visiting programs. And a pool o unders helps us

research which investments in young children generate solid returns.

The Pew Childrens Dental Campaign is a national eort to increase access to dental care or kids. We

seek to raise awareness o the problem, recruit infuential leaders to call or change, and advocate in

states where policy changes can dramatically improve childrens lives. We are helping millions o kids

maintain healthy mouths, get the restorative care they need and come to school ree o pain and ready

to learn.

Pew, the DentaQuest Foundation and the W.K. Kellogg Foundation are committed to supporting states

eorts to achieve these goals. Many issues in health care today seem intractable. Improving childrens

dental health is not one o them.

Sincerely,

Susan Urahn

Managing Director, Pew Center on the States


4/74The Cost o Delay: State Dental Policies Fail One in Fie Children

Eecutie Summary ......................................................................................................................................................................1

Chapter 1: Americas Children Face Signiicant Dental Health Challenges ............................................12

Low-Income Children are Disproportionately Aected .....................................................................12

Minority and Disabled Children are the Hardest Hit ............................................................................14

Why It Matters ...............................................................................................................................................................16

Why is This Happening? .........................................................................................................................................20

Chapter 2: Solutions ...................................................................................................................................................................25

Cost-Eectie Ways to Help Preent Problems Beore They Occur:Sealants and Fluoridation ......................................................................................................................................26

Medicaid Improements That Enable and Motiate MoreDentists to Treat Low-Income Kids..................................................................................................................29

Innoatie Workorce Models That Epand the Numbero Qualiied Dental Proiders ...............................................................................................................................31

Inormation: Collecting Data, Gauging Progress and Improing Perormance ..................34

Chapter 3: Grading the States ..............................................................................................................................................37

Key Perormance Indicators..................................................................................................................................391. Proiding Sealant Programs in High-Risk Schools ...................................................................39

2. Adopting New Rules or Hygienists in School Sealant Programs ..................................39

3. Fluoridating Community Water Supplies ......................................................................................39

4. Proiding Care to Medicaid-enrolled Children...........................................................................40

5. Improing Medicaid Reimbursement Rates or Dentists .....................................................40

6. Reimbursing Medical Proiders or Basic Preentie Care ..................................................40

7. Authorizing New Primary Care Dental Proiders ......................................................................41

8. Tracking Basic Data on Childrens Dental Health ............... ............... ................ ............... ......... 41

The Leaders .....................................................................................................................................................................41

States Making Progress ...........................................................................................................................................44

States Falling Short ....................................................................................................................................................44

Conclusion ........................................................................................................................................................................................51Methodology ..................................................................................................................................................................................52Endnotes ............................................................................................................................................................................................57Appendi ...........................................................................................................................................................................................65

Table o Contents



An estimated 17 million low-income children in

America go without dental care each year.1

Thisrepresents one out o eery e children between

the ages o 1 and 18 in the United States. The

problem is critical or these kids, or whom the

consequences o a simple caity can escalate

through their childhoods and well into their adult

lies, rom missing signicant numbers o school

days to risk o serious health problems and diculty

nding a job.

Striking acts and gures about health insuranceand the high cost o care hae ueled the national

debate about health care reorm. In act, twice as

many Americans lack dental insurance as lack health

insurance. Yet improing access to dental care has

remained largely absent rom the conersation.2

The good news: Unlike so many o Americas other

health care problems, the challenge o ensuring

childrens dental health and access to care is

one that can be oercome. There are a ariety osolutions, they can be achieed at relatiely little

cost, and the return on inestment or children

and tapayers will be signicant. The $106 billion

that Americans are epected to spend on dental

care in 2010 includes many epensie treatments

rom llings to root canalsthat could be

mitigated or aoided altogether through earlier,

cheaper and easier ways o ensuring adequate

dental care or kids.3

Most low-income children nationwide do not

receie basic dental care that can preent the

need or higher-cost treatment later. States play a

key role in making sure they receie such care, yet

research by the Pew Center on the States shows

that two-thirds o states are doing a poor job. These

states hae not yet implemented proen, cost-

eectie policies that could dramatically improe

disadantaged childrens dental health.

A problem with lasting eects

Oerall, dental health has been improing in the

United States, but children hae not beneted at

the same rates as adults. The proportion o children

between 2 and 5 years old with caities actually

increased 15 percent during the past decade,

according to a 2007 ederal Centers or Disease

Control and Preention (CDC) study. The same

surey ound that poor children continue to suer

the most rom dental decay. Kids ages 2 to 11

whose amilies lie below the ederal poerty leel

are twice as likely to hae untreated decay as their

more auent peers.4

Eecutie Summary

Unlike so many o Americas

other health care problems,

the challenge o ensuring

disadvantaged childrens dental

health and access to care is onethat can be overcome. There

are a variety o solutions, they

can be achieved at relatively

little cost, and the return on

investment or children and

taxpayers will be signicant.


6/7422 Pew Childrens Dental Campaign | Pew Center on the States

E x E C U T I v E S U M M A R Y

Those statistics are not surprising, considering the

diculty low-income kids hae accessing care.

Nationally, just 38.1 percent o Medicaid-enrolled

children between ages 1 and 18 receied any dental

care in 2007, the latest year or which data areaailable. That stands in contrast to an estimated

58 percent o children with priate insurance who

receie care each year.5

The consequences o poor dental health among

children are ar worseand longer lastingthan

most policy makers and the public realize.

Early growth and development. Caities are

caused by a bacterial inection o the mouth. For

children at high risk o dental disease, the inection

can quickly progress into rampant decay that can

destroy a childs baby teeth as they emerge. Haing

healthy baby teeth is ital to proper nutrition and

speech deelopment and sets the stage or a

lietime o dental health.

School readiness and perormance. Poor dental

health has a serious impact on childrens readiness

or school and ability to succeed in the classroom.

In a single year, more than 51 million hours o

school may be missed because o dental-related

illness, according to a study cited in a 2000 report

o the U.S. Surgeon General.6 Research shows that

dental problems, when untreated, impair classroom

learning and behaior, which can negatiely aect

a childs social and cognitie deelopment.7 Pain

rom caities, abscesses and toothaches oten

preents children rom being able to ocus in

class and, in seere cases, results in chronic schoolabsence. School absences contribute to the

widening achieement gap, making it dicult or

children with chronic toothaches to perorm as well

as their peers, prepare or subsequent grades and

ultimately graduate.

Overall health. Poor dental health can escalate into

ar more serious problems later in lie. For adults,

the health o a persons mouth, teeth and gums

interacts in comple ways with the rest o the

body. A growing body o research indicates thatperiodontal diseasegum diseaseis linked to

cardioascular disease, diabetes and stroke.8

Complications rom dental disease can kill. In 2007,

in stories that made national headlines, a 12-year-

old Maryland youth and a 6-year-old Mississippi

boy died because o seere tooth inections. Both

were eligible or Medicaid but did not receie the

dental care they needed. No one knows how many

children hae lost their l ies because o untreateddental problems; deaths related to dental illness are

dicult to track because the ocial cause o death

is usually identied as the related conditionor

eample, a brain inectionrather than the dental

disease that initially caused the inection.

Economic consequences. Untreated dental

conditions among children also impose broader

economic and health costs on American tapayers

and society. Between 2009 and 2018, annualspending or dental serices in the United States is

epected to increase 58 percent, rom $101.9 billion

to $161.4 billion. Approimately one-third o the

money will go to dental serices or children.9

While dental care represents a small raction o

oerall health spending, improing the dental

health o children has lietime eects. When children

with seere dental problems grow up to be adults

with seere dental problems, their ability to workproductiely will be impaired. Take the military.

A 2000 study o the armed orces ound that 42

percent o incoming Army recruits had at least

one dental condition that needed to be treated

beore they could be deployed, and more than

15 percent o recruits had our or more teeth in

urgent need o repair.10




Particularly or people with low incomes, who

oten work in the serice sector without sick

leae, decayed and missing teeth can pose major

obstacles to gainul employment. An estimated 164

million work hours each year are lost because odental disease.11 In act, dental problems can hinder

a persons ability to get a job in the rst place.

Why is this crisis happening? Parental guidance,

good hygiene and a proper diet are critical to

caring or kids teeth. But the national crisis o poor

dental health and lack o access to care among

disadantaged children cannot be attributed

principally to parental inattention, too much candy

or soda, or too ew ruits and egetables.

Broader, systemic actors hae played a signicant

role, and three in particular are at work:

1) too ew children hae access to proen

preentie measures, including sealants and

fuoridation; 2) too ew dentists are willing to

treat Medicaid-enrolled children; and 3) in some

communities, there are simply not enough dentists

to proide care.

Solutions within states reach

Four approaches stand out or their potential

to improe both the dental health o children

and their access to care: 1) school-based sealant

programs and 2) community water fuoridation,

both o which are cost-eectie ways to help

preent problems rom occurring in the rst

place; 3) Medicaid improements that enable and

motiate more dentists to treat low-income kids;

and 4) innoatie workorce models that epand

the number o qualied dental proiders, including

medical personnel, hygienists and new primary care

dental proessionals, who can proide care when

dentists are unaailable.

States do not hae to start rom scratch. A number

already hae implemented these approaches. Too

many, howeer, hae not. Pews analysis shows that

about two-thirds o states do not hae key policies

in place to ensure proper dental health and access

to care or children most in need.




Pew assessed and graded all 50 states and the

District o Columbia, using an A to F scale, on

whether and how well they are employing eight

proen and promising policy approaches at their

disposal to ensure dental health and access to careor disadantaged children (see Ehibit 1). (Because

data on indicators such as childrens untreated

tooth decay were not aailable or eery state, these

could not be actored into the grade.) These policies

all into our groups:

Cost-eectie ways to help preentproblems rom occurring in the irst

place: sealants and luoridation

Medicaid improements that enable

and motiate more dentists to treat

low-income kids

Innoatie workorce models thatepand the number o qualiied dental

proiders

Inormation: collecting data, gaugingprogress and improing perormance

Only si states merited A grades: Connecticut,

Iowa, Maryland, New Meico, Rhode Island and

South Carolina. These states met at least si o

the eight policy benchmarksthat is, they had

particular policies in place that met or eceeded the

national perormance thresholds. South Carolina

was the nations top perormer, meeting seen o

the eight policy benchmarks. Although these states

are doing well on the benchmarks, eery state has

a great deal o room to improe. No state met all

A

B

C

D

F

68 benchmarks

5 benchmarks

4 benchmarks

3 benchmarks

02 benchmarks

IN

WI

UT

GA

RI

CA

AZ

NDMT

KY

MS

CO

AK

HI

WA

MO

IL

OR

KS VA

OH

NYSD

NC

NH

DC

TX

SCNM

IA

MN

ME

MI

NV

AL

OK

ID

NE

VT

MA

CT

TN

Pew assessed and graded states and the District of Columbia on whether and how well they are employing eight proven and promising

policy approaches at their disposal to ensure dental health and access to care for disadvantaged children.

Exhibit 1 GRADING THE STATES

SOURCE: Pew Center on the States, 2010.

FL

NJPA

HI

LA

WY

AR

DEWV

MD




eight targets and een those with good policy

rameworks can do ar more to proide children

with access to care.

Thirty-three states and the District o Columbia

receied a grade o C or below because they met

our or ewer o the eight policy benchmarks. Nine

o those states earned an F, meeting only one or

two policy benchmarks: Arkansas, Delaware, Florida,

Hawaii, Louisiana, New Jersey, Pennsylania, West

virginia and Wyoming.

See Pews indiidual state act sheets or a detailed

description o each states grade and assessment.

The act sheets are aailable at

www.pewcenteronthestates.org/costodelay.

Cost-eectie ways to help preent problems

rom occurring in the rst place: sealants and

fuoridation

Sealants.Dental sealants hae been recognized

by the CDC and the American Dental Association

(ADA) as one o the best preentie strategies

that can be used to benet children at high risk

or caities. Sealantsclear plastic coatings

applied by a hygienist or dentistcost one-third

as much as lling a caity,12 and hae been shown

ater just one application to preent 60 percent o

decay in molars.13

Healthy People 2010, a set o national objecties

monitored by the U.S. Department o Health and

Human Serices, calls or at least hal o the third

graders in each state to hae sealants by 2010. Data

submitted by 37 states as o 2008, howeer, show

that the nation alls well short o this goal. Only

eight states hae reached it, and in 11 states, ewerthan one in three third graders hae sealants.14

Studies hae shown that targeting sealant programs

to schools with many high-risk children is a cost-

eectie strategy or proiding sealants to children

who need thembut this strategy is astly

underutilized.15 New data collected or Pew by the

Association o State and Territorial Dental Directors

show that only 10 states hae school-based sealant

programs that reach hal or more o their high-riskschools. These 10 states are Alaska, I llinois, Iowa,

Maine, New Hampshire, Ohio, Oregon, Rhode Island,

South Carolina and Tennessee. Eleen states hae

no organized programs at all to etend this serice

to the schools most in need: Delaware, Hawaii,

Missouri, Montana, New Jersey, North Dakota,

Oklahoma, South Dakota, vermont, West virginia

and Wyoming.16 Oerall, in Pews analysis, just 17

states met the minimum threshold o reaching at

least 25 percent o high-risk schools.

Not only do sealants cost a third o what llings

do, they also can be applied by a less epensie

workorce.17 Dental hygienists are the primary

proiders in school-based sealant programs. How

many kids are sered by a sealant program and how

cost eectie it is depends in part on whether the

program must locate and pay dentists to eamine

P B 1

S t a t e h a s s e a l a n t p r o g r a m s i n p l a c e i n

a t l e a s t 2 5 p e r c e n t o f h i g h - r i s k s c h o o l s

Percentage of high-risk schoolswith sealant programs, 2009

Numberof states

75 - 100% 3

50 - 74% 7

25 - 49% 7

1 - 24% 23

None 11

P B 2

S t a t e d o e s n o t r e q u i r e a d e n t i s t s e x a m

b e f o r e a h y g i e n i s t s e e s a c h i l d i n a s c h o o l

s e a l a n t p r o g r a m

State allows hygienist to providesealants without a prior dentistsexam, 2009

Numberof states

Yes 30

No 21




children beore sealants can be placed. Dental

hygienists must hae at least a two-year associate

degree and clinical training that qualies them

to conduct the necessary isual assessments and

apply sealants.18

But states ary greatly in their lawsgoerning hygienists work in these programs, and

many hae not been updated to refect current

science, which indicates that -rays and other

adanced diagnostic tools are not necessary to

determine the need or sealants. Thirty states

currently allow a child to hae hygienists place

sealants without a prior dentists eam, while

seen states require not only a dentists eam,

but also that a dentist be present on-site when the

sealant is proided.19

Fluoridation. Water fuoridation stands out as one

o the most eectie public health interentions

that the United States has eer undertaken. Fluoride

counteracts tooth decay and, in act, strengthens

the teeth. It occurs naturally in water, but the leel

aries within states and across the country. About

eight million people are on community systems

whose leels o naturally occurring fuoride arehigh enough to preent decay, but most other

Americans receie water supplies with lower natural

leels. Through community water fuoridation,

water engineers adjust the leel o fuoride to about

one part per millionabout one teaspoon o

fuoride or eery 1,300 gallons o water. This small

leel o fuoride is sucient to reduce rates o tooth

decay or childrenand adultsby between 18

percent and 40 percent.20

Fluoridation also saes money. A 2001 CDC study

estimated that or eery $1 inested in water

fuoridation, communities sae $38 in dental

treatment costs.21 Perhaps more than $1 billion

could be saed eery year i the remaining water

supplies in the United States, sering 80 million

persons, were fuoridated.22

With those kinds o results, it is no surprise that the

CDC identied community water fuoridation as one

o 10 great public health achieements o the 20th

Century and a major contributor to the dramatic

decline in tooth decay oer the last e decades.23

Approimately 88 percent o Americans receie

their household water through a community system

(the rest use well water), yet more than one-quarter

do not hae access to optimally fuoridated water.24

Pews reiew o CDC data ound that in 2006, 25

states did not meet the national benchmark, based

on Healthy People 2010 objecties, o proiding

fuoridated water to 75 percent o their populationon community water systems. In nine states

Caliornia, Hawaii, Idaho, Louisiana, Montana, New

Hampshire, New Jersey, Oregon and Wyomingthe

share o the population with fuoridated water had

not reached een 50 percent.25

The CDC is working to update its fuoridation data

as o 2008. Although they were not aailable at the

time this report went to press, the newer data are

epected to refect progress in the last ew years inCaliornia because o a state law that has produced

gains in cities like Los Angeles and San Diego. They

also may show that states such as Delaware and

Oklahoma that were close to the national goal in

2006 now hae met it.

P B 3

S t a t e p r o v i d e s o p t i m a l l y f l u o r i d a t e d w a t e r

t o a t l e a s t 7 5 p e r c e n t o f c i t i z e n s o n c o m m u n i t y

s y s t e m s

Percentage of population oncommunity water supplies receivingoptimally fluoridated water, 2006

Numberof states

75% or greater 26

50 - 74% 16

25 - 49% 7

Less than 25% 2



Medicaid improements that enable and

motiate more dentists to treat low-income kids

Medicaid utilization. States are required by ederallaw to proide medically necessary dental serices

to Medicaid-enrolled children, but nationwide only

38.1 percent o such children ages 1 to 18 receied

any dental care in 2007. That national aerage is

ery low, but een so, 21 states and the District o

Columbia ailed to meet it, and some ell abysmally

short. Dental care was still out o reach or more

than three-quarters o all children using Medicaid in

Delaware, Florida and Kentucky. More than hal o

Medicaid-enrolled kids receied dental care in just

three states: Alabama, Teas and vermont.

Medicaid participation. In part, the low number

o children accessing care is because not enough

dentists are willing to treat Medicaid-enrolled

patients. Dentists point to low reimbursement rates,

administratie hassles and requent no-shows bypatients as deterrents to sering them. It is easy to

see why they cite low reimbursement rates: Pew

ound that or e common procedures, 26 states

pay less than the national aerage (60.5 percent) o

Medicaid rates as a percentage o dentists median

retail ees. In other words, their Medicaid programs

reimburse less than 60.5 cents o eery $1 billed by

a dentist.26

States are taking steps to address these issues andas a result are seeing signicant improements in

dentists willingness to treat children on Medicaid

and in childrens ability to access the care they need.

The si states that hae gone the urthest to raise

reimbursement rates and minimize administratie

hurdlesAlabama, Michigan, South Carolina,

Tennessee, virginia and Washingtonall hae seen

greater willingness among dentists to accept new

Medicaid-enrolled patients and more patients

taking adantage o this access, a 2008 study by the

National Academy or State Health Policy ound. In

those states, proider participation increased by at

least one-third and sometimes more than doubled

ollowing rate increases.27

And while increasing inestments in Medicaid is

dicult during tight scal times, some states hae

shown that it is possible to make improements

with limited dollars. Despite budget constraints,

27 states increased reimbursement rates or dental

serices in 2009 and 2010, while only 12 states

made cuts during the same period.28


P B 4

S t a t e m e e t s o r e x c e e d s t h e n a t i o n a l a v e r a g e

( 3 8 . 1 p e r c e n t ) o f c h i l d r e n a g e s 1 t o 1 8 o n

M e d i c a i d r e c e i v i n g d e n t a l s e r v i c e s

Percentage of Medicaid childrenreceiving any dental service,2007

Numberof states

59% or greater 0

50 - 58% 3

38.1 - 49.9% 26

30 - 38.0% 13

Less than 30% 9

P B 5

S t a t e p a y s d e n t i s t s w h o s e r v e M e d i c a i d -

e n r o l l e d c h i l d r e n a t l e a s t t h e n a t i o n a l a v e r a g e

( 6 0 . 5 p e r c e n t ) o f M e d i c a i d r a t e s a s a

p e r c e n t a g e o f d e n t i s t s m e d i a n r e t a i l f e e s

Medicaid reimbursement ratesas a percentage of dentistsmedian retail fees, 2008

Numberof states

100% or greater 1

90 - 99% 2

80 - 89% 3

70 - 79% 10

60.5 - 69% 9

50 - 60.4% 12

40 - 49% 10

Less than 40% 4




Innoatie workorce models that epand the

number o qualied dental proiders

Medicaid reimbursement or medical providers.

Some communities hae a dearth o dentistsand

particular areas, including rural and low-income

urban locales, hae little chance o attracting

enough new dentists to meet their needs. In act,

Pew calculates that more than 10 percent o the

nations population is unlikely to be able to nd a

dentist in their area who is willing to treat them.29 In

some states, such as Louisiana, this rises to one-third

o the general population. Nationwide, it would take

more than 6,600 dentists choosing to practice in the

highest-need areas to ll the gap.

A growing number o states are eploring ways

to epand the types o skilled proessionals who

can proide high-quality dental health care. They

are looking at three groups o proessionals in

particular: 1) medical proiders; 2) dental hygienists;

and 3) new types o dental proessionals.

Doctors, nurses, nurse practitioners and physician

assistants are increasingly being recognized or

their ability to see children, especially inants

and toddlers, earlier and more requently than

dentists. Currently, 35 states take adantage o

this opportunity by making Medicaid payments

aailable to medical proiders or preentie dental

health serices.

Authorization o new providers. An increasing

number o states are eploring new types o dental

proessionals to epand access and ll specic

gaps. Some are primary care proiders who could

play a similar role on the dental team as nurse

practitioners and physician assistants do on the

medical team, epanding access to basic care and

reerring more comple cases to dentists who

may proide superision on- or o-site. In a model

proposed by the ADA, these proessionals would

play a supportie role similar to a social worker or

community health worker. In remote locations, the

most highly trained proessionals could proide

basic preentie and restoratie care as part o a

dental team with superision by an o-site dentist.

In 2009, Minnesota became the rst state in the

country to authorize a new primary care dental

proider. Dental therapists (who must attain a

our-year bachelors degree) and adanced dental

therapists (who must attain a two-year masters

degree) will be authorized to proide routine

preentie and restoratie care. While dental

therapists will require the on-site superision o

dentists, adanced dental therapists may proide

care under collaboratie practice agreementswith dentists.30 In Noember, the Connecticut

State Dental Association endorsed a pilot project

to test a two-year dental therapist model, under

which proiders would be able to work without

on-site dental superision in public health and

institutional settings.31

P B 7

S t a t e h a s a u t h o r i z e d a n e w p r i m a r y c a r e d e n t a l

p r o v i d e r

State has authorized a new

primary care dental provider,2009

Numberof states

Yes 1

No 50

P B 6

S t a t e M e d i c a i d p r o g r a m r e i m b u r s e s m e d i c a l c a r e

p r o v i d e r s f o r p r e v e n t i v e d e n t a l h e a l t h s e r v i c e s

Medicaid pays medical stafffor early preventive dentalhealth care, 2009

Numberof states

Yes 35

No 16



Inormation: Collecting data, gauging

progress and improing perormance

Data collection on childrens dental health.

Epertise and the ability to collect data and plan

programs are critical elements o an eectie state

dental health program. They also are necessaryor states to appropriately allocate resources and

compete or grant and oundation undingall

the more important at a time when state budgets

are increasingly strained. Tracking the number

o children with untreated tooth decay and the

number with sealants is essential to states ability to

crat policy solutions and measure their progress.

Thirteen states and the District o Columbia,

howeer, hae neer submitted this data to the

National Oral Health Sureillance System. Whilesome states, such as Teas and North Carolina,

collect data using their own, independent methods,

the lack o nationally comparable inormation leaes

the states without a ital tool rom which to learn

and chart their paths orward.

Conclusion

Millions o disadantaged children suer rom

sub-par dental health and access to care. This is a

national epidemic with sobering consequences

that can aect kids throughout their childhoods

and well into their adult lies. The good news? This

is not an intractable problem. Far rom it. There

are a ariety o solutions, they can be achieed at

relatiely little cost, and the return on inestment

or children and tapayers will be signicant.

Yet dental disease is perasie among low-income

children in America in large part because they do

not hae access to basic care. A simple caity can

snowball into a lietime o challenges. Children with

seere dental problems are more likely to grow up

to be adults with seere dental problems, impairing

their ability to work productiely and maintain

gainul employment.

By making targeted inestments in eectie policy

approaches, states can help eliminate the pain,

missed school hours and long-term health and

economic consequences o untreated dental

disease among kids. A handul o states are leading

the way, but all states can and must do more to

ensure access to dental care or Americas children

most in need.


P B 8

S t a t e s u b m i t s b a s i c s c r e e n i n g d a t a t o t h e

n a t i o n a l d a t a b a s e

State submits basic screeningdata to the national database,2009

Numberof states

Yes 37

No 14




Endnotes1 The estimate o low-income children without dental care

comes rom U.S. Department o Health and Human Serices,

Centers or Medicare and Medicaid Serices, Medicaid Early

& Periodic Screening & Diagnostic Treatment BenetState

Agency Responsibilities (CMS-416) http://www.cms.hhs.go/MedicaidEarlyPeriodicScrn/03_ StateAgencyResponsibilities.asp.

(accessed July 8, 2009). The CMS-416 report collects data on the

statewide perormance o states Early and Periodic Screening,

Diagnosis, and Treatment (EPSDT) program or all children rom

birth through age 20. In this report, we chose to eamine a

subset o that population, children ages 1 to 18. We chose the

lower bound o age 1 because proessional organizations like the

American Academy o Pediatric Dentistry recommend that a child

hae his or her rst dental isit by age 1. We chose the upper

bound o 18 because not all state Medicaid programs opt to oer

coerage to low-income 19- and 20-year-olds. Data are drawn rom

lines 12a and 1 o the CMS-416 state and national reports; the sum

o children ages 1 to 18 receiing dental serices was diided by

the sum o all children ages 1 to 18 enrolled in the program. Notethat the denominator (line 1) includes any child enrolled or one

month or more during the year. It is estimated that in July 2007

the ciilian population o children ages 1 to 18 was 73,813,044,

meaning that about 22.8 percent, or 1 in 5, were enrolled in

Medicaid and did not receie dental serices. U.S. Bureau o the

Census, Monthly Postcensal Ciilian Population, by Single Year o

Age, Se, Race, and Hispanic Origin: 7/1/2007 to 12/1/2007, http://

www.census.go/popest/national/asrh/2008-nat-ci.html (accessed

January 5, 2010).

2 The most recent aailable data rom the Medical Ependiture

Panel Surey showed that 35 percent o the United States

population had no dental coerage in 2004. Data rom the Kaiser

Family Foundation showed that 15 percent o the population had

no medical coerage in 2008. R. Manski and E. Brown, Dental Use,

Epenses, Priate Dental Coerage, and Changes, 1996 and 2004.

Agency or Healthcare Research and Quality 2007, 10, http://www.

meps.ahrq.go/mepsweb/data_les/publications/cb17/cb17.pd

(accessed December 7, 2009); Kaiser Family Foundation. Health

Insurance Coerage in the U.S. (2008), http://acts.k.org/chart.

asp?ch=477 (accessed December 16, 2009).

3 U.S. Department o Health and Human Serices, Centers or

Medicare and Medicaid Serices, National Health Ependiture

Projections, 2008-2018, 4, http://www.cms.hhs.go/

NationalHealthEpendData/downloads/proj2008.pd (accessed

Noember 10, 2009). In 2004, the latest year or which data

were aailable, 30.4 percent o personal health ependitures or

dental care were or children ages 1 to 18. See CMS NationalHealth Ependiture Data, Health Ependitures by Age, 2004

Age Tables, Personal Health Care Spending by Age Group and

Type o Serice, Calendar Year 2004, 8, http://www.cms.hhs.

go/NationalHealthEpendData/downloads/2004-age-tables.pd

(accessed December 16, 2009).

4 B. Dye, et al., Trends in Oral Health Status: United States, 1988-

1994 and 1999-2004, vital Health and Statistics Series 11, 248

(2007), Table 5, http://www.cdc.go/nchs/data/series/sr_11/

sr11_248.pd (accessed December 4, 2009).

5 The gure o 58 percent refects data as o 2006, the latest year or

which inormation was aailable. That gure was unchanged rom

2004 and only slightly changed rom 1996, when it was 55 percent.

R. Manski and E. Brown, Dental Coerage o Children and Young

Adults under Age 21, United States, 1996 and 2006, Agency or

Health Care Research and Quality, Statistical Brie 221 (September

2008), http://www.meps.ahrq.go/mepsweb/data_les/publications/st221/stat221.pd (accessed January 14, 2010).

6 H. Git, S. Reisine and D. Larach, The Social Impact o Dental

Problems and visits, American Journal o Public Health 82 (1992)

1663-1668, in U.S. Department o Health and Human Serices,

Oral Health in America: A Report o the Surgeon General, National

Institutes o Health (2000), 143, http://silk.nih.go/public/hck1oc.@

www.surgeon.ullrpt.pd (accessed December 16, 2009).

7 S. Blumenshine et al., Childrens School Perormance: Impact o

General and Oral Health, Journal o Public Health Dentistry 68 (2008):

8287.

8 See, or eample, D. Albert et al., An Eamination o Periodontal

Treatment and per Member per Month (PMPM) Medical Costs in anInsured Population, BMC Health Services Research 6 (2006): 103.

9 National Health Ependiture data.

10 Unpublished data rom Tri-Serice Center or Oral Health Studies,

in J. G. Chan, et al., First Term Dental Readiness, Military Medicine,

171 (2006): 25-28, http://ndarticles.com/p/articles/mi_qa3912/

is_200601/ai_n17180121/ (accessed Noember 19, 2009).

11 Centers or Disease Control and Preention, Diision o Oral

Health, Oral Health or Adults, December 2006, http://www.

cdc.go/OralHealth/publications/actsheets/adult.htm (accessed

Noember 18, 2009).

12 National median charge among general practice dentists or

procedure D1351 (dental sealant) is $40 and national meancharge or procedure D2150 (two-surace amalgam lling) is $145.

American Dental Association. 2007 Surey o Dental Fees. (2007), 17,

http://www.ada.org/ada/prod/surey/publications_reereports.asp

(accessed January 25, 2010).

13 Task Force on Community Preentie Serices, Reiews o

Eidence on Interentions to Preent Dental Caries, Oral and

Pharyngeal Cancers, and Sports-Related Cranioacial Injuries,

American Journal o Preventive Medicine, 23 (2002):21-54.

14 National Oral Health Sureillance System, Percentage o Third-

Grade Students with Untreated Tooth Decay, and Percentage o

Third-Grade Students with Dental Sealants. http://apps.nccd.cdc.

go/nohss/ (accessed July 8, 2009).

15 Task Force on Community Preentie Serices, 2002.

16 Delaware reports that its sealant program was suspended in 2008

because o loss o sta, but the state plans to reinstate the program

in 2010.




17 According to the Bureau o Labor Statistics (BLS), the dierence

in mean annual wage between a dentist and a dental hygienist

is about $87,000. BLS Occupational Employment Statistics gies

the mean annual wage or dentists (Dentists, General, 29-1021)

as $154,270 and $66,950 or dental hygienists (Dental Hygienists,

29-2021) as o May 2008. Bureau o Labor Statistics, Occupational

Employment Statistics, May 2008 National OccupationalEmployment and Wage Estimates. http://www.bls.go/oes/2008/

may/oes_nat.htm#b29-0000 (accessed December 16, 2009).

18 Recent systematic reiew by the CDC and the ADA indicated that

it is appropriate to seal teeth that hae early noncaitated lesions,

and that isual assessments are sucient to determine whether

noncaitated lesions are present. J. Beauchamp et al. Eidence-

Based Clinical Recommendations or Use o Pit-and-Fissure Sealants:

A Report o the American Dental Association Council on Scientic

Aairs, Journal o the American Dental Association 139(2008):257

267. Accreditation standards or dental hygiene training programs

include standard 2-1: Graduates must be competent in proiding

the dental hygiene process o care which includes: Assessment.

Commission on Dental Accreditation, Accreditation Standards or

Dental Hygiene Education Programs, 22, http://www.ada.org/pro/

ed/accred/standards/dh.pd (accessed Noember 23, 2009).

19 American Dental Hygienists Association, Sealant Application

Settings and Superision Leels by State, http://adha.org/

goernmental_aairs/downloads/sealant.pd (accessed July 8,2009);

American Dental Hygienists Association, Dental Hygiene Practice

Act Oeriew: Permitted Functions and Superision Leels by State,

http://adha.org/goernmental_aairs/downloads/tyone.pd

(accessed July 8, 2009).

20 Centers or Disease Control and Preention. Recommendations

or Using Fluoride to Preent and Control Dental Caries in the

United States, Morbidity and Mortality Weekly Report, Reports and

Recommendations, August 17, 2001, http://www.cdc.go/mmwr/preiew/mmwrhtml/rr5014a1.htm (accessed August 7, 2009).

21 Centers or Disease Control and Preention, Cost Saings o

Community Water Fluoridation, August 9, 2007, http://www.cdc.

go/fuoridation/act_sheets/cost.htm (accessed August 7, 2009).

22 Estimate based on per-person annual cost saings rom

community water fuoridation, as calculated in S. Grin, K. Jones

and S. Tomar, An Economic Ealuation o Community Water

Fluoridation,Journal o Public Health Dentistry 61(2001): 78-86. The

gure o more than $1 billion was calculated by multiplying the

lower-bound estimate o annual cost saings per person o $15.95

by the 80 million people without fuoridation.

23 Centers or Disease Control and Preention, Achieements in

Public Health, 1900-1999: Fluoridation o Drinking Water to Preent

Dental Caries, Morbidity and Mortality Weekly Report, October 22,

1999, http://www.cdc.go/mmwr/preiew/mmwrhtml/mm4841a1.

htm (accessed August 6, 2009).

24 W. Bailey, Promoting Community Water Fluoridation: Applied

Research and Legal Issues, Presentation, New York State

Symposium. Albany, New York, October 2009.

25 National Oral Health Sureillance System, Oral Health Indicators,

Fluoridation Status, 2006, http://www.cdc.go/nohss/ (accessed

July 8, 2009).

26 Pew Center on the States analysis o Medicaid reimbursements

and dentists median retail ees. See methodology section o this

report or ull eplanation. American Dental Association, State

Innoations to Improe Access to Oral Health, A Compendium

Update (2008), http://www.ada.org/pro/adocacy/medicaid/

medicaid-sureys.asp (accessed May 28, 2009); American Dental

Association, 2007 Surey o Dental Fees.

27 A. Borchgreink, A. Snyder and S. Gehshan, The Eects oMedicaid Reimbursement Rates on Access to Dental Care, National

Academy o State Health Policy, March 2008, http://nashp.org/

node/670 (accessed January 14, 2010).

28 Data proided by Robin Rudowitz, principal policy analyst, Kaiser

Family Foundation ia e-mail, Noember 11, 2009.

29 Pew Center on the States analysis o the ollowing Health

Resources and Serices Administration shortage data and Census

population estimates: U.S. Department o Health and Human

Serices, Health Resources and Serices Administration, Designated

HPSA Statistics report, Table 4, Health Proessional Shortage Areas

by State Detail or Dental Care Regardless o Metropolitan/Non-

Metropolitan Status as o June 7, 2009, http://datawarehouse.hrsa.

go/quickaccessreports.asp (accessed June 8, 2009); U.S. Bureau o

the Census, State Single Year o Age and Se Population Estimates:

April 1, 2000 to July 1, 2008CIvILIAN, http://www.census.go/

popest/states/asrh/(accessed June 23, 2009).

30 2009 Minnesota Statutes, Chapter 150A.105 and 150A.106,

https://www.reisor.mn.go/statutes/?id=150A (accessed

Noember 24, 2009).

31 Resolution 29-2009, DHAT Pilot Program, Connecticut State

Dental Association, Noember 18, 2009.



Chapter 1: Americas Children FaceSignicant Dental Health Challenges

The national debate about health care reorm raging

across the country has been ueled by astounding

acts and gures. More than 45 million Americans

lack health insurance,1 and some estimate that as

many as 20,000 uninsured adults die each year

because they are unable to obtain timely care.2

Access to dental care has remained largely absent

rom this debate, yet twice as many Americans lack

dental insurance as lack health insurance.3 And eenamong those with insurance, access to dental care

can be elusie because many dentists do not treat

low-income people on Medicaid. Nationally, at least

30 million Americansmore than 10 percent o the

oerall populationare unlikely to be able to nd a

dentist in their area who is willing to treat them. An

analysis by the Pew Center on the States ound that

the problem is ar worse in some states than others:

In Louisiana, roughly 33 percent o the population

is unsered, compared with just 9 percent in

Pennsylania.4 (See bo on page 23.)

The problem is particularly critical or kids, or

whom the consequences o a simple caity

can all like dominoes well into adulthood, rom

missing signicant numbers o school days to risk o

serious health problems and diculty nding a job.

Dental problems hae a huge impact on school

perormance and on eery other aspect o a childs

lie, said Goernor Martin OMalley (D) o Maryland,

where a 12-year-old, Medicaid-eligible boy died in

2007 ater an inection rom an abscessed tooth

spread to his brain.5

One way to measure how children are aring

when it comes to their dental health is to count

the percentage o children who hae untreated

caities. This gure should be 21 percent or less by

2010, according to Healthy People 2010 objecties,

a set o national objecties monitored by the U.S.

Department o Health and Human Serices.6 But

with untreated decay present in almost one in three

6- to 8-year-olds, the United States has not yet met

this goal, according to the most recent national

data.7 Thirty-seen states monitor their progress

and report on this measure, and the problem aries

dramatically. Pew ound that only nine o the 37

states had reached or eceeded the Healthy People

2010 goal by 2008. Neada ranked worst among the

states: 44 percent o its third graders had untreated

caities. Close behind was Arkansas, at 42 percent

o third graders. Iowa and vermont ranked the best,

with just 13 percent and 16 percent o their third

graders haing untreated caities, respectiely.8

(See Ehibit 1.)

Low-income children aredisproportionately aected

Oerall, dental health has been improing in the

United States, but children hae not beneted at

the same rates as adults. The proportion o children

between 2 and 5 years old with caities actually

increased 15 percent during the past decade,

according to a 2007 Centers or Disease Control and

Preention (CDC) study.9

The same surey oundthat poor children continue to suer the most rom

dental decay. Kids ages 2 to 11 whose amilies lie

below the ederal poerty leel are twice as likely to

hae untreated decay as their more auent peers.10

While most Americans hae access to the best oral

health care in the world, low-income children suer

disproportionately rom oral disease,



U.S. Representatie Michael Simpson (R-Idaho),

one o two dentists who sere in the House o

Representaties, said in 2004. Een as our nations

health has progressed, dental caries or tooth

decay remains the most prealent chronic

childhood disease.11

Those statistics are not surprising considering the

diculty disadantaged kids hae accessing care.

Nationally, only 38.1 percent o Medicaid-enrolled

children between the ages o 1 and 18 receied

any dental care in 2007meaning that nearly17 million low-income kids went without care.

This represents one out o eery e children

regardless o amily income leelbetween the

ages o 1 and 18 in the United States.12 On aerage,

58 percent o children with priate insurance

receie care.13 Where you lie matters: More than

hal o Medicaid-enrolled kids receied dental

serices in 2007 in just three statesAlabama, Teas

and vermont. Fewer than one in our Medicaid-

enrolled children in Delaware, Florida and Kentucky

got them. In contrast, 57 percent o vermonts

Medicaid-enrolled children receied care that year.

(See Ehibit 2.)

The national aerage o 38.1 percent is actually an

improement rom 2000, when only 30 percent

o Medicaid-enrolled children receied any care.

But with a majority o low-income children going

without care, America earns a ailing grade or

ensuring their dental health. The problem is

particularly bad or ery young children. Only 13

percent o Medicaid-enrolled 1- and 2-year-olds

receied dental care in 2007, up rom 7 percent

in 2000.14 This is troubling because decay rates

are rising among these groups, and children on

Medicaid are those most at risk or aggressie

tooth decay called Early Childhood Caries. Formerly

known as baby-bottle tooth decay, this seere

bacterial inection can destroy a babys teeth as theyemerge, hampering speech deelopment and the

transition to solid ood.

No reliable national data eist on what low-

income amilies do when their children hae

dental problems but cannot access regular care,

but anecdotal eidence suggests that a sizeable

number turn to emergency rooms. Without

AMERICAS CHILDREN FACE SIGNIFICANT DENTAL HEALTH CHALLENGES

Iowa

Vermont

North Dakota

Nebraska

Massachusetts

Connecticut

Washington

Wisconsin

Maine

New Hampshire

South Carolina

Utah

Colorado

Michigan

Ohio

Maryland

Alaska

Missouri

Georgia

Idaho

Pennsylvania

Kansas

Rhode Island

California

Montana

Delaware

Illinois

South Dakota

New York

Kentucky

Oregon

New Mexico

Mississippi

Arizona

Oklahoma

Arkansas

Nevada

Percentage of third graders with untreated cavities

Just nine states have met the national goal of having no more than

21 percent of children with untreated tooth decay.

Exhibit 1

THIRD GRADERS WITHUNTREATED CAVITIES

SOURCE: Pew Center on the States, 2010; Na tional Oral Health Surveillance System:

Oral Health Indicators, data submitted through 2008.

NOTE: 14

states have

not submitted

data

44%

42.1%

40.2%

39.4%

39.1%

37%

35.4%

34.6%

33.1%

32.9%

30.2%

29.9%

28.9%

28.7%

28.2%

27.6%

27.3%

27.3%

27.1%

27%

26.2%

25.9%

25.7%

25%

24.5%

23%

22.6%

21.7%

20.4%

20.1%

19.1%

17.8%

17.3%

17%

16.9%

16.2%

13.2%

Only 9 statesare meetingthe nationalgoal

28 states

are notmeetingthe nationalgoal




sucient access to dental care in Medicaid, millions

o low-income amilies opt to postpone needed

dental care until a dental emergency occurs

requiring immediate, more complicated and more

epensie treatment, Dr. Frank Catalanotto, a

pediatric dentist and ormer dean o the Uniersity

o Florida dental school, testied beore Congress in

October 2009.15

Children who are taken to hospital emergency

departments or seere dental pain can end up

in a reoling door that costs Medicaidand

tapayerssignicantly more than preentie and

primary care. Hospitals are generally not equipped

to proide denitie treatment or toothaches and

dental abscesses. Unless the hospital has a dental

program, they gie [the child] an antibiotic and

send him on his way, said Dr. Paul Casamassimo,

dental director or Nationwide Childrens Hospital inOhio. The antibiotic may suppress the inection, but

it does not the underlying problem.16

In 2007, Caliornia counted more than 83,000 isits

to emergency departments or both children and

adults or preentable dental conditions, a 12

percent increase oer 2005, at a cost o $55 million.

The rate o emergency room isits in Caliornia or

preentable dental conditions eceeds the number

or diabetes.17

Sometimes a childs dental disease will be so

etensie that it can be treated only under general

anesthesia. In North Carolina alone, 5,500 children

oer two years receied general anesthetics or

dental serices.18 This is a small number o cases, but

they are etraordinarily epensie. Data rom the

ederal Agency or Healthcare Research and Quality

show that 4,272 children were hospitalized in 2006

with principal diagnoses related to oral health

problems. These hospitalizations cost an aerage o

$12,446 and totaled more than $53 million.19

Minority and disabled children arethe hardest hit

As with many other health issues, race and ethnicity

are closely linked to dental health and access to

care. The most recent National Health and Nutrition

Eamination Surey ound that 37 percent o non-

Hispanic black children and 41 percent o Hispanic

children had untreated decay, compared to 25

percent o white children.

Latinos are the most uninsured ethnic group in

the United States, said Dr. Francisco Ramos-Gomez,

Nationally, just

38.1 percent of

Medicaid-enrolled

children received

dental care in 2007.

That share trails

privately insured

children, 58

percent of whom

receive care

each year.

Exhibit 2 LOWINCOME CHILDREN LACK ACCESS TO DENTAL CARE

SOURCE: Pew Center on the States, 2010; Centers for Medicare and Medicaid Services, 1995-2007 Medicaid Early & Periodic Screening & Diagnostic Treatment Benet (CMS-416).

Colorado

Tennessee

Virginia

Kansas

Connecticut

Georgia

Alaska

Oklahoma

Idaho

Indiana

RhodeIsland

Massachusetts

WestVirginia

NorthCarolina

Iowa

SouthCarolina

NewHampshire

NewMexico

Washington

Nebraska

Alabama

Texas

Vermont

57.1

PERCENTAGE OF MEDICAID-ENROLLED CHILDREN RECEIVING DENTAL CARE IN 2007

53.751.9

49.947.6 47.6 47.0 46.9 46.9 45.7 45.6 44.6 43.8 43.0 42.8 42.7 41.9 41.5 41.4 41.2 40.8 40.2 40.2




president-elect o the Hispanic Dental Association.

They are more likely than other groups to hae

low-wage jobs without benets. Many cant aord

dental insurance i not proided by their employer,

much less pay or serices out-o-pocket.20 In 2004,

Hispanics represented 14 percent o U.S. residents

but comprised 30 percent o the uninsured.21

American Indians and Alaska Naties hae the

highest rate o tooth decay o any populationcohort in the United States: e times the national

aerage or children ages 2 to 4.22 A surey by

the Indian Health Serice ound that American

Indians and Alaska Naties had signicantly worse

dental health; 72 percent o 6- to 8-year-olds had

untreated caitiesmore than twice the rate o the

general population.23 (See Ehibit 3.)

Nationwide, people with disabilities suer rom

dental disease at higher rates than non-disabledpeople.24 In act, the most prealent unmet need

or children with special health care needs is dental

care, according to a national telephone surey

o amilies.25 The root o this crisis is threeold:

Mental and physical impairments oten prohibit

indiiduals rom caring or their mouths; disabilities

and sensitiities create dicult eperiences during

dental isits; and amilies struggle to nd dentists

who are able to cater to patients special needs.

Clinical dental treatment is the most eacting and

demanding medical procedure that [people with

deelopmental disabilities] must undergo on a

regular basis throughout their lietimes, eplained

Dr. Ray Lyons, chie o dental serices with the Los

Lunas Community Program in New Meico and

ormer president o the Academy o Dentistry or

Persons with Disabilities.26

Exhibit 2 LOWINCOME CHILDREN LACK ACCESS TO DENTAL CARE

NOTE: Percentages were calculated by dividing the number of children ages 1-18 receiving any dental service by the total number of enrollees ages 1-18.

Delaware

Florida

Kentucky

Wisconsin

Nevada

Missouri

NorthDakota

Montana

Arkansas

California

Pennsylvania

Louisiana

NewYork

NewJersey

Michigan

Oregon

DistrictofColumbia

Maryland

SouthDakota

Maine

Wyoming

Minnesota

Mississippi

Utah

Hawaii

Ohio

Illinois

Arizona

40. 1 40. 1 39.9 39.9 39.5 38.1 37.7 37.3 37.1 37.0 36.1 35.5 34.9 34.5 33.9 33.7 32.4 32.2 31.329.5 29.2 28.1 27.9 27.5

25.7 24.5 23.8 23.7

29.2%

National average

PERCENT OF 6- TO 8-YEAR-OLDS

WITH UNTREATED DECAY

IN THEIR PERMANENT

OR PRIMARY TEETH

Dental health varies drastically by ethnicity; American Indian

and Alaska Native children fare the worst.

Exhibit 3

UNTREATED TOOTH DECAY BY ETHNICITY

SOURCES: Pew Center on the States, 2010; Data from National Health and Nutrition

Examination Survey, 1999-2004; Indian Health Service, 1999.

White

Black, non-Hispanic

Mexican American

American Indian/Alaska Native

25%

2010 goal 21% or less

37.4%

40.6%

72%




Why it matters

The national epidemic o poor oral health and lack

o access to dental care among low-income kids has

not captured the publics attentionbut it should.

While to date the issue has been oershadowed

by other health reorm challenges, the

consequences o poor dental health among

children are ar worseand longer lasting

than most people realize.

Early Growth and Development. Caities are

caused by a bacterial inection o the mouth. Those

bacteria lie in a sticky lm on the teethplaque

and use the sugars in the ood we eat to grow and

create acid. That acid, unchecked, can create sot

spots and eentually holes in teethwhat we

know as caities.

Caity-causing bacteria are passed rom caregiers

to inants in the rst ew months o lie, een beore

a childs rst tooth erupts. It happens through

regular daily actiities, like sharing a spoon. Almost

eeryone has these bacteria, but whether a child

deelops caities hangs in the balance between risk

actors, like diet and the seerity o the inection,

and preentie actors like access to fuoride.27

For children at high risk o dental disease, inection

can quickly progress into Early Childhood Caries,

rampant decay that can destroy a childs baby

teeth as they emerge. These teeth are more

important than they may seem. Primary teeth are

ital to lietime dental health and oerall child

deelopment. They are necessary or children to

make the transition rom milk to solid ood and to

deelop speech. They hold space in the mouth or

the permanent teeth that will emerge as a child

ages. Losing baby teeth prematurely can cause

permanent teeth to come in crowded or crooked,

which can result in worsened orthodontic problems

in adolescence.

Decay in primary teeth, particularly in molars, is a

predictor o decay in permanent teeth, and caity-

causing bacteria persist in the mouth as permanent

teeth grow in.28

School Readiness and Perormance. Poor dental

health has a serious impact on childrens readiness

or school and ability to succeed in the classroom. In

a single year, more than 51 million hours o school

may be missed because o dental-related illness,

according to a study cited in a 2000 report o the U.S.

Surgeon General.29 I a child is missing teeth, [t]hat

could aect school perormance or school readiness,

particularly in being able to relate to other children,

said Ben Allen, public policy and research director othe National Head Start Association.30

Research shows that dental problems, when

untreated, impair classroom learning and behaior,

which can negatiely aect a childs social and

cognitie deelopment.31 The pain rom caities,

abscesses and toothaches oten preents children

rom being able to ocus in class and, in seere

cases, results in chronic school absence.32 A 2009

study rom Caliornia showed that among childrenmissing school or dental problems those who

needed dental care but could not aord it were

much more likely to miss two or more school days

than those whose amilies could aord it.33 School

absences contribute to the widening achieement

gap, making it dicult or children with chronic

toothaches to perorm as well as their peers, prepare

or subsequent grades and ultimately graduate.

A 2008 study in North Carolina ound that childrenwith both poor oral and general health were 2.3

times more likely to perorm badly in school than

their healthier peers, while children with either

poor dental or general health were 1.4 times more

likely to perorm badly. The study concluded that

improing childrens oral health may be a ehicle or

improing their educational eperience.34




Poor dental health can cause speech impairments

and physical abnormalities that can also make

learning dicult. Children whose speech is aected

may be reluctant to participate in school actiities

and discussions, an important part o learningand o social deelopment.35 This is also true with

physical abnormalities, most commonly missing

teeth. Children with abscesses oten do not smile

because they are embarrassed about their

physical appearance.36

Overall Health. Poor dental health in childhood

can escalate into ar more serious problems later

in lie. For adults, the health o a persons mouth,

teeth and gums interacts in comple ways withthe rest o the body.37

A growing body o research indicates that

periodontal diseasegum diseaseis linked to

cardioascular disease, diabetes and stroke.38 Seere

gum disease in older Americans is een linked

to increased risk o death rom pneumonia.39The

connection to diabetes is particularly strong, and

a 2006 article in theJournal o the American Dental

Association described the relationship as a two-waystreet, with diabetes being linked to worsened gum

disease, and uncontrolled gum disease making it

harder or diabetics to control their blood sugar.40

Seeral studies hae suggested an association

between untreated gum disease and increased

likelihood o preterm labor and low birth weight.41

Although recent studies hae raised doubts about

whether treating gum disease in pregnant women

can improe birth outcomes, the dental healtho pregnant women and new mothers is critically

important, because caity-causing bacteria are

passed rom parents to their children.42

In some cases, complications rom dental disease

hae taken lies. In 2007, a 12-year-old Maryland

boy, Deamonte Drier, died ater an inection

rom an abscessed tooth spread to his brain. An

$80 tooth etraction could hae saed his lie, but

his mother did not hae priate dental insurance

and the amily s Medicaid coerage had lapsed.

Deamontes death eposed a huge chasm in our

nations health coerage or children, said U.S.Representatie Elijah Cummings (D-Maryland).43

(See sidebar on page 18.)

No one knows how many children hae lost their

lies because o complications stemming rom

untreated dental problems. But Deamonte Drier is

not alone. In 2007, or instance, Aleander Callendar,

a 6-year-old boy in Mississippi, was not able to get

treatment or two inected teeth in his lower jaw.

When Ales teeth were pulled, he went into shockand died. Doctors reported that he went into shock

rom the seerity o the inection.48

In October 2009, a mentally impaired woman in

Michigan died rom a chronic dental inection ater

cuts to the adult dental Medicaid benet preented

her rom getting the surgery she needed.49 Her

teeth were so badly inected that she needed a

surgical etraction in a hospital setting, but lack

o Medicaid coerage orced her to wait until theinection became seere enough to qualiy or

emergency dental coerage. Ater she waited or

three months, the inection killed her.50

Deaths related to dental illness are dicult to

track because the ocial cause o death is usually

identied as the related conditionor eample, a

brain inectionrather than the dental disease that

initially caused the inection. The number o deaths

related to childhood dental disease likely neerwill be known owing to inadequate sureillance,

lack o an [Early Childhood Caries] registry, issues

o condentiality, and een inconsistent

diagnostic coding choices by hospitals and

physicians, concluded a 2009 article in the Journal

o the American Dental Association. Among brain

abscesses alone, 15 percent result rom inections o




d a s h a w n d r i v e r s y e a r l o n g s e a r c h f o r c a r e

When Deamonte Driver, a 12-year-old boy rom Prince Georges

County, Maryland, died rom a dental inection that spread to his

brain in February 2007, the tragedy quickly attracted national and

international attention and prompted a congressional investigation.

Yet policy makers would be equally wise to pay attention to the story

o Deamontes younger brother, DaShawn Driver. It took DaShawns

mother, Alyce Driver, and a team o social workers, advocates and

public health oicials nearly a year o urgently seeking care to ind

a dentist willing to t reat DaShawns oral health problems under his

existing Medicaid coverage.44

The story began in 2006 when DaShawn, then 9 years old, began having severe toothaches and mouth pain.

He had to miss school because o the pain, and at other times, had to go to class with swollen cheeks. It hurt

all the time unless I put pressure on it, said DaShawn, who carried around old candy wrappers to bite down on

or that purpose.45

The irst dentist who agreed to see DaShawn under Medicaid did a consultation but reused to take him as

a patient because the youth was idgety and wiggled too much in the dentists chair, said Alyce Driver.46

She then sought help rom the Public Justice Center in Baltimore, Maryland.47 The sta obtained a list o

primary care dentists who claimed to accept DaShawns Medicaid managed care plan. The irst 26 providers

on the list turned them down. They eventually ound a primary care dentist or DaShawn, who conirmed that

he had six severely diseased teeth that needed to be pulled, and advised his mother to take him to an oral

surgeon. Alyce Driver once again turned to the Public Justice Center, which in turn consulted the Department

o Health and Mental Hygiene, the local health department and the states Medicaid plan. They secured the

earliest available appointment with a contracted oral surgeonsix weeks later. Ater an initial consultation, an

appointment was set several weeks ater that to begin the extractions. But when Alyce and DaShawn Driver

showed up or the rescheduled appointment, the surgeons sta told them they no longer accepted Medicaid

patients, Alyce Driver said.

It was at about this time that Deamontewhose teeth appeared to Alyce Driver to be in much better shape than

DaShawnsbecame severely ill rom an inection rom an abscessed tooth that had spread to his brain. He washospitalized, underwent two brain surgeries and died six weeks later.

The next oral surgeon the Drivers ound or DaShawn a month lateragain with the help o the Public Justice

Centers sta and a team o case workersimmediately pulled one tooth and agreed that ive others were badly

enough inected to require extraction. But the dentist insisted that DaShawn come back to have one tooth

taken out every month or ive months, said Alyce Driver. I said, Wow, am I going to lose my other son, too?

she recalled. The University o Maryland Dental School clinic in Baltimore agreed to take DaShawns case, and

removed the rest o the diseased teeth promptly.

Now, DaShawn sees a dentist every six months. In act, the dentist that DaShawn sees is Alyce Drivers new

employer. Devastated by Deamontes death and inspired to make a dierence in his memory, she applied or a

training program to become a dental assistant and was given a ull scholarship. She now works part time as a

dental assistant, and periodically accompanies her employer to work in schools as part o the Deamonte Driver

Dental Project. The Project, ounded by the Robert T. Freeman Dental Society Foundation and unded by theState o Maryland and several oundations, includes education and outreach, dental screenings, luoride varnish

and reerrals. Dentists in Action, a group o local dentists, has vowed to provide regular sources o care to all

children reerred by the project with hope o preventing another Deamonte Driverand maybe even another

DaShawn Driverrom happening again.




unknown source, some or many o which may be o

dental origin.51

Economic Consequences. Untreated dental

conditions among children also impose broader

economic and health costs on American tapayers

and society. Between 2009 and 2018, annual

spending or dental serices in the United States is

epected to increase 58 percent, rom $101.9 billion

to $161.4 billion. Approimately one-third o the

money spent on dental serices goes to serices

or children.52 Added to that are the tens o millions

o dollars spent on children requiring etensie

treatment in hospital operating rooms, estimated at

more than $53 million in 2006 alone, according toederal data.53

While dental care represents a small raction o

oerall health spending, it is signicant because

neglecting the dental health o children has lietime

eects. A good predictor o uture decay is past

eperience with tooth decay.54 When children

with seere dental problems grow up to be adults

with seere dental problems, their ability to work

productiely will be impaired.

Consider the military. A 2000 study o the armed

orces ound that 42 percent o incoming Army

recruits had at least one dental condition that

needed to be treated beore they could be

deployed, and more than 15 percent o recruits

had our or more teeth in urgent need o repair.55

Particularly or people with low incomes, who

oten work in the serice sector without sick

leae, decayed and missing teeth can pose major

obstacles to gainul employment. An estimated

164 million work hours each year are lost because

o oral disease.56

Dental problems can hinder a persons ability to

get a job in the rst place. A 2008 study rom the

Uniersity o Nebraska conrmed a widely held

but little-discussed prejudice: People who are

missing ront teeth are seen to be less intelligent,

less desirable and less trustworthy than people

without a gap in their smile.57 Stories o personal

embarrassment and lost opportunities rom poor

dental health are easy to nd. Take, or eample, this2007 account rom the New York Times:

Try nding work when youre in your 30s or

40s and youre missing ront teeth, said Jane

Stephenson, ounder o the New Opportunity

School in Berea, Ky., which proides job training

to low-income Appalachian women.

Ms. Stephenson said the program started

helping women buy dentures 10 years ago. She

said about hal o the women who go through

the program, most in their 40s, were missing

teeth or had ones that were inected. As a

result, she said, they are shunned by employers,

ashamed to go back to school and to be around

younger peers and oten miss work because o

pain or complications o the inections.58

A 2000 study o the armed

orces ound that 42 percent

o incoming Army recruits had

at least one dental condition

that needed to be treated

beore they could be deployed,

and more than 15 percent o

recruits had our or more teeth

in urgent need o repair.



But this is not just anecdote. A 2008 study ound

that women who grew up in communities with

fuoridated water earned approimately 4 percent

more than women who did not. The eect was

almost eclusiely concentrated among womenrom low-income amilies, and fuoride eposure in

childhood was ound to hae a robust, statistically

signicant eect on income, een ater controlling

or a ariety o trends and community-leel

ariables. The authors o the study attributed this

dierence primarily to consumer and employer

discrimination against women with missing or

damaged teeth.59

Another study rom the Uniersity o Caliornia-SanFrancisco tracked 377 welare recipients in need o

etensie dental repair. Eighty percent o the 265

people who nished treatment said their quality

o lie had improed dramatically, and this group

was twice as likely to receie aorable or neutral

employment outcomes as those who did not ollow

through with treatment. The article concluded that

by proiding dental treatment to this group, barriers

to employment were reduced.60

As Harard Uniersity proessor Dr. Chester Douglass

described in a recent interiew with the online

magazine Slate: I you enjoy chewing; i you enjoy

speaking; i you enjoy social interaction; i you enjoy

haing a joba responsible positionyoue got

to hae oral health. So the question becomes how

important is eating, speaking, social lie, and a job?61

Why is this happening?

Dental hygiene should begin at home, where parents

can teach their children about the importance

o brushing and fossing regularly and eating a

healthy diet. But too oten, parents themseles

do not practice these behaiors. Their ailure to

model them hurts their childrens oral health, as

does the abundance o sugary oods aailable to

childrenand the lack o nutritional oods aailable

to low-income kids in particular. More can be done

to help educate parents about the importance o

their childrens oral hygiene. But the national crisis

o poor dental health and lack o access to care

among disadantaged children cannot be attributedprincipally to parental inattention, too much candy or

soda or not enough ruits and egetables.

In act, broader, systemic actors hae played a

signicant role. Three in particular are at work:

1) too ew children hae access to proen

preentie measures, including sealants and

fuoridation; 2) too ew dentists are willing to treat

Medicaid-enrolled children; and 3) in some places in

America, there are simply not enough dentistsorno dentists at allto proide care to the people

who need it most.

Too Few Children Hae Access to Proen

Preentie Measures

The U.S. Task Force on Community Preentie

Serices has identied two eectie community-

based strategies that it recommends states pursue

to combat tooth decay: school-based sealant

programs and community water fuoridation.62

These proen methods, howeer, hae not reached

all the children who need them.

Sealants. Dental sealants are not a replacement or

regular dental care, but they hae been recognized

by the American Dental Association (ADA) as one o

the best preentie strategies that can be used to

benet children at high risk or caities. Sealants

clear plastic coatings applied by a hygienist or

dentistcost one-third as much as lling a caity,63

and hae been shown ater just one application to

preent 60 percent o decay in molars.64

Ninety percent o caities in children occur on the

rst and second molars, so protecting those back

teeth is crucial to childrens dental health.65 The

deep grooes in molars, too narrow to be brushed





eectiely, make these teeth ecellent habitatsor bacteria and particularly susceptible to decay.

Walling o the deep grooes with a sealant blocks

bacteria and ood particles and greatly reduces the

chances o deeloping a caity.

The Healthy People 2010 national goal is or at least

hal o third graders in each state to hae sealants

but data submitted by 37 states show that the

nation alls well short o this goal. Pews analysis

ound that only eight states hae reached it, and in11 states, ewer than one in three third graders hae

sealants. Four o the states meeting the Healthy

People goalNorth Dakota, vermont, Washington

and Wisconsinalso claim some o the lowest

rates o childhood tooth decay, while Arkansas and

Mississippi, two o the states that do not meet the

sealants goal, are among the states with the highest

decay rates.

Unortunately, this eectie serice is unaailableto many kids.66 When children liing in or close to

poerty are unable to isit a dentist or preentie

care, they miss the chance to get the sealants

that could preent the need or more urgent and

epensie restoratie care later.

Some states hae deeloped school-based sealant

programs in low-income neighborhoods

to help meet the need, but this strategy is astly

underutilized. New data collected or Pew by the

Association o State and Territorial Dental Directors

show that only 10 states hae school-based sealant

programs that reach hal or more o their high-riskschools. These 10 states are Alaska, Illinois, Iowa,

Maine, New Hampshire, Ohio, Oregon, Rhode Island,

South Carolina and Tennessee. Eleen states hae no

organized programs at all to proide this serice to

the schools most in need: Delaware, Hawaii, Missouri,

Montana, New Jersey, North Dakota

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