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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
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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
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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.
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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
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E x E C U T I v E S U M M A R Y
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.
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8/7444 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
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
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E x E C U T I v E S U M M A R Y
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
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E x E C U T I v E S U M M A R Y
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
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11/74The Cost o Delay: State Dental Policies Fail One in Fie Children
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
E x E C U T I v E S U M M A R Y
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
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E x E C U T I v E S U M M A R Y
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
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13/74The Cost o Delay: State Dental Policies Fail One in Fie Children
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.
E x E C U T I v E S U M M A R Y
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
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14/7400 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
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.
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15/74The Cost o Delay: State Dental Policies Fail One in Fie Children
E x E C U T I v E S U M M A R Y
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.
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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,
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17/74The Cost o Delay: State Dental Policies Fail One in Fie Children
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
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18/7444 Pew Childrens Dental Campaign | Pew Center on the States
AMERICAS CHILDREN FACE SIGNIFICANT DENTAL HEALTH CHALLENGES
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
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AMERICAS CHILDREN FACE SIGNIFICANT DENTAL HEALTH CHALLENGES
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%
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AMERICAS CHILDREN FACE SIGNIFICANT DENTAL HEALTH CHALLENGES
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
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AMERICAS CHILDREN FACE SIGNIFICANT DENTAL HEALTH CHALLENGES
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
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AMERICAS CHILDREN FACE SIGNIFICANT DENTAL HEALTH CHALLENGES
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.
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AMERICAS CHILDREN FACE SIGNIFICANT DENTAL HEALTH CHALLENGES
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.
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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
AMERICAS CHILDREN FACE SIGNIFICANT DENTAL HEALTH CHALLENGES
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AMERICAS CHILDREN FACE SIGNIFICANT DENTAL HEALTH CHALLENGES
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