improving oral health care for young children · • convene state leaders to solve problems and...

Improving Oral Health Care for Young Children

Shelly Gehshan Matt Wyatt

April2007

Improving Oral Health Care for Young Children

Shelly GehshanMatt Wyatt

Copyright©April2007

NationalAcademyforStateHealthPolicy

TheNationalAcademyforStateHealthPolicyisanindependentacademyofstatehealthpolicymakersworkingtogethertoidentifyemergingissues,developpolicysolutions,andimprovestatehealthpolicyandpractice.

NASHPprovidesaforumforconstructive,nonpartisanworkacrossbranchesandagenciesofstategovernmentoncriticalhealthissuesfacingstates.Weareanon-profit, non-partisan, non-membership organization dedicatedtohelpingstatesachieveexcellenceinhealthpolicyandpractice.NASHP’sfundersincludebothpublic and private organizations that contract for our services.

Toaccomplishourmissionwe:

• Convenestateleaderstosolveproblemsandsharesolutions.

• Conductpolicyanalysesandresearch.• Disseminateinformationonstatepoliciesand

programs.• Providetechnicalassistancetostates.

Theresponsibilityforhealthcareandhealthcarepolicydoesnotresideinasinglestateagencyordepartment.NASHPprovidesauniqueforumforproductiveinterchangeacrossalllinesofauthority,includingexecutive offices and the legislative branch

Weworkacrossabroadrangeofhealthpolicytopicsincluding:

• Medicaid.• Long-termandchroniccare.• Publichealthissues,includingobesity.• Qualityandpatientsafety.• Insurancecoverageandcostcontainment.• TheStateChildren’sHealthInsurance

Program.

NASHP’sstrengthsandcapabilitiesinclude:

• Activeparticipationbyalargenumberofvolunteer state officials.

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ImprovingOralHealthCareforYoungChildren

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iv

Table of ConTenTs

TableofContents............................................................................................................................ vAcknowledgements........................................................................................................................ viTheNeedforDentalCareforYoungChildren............................................................................... 1FinancingOralHealthCareforChildren........................................................................................ 3

Table1EPSDTMedicaidDentalServicesforChildren........................................................ 3WorkforceAvailabletoCareforYoungChildren........................................................................... 7

Figure1Dentistsper100,000Population(2000):................................................................. 8Figure2.HygienistsSupervisionRequirementsVarybyStateandProcedure...................... 9

CouldNewDentalProvidersHelp?...........................................................................................11Table2ProviderCapacityforWorkingwithYoungChildren............................................. 13Table3ProposedandCurrentDentalProviders.................................................................. 15

PublicHealthMeasures............................................................................................................... 17Fluoridation.............................................................................................................................. 17

Table4The15MostPopulousNon-FluoridatedCommunities.......................................... 18Figure3PercentageofStatePopulationServedbyPublicWaterSystemsthatReceiveFluoridatedWater-2005....................................................................................................... 18DentalSealantPrograms....................................................................................................... 19

HealthEducationandPromotion.............................................................................................. 20PromisingModelsforCaringforYoungChildren........................................................................ 21

Washington’sABCDProgram.................................................................................................. 21Michigan’sHealthyKidsDentalProgram................................................................................ 22NorthCarolina’sSmartSmilesandIntotheMouthofBabesPrograms.................................. 23

Findings......................................................................................................................................... 25Appendix- Dental Benefits in Non-Medicaid SCHIP Plans August 2006.................................... 33

Notes......................................................................................................................................... 35

v

aCknowledgemenTs

Theauthorsaresincerelygratefulforthetimeandexpertiseofthefollowingpeoplewhoreviewedandgavecommentsondraftsofthisreport:Dr.JimBramson,Dr.AlGuay,andDr.Laura Neumann of the American Dental Association; Tim Lynch and Megan Fitzpatrick of the AmericanDentalHygienists’Association;Dr.DavidNashoftheUniversityofKentucky;Dr.RonNageloftheIndianHealthService;MegBoothoftheChildren’sDentalHealthProject;Beth Mertz of the Center for Health Policy Studies at the University of California; and Andy SnyderofNASHP.

vi

The need for denTal Care for Young Children

Sinceatleast1990,astrategicnationalefforthasbeenunderwaytoensurethatchildrenstartschool ready to learn. Although school readiness is broadly defined to include a variety of health conditions,untilrecentlylittleattentionhasbeengiventoensuringthattheoralhealthneedsofyoungchildrenaremetbeforetheyenterschool.Thisisaseriousomission,sincedentalproblemsarethemostcommonunmetneedamongchildren.1Nearly59percentofchildrenexperiencedentalcaries,farmorethanthenumberwhohaveasthma(11percent)orhayfever(8percent).2

Althoughtheoralhealthofthenationoverallhasimproveddramaticallyinthelast50years,asegmentofsocietyhasbeenleftbehind.Peoplewithlowincomes,minoritiesandimmigrants,those with special health care needs, and people in rural areas have the greatest difficulty accessingcareandmaintaininggoodoralhealth.Needsareparticularlystarkamongpoorchildren:20.7percentofpoorwhitechildren,47.2percentofpoorMexican-Americanchildren,and43.6percentofnon-Hispanicblackchildrenhaveuntreateddentalcaries.3Amongpre-schoolchildrenwhoarepoor,nearly30percenthaveuntreatedcavities,comparedtoonly6percentamongchildrenfromfamiliesabove300percentofthefederalpovertylevel.4Infact,theCentersforDiseaseControlrecentlyreporteda15.2percentincreaseincariesamongchildrenages2through5years.5Parentsarefullyawareoftheirchildren’sproblems:arecentfederalsurveyofparentsfoundthat53percentofLatino,39percentofblack,and23percentofwhitechildrenhavegood,fairorpoororalhealth,ratherthanexcellentorverygood.6Theconsequencesofuntreateddentalproblemsonschoolreadinessareclear.Childrenwithuntreateddentalproblemsexperience pain and difficulty eating and sleeping, and can have trouble adjusting socially. Learning under these circumstances can be difficult.

Dental and public health organizations recommend that dental care for children begin within six months of the eruption of the child’s first tooth, or no later than the first birthday. However, forhighriskfamilies,theAmericanAcademyofPediatricsrecommendsthatcarebeginmuchearlierbyidentifyingandworkingproactivelywithpregnantwomenandestablishingadentalhomebeforechildrenreachtheageofone.7Servingmoreyoungchildrenandpregnantwomenwill present a host of challenges, as the current system of financing and delivering dental care isfragmentedandinadequateevenwithoutexpandingthetargetpopulation.Thispaperfocuseson those financing and workforce challenges, describes promising models of care, and discusses optionsforpolicymakersseekingtoimproveaccesstooralhealthcareforyoungchildren.

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ImprovingOralHealthCareforYoungChildren 1

finanCing oral healTh Care for Children

PartofthechallengeinservinghighriskyoungchildrenisthatMedicaiddentalprogramsdon’tworkverywell,despitemanystateeffortstoimprovethem.AlthoughtheEarlyandPeriodicScreening,DiagnosisandTreatment(EPSDT)programrequiresthatMedicaid-enrolledchildrenreceiveregularscreenings–andanytreatmentneeded–frommedical,dental,andvisionproviders,onlyabout1in5childrendo.TherearetoofewdentistswillingtoacceptMedicaidandmanywhodolimitthenumberofMedicaidpatientstheysee.DentistsarereluctanttobecomeMedicaidprovidersbecausereimbursementratesareoftenbelowthecostofprovidingthe service, paperwork and preauthorization burdens are onerous, and payment is slow. In addition,care-seekingbehavioramongMedicaidrecipientsisspottyandtheno-showratefordentalappointmentsishigh.8

Theseaccessbarrierscanaffectcareformillions,asnearlyhalfofthe44.7millionMedicaidenrolleesarechildren.9Since2000,theportionofchildrenwhoreceiveEPSDTdentalserviceshas edged upward (see Table 1), reflecting state efforts to improve dental access and a change inreportingmechanismsthatcountedmoreservicesprovided.In2004,about30percentofallchildrenenrolledinMedicaidreceivedsomedentalservice.However,thegreatmajorityofchildrenenrolledinMedicaidstilldonotreceivedentalservices,andtheportionundertheageofsixwhoreceiveanydentalservicesisverysmall.

Table 1 EPSDT Medicaid Dental Services for Children

ServicesforallEligibleChildren

2000

ServicesforChildrenAges0-5

2000

ServicesforallChildren

2004

ServicesforChildrenAges0-5

2004Receivedanydentalservice 27% 16% 30% 19.4%

Receivedpreventivedental

service 21% 12.6% 21.7% 13.6%

Receiveddentaltreatment 14% 6.8% 15.7% 7.7%

Source:AnnualEPSDTParticipationReportFormCMS416(National).

Access to dental benefits for children enrolled in Medicaid may change under the new Deficit ReductionActof2005(DRA).TheDRAmakesthemostsweepingchangesinMedicaidsinceits enactment, giving states substantial flexibility to change benefit packages, impose cost sharing,andofferdifferentplansindifferentregionsofastatewithoutpriorfederalpermission.The Centers for Medicare and Medicaid Services (CMS) have clarified that EPSDT remains arequirement.However,statesmayuseoneoffourpossiblebenchmarkpackagesinsteadoftraditional Medicaid benefits, and add or “wrap-around” any that are not included in the new package. None of the proposed benchmark benefit packages include dental benefits. Using a wrap-aroundmechanismmaybecumbersomeforfamiliesandprovidersanditisnotyetclear


whether this will further restrict access to dental benefits. The new law also requires a majority of people to document their citizenship during renewals or applications, which may reduce enrollment among eligible citizens and cause backlogs in eligibility processing. One study estimated that 3.2 to 4.6 million citizens will have difficulty producing a birth certificate or passportandmaybedeniecoverage.10

DentalcoverageundertheStateChildren’sHealthInsuranceProgram(SCHIP)isasomewhatdifferentstory.SCHIPtargetschildrenunder200percentofthefederalpovertylevel(orhigher,dependingonstateMedicaideligibilitylevels)whoarenoteligibleforMedicaid.Stateshaveoptionsforhowtheyshapetheirprograms,andatthispoint,12usetheirSCHIPfundstoexpandMedicaid,andtheresthaveestablishedseparateSCHIPplans,orenactedsomecombinationofMedicaid and non-Medicaid programs. Unlike in Medicaid, dental benefits are optional in stand-alone SCHIP plans. That means that when states face a financial pinch, dental benefits are one of the first places they cut, either by paring down covered services, imposing a cap, or cutting benefits altogether. Once cut, states struggle to find funding to reestablish their dental programs. However, in some non-Medicaid SCHIP plans, dental benefits are administered through managed care,paydentistshigherrates,andareeasierforpatientstoaccess.

UnlikeMedicaid,whichmatchesallowableadministrativeexpensesat50percent,theSCHIPlegislationcapsadministrativeexpenses,includingoutreachandhealthservicesinitiatives(whichcanincludepublichealth),at10percent.Currently,threestatesusesomeadministrativefundsforpublichealthefforts.Thesecouldbeexpandedorusedtoincludepublicoralhealth,suchassealantprogramsororalhealtheducationforat-riskchildren.

Currently,all39ofthestateswithseparateSCHIPplansorcombinationplansincludedentalcoverage. (For a full description of SCHIP dental benefits, see the Appendix.) Fully one-third

EPSDT COVERAGE

Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit required forchildrenintheMedicaidprogram,dentalservicesmustbeprovidedatregularintervalsthatmeetthereasonablestandardssetbyeachstate.Statesarerequiredtoestablishtheseperiodicityschedules through consultation with state and local dental organizations. EPSDT covers any andallservicesthataredeterminedtobemedicallynecessary.Medicalnecessityisdeterminedbythestateandencompassesanyprocedureorservicerequiredtodeterminetheexistenceofasuspecteddiseaseorillness.Ataminimum,childrentreatedunderEPSDTmustreceiveservicesthatprovidereliefforpainandinfection,restorationofteeth,andmaintenanceofdentalcare.Further,theemphasisandscopeofEPSDTservicesarenottobelimitedtoemergencyuseonlybutshouldincludeprimaryoralhealthpreventionandeducation,suchas:instructioninoralhygiene procedures, cleaning, and sealants for pit and fissure caries. Direct dental visits are also required under the EPSDT benefit; most notably, this requirement is only met through direct dentalreferralsandnotbyhavinganoralhealthexaminationorscreeningduringthemandatoryphysicalexaminationportionoftheEPSDTservices.Dentalreferralsarerequiredforeverychildbasedonperiodicityscheduledeterminedbythestate.

EPSDT COVERAGE

Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit required forchildrenintheMedicaidprogram,dentalservicesmustbeprovidedatregularintervalsthatmeetthereasonablestandardssetbyeachstate.Statesarerequiredtoestablishtheseperiodicityschedules through consultation with state and local dental organizations. EPSDT covers any andallservicesthataredeterminedtobemedicallynecessary.Medicalnecessityisdeterminedbythestateandencompassesanyprocedureorservicerequiredtodeterminetheexistenceofasuspecteddiseaseorillness.Ataminimum,childrentreatedunderEPSDTmustreceiveservicesthatprovidereliefforpainandinfection,restorationofteeth,andmaintenanceofdentalcare.Further,theemphasisandscopeofEPSDTservicesarenottobelimitedtoemergencyuseonlybutshouldincludeprimaryoralhealthpreventionandeducation,suchas:instructioninoralhygiene procedures, cleaning, and sealants for pit and fissure caries. Direct dental visits are also required under the EPSDT benefit; most notably, this requirement is only met through direct dentalreferralsandnotbyhavinganoralhealthexaminationorscreeningduringthemandatoryphysicalexaminationportionoftheEPSDTservices.Dentalreferralsarerequiredforeverychildbasedonperiodicityscheduledeterminedbythestate.

4 NationalAcademyforStateHealthPolicy

of states with separate SCHIP plans provide benefits that mirror Medicaid (Delaware, Idaho, Indiana,Illinois,Kansas,Kentucky,Maine,Maryland,Minnesota,Nevada,RhodeIsland,SouthDakota,andVermont).Mostoftheremainderprovidebasicservicesthataremodeledafterprivate insurance benefits. Seven states have an annual benefit cap that could make it difficult forchildrenwithpoororalhealthtogetcomprehensivecare.Forexample,Montana’scapof$350andMichigan’scapof$600wouldbeexceededquicklyifachildneededrestorativecare.DentiststreatingchildreninsuredunderSCHIPcomplainaboutcapsaswell,astheymaybeforcedtodonatecareoncethecapisreached,orgivechildrenlesstreatmentthanismedicallyappropriatebecausetheplanwon’tpayformore.Elevenstatesrequireproviderstocollectcopaymentsfordentalservicesthatarenotpreventative,whichisanotherimpedimentforlowincomefamilies.

□ □ □


workforCe available To Care for Young Children

Apart from financing oral health care for at-risk young children is the critical question of who canprovidesuchcare?Thereisampleevidenceforconcernthattherearen’tenoughpractitionerstocareforyoungchildrennow,letaloneifmoreseekcare.Generaldentistsarethemostlikelytotreatfamiliesandchildren.However,mostoftheroughly126,000generaldentistsaren’ttrainedtotreatyoungchildrenandsoreferveryyoungchildren,thosewithadvanceddisease,orwithspecialneeds,topediatricdentists.Despiteanincreaseintrainingprogramsinthe1990s,thereisstillashortageofpediatricdentists(onlyabout3,800).11In2001,lessthan3percentof all dentists were pediatric dentists; twelve states have fifteen or fewer.12Also,theportionofdentiststhatareingeneralpracticeisdecliningrelativetothenumberofdentistsinspecialties,which may exacerbate difficulties getting care for young children. There are roughly four general dentiststoeveryonespecialist,butthatratioisexpectedtodroptothreetoonebyearlyinthe21stcentury.13Dentistsareatthetopofthepyramidofprofessionalswhocanprovidecareforyoungchildren.Theyarethemostexpensivetotrain,butalsocanperformthemostcomplexprocedures.

Thedentalprofessionisdividedaboutwhetherthereisanoverallshortageofdentists,butthereisgeneralagreementthattherearetoofewwhocareforpubliclyfundedandspecialneedspatients.14Despitethecontroversy,theBureauofHealthProfessionssaysthatbetween6,610and9,228dentistsorotherpractitionersareneededtoserve3,329designatedshortageareas,inwhichnearly31millionunderservedpeoplelive.15 However, organized dentistry has resisted manyattemptstoexpandthesupplyofdentists.Thisisbecauseoftheeconomicsofdentalpractice,whichisquitesensitivetooversupplyandchangesintheeconomy.Abouthalfofallpaymentsfordentalservicesaremadeoutofpocket,ratherthanbyinsurance.Inleantimes,manypeoplepostponecareanddentalpracticeincomessuffer.Morethan92percentofdentistsareinprivatepractices,and79percentaresoleproprietors.Overheadishigh,averagingabove60 cents of every dollar earned, which makes it more difficult economically for dentists to accept MedicaidorSCHIPratesthatarelowerthancommercialinsurance.Thehighcostofadentaleducation,andhighlevelsofeducationaldebtforgraduatingdentists,contributetothelownumberwhoacceptMedicaidandSCHIPpatients.

TheAmericanDentalAssociationdoesnotforecastashortageofdentists,butmanyotherorganizations and reports, such as the Institute of Medicine and the U.S. Surgeon General’s office, do.16 More and more state health officials and policymakers now discuss their impending “cliff problem,” meaning that in 2014 the number of dentists retiring will begin to exceed the numbergraduatingandenteringpractice.Then,theratioofpopulationtodentistswillsteadilyincrease and even private pay or insured patients in some areas will have difficulty finding a dentist.Asitisnow,theratioofdentiststopopulationvariesgreatly,fromalowof39.2per100,000peopleinNevadatoahighof83.1inNewYork.Nineteenstateshavefewerthan50dentistsper100,000people(seeFigure1).Almosteveryonecanagreethatthereisageographicmaldistributionofdentists,withtoofewinruralandunderservedareas,buttherearefewpolicytoolstoaddressit.TheNationalHealthServiceCorpsandabouthalfofstateshaveloanrepaymentprogramsthatareusedtoattractandretaindentists(andotherprofessionals)toserveinpublicclinicsorcommunityhealthcentersinunderservedareas.Whiletheseareeffectivestrategies,theyaregenerallysmallinscopeduetofundinglimitations.17


Source:AmericanDentalAssociation,SurveyCenter.USCensusBureau(2001).

Thenumberanddistributionofdentalauxiliaries–dentalassistantsandregistereddentalhygienists – is also a potential problem. While the number of hygienists has grown significantly inthelast15years,manyworkparttime,taketimeoffforfamilyresponsibilities,orleavethefield before retirement. Dentists often have trouble hiring and retaining them. There are roughly 5,000newhygienistsanddentalassistantsgraduatingfromschooleachyear,comparedtoabout4,000newlygraduatingdentists.18However,thenumberofhygienistsgraduatingfromschoolisexpectedtorisetoabout6,000peryear,outstrippingthenumberofdentistsenteringpracticeeveryyear.19Thismayeasecurrentshortagesandmakeiteasierforfamilieswithyoungchildrentoreceivepreventiveservices.

Diversityandculturalcompetenceisaseriouschallengeforthedentalprofessionaswell,onethatsomeschoolsandfoundationsaretryingtoaddress.Studieshaveshownthattheracialandethnicbackgroundofdentistsaffectstheracialdistributionofthepatientpopulation.Simplyput,dentistsofcolortendtohavemorediversepatientpopulations.Dentalhygienistsarealmostentirelywhitewomen,anddentistsaremostlywhitemen.Whiledentalschoolclassesarenownearlyone-thirdwomen,thebulkofdentistsinpracticesaremale.TheportionofdentalstudentswhoareAfrican-American,NativeAmericans,orHispanichasbeendeclininginthelast15years. Asian students now comprise nearly 25 percent of first year students, but the remainder ofthestudentbodyisbecominglessdiverse.20ThePipelinesProfessionsandPracticeprogram

Figure 1 Dentists per 100,000 Population (2000):


Less than 50

50-60

60-70

70+

AR 42.2

OK49.4

WV 46.2

OH54.2

NY83.1

NH – 57.5 MA – 81.2

ME47.9

NJ – 80.4CT – 79.6

RI – 59.5

DE – 46.7

VT 60.1

MD– 76.5

NC43.1

PA 67.3

VA 58.1

FL 53.2

GA 45.5

SC 45.4

KY 55.9

IN 48.0

MI59.7

TN53.2

MS39.7

AL 43.5

MO49.2

IL67.4

IA 54.3

MN61.1

WI58.7

LA 48.2

TX48.2

KS50.6

NE65.5

ND48.3

SD49.2

HI 84.7

MT55.6

WY56.7

UT63.7 CO

69.8

AK 72.7

AZ 47.6 NM

45.1

ID52.4

OR67.4

WA 65.3

NV39.2CA

68.3

56

5

910

10

1 1 10

34

7

5

3

5 54

5 5

2

5

9

0

2

4

6

8

10

12

PROPHYLAXIS X-RAYS TOPICALANESTHESIA

FLUORIDE PIT\FISSURESEALANTS

PLACETEMPORARY

RESTORATIONSPhysical presence of dentist requiredPhysical presence not required; states may require cooperative arrangement, experience or education.Physical presence not required in private dental office, but states may require cooperative arrangement in other settingsPhysical presence of dentist required in private dental office, but not in other settings.

fundedbytheRobertWoodJohnsonFoundationandtheCaliforniaEndowmentisseekingtodiversifythestudentbodyin15dentalschoolsaroundthecountryandprovideamodelforotherschoolsseekingtoaddressthisissue.

Supplyofhealthprofessionalsisnottheonlyconcern.Thescopeofpracticeandsupervisionissuesfordentalauxiliariesbecomeparticularlyimportantinthecontextofexpandingaccesstocareforyoungchildren.AccordingtoBrightFutures,thefederalguidetobestpractices,oralhealthcareforyoungchildrenneedstoincluderiskassessment,screening,examinations,andanticipatoryguidanceforparents.21Allofthesethingscanbedonebyregistereddentalhygienists.Ifrestorativetreatmentisneeded,however,itmustbeprovidedbyadentist.Hygienistspracticingregularlyinpublichealthsettingssuchasschools,childcarecenters,orschool-basedclinicscouldmakeahugeimpactinpreventingcaries,suppressinginfection,andidentifyingandreferringtodentistschildrenwhoneedrestorativecare.

Statedentalpracticeactshavebeenlooseninggraduallyovertheyears.Now,hygienistscannowpracticeinatleastonesettingundergeneralsupervision–alessrestrictivearrangementthanindirectordirect–in45states,comparedtoonly30statesin1993.Moreimportantly,in20states(seeFigure2),hygienistscantreatapatientwithoutinitialconsultationwithadentist(calleddirectaccess)–usuallyinapublichealthsettingsuchasaschool,clinic,dentalvan,nursinghome,orHeadStartprogram.22Thisisparticularlyimportantinexpandingcareneededforat-riskyoungchildren.However,inmoststates,scopeofpracticeisunnecessarilyrestrictiveandimpedestheabilityofhygieniststopracticetothefullextentoftheirtrainingorinthetypesof settings that might benefit patients the most. For example, the physical presence of a dentist

Figure 2. Hygienists Supervision Requirements Vary by State and Procedue

Source:ADHAPracticeActOverviewChartofPermittedFunctionsandSupervisionLevelsbyState,July24,2006.Source:ADHAPracticeActOverviewChartofPermittedFunctionsandSupervisionLevelsbyState,July24,2006.


on site is still required for hygienists to clean a patient’s teeth in a private dental office in 10 states,primarilyintheSouth.Ontheotherendofthespectrum,hygienistscancarveand/orfinish amalgam restorations (fillings for cavities) in eight states, and in three of those the dentist isnotrequiredtobepresent.Inmanystates,supervisionlevelsaresplit,withmoresupervisionrequired in dental offices and less in public health settings. When services are provided by adentistthatcouldbeprovidedbyahygienist,oronlywhenadentistispresent,thecostofprovidingcareishigherthanitneedstobeandcareislesseasilyavailable.Hygienistsareakeyfirst line of defense in prevention of dental caries, patient and family education, and screening for problemsadentistmustaddress.ExpandingtheirabilitytoprovidepreventivehygieneservicesinpublichealthsettingsisagoodupstreamstrategytosavestatesmoneyinMedicaidandSCHIPprogramsthatisnowspentdownstreamondentalrestorativeservices.

Statescopeofpracticeruleshavebeenlooseninggraduallyfordentalassistantsaswell,sothatinmanystatestheycanperformsomeservicesthatwereonceonlydonebyhygienistsordentists.Dentalassistantswithextratraininghaveavarietyofnamesinstatedentalpracticeacts,andin most states, they must complete a training program that leads to certification or registration. Washington state allows specially trained dental assistants to apply fluoride varnishes and sealantsinschoolsundergeneralsupervision.Massachusetts,Michigan,NewMexico,andNebraska also allow trained or certified assistants to apply fluoride varnishes and/or sealants undergeneralsupervision.Expansionsthatinvolverestorativeworkarecontroversial.Sixstatesexplicitlybardentalassistantsfromplacingamalgamrestorations,and14barthemfromcarvingrestorations.Nostatesallowdentalassistantstoperformcompletehygieneservices.However,expandingthescopeofpracticeandlooseningsupervisionrequirementsforpreventiveservicescouldassistinpublichealtheffortstargetedatyoungchildreninpre-schoolprogramsordaycarecenters.

ExpandedFunctionDentalAssistants(EFDAs)areanexampleofadentalprofessionalthatstatescouldusestrategicallytoexpandtheworkforceforyoungchildren.EFDAs(sometimescalledregistereddentalassistantsinexpandedfunction)arelicensedandinpracticein17states.Theywork under the direct supervision of a dentist to prepare or finish up restorations, take x-rays, apply sealants and fluoride varnishes, and polish teeth.23Theyalsocanperformlimitedcleanings,called “toothbrush cleanings” with a rubber cup or brush, that are well-suited to young children. EFDAscangreatlyexpandtheproductivityofdentistsandmakeservingMedicaidandSCHIPpatients more profitable. Unfortunately, in many states, EFDAs are in short supply and dentists aren’taccustomedtoworkingwiththem.PennsylvaniahasgonethefarthestinintegratingEFDAsintodentalpractices.AninnovativeprogramfundedbytheRobertWoodJohnsonFoundationhasallowedthestatetoexpandtrainingforanduseofEFDAs.

Inrecentyears,stateshavebeguntoenlistphysiciansandnursepractitionersindeliveringoralhealthservicestochildren,sometimeswithreimbursementbyMedicaid.Usingpediatricprovidersmakesperfectsensesincetheyseeinfants,youngchildren,andtheircaregiversmanytimes in the first two years of life for well-child care and immunizations, whereas most families don’ttakeyoungchildrentothedentistuntiltheyarethreeorolder.Itisnotuncommonforat-riskyoungchildrentohaveadvancedtoothdecaybyage3.Pediatricproviders,particularlythose who see low-income, minority and other high-risk families, could make a sizable impact


inscreening,oralhealtheducation,preventionanddiseasesuppression,andidentifyingandreferringtodentiststhosechildrenwhoneedrestorativecare.

Thereareanumberofissuesthatneedtobeaddressedwhenincorporatingmedicalprofessionalsintooralhealthcaredelivery.Notallstatemedicalanddentalpracticeactspermitit,additionaltrainingisgenerallynecessary,referralmechanismsbetweenmedicalanddentalsitesareneeded,andreimbursementfromMedicaidorotherpayersmustbearranged.

Experts in pediatric dentistry have identified seven strategies for preventing caries in preschool children:

• education,• diet,• toothbrushing,• fluoridated water or supplements, • topical fluorides, • antimicrobials(suchasxylitolandchlorhexidine),and• sealants.

Medicalproviderscanprovidemostoralloftheseservicesforyoungchildrenandtheirfamilies.24Inthe1990s,NorthCarolinabegantrainingphysicians–primarilypediatricians,nurses,andphysicianassistants–toscreenfordecay,referasappropriatetodentistsforrestorative treatment, educate parents about proper hygiene, and apply fluoride varnishes. Oregonisalsousingpediatricianstoscreenyoungchildrenfordentalcaries.25In32states,dentalpracticeactsallowphysicianstoprovidepreventiveoralhealthservices,and13statesallowthemtoprovideotherservicesincertainsettings(suchasextractteeth).26

Could New Dental Providers Help?

Currently,thereareanumberofproposalsunderdevelopmentfornewtypesofdentalprofessionals who could add significantly to the workforce able to care for young children (see Table2).Somearemidlevelprofessionalswhowouldfunctionatalevelaboveadentalhygienistbutbelowthatofadentist.Inmedicine,physicianassistantsaremidlevelswithmaster’s-leveltraining who can perform 86 percent of the tasks in primary care practice. They are significantly cheapertoeducateandemploythanphysicians.27Newprovidersindentistrycouldbeaddedtothedentalteam,functionindependentlyincollaborativepracticewithadentist,orpracticeundergeneralsupervision.Theycouldincludelicensedmidlevelproviderswithamaster’sdegree,orgraduates of bachelor’s degree or two-year programs that practice after either certification or licensure.

Inthe1950sandthe1970s,attemptsweremadetointroduceanewtypeofmidleveltoaugmentthecarethatdentistsprovide,serveasadentalextenderthewayphysicianassistantsandnursepractitionersdo,andimproveaccesstocareforunderservedgroups.Theconceptofandneedfor a midlevel is controversial and, thus far, opposition from organized dentistry has stymied


development.However,sinceaccessproblemsareacute,andshortagesofdentistsareoccurringinmoreregionsandstates,momentumtodevelopanewtypeofdentalmidlevelprofessionalhasrecurred.Anynewpractitioners,whetheratthemaster’slevelorbelow,wouldbealong-termsolution.Ittakesyearsforastatepolicycommunitytocometoconsensus,schoolstodevelopacurriculum,legislaturestoamendthestatedentalpracticeacttoprovideforlicensingorcertification, and payers to decide on reimbursement. The American Dental Association fears that allowing professionals other than dentists to provide restorative care could jeopardize patient safetyorprovideinferiorcare.However,allhealthpractitionersoperateunderscopesofpracticethat are tightly defined by state practice acts, with stringent training, examination, licensing or certification requirements, and regulatory oversight by state boards. States can and do use their currentlegalandregulatoryauthoritiestoexpandthescopeofcurrentprofessionals,establishnewones,andensurethatthesafetyofthepublicissafeguarded.

ThereisonlyonenewtypeofdentalprofessionalcurrentlypracticingintheUnitedStates:dentaltherapists(calledDentalHealthAideTherapists),whoworkonIndianreservationsinAlaska.Dentaltherapistscanbetrainedandsenttoremoteareastopracticebecauseofthe150sitesinAlaskathatareequippedfortelemedicineandteledentistry.DHATsoperateundergeneralsupervisionofadentistinaclinicusingcartsthattakeandsendx-raystoadentistelectronically;thedentistandDHATconferontreatmentplansbyphone.Thisisapromisingmodelforallrural and frontier areas in the United States that have difficulty attracting, supporting, and retainingadentalpractice.

The Indian Health Service (IHS) moved to train dental therapists after years of difficulty attractingdentiststoliveandserveinremoteareasofAlaska,andmixedsuccessusingvolunteerdentistsfromotherstates.DentalHealthAidTherapistsareequivalenttothedentaltherapistmodeldevelopedinNewZealandin1921andnowinusein40countries,includingGreatBritainandCanada.Theycomefromandreturntothecommunitiestheyserve,whichensuresculturalandlinguisticcompetence.TherearenocurrentplanstoextendtheiruseintheIHSinthelower48statesorinareasotherthantriballands.BeginninginJanuary,2007,theUniversityofWashingtonSchoolofMedicine’sMEDEXNorthwest,aprogramthattrainsphysicianassistantsfor five western states, will begin training dental therapists in Anchorage using Washington dentalschoolfacultyandAlaskadentistsforclinicalrotations.

Dentaltherapistsmustcompleteatwo-yearcurriculumatadentalschool,butabachelorsorassociates degree is not required first. In this respect, they are roughly equivalent to dental hygienists,exceptthattheyfocusonbothrestorativeandpreventivecare.Dentaltherapistsreceive2,400hoursofcurriculumtraining,ofwhichaboutone-thirdisspenttreatingchildren.Theirclinicalscopeofpracticeismuchnarrowerthandentists,butincludesbothpreventiveandrestorativeservices(seeTable2).Dentaltherapistsareapotentialsolutiontoprovidingessentialoralhealthservicestoyoungchildreninotherunderservedareas,sincetheycanperformmanyofthefunctionsofdentalhygienistsanddentists,butarecheaperandquickertotrain.28AnumberoforalhealthexpertshavecalledforthedevelopmentofaPediatricOralHealthTherapist,modeledontheNewZealanddentaltherapist,29topracticeinunderservedareas.


Table 2 Provider Capacity for W

orking with Young C

hildren

LevelofC

areProcedures

Expanded

FunctionD

entalA

ssistants

Dental

Therapists

30

RegisteredD

entalH

ygienistD

entistN

ursePractitioneror

PhysicianAssistant

Physician

RiskA

ssessment

Parentintervew,visualscreeningx

xx

xx

Anticipatory

Guidance

Patientandparenteducationandcounselinggearedtolevelofrisk

xx

xx

x

Primary

Prevention

Oralhygieneinstruction

Dietarycounseling

Topical fluoridesD

entalsealants

xxxxx

xxxx

xxx

xxx

ProphylaxisM

echanicalcleaningofteethx 31

xx

x

Disease

Suppression

Fluorideregimens,

antimicrobials,plaque

managem

entx

xx

x32

x

Cavitytreatm

ent

Atraum

aticRestorative

Technique(ART)

Restorations

ExtractionsStainlesssteelcrow

ns

x33

xxxx

xxxx

Source: Com

piledbytheNationalA

cademyforStateH

ealthPolicyN

ote: Permittedfunctionsandsupervisionlevelvarybystatedentalandm

edicalpracticeacts.


TheAmericanDentalHygienistsAssociationhasbeenworkingforseveralyearstodevelopamidlevelprofessionalwithamuchbroaderrangeofdutiesthanadentaltherapistcalledtheAdvancedDentalHygienePractitioner(ADHP).Thiswouldbeamasters-levelprofessionalwhocouldfunctionindependently,inacommunityorpublicsetting,andcouldmanagecases,providehealtheducationandfullpreventiveservices,andcouldalsoperformsimpleextractionsandrestorations(seeTable3).TheADHPwouldalsobeabletoperforminanumberofnon-clinicalcapacities,establishcollaborativerelationshipswithotherproviders,workonpolicyandadvocacyissues,andconductresearch.TheADHAenvisionsthisnewprofessionalworkinginavarietyofsettingsinacollaborativerelationshipwithadentist,physician,orclinicmanager.Sincetheirscopeofrestorativeserviceswouldbelimited,theywouldestablishreferralrelationshipsforpatientswhoneedmorecomplexclinicalservicesthantheycoulddeliver.TheADHAiscurrentlydevelopingacurriculumtotrainADHPs.

Partlyinanefforttoassistinimprovingaccess,theAmericanDentalAssociationconvenedataskforcetoexamineworkforceneedsandmodels,anddevelopedacarefullyconsideredplanforaladderofincreasinglyskilledprofessionalsthatincludesaCommunityDentalHealthCoordinator(CDHC).ThisnewprofessionalwouldhavedutiesthatareverysimilartothePrimaryDentalHealthAide,aprofessionalwithlesstrainingthanadentaltherapistthatcurrentlyisinuseinAlaskafortheIndianHealthService.CDHCswouldprovidebothdirectpatientcare(underdirectorindirectsupervision),preventiveservices(undergeneralsupervision),andpublichealthservices,althoughnorestorativecare.CDHCswouldbeableto provide some dental hygiene services, apply fluoride varnishes and sealants, but would also be trained to work on community water fluoridation and with an array of organizations and programsservingwomenandchildren.

Training would be 12-18 months, followed by a certification process. CDHCs could be very helpfulinsettingsservingyoungchildren,suchaspre-schools,HeadStartprograms,anddaycarecenters.TheprimaryadvantagetotheplanforaCDHCisthattheproposedpublichealthcompetenciescouldexpandthepoolofpeoplewhocanmountoralhealthpromotioncampaigns,whicharebadlyneeded.However,therestrictionsonrestorativecareandaslimmerpackageofpreventiveservicesmakesthismodelsomewhatlessattractivethantraditionaldentalhygienistsordentaltherapiststocareforyoungchildren.Theywouldbelesshelpfulinrural,frontierorchronicallyunderservedareasthanadentaltherapistoradvanceddentalhygienepractitionerbecauseofthelimitedscopeofclinicalservices.Sincetheirrangeofclinicalservicesisnarrow,itisn’tclearhowCDHCswouldbereimbursedexceptassalariedorgrant-fundedpositions.


Table 3 Proposed and Current Dental Providers

Com

munityD

entalHealth

Coordinator 34

AdvancedD

entalHygiene

PractitionerD

entalTherapists

Developedby

Am

ericanDentalA

ssociationA

mericanD

entalHygienists’

Association

Dentaltherapistm

odeldevelopedinNew

Zealand,inusein40countries.TheIndianH

ealthService,A

laskaTribalHealthC

onsortium,em

ploysDental

HealthA

ideTherapists.

Stageofdevelopm

entPlanningstage.

Planningstage;curriculumbeing

developed.8trainedandpracticinginIH

SAlaskasites.

Education/

training12-18m

onths.2-yearM

astersprogram.

2-yearprogramatdentalschoolinN

ewZealand;

trainingbeginsinAlaskain2007.

Certification/

licensureC

ertification.Licensure.

Certified by IH

S board.

ProposedsettingsC

omm

unity-basedandpublichealth roles; private offices.

Hospitals,nursinghom

es,clinics,publichealth settings, or private offices.

IHSclinics.

Proposedsupervision

Dual;educationundergeneral

supervision;patientcareunderdirectorindirectsupervision.

Unsupervisedorgeneralsupervision;

incollaborativepracticewithdentist,

physicianorclinicmanager.

Generalsupervision;operatesunderstanding

orders;dentistsreviewx-raysandtreatm

entplanselectronically.

Preventivecapacity

Preventioneducation.Fluorides.Sealants.

Com

prehensivepreventionservices.Fluoridetreatm

ents.Sealants.

Treatment

capacityG

ingivalscaling.C

oronalpolishing.M

anagecareforreferredperiodontalpatients;prophylaxis.

x-rays.G

ingivalscaling.Prophylaxis.

Restorative

capacityN

one.R

estorations.Sim

pleextractions.R

estorations.Stainlesssteelcrow

ns.Extractions.

Source:Am

ericanDentalA

ssociationWorkforceTaskForceReport,M

ay,2006;Am

ericanDentalH

ygienistsAssociationD

raftCurriculum,January,2006;A

laskaD

epartmentofH

ealthandSocialServices,DivisionofPublicH

ealth,January,2005.□ □ □


PubliC healTh measures

Perhapsthemosttroublingaspectoftheproblemwithaccesstodentalcareisthatmostcasesofdentalcariescouldbepreventedusingsimple,affordablepreventivemeasures.Withoutprevention,dentalcariescandevelopintopainfulconditionsthatareexpensivetotreatandthathaveprofoundeffectsonachild’severydaylife.Publichealthmeasuresaimedatoralhealthareveryeffectivebutunderfunded.

Community-based public health strategies such as water fluoridation, dental sealants, and school-basedpreventionandpromotionprogramsarecosteffectivewaystoreducethedemandfordentalcareandpreventdentaldiseaseamonghigh-riskgroups.Apromisingnewstrategybeingdevelopedisusingantimicrobialproducts,suchasxylitolgumandchlorhexidinerinse,inconjunctionwithschooloralhealthscreenings.Xylitolisanaturalsugarsubstitutewithproperties that greatly reduce caries-causing bacteria. Researchers and public health officials are consideringwaystoincorporatexylitolgum,candy,orotherproductsintothedietofhighriskchildrentoreducetherateofdentalcaries.Itisalsobeingstudiedinpregnantwomenandnewmotherstoeliminatebacteriatheynowpasstotheirnewborns.Oneadvantagetothisstrategyisthatxylitolproductscanbeadministeredbyparents,caregivers,orvolunteerswithnohealthtraining,inmanysettingsandwithoutthecostorstressofseekingdentalcare.35Morepublichealthinitiativescoulddecreasetheprevalenceofdentalcariesamongschool-agedchildren,reducecosts,andconservescarcepublicdollarsforconditionsthataren’tpreventable.

Fluoridation

Although the benefits of water fluoridation are well known and extensively documented, close to 35 percent of the population does not have adequate levels of fluoride in their drinking water.36AsTable4shows,thisincludesfairlylargeandpopulouscommunitiesinmanyareasofthecountry.37Fluoridationiseasytoadministerandverycosteffective.Estimatedsavingsrangefrom $7 to $42 for every dollar spent on water fluoridation.38Theaveragecostislessthanadollarperpersonincommunitieswithmorethan50,000residents.Itismorecostlytoservesmaller,moreruralcommunities.39Withinthelastdecadealone,Americanshavesavedmorethan $25.7 billion on dental services due to water fluoridation. According to the Centers for Disease Control and Prevention, water fluoridation can reduce the amount of decay in children’s teeth by up to 60 percent. Even with the availability of fluoride in over-the-counter products, fluoridated water reduces tooth decay among children by 18 to 40 percent and among adults by35percent.40ArecentCDCreportsuggestedthatover$1.5billiondollarscouldbesavedannually, and the oral health of high-risk communities significantly improved, if the remaining public water supplies were fluoridated.41


Table 4 The 15 Most Populous Non-Fluoridated CommunitiesLongIsland,NewYork

1,239,564SanJose,California

979,000SouthEastPennsylvania(Philadelphiasuburbs) 820,000

BergenandHudsonCounties,NewJersey 764,820Tucson, Arizona 675,000Fresno,California

485,000EasternMunicipalCalifornia(MorenoValley,Perris,Hemet,Murrieta,Temecula,andSanJacinto) 458,000

BatonRouge,Louisiana385,272

ColoradoSprings,Colorado360,890

Newark,NewJersey275,221

PassaicValley,NewJersey(Clifton,Passaic,andPaterson) 275,000

Reno,Nevada 270,000Riverside,California

259,738JerseyCity,NewJersey

238,000RocklandCounty,NewYork 225,000

Source:CentersforDiseasePreventionandControl

The push to fluoridate water systems is hampered by several variables, including lack of federal andstatelegislativemandatesandfunding,whichleavesmanylocalgovernmentswithoutthe necessary funds to pay for a fluoridation system. Lack of mandates also means that each communitymustnavigateitsowndecision-makingandpubliccommentprocess.Despitedecades of research proving its safety, water fluoridation is still controversial and subject to persistentmisinformationcampaignsthatmakeunsubstantiatedclaimsthatitcausesahostofillnessesandconditions.

Even though the use of water fluoridation has grown in the past decade, there are still 4 states in which less than 25 percent of the population has access to fluoridated water42(seeFigure3).Interms of public health initiatives, fluoridating drinking water has the most far-reaching effects and has the highest return on investment, benefiting all members of a community regardless of socioeconomicstatus.


Figure 3

Dental Sealant Programs

Dentalsealantsofferyetanothercost-effectiveoptionforpreventingordecreasingdentalcariesinchildrenandadolescents.Sealantsareclearplasticcoatingsthathelppreventthecavitiesthatform in the pits and fissures of molars, where nearly 90 percent of all caries in children occur. Sealantsworkbypreventingfoodfrombecominglodgedinareastoosmallfortoothbrushestoreach. The benefits of sealants are profound – children receiving only one application of a dental sealant had 60 percent fewer decayed pit and fissure areas for up to five years.43

Dentalsealantsareidealforhigh-riskpopulations,especiallythosewithconditionsthatincreasedentalcaries,childrenwhoalreadysufferfromcaries,orthosewithincipientcariesinmolars.Although not as far-reaching or as easily administered as water fluoridation, dental sealants canbeappliedinanumberofsettingsusingportabledentalequipment.Thismakesthemeasy to use in school and community-based settings. Most sealant programs target specific at-riskpopulations,includingchildrenreceivingfreeorreducedcostlunchprograms,thoseonMedicaid,andracialandethnicminorities,whoarelesslikelytohaveregularaccesstooralhealthcare.Childrenwhoareracialandethnicminoritiesarethreetimesmorelikelytohaveuntreateddecayandonlyone-thirdaslikelytoreceivesealants.44Byadministeringdental sealants at school and in the community, public health officials can focus attention on underserved populations that could significantly benefit from the preventive power of sealants.

Although dental sealants are covered under EPSDT, the difficulty for Medicaid patients in being seenbyadentistmeansthatfarfromallwhoneedsealantsreceivethem.Thismakescommunity


and school-based programs more important as a source of dental care and prevention. Realizing this,morethan34statesnowhavesealantprogramsinplacetoaddressvulnerablepopulations,45includingmanyinschools.Ohiodevelopedasealantprogramin1984andhasseenpromisingresults;over30percentof8yearoldsinOhiohadsealantsin2000–upfromonly11percentin1988.Likewise,nearly60percentofMedicaidchildrenwithschool-basedsealantprogramshadsealantscomparedto22percentofchildreninschoolswithoutsealantprograms.Similarly,Wisconsinestablishedacommunityandschool-basedsealantprogramin2000thatcreated40programs to administer sealants. During the first year of the program alone, more than 4,500 childrenreceiveddentalsealants.Increasingthenumberofhigh-riskandunderservedchildrenwhoparticipateincommunityandschool-basedsealantprogramscouldhaveaconsiderableimpactonoralhealthoutcomesandlowerhealthcosts.

Health Education and Promotion

Oneofthemostimportantfacetsofanypublichealthinitiativeishealtheducationandpromotion.Manylowincomepeopleandimmigrantsdonotunderstandtheimportanceofseekingcareorpreventiveservices.Itisalsodoubtfulthatmostpeople,letalonelowincomepeople,areawarethatdentalcariesisatransmissablediseasecausedbybacteria,andthatsimplebehaviorchangescanlimittheriskofdecay.Whenaskedwhichofthesemethodswasmost effective at preventing dental caries, (using fluorides, limiting sugary snacks, chewing sugarless gum, brushing and flossing, or visiting the dentists every six months) only seven percentofrespondentsinaNationalHealthInterviewSurvey(NHIS)selectedtherightanswer(using fluorides).46Thiswouldseemtosuggestthatamajoritydonotunderstandtheimportanceof using fluorides. This is where community coalitions can have an impact in informing and educating citizens. Citizen coalitions played significant roles in getting fluoridated water systems implementedinSanAntonio,LasVegas,Sacramento,SaltLakeCity,andLosAngeles.47

InthesameNHISsurvey,only32percentofrespondentshadeverevenheardofdentalsealants,letaloneunderstoodtheirroleinprevention.48Publichealtheffortsneedtofocusonbringingtheseissuestolight.OutreacheffortscouldtargetWomen,InfantandChildren(WIC)centerstobetter reach the underserved. Teaching parents that fluoride treatments and dental sealants can have a significant impact on long-term oral health outcomes is essential in building a foundation forimprovingoralhealth.Thesestatisticswouldindicatetheneedforfurthereducationaleffortsbybothpublichealthprofessionalsandoralhealthproviders.Educationandawarenessarecost-effective and beneficial tools to improve oral health in our communities.

□ □ □


Promising models for Caring for Young Children

AccesstooralhealthcareforMedicaidpopulationshaslongbeenanareaofconcernforpublichealth officials and oral health providers alike. Although basic oral health care is covered by Medicaid,manyvariablescontinuetolimitaccessforunderservedpopulations,especiallychildren.Asthisproblemcontinuestoevolve,sotoowilltheneedforinnovativestrategiesandmodelsthatimproveaccesstocareandcreateawarenessforlow-incomechildrenwithsignificant oral health needs. A detailed analysis of several successful models can serve as a referenceforpolicymakersastheproblemoforalhealthdisparitiesbecomesincreasinglymoreprevalent.

Washington’s ABCD Program

Institutedin1995,Washingtonstate’sAccesstoBabyandChildDentistry(ABCD)programsoughttoimproveaccesstodentalcareforlow-incomechildrenfrombirthto5yearsofage.Inordertoachievethisgoal,theABCDprogramfocusedonfourareas:

• communityoutreach,• training and certification for oral health providers, • improved dental benefits, and • amoreattractivereimbursementstructure.

Stakeholders soon realized the need for a collaborative approach; this ultimately led to partnershipsbetweenlocaldentalsocieties,stateandlocalhealthdepartments,publichealthofficials, and academic institutions.49

Thecommunityoutreachportionoftheprogramsoughttocreatemoreawarenessabouttheoralhealthneedsofchildren.Targetinghealthfairs,centersfortheWomen,InfantandChildrenprogram, local welfare offices, churches, and Head Start programs, the ABCD program stressed theimportanceofpreventivedentalcareandmakingandkeepingscheduledappointments.Byexposingchildrentodentalcareatyoungerages,theprogramalsohelpedreducesomeofthefearoftenassociatedwithdentalcare.

Dentists who participated in the program received specialized training and certification in pediatric dentistry at the University of Washington. This certification allowed them to receive enhancedMedicaidreimbursementsfordentalservicesprovidedtochildren.Thetrainingalsoservedasarefreshercourseformanydentistswhodidnotregularlyworkwithyoungerchildren.

The enhanced benefits sought to build on the routine care already provided under the EPSDT program for Medicaid children. By covering up to three fluoride varnish treatments, restorative treatments, and glass ionomer fillings50 (which contain fluoride to protect teeth and often do not requiredrilling,makingthemidealforyoungchildren),enrolleesintheABCDprogramcanreceive more comprehensive preventive care. Another benefit is the opportunity to participate in


educationaloralhealthsessionswhichprovidefamilieswithinformationontheimportanceandnecessityofpreventiveoralcare.

PerhapsthemostcriticalportionoftheABCDprogramwastheadjustmentmadetofee-for-servicereimbursementmechanisms.Add-onfeesforparticipatingprovidersraisedreimbursementlevelstothe75thpercentileofusualandcustomaryfeesandprovidedamorepowerfulincentivetojoin.51ByimprovingMedicaidreimbursementrates,WashingtonwasabletoattractmoreprivatesectordentistsandincreasethenumbertreatingMedicaidpatients.

EvaluationsoftheABCDprogramhavedemonstrateditsoveralleffectiveness.Asurveyofparticipants after the first year found that parents with children in the ABCD program were 60 percentmorelikelytohavescheduledadentalappointmentfortheirchildrenthanthosewhowerenotinvolved.52Nearly78percentofparentswithchildrenintheprogramhadscheduledadentalappointmentfortheirchildren,whereasonly48percentofparentswithchildrennotenrolledintheprogramsoughtdentalcare.53ThesamereportfoundthattheABCDprogramsignificantly increased access to oral health care among Medicaid children, reduced fear of dental services, and improved the use of preventive fluoride treatments. Also, the program increased thenumberofproviderstreatingMedicaidpatients.InoneWashingtonCounty,only15dentistsreportedseeingMedicaidchildrenpriortotheABCDprogram;aftertwoyears,thatnumberincreasedto38.54

BuildingonthesuccessoftheABCDprogram,WashingtonsoughttoexpandprovidernetworksevenmorebyincreasingaccessthroughanewABCDE(AccesstoBabyandChildDentistryExpanded)program.Thisprogramreachedouttoprimarycareproviderssuchaspediatriciansandfamilyphysicians,andencouragedthemtoprovidepreventiveandbasicoralhealthcareduringwell-childcheck-ups.Undertheprogram,primarycareproviderscouldbereimbursedthroughMedicaidforproviding:

• Basicevaluationsofachild’soralhealth;• Instructionsonproperoralhygienetechniques;• Up to three fluoride varnish applications a year; and• Dentalreferrals.55

Michigan’s Healthy Kids Dental Program

TheHealthyKidsDental(HKD)programwasimplementedin22MichigancountiesonMay1,2000.AlthoughaimedatsolvingthesameoralhealthproblemthatfacedWashingtonandtherestofthecountry,theMichiganplanisuniqueinthatitisusesaprivatemanagedcaredentalprovider.Michigan’sHKDprogramwascreatedwhentheDepartmentofCommunityHealthcontractedwiththestate’slargestoralhealthprovidernetwork,DeltaDental,toadministerMedicaid dental benefits. The HKD program sought to increase the pediatric dental workforce by eliminatingtwoofthelargestobstaclescitedbydentistsasreasonsfornotacceptingMedicaidpatients:lowreimbursementandtheadministrativeburdenofparticipatinginMedicaid.56


ThelargestreasonreportedbydentistsfornottreatingMedicaidpatientswastheinadequatereimbursementlevelsthatwouldoftennotcoverthecostsassociatedwithprovidingcare.57InordertomakeMedicaidpatientsmoreappealing,theHKDprogramofferedreimbursementlevelsidenticaltothosefoundinDeltaDental’scommercialplans.Undertheprogram,reimbursementlevelsrosetonearlythe80thpercentile.58Withthehigherreimbursementrates,theHKDprogramsawadramaticincreaseinthenumberofproviderswillingtotreatMedicaidpatients.HKDalsoremovedotherobstaclesfrequentlycitedbydentists,sincetheprocessof verifying enrollment and submitting detailed claims to the Medicaid office is handled by Delta Dental. This has made the Medicaid program more efficient and provider-friendly, and acceleratedthereimbursementprocessfororalhealthservices.

EvaluationsofMichigan’sprogrambyresearchersattheUniversityofMichiganfoundthatthenumberofdentiststreatingMedicaidchildrenincreasedbymorethan24percentaftertheimplementationoftheHDKprogram.Alsonoteworthywasthedecreaseinthedistancetraveledtoreceivedentalcare;theaveragedistancedecreasedfrom24.8milesto12.1milesasaresultoftheincreasednumberofproviders.Intuitively,thiswouldsuggestthatmorechildrenarebeingtreatedbydentistsintheircommunities.Thedistancetraveledtoreceivecareisdirectlyrelatedtothenumberofproviders,whichincreasedby236dentistsinthe22countiesparticipatingintheHKDprogram.59

North Carolina’s Smart Smiles and Into the Mouth of Babes Programs

Thepresenceofearlychildhoodcaries(ECC)hasbeenalong-standingproblemforNorthCarolina.Whenapublichealthreportrevealedthatcloseto40percentofchildrenstatewidehaddentalcariesbythetimetheyhadreachedkindergarten,itwasobviousthatnewinitiativesneededtobedevelopedtoaddressit.60TheSmartSmilesprogramwasimplementedintheAppalachian region of North Carolina in the mid 1990s. Realizing that low-income children oftenhadbetteraccesstoprimarycarethantodentalcare,theSmartSmilesprogramsoughttoengageprimarycareprovidersintheefforttoreducetheoralhealthdisparitiesinyoungchildrenenrolledinMedicaid.Undertheprogram,primarycareprovidersscreenedchildrenfororalhealth problems, applied fluoride varnishes, and educated parents and children about proper oral caretechniques.

Followingasuccessfulpilotprogram,theSmartSmilesprogramwasexpandedtocovertheentirestateandrenamedtheIntotheMouthofBabesprogram.Thisprogramwasaimedatthemorethan200,000children,age0-3,coveredbyMedicaidwhodidnotreceiveregulardentalcare.61Bytrainingprimarycareprovidersandtheirstaff,theprogramcreatedanothervenueinwhichoralhealthneedscouldbeaddressed.

Inordertobeeligibleforreimbursement,providersthatchoosetoparticipateintheprogramattendaneducationalcourseofferedbytheNorthCarolinaAcademyforFamilyPhysicians.Duringthetrainingsessionsparticipantsaretaughtto:

• DescribeanddiscussECCproblemsandcauses;


• IdentifyriskfactorsforECCandconductassessmentsforinfantsandtoddlersatrisk;• Screenforabnormaloralhealthconditions;• Discuss the benefits of fluoride treatments and apply varnishes to at-risk children;• Educateparentsandcaregiversonproperoralhealthtechniquesandproceduresfor

children;and• FileandsubmitMedicaidreimbursementforms.62

Afterthetraining,providersareeligibletobillMedicaiduptosixtimesfororalcareprovidedduring the first three years of a child’s life. A provider must address each issue listed above in ordertoqualifyforMedicaidreimbursement.Thecareincludes:

1) Ariskassessmentcombinedwithanoralscreeningandreferralifproblemsaredetected;2) Prevention services, including fluoride treatments to prevent future caries; and3) Educationforchildrenandparentsabouttheneedfordentalcareandthestepsnecessary

tomaintainsafeandeffectiveoralhealth.

In the first year, 1,595 medical professionals completed the training program. Trainees included pediatricians,familypractitioners,nurses,nursepractitioners,physicianassistants,andanumberofotherpublichealthandcommunityhealthworkers.Astheoralhealthworkforcegrew,sotoodidaccessfortheMedicaidpopulation.Afteroneyear,only16ofthe100countiesinNorthCarolinadidnothaveaproviderenrolledintheIntotheMouthofBabesProgram.63Theoveralleffectoftheprogramwastoincreasethenumberofinitialvisitsforchildrenundertheageofthree.Theeducationalportionoftheprogram,andlinkingoralcarewithprimarycare,wassuccessfulinmakingcaregiversawareoftheimportanceoforalhealth.Thenumberoffollow-upvisitssignaledacommitmentamongparentsandprovidersaliketowardimprovingandmaintainingchildren’soralhealth.

□ □ □


findings

Policy makers at the federal, state, community, and organization level have many options to considerforimprovingoralhealthforyoungchildren.Theycanprovidefundingforservices,focusoneducationofthedentalworkforce,ensurethereisaworkforceadequatetomeettheirneeds,andenhancepublichealthefforts.

Financing Statesshouldconsiderreimbursingpediatricprovidersfororalhealthscreening,

preventionandeducationservices,asseveralstatesnowdowithexcellentresults.Thiswouldprovideearlyencounterswithcaregiversforfamiliesandchildrenandopenupopportunitiestopreventdentalcaries.

Congress should consider making dental services a mandatory benefit, and a required part of well child check-ups, in the reauthorization of the SCHIP in 2007. Since almost all states cover such benefits anyway, mandating dental benefits would allow states to buildtheirprogramsandrelationshipswithproviderswithoutinterruption,andensurethatchildrengetneededcare.

StatesshouldconsiderraisingreimbursementratesfordentalservicesinMedicaidandSCHIPtoattractandretaindentists.Attheveryleast,statesshouldconsiderpayingratesthatareabovewhatitcoststoprovidetheservice.Modestlyhigherrateshaveproven sufficient to persuade dentists to participate so that low-income, high-risk familieshaveaccesstodentalservices.

EducationFederalandstategovernmentsshouldconsiderincreasingfundingfordentaleducation,

particularlyforscholarshipsorloanrepaymentwithaserviceobligation.Thehighcostofadentaleducation,andhighdebtlevelsamongdentalgraduates,makeitlessfeasibleandlikelythattheywillacceptMedicaidandSCHIPwhentheyestablishpractices.

Dentalandhygieneprofessionalschoolsshouldconsiderwaystodiversifytheirstudentbody,andteachculturalandlinguisticcompetence.Diversityandculturalcompetencemakecaremoreaccessibletothosewhoneedtreatment.

Statepolicymakersshouldstudytheirlong-termworkforceneedswithaneyetoincreasingthenumberofpediatricdentists,generaldentists,andthosedentistsinterestedintreatingpublicly-fundedpatients.Notallstatesfaceshortagesnow,butforecastsaretroublingacrosstheboard.Sinceittakesyearstoproducemoredentists,policymakersand state agency officials should consider and plan for their future needs.

Dentalschoolsshouldconsiderincludingmoretrainingforgeneraldentistsinhowtocareforyoungchildrenandchildrenwithspecialneeds.Iftheshortageofpediatricdentistspersists,andnoprogressismadeondevelopingotherdentalproviderswhocanfill the need, general dentists will need an increased capacity and comfort level in treating children.Onecomponentthatshouldbeaddedismoretraininginworkingwithavarietyofallieddentalproviders,suchasEFDAsandhygienistswithexpandedduties,andwithmedicalproviders.


WorkforceStatesthathaven’talreadydonesoshouldconsiderimprovingtheproductivityandreach

oftheirexistingworkforcebylooseningsupervisionrequirementsforhygienistssotheycanprovidepreventiveservicesinpublichealthsettingssuchasschools,childcarecenters,clinics,andHeadStartprograms.Fully20stateshavealreadymovedtodothis.Allowinghygieniststoseechildreninthesesettingswouldtargetresourceswheretheyare most needed and prevent problems before they are expensive to treat and difficult for childrentobear.

State policy makers should work with organized medicine and dentistry to revise medical anddentalpracticeactstoremovebarriersandexplicitlypermitmedicalprofessionalstoprovidepreventiveoralhealthservicesforyoungchildrenandhealtheducationfortheirparents.Localdentalsocietiesinafewstateshavebeeninstrumentalintrainingphysicians and nurse practitioners to do screening and education, and apply fluoride varnishandanti-microbials.

Statesshouldconsiderestablishingloanrepaymentprogramsfordentiststoremedymaldistributionandassistinretainingpractitionersinunderservedareas.Nearlyhalfthestatesalreadyhavesuchprograms.Increasesinfundingcouldassistclinicsthatservelowincomepeopleinhiringdentistsandhygienists.

Statesshouldstudyandconsideradoptingnewmodelsfordentalprovidersthatshowpromiseformeetingtheneedsofyoungchildrenandotherunderservedpeople,includingdentaltherapists,ExpandedFunctionDentalAssistants(EFDAs),and–whenplansarefinal – Advanced Dental Hygiene Practitioners (ADHPs) and Community Dental Health Coordinators(CDHCs).Whileeachstate’sworkforceneedsareunique,allfacedemandinexcessofsupplyinexpandingdentalcareforyoungchildren.Dentaltherapistsareusedworldwideintreatingchildren,butwouldbenewtoallstatesbutAlaska.EFDAswouldbeawelcomeadditiontoandexpandtheproductivityofthedentalteaminstatesthatdon’tnowusethem.ADHPsandCDHCs,whilestillintheplanningstages,could offer significant advantages in certain settings and functions as well. Each state policycommunityatlarge(includingpolicymakers,programadministrators,educators,providers,payers,andadvocates)bearstheresponsibilitytocometoconsensusonhowtomeettheneedsofatriskyoungchildrenwhoarenowunderserved.

PublicHealthStatesshouldconsiderspendingunusedSCHIPadministrativefundsfororalpublic

healthmeasurestargetedathigh-riskchildren.ThreestatescurrentlyhaveapprovalfromtheCentersforMedicareandMedicaidServicestospendsomeadministrativeSCHIPfundsforpublichealth.

Statesshouldconsiderinvestingmorefundsintargetedpreventionincommunitieswithahighproportionofat-riskchildren.Preventionsavesmoneyintreatment,andhelpschildren stay healthy and prepared for school. Screenings, fluoride varnish application, education,andsealantsareeffectivebutunderfunded.

Statesandcommunitiesshouldreconsidertheireffortstoensureequalaccesstocommunity water with optimal fluoride levels. Despite being one of the top ten public healthaccomplishmentsinthe20th century, fluoridated water is still under-utilized as a source of dental caries prevention. Rural communities without access to fluoridated water might consider fluoridating water in their schools.


aPPendix

Dental Benefits in Non-Medicaid SCHIP Plans1

August 2006 ServicesCovered

State Preventive/Diagnostic Basic/Major Orthodontics CostSharing2

Alabama Routineservicescovered.

Routineservicescovered.

Onlywhencongenitalmalformationoftheteethandjawsinterferewithnormalfunctioning.

151%-200%FPL:$5copaymentforbasicandmajorservices;totalof$1,000maximum/year.

Arizona Routineservicescovered;limitsnotspecified.

Therapeuticandemergency;limitsnot specified.

Denturesanddentaldevicesifauthorized.

$5copaymentfornonemergencyuseofER.

Arkansas Routineservices;limitsnot specified.

Oralsurgery;prior authorization requiredformorethan3simpleextractionsandforsurgicalextractions.

NotCovered. $10copaymentforoffice visits.

California Exams,prophylaxis,fluoride, sealants.

Restorations,oralsurgery,endodontics,periodontics,crownsandbridges,removableprosthetics.

IfchildmeetseligibilityrequirementsofCaliforniaChildren’sServicesprogramforhandicappingmalocclusion.

$5copaymentfornonpreventiveservices.

Colorado Exams,x-rays,prophylaxis, fluoride, sealants,spacemaintainer.

Amalgam,ResinFilling.Rootcanal,removalofimpactedtooth,restorativeservices.

NotCovered. Nocostforpreventive$5.00Co-payforbasicandmajor.

Connecticut3 Exams, x-rays, fillings, fluoride.

Oralsurgery,sealants,crownandbridge,rootcanal,extractions.

$725allowanceperorthodontiacase.

Above235%FPL,$5forclinicservices;copaymentsforcrownandbridge,rootcanals,denturesandextractions.

Delaware SameasMedicaid. SameasMedicaid. SameasMedicaid.

None.


ServicesCovered


Florida4 Initialoralexam;periodicoralexam,1/6months;cleaningsandprophylaxis; fluoride 1/6months;sealants1pertooth/3years;spacemaintainers;fullmouthx-rays,1/3years;panoramicx-rays,1/year;bitewings,1/6months.

Amalgamandcomposite fillings; stainlesssteelandregularcrowns;extractions,biopsies,surgicaltreatmentofdisease,injuries,anddeformities.

Endodontics,includingrootcanaltherapy,onprimaryandpermanentteeth;apioectomy,surgeryinvolvingrootsurface;upper,lowerorcompletesetofdentures,1/lifetime;bracesifconditionisdisabling.

None.

Georgia5 2visits/yearfordentalexamsandscreens;2cleanings/calendaryear.

2emergencyexamsduring office hours, and2emergencyafter-hoursexams;1 filling/tooth per restoration;Maximumnumberofsurfacescoveredis4;sealantson1stand2ndmolars.

Prior authorization required.

None.

Illinois Dental benefits mirror Medicaidinamount,durationandscope.

Limits not specified. Limitsnotspecified.

133%-150%FPL,$2/visitforoutpatientservices,$2/visitforrestorativedentalservices;forfamilieswithincomebetween133%-200%FPL,$5/visitforrestorativedentalservices;$100annualmaximumcopayment/family.

Idaho SameasMedicaid. SameasMedicaid. Onlymedicallynecessarycovered.

None.

Indiana6 SameasMedicaid. SameasMedicaid. Onlymedicallynecessarycovered.

None.


ServicesCovered


Iowa HAWK-I–WellmarkBlueDentalandDeltaDentalExamsandcleanings2x/12 months, fluoride andx-raysonceevery12months.

Cavityrepair,toothextractions,gumandbonedisease,castrestorations,denturesandbridges.

Notcovered. $1000maximumpercalendaryear.

Kansas SameasMedicaid. SameasMedicaid. Coveredforcasesofsevereabnormalitycausedbygeneticdeformity(cleftlip/cleftpalate)ortraumaticfacialinjuryresultinginserioushealthimpairment.

None.

Kentucky SameasMedicaid. SameasMedicaid. Covered. None.

Maine SameasMedicaid. SameasMedicaid. SameasMedicaid:priorauthorization required.

None.

Maryland SameasMedicaid. SameasMedicaid. SameasMedicaid.

None.

Massachusetts7 Comprehensiveexam:oncepermemberperdentist;Periodicoralexam:twiceperyear;Prophys:twiceperyear;FluorideTX:unlimitedforages<21;Sealants:onceperthreeyearspertooth;Radiographs:FMXonceeverythreecalendaryears;Bitewings:twicepercalendaryear.

Restorations,oralsurgery,endodontics(nolimitationonnumberperformedpertreatmentperiod.Includesanteriors,bicuspids,andMolars).CrownsandBridges,removableprosthetics.

Severeandhandicappingmalocclusionscovered.

None.

Michigan 2visits/year:exams;x-rays;prophylaxis;restorations.

1stand2ndmolarsealants;emergencyvisits;crowns;pulpotomies;extractions.

Spacemaintainers. $600annualmaximumcoverage.

Minnesota SameasMedicaid. SameasMedicaid. SameasMedicaid.

None.


ServicesCovered


Mississippi CoveredasrecommendedbytheAmericanDentalAssociationschedule.

Fillings;surgeryforimpactedteeth;emergencies;temporo-mandibularjointdisorder($5,000maximum);crownsandinlayscoveredonlyifmedicallynecessaryandwithpriorapproval.

Orthodontics,dentures,occlusalreconstructioncoveredonlyifmedicallynecessaryandwithpriorapproval.

Above150%FPL,$5fornonpreventiveservices.

Montana Coveredbutsubjectto benefit cap of $350 annualmaximum.

Alltreatmentcodescoveredbutsubjectto benefit cap. Accidentrelateddentalproceduresarecoveredunderthemedicalplan.

Notcoveredunderthedentalplan.Maybecoveredunderthemedicalplanwhenpre-approvedasmedicallynecessary.

None.

Nevada8 SameasMedicaid. Treatmentandemergencyassessments;morethan7steelcrownsin1visitrequirepriorapproval.

Medicallynecessary;priorauthorization required.

None.

NewHampshire Coveredat100%2examsandcleanings/year; 1 fluoride; x-rays; 1toothasneeded;bitewingsannually;panoramicevery3years.

Sealants; fillings and emergencytreatmentat100%Fluoridetreat-mentsonce/yearuptoage19.

Spacemaintainers. $600annualmaximumcoveragefor fillings, simple extractions,preventiveandsealants.

NewJersey9 PlansBandC,100%;limits not specified; Plan D,coveredforchildrenunderage12only;otherlimits not specified.

PlansBandC,fillings; extractions; emergencies;PlanD,notcovered.

PlansBandC:orthodonticscoveredwithnolimitation;PlanD,notcovered.

150%-200%FPL(PlanC),$5copaymentfornonpreventivedentalservices.

NewYork10 Coveredat6-monthintervals; fluoride where localwatersupplyisnotfluoridated.

Sealants;crowns;extractions;emergencytreatment;cleftpalate stabilization.

Endodontics;prosthodontics(includingremovabledenturesandfixed bridges with limitations);spacemaintainers.

None.


ServicesCovered


NorthCarolina Exams,cleaningsand scalings, fluoride treatments, fluoride varnishapplication,every6months;fullmouthx-rays,1/5years;bitewing,1/year.

Sealants;crowns,extractions(exceptimpactedteeth); fillings; pulpotomies;tempero-mandibularjointdisorderifresultofaccident.

Orthognathicsurgeryfordevelopmentalproblemsifsurgeryisonlyremedy.

Above150%FPL,$5copaymentfornonpreventivedentalservices.

NorthDakota Covered:exams,x-raysandprophylaxishavelimits(limitsnotspecified); fluoride applications.

Emergency,restorative,crowns,extractions,pulpotomies,sealants,anesthesia,amalgamandresinrestoration;accidentalinjuryifwithin12months;andtempero-mandibularjointdisordersurgicalandnonsurgicalwithlifetimelimits.

Spacemaintainers. None.

Oregon11 Prophylaxis,x-raysandfluoride treatment.

Sealants,restora-tionsusingamal-gamandcrowns.

Asmedicallynecessary.

None.

Pennsylvania Examsevery6months;fullx-rayevery5years;bitewings,1/year;prophylaxis and fluoride every6months.

Restorative:nolimitsonvisits;crowns,resins,extractions,sealants,amalgams,wisdomtoothextractionandrootcanals,periodontics.

Spacemaintainers. None.

RhodeIsland12 SameasMedicaid. SameasMedicaid. SameasMedicaid.

None.

SouthDakota SameasMedicaid;limits not specified.

SameasMedicaidandrestorativedentalserviceswhenmedicallynecessary.

SameasMedicaid;limitsnot specified.

None.

Tennessee13 No dental benefit. None. None. None.


ServicesCovered


Texas Preventativeservicesprovidedupto$175fora12-monthperiod.Routinecheckups,routinecleaning,X-raysandsealantsarecovered.

Therapeuticservicesprovidedasfollows:TierI:upto200,TierII:upto$300,TierIII:upto$400.Thera-peuticservicesincludefillings, root canals, extractionsEmergencydentalservicesarelimitedto:Proceduresnecessarytocontrolbleeding,relievepain,elimi-nateacuteinfec-tion,andpreventlossofteeth;Treatmentofinjuriestotheteethandsupportingstructures,andcrowns.

None. None.

Utah 100%forexams,cleanings, fluoride, selectedx-raysandselectedsealants.

Selected fillings, extractions,pulpotomiesandstainlesssteelcrowns.

Selectedspacemaintainers.

<150%FPL—PlanA:$3copaymentforbasic/majorandorthodontics151%-200%FPL—PlanB:20%coinsuranceforbasic/majorandorthodontics.

Vermont SameasMedicaid;limits not specified.

SameasMedicaid;limits not specified.

SameasMedicaid;limitsnot specified.

None.

Virginia14 Initialandperiodicexams;x-rays(every6months);prophylaxis(every6months);fluoride (every 6 months).

Amalgamandcompositerestorations(once/3years);crownsandbridges(once/5years);bands;pulpcapping;palliativecare;rootrecovery;abscesscare;extractions(once);somesurgicalservices;sealants(once).

Authorization required:medicallynecessaryorthodontics.

None.


ServicesCovered


Washington15 Exams; fluoride-topicalapplicationupto3x/12monthperiod;prophylaxisevery6months;x-raysevery3years.

Emergencysurgeryandextractions;sealantsevery3years;crownsandbridgesnotcovered.

Forseveremalocclusiononly;priorauthorization requiredexceptforcleftlip/palateandcraniofacialanomalies.

None.

WestVirginia Routinesemi-annualexams;allpreventive.

Therapeuticandemergencyservicescovered.

Onlyincasesofmandibulardegeneration.

None.

Wyoming KidCareCHIP:TwoExamsayear;TwoBitewingx-raysinoneyear;Onefullmouthx-rayevery36months;Onecleaningevery6months;One fluoride application every12months;Sealants.

Simpleextractions;Emergencyreliefofpain;amalgamrestorations;sedationforchildrenuptoage8;fullmouthdebridement;pulpotomyandrootcanalsforolderchildren;stainlesssteelcrowns;goldorporcelaincrownsforolderchildren;partialdenturesforolderchildren.

Spacemaintainers,butnothingelse.

Maximum benefit of $1,000/year.

Sources:DatacompiledfromanemailandtelephonesurveyofplansconductedbytheNationalAcademyforStateHealthPolicyinJulyandAugust,2006.

Key:

• Preventive/Diagnostic=Includesroutinedentalwork,x-rays,cleaningsandcheck-ups.• Basic/Major=Includesafter-hourscare,emergencyvisits,crownsandbridges,surgeryandextractions.• Orthodontics=Adentalspecialty,whichincludescorrectionsofirregularitiesoftheteethsuchasbraces.• Costsharing=Copaymentsandothercostsharingrequiredforreceiptofservices.

Notes to the Appendix

1 This table lists the dental benefits offered through the state-designed SCHIP programs in each state. Entries for stateswithtwoplanscontaininformationonlyonthestate-designedcomponentoftheplan.Medicaidexpansionstatesandcomponentsarenotincludedinthistable.2AmericanIndianandAlaskanNativechildrenareexemptfromcostsharing.3InConnecticut,supplementaldentalcoverageisavailableunderHUSKYPlus.4In March 2000, the Florida Legislature created a pilot project that provided limited dental benefits to Healthy Kids enrollees in several counties. The dental benefit was expanded the following year and beginning in February 2001, Healthy Kids began implementation of a comprehensive dental benefit package. This benefit package is the same as that offered to Medicaid recipients. During the 2002-2003 legislative session a $750 maximum benefit cap wasimplemented. This cap is for services provided during a July 1-June 30 plan/fiscal year.5InGeorgia,dentalservicesareexcludedfromcoveragebyMCOprograms.


6 Indiana’s SCHIP dental benefits are the same as Medicaid; medically necessary dental services must be provided eveniftheyarenotcoveredunderSCHIP.7Pleasenote:Duetoanewstatelaw,effectiveJuly1st,2006,MassHealthwillcoverdentalservicestoeligiblemembersaged21yearsorolder(adults).8InNevada,dentalservicesareadministeredthroughtheMCOsprovidernetworksforbothurbanClarkCounty(LasVegas)andurbanWashoeCounty(Reno).FortherestofthestateofNevada(mostlyruralareas)dentalisafee-for-service benefit.9TheNewJerseySCHIPprogramhasfourcomponents:aMedicaidexpansion(KidcarePlanA,aMedicaidexpansionthatcoverschildrenuptoage19infamilieswithincomesupto133percentoftheFPL)andthreeseparatestateplans(KidcarePlanB,whichcoverschildreninfamiliesbetween133percentand150percentoftheFPL;KidcarePlanC,whichcoverschildreninfamiliesbetween150percentand200percentoftheFPL;andKidcarePlanD,whichcoverschildreninfamiliesbetween200percentand350percentoftheFPLthroughincomedisregards).10 New York does not cover fixed bridges unless required for replacement of a single upper anterior full complement of natural, functional and/or restored teeth. Bridges also are covered for cleft palate stabilization or when required by aneurologicalorphysiologicalconditionthatprecludesplacementofaremovableprosthesis.11 Oregon provides dental services through dental care organizations (DCOs). All services are covered that are medically necessary for the treatment of health conditions and listed under the Oregon Health Plan Prioritized List andfundedbythelegislature.12 Rhode Island’s separate SCHIP plan covers unborn children up to 250 percent of the FPL. Dental benefits are providedthroughRiteSmiles,amanageddentalcareplan.13TennesseebeganitsCoverKidsSCHIPprograminApril2007.AsofApril5,2007,CoverKidsdoesnotincludedental benefits. See the Cover Kids website at http://www.covertn.gov/cover_kids.html.AccessedApril5,2007.14Virginia–DentalservicesarecarvedoutofmanagedcareandSCHIPcoverageisconsistentwithMedicaiddentalcoverage.AgelimitforSCHIPis19exceptforsomepregnantmothercoverageages19and20.15InWashington,dentalservicesarecarvedoutofmanagedcareandprovidedonawrap-around,fee-for-servicebasis.

□ □ □


Endnotes1P.W. Newacheck, D.C. Hughes, Y.Y. Hung, S. Wong, J.J. Stoddard, “The Unmet Health Needs of America’s Children,” Pediatrics105(4Pt2)(April2000):989-97.2NationalInstituteofDentalandCraniofacialResearch,NationalInstitutesofHealth,OralHealthinAmerica:AReportoftheSurgeonGeneral(Rockville,MD:U.S.Dept.ofHealthandHumanServices,2000).3Ibid.4 C.M. Vargas, J.J. Crall, D.A. Schneider, “Sociodemographic Distribution of Dental Caries: NHANES III: 1988-1994,” JournaloftheAmericanDentalAssociation129,(1998):1229-1238.5CDHPIssueBrief,EarlyChildhoodCariesTrendsUpward(Washington,DC,September2005).6HealthResourcesandServicesAdministration,MaternalandChildHealthBureau.TheNationalSurveyofChildren’sHealth2003.(Rockville,MD:U.S.DepartmentofHealthandHumanServices,2005).7 K.J. Hale, American Academy of Pediatrics Section on Pediatric Dentistry, “Oral Health Risk Assessment Timing and Establishment of the Dental Home,” Pediatrics111(2003):1113-1116.8S.Gehshan,P.Hauck,J.Scales,IncreasingDentists’ParticipationinMedicaidandSCHIP(Washington,DC:NationalConferenceofStateLegislatures,2001).9CentersforMedicareandMedicaidServices,CMSFinancialReportFY2005(Washington,DC:U.S.DepartmentofHealthandHumanServices),6.10L.Ku,RevisedMedicaidDocumentationRequirementJeopardizesCoveragefor1to2MillionCitizens(Washington,DC:CenteronBudgetandPolicyPriorities,July13,2006).11AmericanDentalAssociation,SurveyCenter,DistributionofDentistsintheUnitedStatesbyRegionandState(Chicago,IL,2001),38.12Ibid.13AmericanDentalAssociation,TheFutureofDentistry(Chicago,IL,2001),37.14S.Gehsahn,T.Straw,AccesstoOralHealthServicesforLowIncomePeople:PolicyBarriersandOpportunitiesforInterventionfortheRobertWoodJohnsonFoundation(Washington,DC,NationalConferenceofStateLegislatures,Oct.2002).15BureauofHealthProfessions,SelectedStatisticsonHealthProfessionalShortageAreas,asofMarch31,2006.16NationalInstituteofDentalandCraniofacialResearch,NationalInstitutesofHealth,,OralHealthinAmerica:AReportoftheSurgeonGeneral(Rockville,MD:U.S.DeptofHealthandHumanServices,2000),235.17NationalConferenceofStateLegislatures,StateExperiencewithDentalLoanRepaymentPrograms,Washington,DC,2005).18AmericanDentalAssociation,TheFutureofDentistry(Chicago,IL:2001),41-43.

19E.Solomon,TheFutureofDentistry,Part1of4partseries,ETSDental.20AmericanDentalAssociation,TheFutureofDentistry,37.21P.Casamassimo,K.Holt,eds,BrightFuturesinPractice:OralHealth-PocketGuide(Washington,DC:NationalMaternalandChildOralHealthResourceCenter,2004).22AmericanDentalHygienists’Association,ADHApracticeactoverviewchartofpermittedfunctionsandsupervisionlevelsbystate,UpdatedJuly24,2006.23DentalAssistingNationalBoard.Accessed14Dec2006.http://www.danb.org/main/statespecificinfo.asp.24N.Tinanoff,M.Kanellis,andC.Vargas,DentalCariesinPreschoolChildren:Epidemiology,Mechanisms,PreventionandCareDelivery(TheChildren’sDentalHealthProject,2003).25BureauofHealthProfessions,TheProfessionalPracticeEnvironmentofDentalHygienistsintheFiftyStatesandtheDistrictofColumbia(Rockville,MD:HealthResourcesandServicesAdministration,April2004).26S.Rosenbaum,B.Kamoie,ExpandingAccesstoPediatricDentalCare:OpportunitiesandChallengesCreatedbytheLaw(Washington,DC),8.27D.M. Grzybicki,P.J.Sullivan,J.M.Oppy,A.M.Bethke,S.S.Raab,“TheEconomicBenefitforFamily/generalMedicine Practices Employing Physician Assistants,”AmericanJournalofManagedCare8(7)(July2002):613-620.

28An evaluation of the work of the first dental therapists is available at: A. Fiset, DDS, AReportonQualityAssessmentofPrimaryCareProvidedbyDentalTherapiststoAlaskaNatives,(Seattle,WA:UniversityofWashingtonSchoolofDentistry,2005).

29 D.A. Nash, R.J. Nagel, “Confronting Oral Health Disparities Among American Indian/Alaska Native Children: The Pediatric Oral Health Therapist,” AmericanJournalofPublicHealthvol.95,no.8(2005):1325.30DentalHealthAideTherapistscurrentlypracticingatIndianHealthServicesitesinAlaskacompletethe2-yeardentaltherapytrainingprograminNewZealand.TheirtrainingisduetoshifttoaprogramofferedbytheUniversityofWashingtonSchoolofMedicine.Currently,nostatelicensesortrainsdentaltherapists.


31 Expanded Function Dental Assistants perform parts of a prophylaxis: “toothbrush” cleanings using a rubber cup or brush.32Nursepractitionersandphysicianassistantshavelimitedprescriptiveauthoritythatvariesbystate.Theyoftenprescribeunderstandingordersfromaphysician,whichcouldbeexpandedtoincludediseasesuppressiontreatments.33 Expanded Function Dental Assistants place temporary restorations, placing and finishing amalgam and composite resinrestorations.Theymaynotdiagnoseorprescribe,cuthardorsofttissue,administeranesthesia.34CommunityDentalHealthCoordinatorshaveaproposedskillsetthatisverysimilartothePrimaryDentalHealthAides (PDHA) who are practicing in Alaska for the Indian Health Service. Currently, there are 11 federally certified PDHAs in practice and 9 more finishing training.35 J. Lynch, P. Milgrom, “Xylitol and Dental Caries: An Overview for Clinicians,” JournaloftheCaliforniaDentalAssociation(March2003).36Ibid37CentersforDiseaseControlWaterFluoridationData(2006).AccessedAugust2006.http://www.cdc.gov/fluoridation/statistics.htm..38NationalInstituteofDentalandCraniofacialResearch,NationalInstitutesofHealth,OralHealthinAmerica:AReportoftheSurgeonGeneral(Rockville,MD:U.S.DepartmentofHealthandHumanServices,2000).39Ibid.40WaterFluoridation,Nature’sWaytoPreventToothDecay(TheCentersforDiseaseControlandPrevention,Atlanta,Georgia,andtheAmericanDentalAssociation,Chicago,Illinois,2006).41CentersforDiseaseControlandPrevention.PreventingChronicDiseases:InvestingWiselyinHealth-PreventingDentalCaries.http://www.cdc.gov/Oralhealth/factsheets/dental_caries.htm42Ibid.43Ibid.44Ibid.45Ibid.46NationalInstituteofDentalandCraniofacialResearch,NationalInstitutesofHealth,OralHealthinAmerica:AReportoftheSurgeonGeneral(Rockville,MD:U.S.DepartmentofHealthandHumanServices,2000).47CentersforDiseaseControlandPrevention.PreventingChronicDiseases:InvestingWiselyinHealth—PreventingDentalCaries.http://www.cdc.gov/Oralhealth/factsheets/dental_caries.htm48\NationalInstituteofDentalandCraniofacialResearch,NationalInstitutesofHealth,OralHealthinAmerica:AReportoftheSurgeonGeneral(Rockville,MD:U.S.DepartmentofHealthandHumanServices,2000).49DavidGrembowskiandPeterM.Milgrom.IncreasingAccesstoDentalCareforMedicaidPreschoolChildren:TheAccesstoBabyandChildDentistry(ABCD)Program.(Washington,DC:U.S.DepartmentofHealthandHumanServicesPublicHealthReports,SeptemberandOctober2000).50Ibid.51Ibid.52Ibid.53Ibid.54SoniaI.Nagahama,StevenE.Fuhriman,CarreeS.Moore,andPeterMilgrom,“EvaluationofaDentalSociety-BasedABCDPrograminWashingtonState,”JournaloftheAmericanDentalAssociationvol.133(September2002).55SpokaneRegionalHealthDistrict.http://www.srhd.org/health/dental/abcde.asp.56JulieN.MansourandJudithCooksey.TheMichiganHealthyKidsDentalMedicaidProgram:Background,ProgramDesign,andBaselineAssessmen.(IllinoisCenterforHealthWorkforceStudies,December2000).57 Stephen A Ecklund, James L. Pittman, and Sarah Clark. “Michigan Medicaid’s Healthy Kids Dental Program: An assessment of the first 12 months,” JournaloftheAmericanDentalAssociation,vol.134(November2003).58MansourandJudithCooksey,opcit.59Ecklund,Pittman,andClark,opcit.60 R. Gary Rozier, Betty King Sutton, James W. Bawden, Kelly Haupt, Gary D. Slade, and Rebecca S. King, “Prevention of Early Childhood Caries in North Carolina Medical Practices:ImplicationsforResearch and Practice,” JournalofDentalEducation67,8(2003).61Ibid.62Ibid.63Ibid.


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