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Medicaid and SCHIP || Access to Services || Workforce Issues || Prevention and Awareness || Resources
Dental disease is the most common chronic illness for children in the United States. According to the Centers for Disease Control and Prevention (CDC) more than one-quarter of children have tooth decay in baby teeth before entering kindergarten. By age 19, 68 percent of youth have experienced tooth decay in permanent teeth.
Dental disease is preventable, yet dental care is the most common unmet health treatment need in children. In the U.S., 9 million children lack health insurance, and more than twice that number lack access to oral health services. Untreated dental caries can lead to pain, weight loss, missed school days, poor appearance, decreased self-esteem and even death.
Childhood tooth decay disproportionately affects low-income families and racial or ethnic minorities. The rate of untreated dental caries in children from families with incomes below the poverty level is double that of non-poor children. According to the National Survey of Children's Health in 2003, Hispanic children were the least likely racial/ethnic group to receive preventive dental care.
The nation's Healthy People 2010 initiative contains a chapter on oral health objectives, where children's oral health issues are highlighted. The initiative includes objectives for dental sealants, community water fluoridation, increasing use of the oral health system, dental services for low-income children, and school-based health centers with an oral health component. A midcourse review of the oral health objectives was released in 2005.
The following sections examine oral health through Medicaid and SCHIP, Access to Services, Workforce Issues, and Prevention and Awareness. State legislators can play important roles in improving children's oral health.
Click here for a list of State Oral Health Offices from the National Maternal and Child Oral Health Resource Center.
Click here for the Centers for Disease Control and Prevention synopses of state and territorial dental public health programs.
Federal law requires all states to include dental benefits for children in Medicaid programs. However according to the 2000 Surgeon General's Report, less than 20 percent of Medicaid children actually saw a dentist at least once in a one year period. Most Medicaid programs experience a low rate of dentist participation.
All states provide some level of dental benefits through their State Children’s Health Insurance Programs (SCHIP), although coverage varies from state-to-state. Federal SCHIP provisions allow states to implement cost sharing or waiting period policies, which can make access more difficult for SCHIP enrollees than it is for their Medicaid counterparts. SCHIP faces similar challenges in low rates of dentist participation.
State Examples
Virginia’s Smiles for Children program, which enrolls children with Medicaid and SCHIP public health insurance, saw a 24 percent increase in the number of children receiving oral health care in its first year of operation. Dentist participation increased significantly, thanks to a 30 percent increase in reimbursement rates and a streamlined administrative process. As of 2006, a year after it began, one-quarter of dentists in Virginia participated.
Similar programs were developed in South Carolina and Tennessee. Both the South Carolina Medicaid Dental Program and TennCare Dental Program raised reimbursement rates to dentists, developed outreach programs to increase participation, and eased administrative barriers. South Carolina's program also reduced waiting periods by streamlining the authorization process. As a result of these efforts in South Carolina, the percentage of children receiving dental services has increased every year, reaching 38.5 percent in 2005. As of 2005, the TennCare Dental Program has increased statewide dentist participation in Medicaid by 112 percent and by 118 percent in rural areas.
Click here for evaluations of the Virginia, Rhode Island and South Carolina programs from the Centers for Medicare and Medicaid Services (CMS).
Click here for a factsheet on " Dental Coverage and Care for Low-Income Children: The Role of Medicaid and SCHIP" from the Kaiser Family Foundation (July 2008).
Click here for NCSL's Issue Brief "Increasing Dentists' Participation in Medicaid and SCHIP" (2001).
In addition to financial barriers and low dentist participation rates in public programs, geographic barriers also impede access to oral health services. Thirty-eight percent of rural counties have dental health professional shortages. Children in rural areas have to travel farther for dental care, and are less likely to receive dental services.
To help alleviate the shortage of dentists in rural parts of Arizona, the state allows dental hygienists to form "affiliated practices" with dentists to provide care without a dentist's direct supervision. The state also increased the number of dental hygienists by funding a community college program. In addition to a shortage of dentists in its rural areas, South Carolina found an even greater shortage of dentists who are prepared to treat children. In response, South Carolina developed an initiative to train general dentists to treat children as well. Between 2003 and 2005, South Carolina's program was able to train more than 100 rural dentists to treat pediatric patients, enabling these dentists to expand access within their communities. Rhode Island expanded its network of oral health services to include community health centers, school-based health clinics and hospital dental centers to help meet the needs of children in low-income and rural communities.
Click here to read the Center for Health Care Strategies Report on these and other programs.
To increase dental care access in underserved rural areas, Maine passed a bill (LD 2192) in April 2008 that offers tax incentives to dentists who practice in underserved areas of the state.
Oral health programs have not generally been integrated well with other health programs. The Association of State and Territorial Health Officials (ASTHO) suggests in "Children's Oral Health: State Initiatives and Opportunities to Address the Silent Epidemic" that partnerships be formed between communities and dental, medical, and public health delivery systems. In a 2007 report the Kaiser Family Foundation emphasizes the importance of educating parents about the benefits and necessities of children having access to oral health, because it increases the likelihood that they will seek oral care for their children. Other health care professionals such as dental hygienists, pediatricians, OB/GYNs, and family practitioners can also be encouraged to educate pregnant women, parents and young children about the importance of children's dental care.
Dental Hygienists
States have expanded the services of dental hygienists to provide dental health care to underserved populations. According to the American Dental Hygienists' Association (ADHA), as of July 2008, 27 states have laws to allow dental hygienists to provide dental services to patients, often without the direct supervision of a dentist. Twelve states also allow direct Medicaid reimbursements to hygienists for procedures performed.
Click here to see the American Dental Hygienists' Association compilation of state laws about direct access to dental services through dental hygienists.
Click here to see the American Dental Hygienists' Association compilation of state laws about direct Medicaid reimbursements to dental hygienists.
Pediatricians
Pediatricians also can be encouraged to provide diagnostic dental services, referring patients to local dentists, and educating children and their parents about the importance of oral health care. According to Grantmakers in Health, programs are developing that incorporate training on oral health issues for pediatricians to improve early diagnostic screening. North Carolina's Into the Mouths of Babes is a statewide program that trains primary care providers in oral health care prevention. These primary care providers are eligible for Medicaid reimbursements. Overall, North Carolina's program has increased preventive dental services for Medicaid children.
Parent and Guardian Involvement
As a collaborative effort from partners in public and private sectors, Washington's Access to Baby and Child Dentistry Program (ABCD) provides preventive and restorative dental care to Medicaid-eligible children from birth to age 6. ABCD has recruited pediatricians and other primary care providers into the program. ABCD also emphasizes parental involvement in children's dental care by coaching parents in an initial orientation as well as follow-up appointments.
Preventive dental services are a cost effective way to improve children's oral health. According to the Children's Dental Health Project, low-income children who have their first dental visit by age 1 have dental costs that average 40 percent lower over a five-year period than children who do not. Preventive services include school-based dental sealant programs, school fluoride mouthrinse programs, preventive dental checkups through school mandates, and community water fluoridation.
School-based Dental Sealant Programs
Dental sealants—plastic coatings on vulnerable molars—help prevent decay. As of 2005, 40 state or local health departments had developed community- and school-based sealant programs, typically in poor or underserved areas where children were unlikely to receive private oral health care. Programs vary, but often use school-based clinics or mobile vans to apply sealants or link schools to private dental practices where children can receive these services. A CDC review shows that school-based dental sealant programs effectively prevent and decrease decay for children and adolescents by 60 percent. Healthy People 2010 calls for increasing the total number of children with dental sealants to 50 percent.
Click here for an online guide to developing and implementing school-based dental sealant programs, from the National Maternal and Child Oral Health Resource Center
Click here for a fact sheet about dental sealants from the Centers for Disease Control and Prevention.
School Fluoride Mouthrinse Programs
Some states sponsor school fluoride mouthrinse programs, especially in communities that lack water fluoridation.
Click here to view a report by the Association of State and Territorial Dental Directors with state program examples that address school fluoride mouthrinse and other preventive programs.
State Mandated Dental Check-ups
According to the American Dental Association (ADA), California, Georgia, Illinois, Iowa, Massachusetts, New York, Oregon, Pennsylvania, Rhode Island and the District of Columbia require children to have a dental exam before they start school. Most of these mandates allow exemptions for religious reasons. Some mandates allow additional exemptions if the exam poses a financial burden or access is unavailable. Pennsylvania and Rhode Island administer these school mandated exams through school dentists or other health care providers. In addition to religious exemptions, New York also provides schools with a list of dentists who will perform these examinations free or at reduced costs. Local ordinances, school districts, and individual schools may also require dental exams for students.
Please contact NCSL for more information about state mandated dental check-ups. (Legislators and Staff Only)
Water Fluoridation
According to the Centers for Disease Control and Prevention, water fluoridation to prevent tooth decay is one of the 10 greatest public health achievements of the 20th century, and has been in practice for more than 60 years. CDC data suggest that each $1 invested in fluoridation saves $38 in avoided dental treatment costs. According to the American Dental Association, California, Connecticut, Delaware, Georgia, Illinois, Kentucky, Minnesota, Nebraska, Nevada, Ohio, South Dakota, the District of Columbia and Puerto Rico have laws that mandate statewide water fluoridation. Most of these laws provide for a minimum qualifier (e.g., population or number of water system hook-ups) and exempt areas that do not meet the criteria. For example, the law may apply only to water systems that serve 5,000 or more households or apply to towns of 10,000 people or more. Other variations include sources of financing and/or provisions for public votes prior to initiation.
In recent years, fluoridation is more likely to be adopted at the local level. From 2000 to 2006, more than 235 U.S. communities in 36 states have voted to adopt fluoridation. Forty-two of the 50 largest cities in the United States fluoridate their water. Three additional cities have natural fluoride at optimal levels. The most recent census data show that 67 percent of the nation’s population is served by fluoridated water systems. Healthy People 2010 objectives call for 75 percent of the population to be served by fluoridated water systems by 2010.
Although organizations such as the CDC and ADA strongly endorse water fluoridation, some controversy remains. Some organizations, such as Fluoride Action Network, argue that there are ethical and physical repercussions to fluoridating water supplies. They say the practice medicates people without informed consent, and claim the practice may be unsafe by causing medical conditions such as bone fractures, arthritis and even cancer. However, according to the National Cancer Institute there is no evidence of an association between water fluoridation and cancer in humans. For more information on the arguments opposing fluoridation contact Fluoride Action Network or Citizens for Safe Drinking Water.
Oral Health
NCSL webpage with oral health information and resources.
Iowa Requires Dental Screening for School Kids
NCSL State Health Notes newsletter article on Iowa's dental screening requirements, August 2008.
Dental Certificates for Students in New York
NCSL State Health Notes newsletter article on New York's new law requiring dental certificates for students, June 2008.
Maryland Revamps Dental Care for Children
NCSL State Health Notes newsletter article on Maryland's revamp of dental programs for children, May 2008.
Oral Health Help
NCSL State Legislatures magazine article discussing the development of the first Oral Health Caucus in the Massachusetts legislature, January 2008.
Children's Oral Health: States Filling the Need
NCSL State Health Notes newsletter article citing ways states may address children's oral health issues, September 2007.
Children's Oral Health
NCSL LegisBrief that examines states' roles in oral health for kids, August/September 2007.
Children's Health: Oral Health
NCSL State Health Notes newsletter article that points out the increase in cavities among young children citing a CDC survey, May 2007.
States Looking to Fill Gaps in Dental Care for Kids
NCSL State Health Notes newsletter article examining state efforts to improve kids' dental care, April 2007.
RIte Smiles: Improving Access to Oral Health Care
NCSL State Health Notes newsletter article that discusses Rhode Island's program to improve oral health care access, November 2006.
Children's Oral Health: Closing the Gaps
NCSL's Health Webcast with speakers from Columbia University and the Children's Dental Health Project, March 2006
NCSL Charts and Other Documents
NCSL webpage with oral health resources predating 2005.
Children's Dental Health Project
CDHP advances policies to improve children's oral health access, providing federal legislative information and other useful resources.
Centers for Disease Control and Prevention
CDC children's oral health webpage.
National Maternal and Child Oral Health Resource Center
OHRC responds to the needs of states and communities in addressing public oral health issues.
American Academy of Pediatric Dentistry
The AAPD is a membership organization consisting of pediatric dentists and promotes optimal oral health for children.
American Dental Association
The ADA is a professional association of dentists, and is committed to the public's oral health.
Association of State and Territorial Dental Directors
ASTDD consists of cheif dental public health officers, aiming to assure optimal oral health in states.
NOTE: NCSL provides links to other Web sites from time to time for information purposes only. Providing these links does not necessarily indicate NCSL's support or endorsement of the site.
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