Children's Oral Health

2/2/2018

Child being examined by a dentist.More children than ever before have dental health care coverage, but still face challenges accessing care.

The percentage of children who visited a dentist in 2011 and 2013 increased from 45.4 percent to 48.3 percent, the highest utilization rate recorded. Despite these gains, locating and accessing dental services remains a challenge for many families.

Provider shortages, low reimbursement rates, and lack of consumer information about the benefits of dental care are just a few of the barriers identified by the Centers for Medicare and Medicaid Services (CMS). As the American Dental Association (ADA) has noted, “Increased benefit coverage does not necessarily equate to increased access to dental care.”

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. About 21 percent of children aged 5 to 11 have at least one untreated decayed tooth. Dental disease is preventable, yet dental care is the most common unmet health treatment need in children.

State policymakers seek creative ways to improve access to oral health care services in their states. Local governments and stakeholders also play important roles in improving children’s oral health. The drop-down menu below highlights a variety of approaches to improve children’s oral health in five categories:

Oral Health Services in the Community: Many schools and community health centers provide dental health services for children who may not have access to a dentist’s office. Teledentistry connects people in their community or home to a dental health provider located in another place.

The Oral Health Workforce: Policymakers can increase the number of dental providers in an area through various state policies, including financial incentives. Some states have changed provider licensing laws and supported mid-level oral health providers to address workforce shortages.

Medicaid and the Children’s Health Insurance Program Coverage (CHIP): These two public health plans continue to drive down the overall children’s uninsured rate, which enables more children to have dental coverage.  

Reimbursement and Dental Health Professional Shortage Areas (Dental HPSAs): Dental HPSAs help policymakers and stakeholders identify access issues. This section details dental HPSAs and outlines the role of reimbursement in improving access and the oral health workforce.

Public Health Approaches: Public health approaches to oral health care, such as community water fluoridation, are long standing and well researched interventions to improve oral health status and prevent disease on a population level.

Oral Health Services in the Community Setting

Teledentistry

Telehealth, is a tool that capitalizes on technology, provides health services remotely. The federal Health Resources and Services Administration (HRSA) defines telehealth as “the use of electronic information and telecommunications technologies to support and promote long distance clinical health care, patient and professional health-related education, public health, and health administration.”

This year 2018, is the first ADA has recognized CDT codes (a code on dental procedure and nomenclature) for teledentistry. The two new CDT codes help document teledentistry services and improve recordkeeping.

To expand the reach of the oral health workforce and services, at least 19 states have adopted policies related to teledentistry—in other words, offering oral health services remotely. 

Community Health Centers

Efforts are underway around the nation to build dental care delivery capacity in a range of community health center settings. In addition to providing routine oral health care services like screenings, cleanings, sealants and fluoride treatments, some community health centers also provide more comprehensive care. For example, San Ysidro Health, a federally qualified health center (FQHC) near San Diego, developed the capacity to perform root canal treatments, oral surgery and orthodontic services, in addition to preventive services and routine care.

Other strategies train both dental and non-dental health providers in oral health prevention and provide dental health services for children in community health center settings. In Washington, the Watch Your Mouth campaign used funds from the Washington Dental Service to start a pilot program with a local children’s clinic and county public health departments to screen children for poor oral health.

School-Based Oral Health Programs

Providing oral health services in schools can help fill needs created by workforce shortages, low reimbursement for or acceptance of public coverage and challenges of providing care to rural and urban populations. School-based health centers (SBHCs) can provide a range of oral health services, from dental sealants and fluoride programs, to oral health screenings and serving as a dental home. School-based dental sealant and school-based fluoride programs can reduce dental decay and, in some cases, connect children and their families to other community oral health services.

In many states, school-based health centers (SBHCs) serve as an alternative setting to address the unmet primary and oral health care needs of children. SBHCs seek to encourage service coordination and improve access to care for high-risk children. Some states’ departments of health work with school-based health centers to provide these services and other states allow local government and other stakeholders to provide school-based services. In Colorado, SBHCs work with medical centers and university systems to provide dental services for underserved rural and urban populations.    

The New Jersey Department of Health's school-based fluoride rinse program began in 1981. This voluntary program allows schools to opt in to trainings in program administration in areas where water does not contain the recommended level of fluoride.

The Arizona Department of Health has maintained a school-based dental sealant program since 1987. All children in qualifying schools from second to sixth grade are eligible for sealants. According to the Arizona Office of Oral Health, “those who are uninsured, Medicaid and CHIP beneficiaries, covered by the Indian Health Service, or by a state-funded primary care health care program and do not have private dental insurance also qualify for dental sealants.”

Prevalence of Dental Sealants in Permanent Teeth by age and race among children aged 6-11 years: United States, 2011-2012

Bar chart of Prevalence of Dental Sealants in Permanent Teeth, 2011-2012Source: The Centers for Disease Control and Prevention (CDC)

The Oral Health Workforce

Student Loan Forgiveness and Scholarships

Dental school tuition continues to rise. The high cost of education coupled with provider shortage areas can restrict access to oral health providers. Student loan forgiveness and scholarship programs increase enrollment or send new dentists to areas where need is greatest by reducing student debt or paying for a portion of the education up front. According to the American Dental Education Association (ADEA), four states include pediatric dentists (or primary care dentists, which include pediatric dentists) in their dental loan forgiveness programs.

The South Dakota Department of Health “provides qualifying physicians, dentists and other health professionals an incentive payment for three continuous years of service in an eligible rural community.” This applies to general and pediatric dentists. Similar to other state programs, in addition to being a licensed dentist, general and pediatric dentists must:

  • Agree to practice full time as a general or pediatric dentist in an eligible community for at least three consecutive years.
  • Agree to be a participating South Dakota medical assistance provider and to serve any individual eligible under chapter 28-6 of South Dakota statutes and may not refuse treatment to any such individual while participating in the program.
  • Provide services to Medicaid, Medicare and State Children's Health Insurance Program patients.
  • Not have previously participated in such program, or any other state or federal scholarship, loan repayment or tuition reimbursement program that obligates the person to provide medical services within an underserved area.

The Mississippi legislature authorized the Mississippi Rural Dentists Scholarship Program in 2013. The program awards scholarships to rural college students who want to practice dentistry in a rural community. The program encourages involvement in Mississippi’s rural health care in all phases of education and training. The purpose is to encourage students to practice general or pediatric dentistry to address workforce shortages in rural Mississippi.

Providers

Hygienists. According to the American Dental Hygienists’ Association (ADHA), all 50 states have laws to allow dental hygienists to provide certain dental services to patients, often without the direct supervision of a dentist. Dental hygienists practice under a variety of levels of required supervision by a dentist, with wide variation among states related to their scope of practice. Some states have expanded the services dental hygienists can provide in order to expand access to underserved populations. At least 18 states allow direct Medicaid reimbursements to hygienists for procedures they perform.  

Community Dental Health Coordinators (CDHCs). In 2006, the American Dental Association (ADA) initiated the CDHC program. CDHCs provide case management, oral health education and community mapping. These providers improve community-based prevention, care coordination and provide patient navigation to reach underserved, rural, urban and Native American communities. The American Dental Association reports that CDHCs work in 21 states. The ADA, in partnership with state dental societies, are working with stakeholders such as state governments, higher education and the private sector to create new CDHC programs.

In Pennsylvania, the Wayne Memorial Community Health Centers use public health dental hygiene practitioners and CDHCs to provide oral health and disease prevention education as well to provide patient navigation services.

Dental Therapists. A few states have recognized dental therapists, who practice at a level somewhere between dentists and dental hygienists. They administer preventive, restorative and minor surgical oral health services. Certain states incorporate the dental therapist provider models into the array of their service offerings to address dental workforce shortages. In 2009, Minnesota was the first state to establish licensure of dental therapists, which have their own education, training and practice requirements (Minn. Stat. § 150A.105). At least five state legislatures have authorized licensure for dental therapists.   

Pediatricians and other general health care providers. Even as the nation makes progress in dental utilization rates, it remains true that more children see a pediatrician each year than a dentist. Pediatricians can plan important roles in children’s oral health care by providing oral health screenings, applying fluoride varnish and referring children to oral health providers for treatment needs. Many oral health advocates work to include oral health in pediatric primary care visits. The American Academy of Pediatrics developed the Bright Futures: Oral Health – Pocket Guide to help pediatricians with oral health risk assessments and other prevention tools.

Medicaid and CHIP Coverage

Medicaid

Every child enrolled in Medicaid or CHIP has dental coverage. Over the years, coverage expanded and pediatric dental uninsured rates are the lowest they have ever been. In Medicaid, all covered children receive dental insurance through the Early, Periodic Screening, Diagnostic and Treatment benefit (EPSDT). The minimum benefits must cover:

  • Relief of pain and infections
  • Tooth restoration
  • Dental health maintenance

The state programs work with children’s dental health organizations to develop a periodicity schedule for pediatric dental services and with pediatric primary care providers to determine a dental referral system.

CHIP

The Children’s Health Insurance Program allows states to cover children through a CHIP Medicaid expansion or through a separate state CHIP program. This makes it difficult to separate the impact of CHIP coverage from Medicaid coverage related to children’s dental services.

Depending on their structure, CHIP dental insurance plans can use one of three methods detailed in a letter to state health officials from the Centers for Medicare and Medicaid Services (CMS):

For states that adopted a CHIP Medicaid expansion program, benefits must align with Medicaid’s Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit. This coverage must include relief of pain and infections, teeth restoration and dental health maintenance.

States that administer a CHIP program separate from Medicaid have two options for dental coverage:

  1. Provide a package of dental benefits that satisfies the minimal requirements defined in the CHIP Reauthorization Act of 2009 (CHIPRA). Under this option, programs must “prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.”
  2. Provide a benchmark dental benefit package equivalent to services offered by the state’s most popular commercial insurer.

 

Source of Dental Benefits, Ages 2-18, 2000-2013

Bar chart of Dental Benefits, Ages 2-18, 2000-2013

Health Policy Institute analysis of the Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality

 

Rates, Reimbursement and Dental HPSAs

The federal government designates specific geographic areas, populations or facilities that have a shortage of dental health providers or health services as dental health professional shortage areas (dental HPSAs). Dental HPSAs can be in rural or urban settings. This information can help policymakers identify access and workforce challenges in their own state.

Many oral health providers and organizations cite low reimbursement rates for Medicaid and CHIP as a barrier to their participation in public programs. While reimbursement plays an important role in provider participation, funds are not always available and it is rarely the sole reason for low provider participation. The California Healthcare Foundation published a brief examining the effects of raising Medicaid reimbursement rates on participation by providers. Minimizing administrative burdens and missed appointments also influence participation rates.

United States map of Health Professional Shortage Area (HPSA) Facilities - Dental Health

Health Resources and Services Administration, 2018

Public Health Approaches

Community Water Fluoridation

According to the Centers for Disease Control and Prevention (CDC), 75 percent of the U.S. population drinks fluoridated water. Fluoride is proven to save communities money and strengthen children’s adult teeth developing beneath their gums. Adults and children who drink fluoridated water have fewer cavities, less need for fillings or extractions and experience less pain.

Although local governments determine most fluoridation policies, according to the Florida Department of Health, 13 states—Arkansas, California, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Minnesota, Nebraska, Nevada, Ohio and South Dakota—mandate community water fluoridation. 

Most of these laws apply only to communities that meet specific criteria, such as a specified population threshold or number of water system hook-ups. 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 fluoride initiation.