Childrens Oral Health Policy Issues Overview

Children's Oral Health

child with dentisttooth brushes

January 2015

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 2005, Hispanic children were the least likely racial/ethnic group to receive preventive dental care.

The following sections examine oral health through the Affordable Care Act, Medicaid and CHIP, 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.
Click here for “The Cost of Delay: State Dental Policies Fail One in Five Children” report from the Pew Children’s Dental Campaign.
Click here for “A Costly Dental Destination: Hospital Care Means States Pay Dearly” report from the Pew Children’s Dental Campaign.

The Affordable Care Act

Click here for the States Implement Health Reform: Oral Health Brief.
Click here for NCSL’s webinar “Oral Health and the Affordable Care Act: State Roles” archive from May 2011.

The 2010 Affordable Care Act (ACA) contains a variety of initiatives that relate to oral health, including those that address coverage and access, prevention, oral health infrastructure and surveillance, and the dental health workforce. Of the many oral health related initiatives in the ACA, some were funded by the law, while others were authorized subject to funding. Among the oral health provisions that either require no separate appropriation or were funded by the ACA, key initiatives include insurance benefits for children, cost-sharing restrictions, public health grants that may include oral health initiatives, and a requirement to review dental provider reimbursement rates. Various additional oral health initiatives within the ACA are authorized, but funding currently is not appropriated. These provisions fall into three categories: oral health infrastructure, prevention and treatment, and workforce.

Most operational oral health provisions of the ACA do not require specific state action; however, state policymakers may play several roles, including the following:

  • Oversee and regulate dental coverage provisions within the insurance exchanges.
  • Address dental provider shortages as more children receive oral health coverage and explore policies to expand the oral health workforce and attract more providers to underserved areas.
  • Explore the use of public health trust fund grants to state and local entities to address oral health.
  • Maintain awareness about authorized programs if funding is provided.

Medicaid and CHIP

Read NCSL's Improving Access to Medicaid Dental Benefits LegisBrief here.

Federal law requires all states to include dental benefits for children in Medicaid programs. According to a 2009 report from the Government Accountability Office (GAO), 35 percent of children under Medicaid received dental services, up from 27 percent in the 2000 Surgeon General's Report.  Most Medicaid programs experience a low rate of dentist participation.
CHIP faces similar challenges in low rates of dentist participation.  The 2009 reauthorization of the Children's Health Insurance Program (CHIP) looks to improve some of the challenges historically faced to get CHIP kids dental care. Below are examples of state efforts to increase access to oral health care for kids under Medicaid.

Children's Health Insurance Program Reform Act of 2009 (CHIPRA)

In February 2009, CHIPRA was approved by Congress and signed by President Obama.  In addition to reauthorizing the twelve year old program, CHIPRA modified various aspects of the program, including a few provisions related to oral health. CHIPRA requires states to include dental benefits in their CHIP programs and provides parameters for these dental benefit plans.  CHIPRA also allows states to provide dental benefits to children eligible for CHIP even if they have health insurance benefits through another source. Additional CHIPRA provisions related to dental care include, education for the parents of newborns, provisions related to dental services from community health centers, a new requirement for states to report dental coverage in annual CHIP reports and a study to be conducted by Government Accountability Office by 2010.

Click here for more information on CHIPRA from NCSL's Children's Health Insurance Program Overview webpage.
Click here for the April 2009 Kaiser Family Foundation report "Oral Health Coverage and Care for Low-Income Children: The Role of Medicaid and CHIP".
Click here for a guidance letter to state health officials from the Centers for Medicaid and Medicare Services on dental coverage under CHIP, October 7, 2009.

State Examples

Virginia’s Smiles for Children program, which enrolls children with Medicaid and CHIP 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.  Connecticut also saw an increase of more than 100% of the state’s dental providers who participated in Medicaid following efforts in 2007 to increase Medicaid reimbursement rates through its Healthcare for Uninsured Kids and Youth (HUSKY) program.

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.

In 2000, Georgia’s Take 5 campaign was launched. The Georgia Dental Association, the Georgia Dental Society, and Department of Community Health joined forces to ask all Georgia dentists to register as Medicaid providers and to voluntarily take on five or more new Medicaid patients into each practice. Each practice could decide if five new patients would be taken on per week, per month, or per year. After one year of the program, dental participation in the program increased by 23.3 percent.

Click here for NCSL's Issue Brief "Increasing Dentists' Participation in Medicaid and SCHIP" (2001).

Access to Services

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. 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.  In 2009, Illinois passed legislation to permit the Department of Healthcare and Family Services to award grants to local health departments for dental clinic development. Through this law (Public Act 96-0067), communities may apply for funding to improve access to dental care for low income residents.

Click here to read the Center for Health Care Strategies Report on these and other programs.

Workforce Issues

Read NCSL's Oral Health Workforce LegisBrief here.

The United States has had a well-documented shortage of dentists for years, a problem that is acutely felt in rural areas. More than 31 million people are located in designated shortage areas, which means that they have no reasonable expectation of finding a dentist in or near their community. The American Dental Association found that approximately 6000 dentists retire each year in this country, and the 62 accredited American dental schools graduated fewer than 5000 predoctoral graduates in 2009. The access problem is aggravated by the fact that in 2008, fewer than half of the dentists in 25 states treated any Medicaid patients. So finding a dentist for those who rely on public insurance is an even greater challenge. Furthermore, the system is set to be pushed to its limits when the Affordable Care Act will allow an estimated 5.3 million additional children to receive dental insurance by 2014.

Various groups and states have differing views on how to address these problems. While some believe the solution lies in educating more dentists and building dentist-led teams of oral health care, others see the answer in widening the scope of practice for dental hygienists and/or creating a new mid-level dental provider.

Click here for NCSL’s meeting session archive “Policy Options for Expanding the Oral Health Workforce” from August 2011.

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 August 2011, 35 states have laws to allow dental hygienists to provide dental services to patients, often without the direct supervision of a dentist.  Fifteen states also allow direct Medicaid reimbursements to hygienists for procedures performed as of June 2011.  

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 also can play a role in oral health care by providing 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 that incorporate training on oral health issues for pediatricians to improve early diagnostic screening are being developed.  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.

Click here to see information from the Pew Children's Dental Campaign on fluoride and Medicaid reimbursement for preventative dental caries services by primary care providers, by state.

Additional Dental Provider Models

Certain states have incorporated other dental provider models into the array of their service offerings in order 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).  In 2011, New Mexico passed HB 187 and became the first state to formally authorize community dental health coordinators (CDHCs). Under the model, CDHCs work under the general supervision of a licensed dentist in non-traditional settings, usually outside of dental offices and dental clinics. While there are no CDHC training programs in New Mexico at this time, discussions are occurring. Alaska grappled for years with many remote tribal villages that had no access to dental care, and in 2000 initiated dental health aide therapists (DHATs), who have been practicing for years in other countries, such as Canada and Great Britain. DHATs provide services to Alaskan natives after completing two years of technical training, and while working under the general supervision of dentists. A recent study of Alaska's dental therapists finds that DHATs are providing effective, high quality oral healthcare to the communities they serve.

Click here to read the American Dental Hygienists’ Association’s The History of Introducing a New Provider in Minnesota: A Chronicle of Legislative Efforts 2008-2009.
Click here to read the American Dental Association statement on the Kellogg Study of Alaska Dental Health Aide Therapist Program.
Click here to read the Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska.


Prevention and Awareness

Preventive dental services are a cost effective way to improve children's oral health.  According to the 2004 study in Pediatrics, dental costs for low-income children who have their first dental visit by age 1 average 40 percent lower over a five-year period than for 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. 

Click here for the Pew Children's Dental Campaign report "Falling Short: Most States Lag on Dental Sealants."
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 information from the Centers for Disease Control and Prevention on School-Based Dental Sealant Programs.

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.
Click here to view information from the Association of State and Territorial Dental Directors on school-based fluoride mouthrinse and supplement programs

State Mandated Dental Check-ups

At least eleven states—California, Georgia, Illinois, Iowa, Kentucky, Massachusetts, New York, Oregon, Pennsylvania, Rhode Island and South Carolina—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.  

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, Arkansas, 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.

Click here for federal, state and local action related to fluoride from the Fluoride Legislative User Information Database (FLUID).


NCSL Resources

Workforce Strategies to Improve Children's Oral Health - NCSL LegisBrief, December 2014
Dental Sealants Can Improve Children's Oral Health - NCSL LegisBrief, November 2014
Improving Access to Medicaid Dental Benefits - NCSL LegisBrief, February 2014
Oral Health Workforce - NCSL LegisBrief, March 2013
Policy Options for Expanding the Oral Health Workforce - NCSL meeting archive, August 2011
Oral Health and the Affordable Care Act: State Roles - NCSL webinar archive, May 2011
States Implement Health Reform: Oral Health - NCSL issue brief, March 2011
Oral Health Care for Children and Pregnant Women - NCSL LegisBrief, March 2010
States Must Comply With New CHIP Rules for Dental Care - NCSL State Health Notes newsletter article on new oral health provisions within CHIPRA, March 2009
Maryland Revamps Dental Care for Children - NCSL State Health Notes newsletter article on Maryland's revamp of dental programs for children, May 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
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
NCSL Charts and Other Documents - NCSL webpage with oral health resources predating 2005

Other Resources

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.
Pew Children’s Dental Campaign - The Pew Children’s Dental Campaign provides information and awareness related to children’s oral health.

NOTE: NCSL provides links to other websites for information purposes only. Providing these links does not necessarily indicate NCSL's support or endorsement of the site.


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