Children’s Oral Health
& Dental Care
Burton L. Edelstein DDS MPH
Children’s Dental Health Project, Washington DC
Columbia University, New York NY
CityMatCH/NACHO PIC Tele-Conference 9-18-03
Charge
Provide overview of
1. Children’s Oral Health & Dental Care Status
2. Action to Improve Children’s Oral Health &
Dental Care
3. Current Policy Threats to Children’s Dental
Care
4. “Opening the Mouth” MCHB Study
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Understanding Children’s Oral Health:
As Simple as Counting the Black Dots
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Context: Oral Health - an MCH
Policy Concern
Oral Health is a uniquely MCH Issue
– By Prevalence:
• Caries (tooth decay) is the single most prevalent disease of
childhood – 5X asthma
• Caries affects 1-in-5 preschoolers, 1-in-2 second graders
• An estimated 5 Million children suffer severe, symptomatic dental
disease that can disrupt normal daily activities
– By Biology:
• Caries is an infectious & transmissible disease caused by bacteria
acquired by children typically from their mothers before age two years
– By Importance:
• Maternal oral disease (periodontitis) is related to unfavorable birth
outcomes (Prematurity, LBW)
– By Cost/Effectiveness
• Both pediatric and maternal oral diseases and their consequences
can be markedly reduced through relatively low-cost interventions
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Context: Growing Policy Concern
Evidence of Governmental Interest
– Federal reports
SG Oral Health in America, National Call to Action
Healthy People 2010
– Congress
GAO reports, Federal legislation, Hill Hearings, Staff briefings
– State Houses
NGA Policy Academies, NCSL legislative support, State
Summits, ASTHO/ AMCHP/ NASMD/AMCHP activity
– Federal Agencies
NIH Disparity Centers, HRSA Oral Health Initiative, AHRQ
Studies, CDC programs, CMS demonstrations
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Context: HRSA/MCHB Concern
HRSA/MCHB Oral Health Programming
– Oral Health Policy Center at Columbia University
– Cooperative Agreement with Association of State and Territorial
Dental Directors
– National Oral Health Resource Center at Georgetown
– New state grant program
– Partnerships in Program Planning for Adolescent Health
(PIPPAH): Awesome Smiles
– Community Integrated Services Systems: Filling the Gaps,
Interfaces
– Title V Sealant measure
– MCH Continuing Education: Opening the Mouth
– Support for State Summits
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Context: Why Oral Health
is of Concern to Policymakers
Because
–
–
–
–
–
–
Constituent complaints
Press visibility (see NewsBytes at www.cdhp.org)
Strong data with negative trends
Advocates’ activity
Racial and income disparities
Oral Health/Dental Care is best and worst case
• Best in public health (fluoridation), past health
improvement trends, primary care focus, perceived quality
• Worst in coverage, unmet need, prevalence of
preventable disease, degree of disparity
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Players
 Federal and State Government
MCH agencies and officials keenly aware of dental problems
 State Conversion Health Foundations
Almost always identify “dental” & “mental” as top two issues
 National Health Foundations
GIH brief, WKKF Community Voices, RWJF Pipeline & State
Initiatives, Kaiser dental stories
 Child & Health Advocates
National & State level coalitions, Legal Aid
 National & Local Press
Print & Broadcast: dental focus & inclusion in health pieces
 Organized Dentistry
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Children’s Oral Health &
Dental Care Status
Facts at a Glance
• Coverage: 2.6x more children have no dental insurance
than medical insurance
• Unmet needs: 3x more parents report unmet needs for
dental than medical care
• Disease prevalence: caries is 5 times more prevalent
than asthma
• Medicaid access: Children in EPSDT are 3-4 times more
likely to obtain medical than dental care
• Disease burden: 1-in-5 preschoolers and 1-in-2 second
graders have visible tooth decay
• Disparities: Low income preschoolers have twice the
caries experience as high income preschoolers but
obtain care half as often
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Coverage
US Uninsured Children
30,000,000
25,000,000
20,000,000
15,000,000
26,000,000
2.6 X more children
lack dental
than medical coverage
10,000,000
10,000,000
5,000,000
0
Medically Uninsured
CDC NHIS Data
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Dentally Uninsured
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Unmet Need
Unmet Need for Health Care
6.0%
Parent-reported
unmet need
is 3X greater for dental
than medical care
5.0%
4.0%
5.3%
3.0%
1.8%
2.0%
1.0%
0.0%
Unmet Need for Medical Care
CDC NHIS data
Unmet need for Dental care
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Leading Health Problem
Childhood Asthma & Caries Prevalence
Dental caries is
5 times more
common than
asthma
60.00%
50.00%
40.00%
Asthma
30.00%
Caries
20.00%
10.00%
0.00%
ages 2-4
CDC NHIS data
ages 6-8
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Poor Access by Medicaid Kids
% Medicaid Children With Visit
90
80
70
60
50
40
30
20
10
0
3-4X more
children in Medicaid
access
medical care
than dental care
Medical
CMS Data
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Dental
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Disease Burden
1 in 2
2nd graders
have obvious
tooth decay
60%
50%
40%
30%
1 in 5
preschool
children
have obvious
tooth decay
20%
10%
0%
2-4 Year Olds
HP 2010
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6-7 Year Olds
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Disease Disparity by Race
1.80
decayed teeth (dft) x 5
1.60
Fastest growing population
has worst disease
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
Overall
White
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Black
Hispanic
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Disease Disparity by Income
1.60
Low-income
young children
have double the
decay experience…
decayed teeth (dft) x 5
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
Overall
NHANES III data
0101-200% 201-300%
100%FPL
FPL
FPL
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>300%
FPL
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Treatment Disparities
Percent Children with Visit
30.00%
25.00%
…. But only
half as much
dental care
20.00%
15.00%
10.00%
5.00%
0.00%
0-200% FPL
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200-400% FPL
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Anecdotes Make It Real
• Wrap around health center lines
e.g. Medicaid Commissioner Bob Smedes prior to MI reform
• Complaints at town meetings
e.g. Senators Collins & Feingold prior to Safety Net Amendments
• Personal Observation / Response to Local Dentist
e.g. Senators Bingaman and Cochran prior to Children’s Dental
Improvement Act; Secty Shalala prior to Surgeon General’s Report
• Home institutions
e.g. Senator Edwards prior to Children’s Perinatal Dental Health
Improvement Act
• Personal Clinical Experience
e.g. HRSA Administrator Earl Fox prior to HRSA/CMS Oral Health
Initiative
• VA and KS “Missions of Mercy”
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Dawn – Awaiting Free MOMs
Dental Care 2003
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Action to Improve Children’s
Oral Health & Dental Care
Requirements for effective action:
WWWWWH
Who:
Working, active, regular, ongoing coalitions
Strong, visible, empowered ($) leadership
What:
First: Assess capacities and needs
Then: Plan  Implement  Evaluate  Refine
Where:
When:
Why:
How:
Defined locale & population
As soon as “Who What Where” are known
Because it matters, is important, & is doable
By targeting a clear, measurable, meaningful, and widely
accepted goal
Essential ingredient
Relentless effort by many interests inspired by demanding leadership &
tied to ongoing goal assessment.
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Workforce
Inherent Constraints
Declining availability of dentists (numbers, distribution, Medicaid
participation)
Unrealized potential of hygienists as disease managers
No mid-level provider analogous to NP or PA
Minimal engagement of non-dental personnel
Safety net
Small, fragile, understaffed, rarely geared to young children
Financing
Medicaid, SCHIP, school-based, & public health delivery programs are
under-funded & often threatened by policy changes/budgets
Prevention/Health Promotion
Inadequate development & implementation of risk-based care
Minimal adoption of Bright Futures & other guidelines
Insufficient attention to key age group – infants and toddlers
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A Core Constraint: Chronically
Inadequate Financing
60,000
50,000
40,000
30,000
20,000
10,000
0
0
6
19
Total
Dental
Total
Exp
Spending in US
($ Millions)
Medicaid
Public
Dental spending
Funds
0
7
19
Source: JJ Crall 2001
0
8
19
0
9
19
7
9
19
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SG Framework for Action
•
US Surgeon General’s 5 Action Steps
1. Address perceptions about oral health &
dental care
2. Address barriers/ replicate successes
3. Build & apply science
4. Increase workforce capacity
5. Collaborate
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Children’s Dental Health Project
Application of Framework
1.
2.
Collaborate: Develop effective, active, local coalitions
Perceptions:
–
3.
Remove Barriers:
–
–
4.
Address financing: Improve financing by replication, negotiation,
advocacy, litigation, experimentation
Address systems of care: e.g. Engage case management, link to
existing venues & programs
Science:
–
5.
Inform and engage public & private policymakers, advocates, business,
faith organizations, academics, health/social providers
Implement risk-based interventions & timely disease management
Workforce:
–
–
–
–
Increase safety net capacity through public-private contracting
Expand clinical and sociocultural competencies
Engage non-traditional providers
Address numbers, distribution, diversity, composition, competencies
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Current Policy Threats to Children’s
Dental Care
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Policy Threats
• Adult dental cuts: Rapidly eroding coverage
• HIFA (Health Insurance Flexibility & Accountability1115
Medicaid Waivers) : UT EPSDT Dental Cap
• SCHIP losses in elective care: TX Cuts
• Block Granting: Head Start Precedent?
• Medicaid Reform: EPSDT Threat?
• Budgets: Endangered MCH Dental Programs?
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“Opening the Mouth” MCHB Study
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Opening the Mouth Project
Columbia University
Goal
To assess and enhance “continuing education and
development” (CDE) of MCH professionals on children’s oral
health
Components
1.
2.
3.
Assess MCH oral health CDE opportunities
Assess MCH professionals’ needs for CDE on children’s oral health
Develop web-based CDE materials on children’s oral health for
MCH professionals
Partners
AMCHP, CityMatCH, ATMCH, Mailman School
Request
Tell us what you need and want in CDE on children’s oral health
by responding to our upcoming electronic survey
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Visit us at www.cdhp.org!
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Thanks to CityMatCH, NACCHO, and Each of You
For Engaging CDHP in your efforts to improve
the Health and Welfare of Children
Throughout our Country
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