Effects of Expanding Preventive Dental Care
in Medical Offices
for Young Children Covered by Medicaid
Sally C. Stearns, PhD
R. Gary Rozier, DDS
Jeongyoung Park, PhD
Bhavna T. Pahel, BDS
Rocio Quinonez, DMD
The University of North Carolina at Chapel Hill
AcademyHealth Annual Research Meeting
Orlando, Florida
June 4, 2007
Overview
• Basic facts:
– Fewer than 1 in 5 preschool-aged children on public
insurance use preventive dental care
– Access exacerbated by declining dental workforce and
low rate of provider participation in public insurance
• Repercussions
– Dental decay most common preventable chronic
disease among preschool children in US
– Rates of decay low at very young ages but accelerate
9 Early childhood caries rates of 1-2% in one year olds
9 40% of entering kindergartners in NC have had decay
Supported by CDC, HRSA, NIDCR, CMS
For Want of a Dentist: Boy Dies After Bacteria
From Tooth Spread to Brain
Washington Post, 2/28/07
• Twelve-year-old Deamonte Driver died of a toothache Sunday.
• A routine $80 tooth extraction might have saved him.
• If his family had not lost its Medicaid.
• If Medicaid dentists weren't so hard to find.
A Possible Solution:
Expand the Sites of Early Preventive Care?
• Physicians already assess teeth and counsel
parents on oral health during well-child visits
• North Carolina started “Into the Mouths of Babes”
(IMB), a preventive dental program for Medicaid
children from birth through 35 months
– IMB offered in medical offices by providers who complete
training regarding fluoride application and detecting disease
– IMB visits include:
9 Screening, risk assessment, counseling
9 The application of a fluoride varnish to children’s teeth
– Children can receive up to six IMB visits up to age 3
• Does IMB reduce need for restorative care?
• What is the cost-effectiveness of the IMB
program?
100
80
High
60
40
None
Low
20
0
0
Ap 0
r-0
0
Ju
l -0
O 0
ct
-0
Ja 0
n0
Ap 1
r-0
1
Ju
l -0
O 1
ct
-0
Ja 1
n0
Ap 2
r-0
2
Ju
l -0
O 2
ct
-0
Ja 2
n0
Ap 3
r-0
3
– Preventive care?
– Restorative care?
Percent of Counties Participating
• How does IMB affect access to dental care for
young children?
Time Frame for IMB Implementation
Ja
n-
Study Questions
Year-month of IMB penetration in county
1
Study Design, Data Sources, and Methods
Visits/month per
1,000 kids
• Pre-post quasi-experimental design
• Medicaid enrollment & claims file
– 3 years of claims data (2000 - 2002)
– Constructed child-month records for longitudinal analysis of up
to ~292,000 children
• Regression analyses
– Controlled for child characteristics (age, gender, race), provider
supply, and area characteristics (urban, fluoridation)
– Access analyses: Intent to treat analysis
– Effectiveness analysis: Effect of treatment among the treated
Why Does IMB Increase Restorative Visits?
• For 1000 children age 24 months:
– Estimates show 6.8 children treated in absence of
IMB but that 7.3 children received restorative
treatment after IMB implementation
• Increase occurs for two reasons
– Analysis during implementation phase means
children with existing decay could not get
beneficial effect of IMB
– Training of providers leads to increased referrals
Effectiveness Increases with Age
Figure 4: Anterior Teeth Probability of Restoration: 0 IMB versus 4+ IMB
Expected Likelihood of Dental Procedures per Month
0
.002
.004
.006
.008
Access to Preventive and Restorative Care
95% CI for Expected Value by Age Category
16
14
12
10
8
6
4
2
0
15.7
Dental Office Pre-IMB
Dental Office Post-IMB
7.4
4.1
0.2 0.4
Preventive
Visit
Any Visit
Medical
Office
Dental Office
Will IMB Ultimately Reduce Treatments?
• Two part regression models used to assess
effect of IMB among the treated
– Likelihood of dental restoration treatments
– Number of treatments conditional upon some
• Data for 98,411 children with no IMB
treatments during study period compared to
1,472 children with 4+ IMB visits
• Separate estimations for anterior (front) and
posterior (back) teeth
Significant Reduction in Restorations on
Anterior Teeth
Effect of 0 versus 4-6 IMB Visits on Expected Dental Treatments
Per 1000 Children up to Four Years of Age By Tooth Category
Dental Treatments
No IMB
0
10
20
Age in Months
4+ IMB visits
30
40
4-6 IMB
Percentage
Visits Reduction Reduction
All Teeth
1697
1433
-264
15.6%
Anterior
Teeth
584
356
-226*
39.0%
Posterior
Teeth
598
527
-70
11.9%
No IMB visits
2
Is IMB Cost-Effective?
• Cost-savings are unlikely from IMB
– Program cost (up to 6 visits) at ~$60 a visit difficult to offset
– Discounting works against cost-savings
– Issue of primary rather than permanent teeth
• But IMB may be cost-effective
– Dental health is improved
– Treatment cost reductions increase with age
• Additional data being obtained to track effect of IMB
for a six year follow-up period
Summary and Policy Implications
• IMB program:
– Increased access to dental care
9But rates of preventive care still modest
– Improved health (timely treatment of existing disease)
– May reduce total treatments once fully implemented
• Cost-effectiveness of IMB currently unknown
– Program may have additional beneficial effects
9Increased prioritization of preventive care
9Could help reduce projected increases in decay and
demand for dentist services
3