Turning the Tide

Dental caries, a preventable disease, can adversely affect children’s health. It can even be life threatening when left untreated.¹ The prevalence of dental caries is four times greater among low-income children than children in higher socioeconomic groups.² In the 1990s, the state of North Carolina faced a growing population of low-income children and an inadequate supply of dental professionals to provide care. Thus, in 2000, a program was initiated that allowed physicians to provide preventive oral services during well-child visits in order to solve this access-to-care problem.³ Dr. Rozier shares the details of this program and its effects on North Carolina’s most vulnerable citizens.

Q. Is the incidence of caries decreasing among children?
A. Caries rates have been declining in children’s permanent dentitions for some time. Substantial improvements have been made among older children because of exposure to preventive interventions, such as water fluoridation, brushing with fluoridated toothpaste, use of dental sealants, and increases in dental visits caused by growing dental insurance coverage that started in the 1970s. The significant improvements that have been achieved are due to long-term investments in oral health in both clinical and public health settings. There is still work to be done to reduce the rates of decay among children and significant disparities in access to care still exist. But overall trends are moving in the right direction for permanent teeth. Unfortunately, the trend in primary teeth is moving in the opposite direction, which surprised many of us in public health when it was first recognized more than a decade ago. During the 1990s, the prevalence of dental caries among preschool-age children increased. National data show that about one-third of children between the ages of 2 years and 5 years have experienced tooth decay.⁴ The causes of this increase are the same factors that helped improve rates among older children, but in reverse: lack of exposure to fluoride, low oral health literacy, barriers in access to professional dental care, and poor diet. Diet is key because the increased consumption of fruit juice and sweetened beverages has had a profound effect on the amount of tooth decay found in very young children. Today, approximately 75% of toddlers drink juice and sweetened beverages.⁵

Q Many low-income children have public insurance that includes dental benefits. Why are they not receiving preventive dental services even when reimbursement is available?
A. Private dental insurance is declining in this country as companies reduce or eliminate these benefits. But the number of children enrolled in public insurance is increasing because of several factors, including the poor economy. As many as three out of four low-income American children are insured under Medicaid or Children’s Health Insurance Program.⁶ Unfortunately, having public dental insurance coverage does not necessarily equate to access to dental services, particularly among very young children. Traditionally, dentists have not been trained to provide care to infants and toddlers, so not only do low-income families face challenges in finding a provider who will accept Medicaid patients but they also must overcome the barrier of dentists who may be reluctant to treat 1-year-olds. This situation is improving, but there are still many dentists who are not trained to see very young children. Another factor is a lack of awareness or even disagreement among both dentists and the public about when children should visit the dental office for the first time. The current recommendation is at 1 year but confusion still remains about this recommendation.

Q. What is the Into the Mouths of Babes program?
A. Into the Mouths of Babes is a Medicaid program that started in North Carolina in 2000. It reimburses physicians, nurses, and physician extenders who provide preventive dental services for children from birth to 42 months. Once trained, physicians can provide the dental services during regularly scheduled well-child visits or during sick appointments in up to six separate visits. Services provided include oral health screening, risk assessment, referral to a dental professional if needed, parental counseling, and application of fluoride varnish.

Hundreds of physicians and extenders have been trained in North Carolina since the program began. Currently, about 450 individual practices (pediatrics, family medicine, and health departments) participate, and we are approaching about 200,000 preventive visits each year. Programs similar to Into the Mouths of Babes have now spread to 40 other states.

Q. What was the impetus behind this approach?
A. North Carolina’s problem of access to care was well documented before this program began. One of the major problems was the shortage of dentists. North Carolina was and still is about 47th in the country in the dentist:population ratio. At the same time, virtually all low-income children in North Carolina visit a physician’s office as soon as they are born, and they make multiple visits as young children. So the medical office is where we could get access to children at a young age and provide effective preventive dental services before they have developed tooth decay.

No one wants to pay for services that aren’t effective and when this program began there was little scientific evidence that these services could be provided successfully in medical settings. But because there was strong evidence that topical fluoride was effective in preventing tooth decay, it was a matter of substituting one type of health care professional for another to deliver the intervention. This approach was very uncommon if not nonexistent when this project started. The support of the physicians participating in this program is admirable. One of the reasons many participating physicians gave for providing these preventive dental services was that they viewed children with caries as sick kids. As a dentist, I sat back and thought about whether dental professionals would describe an 18-month-old child with tooth decay as “sick.” The physicians saw the dental caries problem for what it was—a disease with the potential for harmful outcomes to the child and family. Physicians are responsible for preventing disease and taking care of sick children, so they enthusiastically supported the program.

Q. What effect has the program had in North Carolina?
A. After analyzing data about the program from 2000 to 2006, we concluded that it has substantially increased access to preventive dental services in North Carolina. Nationally, in 2006 the percentage of children aged 6 months to 35 months who received preventive dental services was approximately 2.5%. In North Carolina, in 2006 about 40% of well-child visits included preventive dental treatments.

We’ve conducted a number of studies on various aspects of the program. We looked at whether physicians could be trained to provide these services and whether they would do it. The answer to both questions is yes. In one study, we enrolled a number of practices and randomly assigned them into groups and provided different levels of training. We found that providing expanded preventive oral health services is a relatively easy innovation to adopt. Adoption rates were about 60% to 70% in these busy practices, a reasonably high success rate.⁷. We also conducted quality studies. Parents were extremely satisfied with receiving preventive dental services at physicians’ offices. We are currently studying the effectiveness and costs of the services provided in preventing dental caries. We’re looking at whether children who received preventive dental services experienced fewer caries-related treatments than those who did not receive the preventive services.

Interestingly, the program continues to increase access to care each year that it is in place. We have not observed any leveling off or decreases in the number of visits since the program started. The program is successful because of the dedication of the members of the North Carolina partnership supporting the program, the commitment of the medical profession to oral health, and the program’s coordinator, Kelly Close, RDH, MHA, who provides the training for the medical professionals. Her commitment to promoting the program and to providing the training over the past 10 years has been instrumental to the program’s success. We still have much work to do in addressing oral health disparities, of course.

We need to increase preventive dental services provided in physician’s offices, expand the reach of dental offices, and to foster an integration of the two. When demand for dental care exceeds the supply of dentists, some children should receive preventive dental services in medical offices before establishing a dental home, while others should get care in a dental office from the very beginning because they are at high risk of caries or they already have disease. What we’re working on now is an integration of medicine and dentistry to improve the oral health of children.

REFERENCES

1.  National Institute of Dental and Craniofacial Research. Oral health in America: a report of the surgeon general. Available at: www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Report/ExecutiveSummary.htm. Accessed February 16, 2011.
2. Dye BA, Arevalo O, Vargas CM. Trends in paediatric dental caries by poverty status in the United States, 1988–1994 and 1999–2004. Int J Paediatr Dent. 2010;20:132-143.
3. Rozier RG, Stearns SC, Pahel BT, Quinonez RB, Park J. How a North Carolina program boosted preventive oral health services for low-income children. Health Aff (Millwood). 2010;29:2278-2285.
4. Dye B, Tan S, Smith V, et al. Trends in oral health status: United States, 1988–1994 and 1999–2004. Vital Health Stat. 2007;248:i–viii, 1–102.
5. Marshall TA, Levy SM, Broffitt B, et al. Dental caries and beverage consumption in young children. Pediatrics. 2003;112(3 Pt 1):e184-91.
6. Manski RJ, Brown E. Dental use, expenses, private dental coverage, and changes, 1996 and 2004. Rockville, Md: Agency for Healthcare Research and Quality Available at: www.meps.ahrq.gov/mepsweb/data_files/publications/cb17/cb17.pdf. Accessed February 16, 2011.
7. Slade GD, Rozier RG, Zeldin LP, Margolis PA. Training pediatric health care providers in prevention of dental decay: results from a randomized controlled trial. BMC Health Serv Res. 2007;7:176.

From Dimensions of Dental Hygiene. March 2011; 9(3): 54, 56-57.