Improving oral health disparities and access to care: challenges and opportunities for the states

States and their dental reimbursement, practice, and education policies and programs have done little to address oral health disparities. Particular state policies and programs are often cited as having an adverse impact on oral health access for vulnerable populations. These include poor Medicaid and State Children's Health Insurance Program reimbursement, an inadequate safety net, the ban on the corporate practice of dentistry, and a lack of funding to prepare the dental workforce to treat special needs populations and provide culturally competent care. (The State Children's Health Insurance Program, created by the Balanced Budget Act of 1997, enacted Title XXI of the Social Security Act and allocated about dollar 20 billion over five years to help states insure more children.) While state health officials have paid less attention to oral health disparities, there has been increased interest by state policymakers in addressing the special health care needs of the elderly, disabled, and children. These include state responses to the 1999 Olmstead Supreme Court decision and state pharmaceutical assistance programs for the elderly and disabled. (In rejecting the state of Georgia's appeal to enforce institutionalization of individuals with disabilities, the Supreme Court in 1999 affirmed the right of individuals with disabilities to live in their community in its 6-3 ruling against the state of Georgia in the case Olmstead v. L.C and E.W.) However, a few states have begun to develop solutions to explicitly address oral health access problems. States are considering or testing the following programs and policies pertaining to 1) improving workforce supply and distribution, 2) education reform and increased public accountability, 3) practice reform, and 4) increased data collection and research.     

The virtual dental home: implications for policy and strategy

Widely recognized problems with the U.S. health care system, including rapidly increasing costs and disparities in access and outcomes also exist in oral health. If oral health systems are to meet the "Triple Aim" of improving the experience of care, improving the health of populations, and reducing per capita costs of health care, new and innovative strategies will be needed including new regulatory, delivery, and financing systems. The virtual dental home is one such system.     

Dental therapists in general dental practices: an economic evaluation

Dental access disparities are well documented and have been recognized as a national problem. Their major cause is the lack of reasonable Medicaid reimbursement rates for the underserved. Specifically, Medicaid reimbursement rates for children average 40 percent below market rates. In addition, most state Medicaid programs do not cover adults. To address these issues, advocates of better oral health for the underserved are considering support for a new allied provider-a dental therapist- capable of providing services at a lower cost per service and in low-income and rural areas. Using a standard economic analysis, this study estimated the potential cost, price, utilization, and dentist's income effects of dental therapists employed in general dental practices. The analysis is based on national general dental practice data and the broadest scope of responsibility for dental therapists that their advocates have advanced, including the ability to provide restorations and extractions to adults and children, training for three years, and minimum supervision. Assuming dental therapists provide restorative, extraction, and pulpal services to patients of all ages and dental hygienists continue to deliver all hygiene services, the mean reduction in a general practice costs ranges between 1.57 and 2.36 percent. For dental therapists treating children only, the range is 0.31 to 0.47 percent. The effects on price and utilization are even smaller. In addition, the effects on most dentists' gross income, hours of work, and net income are negative. The estimated economic impact of dental therapists in the United States on private dental practice is very limited; therefore, the demand for dental therapists by private practices also would probably be very limited.     

Evaluating access to pediatric oral health care in the southeastern states

BackgroundIn this article, the authors addressed shortcomings in existing research on pediatric oral health care access using rigorous data and methods for identifying statistically significant disparities in oral health care access for children.MethodsThe study population included children, differentiated by insurance status (Medicaid, Children’s Health Insurance Program, private, none). The authors measured provider-level supply as the number of oral health care visits, stratified by provider type and urbanicity-rurality. The authors defined demand as the number of dental visits for children and derived demand and supply mainly from 2019 and 2020 data. Using statistical modeling, the authors evaluated where disparities in travel distance across communities or by insurance status were statistically significant.ResultsAlthough Dental Health Professional Shortage Areas are primarily rural, this study found that the proportions of rural, suburban, and urban communities identified for access interventions ranged from 24% through 66% and from 8% through 86%, respectively. For some states (Florida, Louisiana, Texas), rural and suburban communities showed a need for interventions for all children, whereas in the remaining states, the lack of Medicaid and Children’s Health Insurance Program access mainly contributed to these disparities. Variations in access disparities with respect to insurance status across states or by urbanicity-rurality were extensive, with the rate of communities identified for reducing disparities ranging from 1% through 100%.ConclusionsAll states showed a need for access interventions and for reducing disparities due to geographic location or insurance status. The sources of disparities were different across states, suggesting need for different policies and interventions across the 10 states.Practical ImplicationsThe study findings support the need for policies toward reducing disparities in oral health care access.     

Access to dental care for Head Start enrollees

OBJECTIVES: The objectives of this review are to characterize the oral health and dental access of Head Start children, describe barriers to their care, advance strategies to address those barriers, and consider how Head Start Performance Standards can be utilized to maximize oral health and access to dental care. METHODS: Published, programmatic, and solicited data describing oral health status and dental service utilization are reviewed together with reports of conferences exploring access barriers. Head Start performance measures for child health and development services, child health and safety, family partnerships, and community partnerships are individually evaluated for their potential to improve oral health. RESULTS: Head Start children, like all low-income children, enjoy the highest rates of dental coverage (because of Medicaid and the State Child Health Insurance Program), yet these children also experience the highest rates of tooth decay, the most unmet dental care needs, the highest rates of dental pain, and the fewest dental visits. Getting children the dental care they need is problematic because of: multiple barriers associated with public and private dental delivery systems, Medicaid program funding and administration, dental workforce sufficiency and distribution, and issues of culture and communication that stand between parents, children, and caregivers. CONCLUSIONS: To move beyond screening and to access necessary dental care requires integration between medical and dental care, recognition and elimination of barriers to care, an understanding of dental provider types and their capacities, a formally structured referral process, and regular monitoring to ensure that complete care is obtained. Action steps are suggested that can maximize the effectiveness of Head Start Performance Standards. Head Start holds tremendous potential to actively develop and implement policies that can markedly improve both access to needed dental services and the oral health status of young disadvantaged children.     

Child dental expenditures: 1996

PURPOSE: Because little has been reported about child dental expenditures, federal data were used to estimate dental care expenditures for U.S. children by age, sex, ethnic/ racial background, family income, parental education and parental employment. METHODS: Parentally reported data on dental expenditures and sources of expenditures were extracted from the most recent available federal healthcare expenditures studies, the 1996 federal Medical Expenditure Panel Survey (MEPS). Using the survey's large sample and complex design, these data represent the entire U.S. child population. RESULTS: Nearly 12 billion dollars were expended for children's dental care averaging $375 per child who obtained care. Overall sources of payment were 47% out of pocket, 45% insurance and 8% "other" including primarily Medicaid. Disproportionately litde spending was made on behalf of low-income and minority children despite their higher disease experience. The proportion of spending that was paid out of pocket was high for all groups of children including those eligible for Medicaid even though Medicaid prohibits cost sharing. CONCLUSIONS: Dental care for children accounts for approximately one-quarter of U.S. dental spending and is a major component of child health care costs. Income and racial disparities in expenditures favor higher income children despite Medicaid coverage for lower income children. High levels of reported out-of-pocket costs for Medicaid eligible children suggest that Medicaid fails to meet families' needs in obtaining care. Meeting the oral health needs of poor children will require considerably greater expenditures, particularly through improved Medicaid financing and administration.     

Beyond access: the role of family and community in children's oral health

Children's health outcomes result from the complex interaction of biological determinants with sociocultural, family, and community variables. Dental professionals' efforts to reduce oral health disparities often focus on improving access to dental care. However, this strategy alone cannot eliminate health disparities. Rising rates of early childhood caries create an urgent need to study family and community factors in oral health. Using Los Angeles as a multicultural laboratory for understanding health disparities, the Santa Fe Group convened an experiential conference to consider models of ensuring child and family health within communities. This article summarizes key conference themes and insights regarding 1) children's needs and societal priorities; 2) the science of child health determinants; 3) the rapidly changing demographics of the United States; and 4) the importance of communities that support children and families. Conference participants concluded that to eliminate children's oral health disparities we must change paradigms to promote health, integrate oral health into other health and social programs, and empower communities. Oral health advocates have a key role in ensuring oral health is integrated into policy for children. Dental schools have a leadership role to play in expanding community partnerships and providing education in health determinants. Participants recommended replicating this experiential conference in other venues.     

The Minnesota Oral Health Care Solutions Project: implications for people with special needs

Disparities in oral health status and access to dental care are major problems for people with special needs in Minnesota and across the country. The current delivery system for people with special needs is failing. Patients, community leaders, private dentists, safety net clinics, and state agencies are frustrated with the Medicaid program that funds the current system; and everyone is looking for new solutions. What would an improved oral health care system and Medicaid model look like? This paper describes Minnesota's Oral Health Care Solutions Project that seeks to answer this question and highlights the implications of a new model for people with special needs. The low reimbursements and administrative burdens of Minnesota's Medicaid program have led many dentists to reduce or stop seeing public program patients. As a result, many people with special needs have been unable to obtain routine dental care and therefore seek treatment in emergency rooms.     

The Central Massachusetts Oral Health Initiative (CMOHI): a successful public–private community health collaboration

Objectives: The Central Massachusetts Oral Health Initiative (CMOHI) aimed to improve access to quality oral health care in central Massachusetts. Methods: A broad‐based public and private organization partnership with local and national funding created a steering committee to organize school administrators, community leaders, and a medical school to collaborate on five goals: advocate for changes in oral health policy, increase oral health care access, provide school‐based dental services for underserved children, establish a Dental General Practice Residency, and educate medical professionals about oral health. Results: A state legislative Oral Health Caucus helped secure sought‐after policy improvements; more regional dentists now accept Medicaid; community health center capacity to provide dental services was expanded; school‐based programs were designed and delivered needed dental services; a dental residency was created; and methods of educating medical professionals were established. Conclusions: Significant sustainable gains in oral health care access were created through our multifaceted approach, ongoing evaluation and communication, coordination of CMOHI partner resources, and collaboration with other involved parties.     

Ethnic disparities in the prevalence of dental caries and restorative dental treatment in Brazilian children

Aim : This study assesses disparities in the oral health status of Brazilian black and white children. Participants : 11‐and 12‐year‐old schoolchildren living in 131 cities of the State of São Paulo, Brazil. Methods : Spatial data analysis of city‐level indexes of oral health, socio‐economic status and provision of dental services. Main outcome measures : Ethnic ratios of the DMFT and the care index. Results : White children had higher indexes of caries in permanent teeth than their black counterparts, concurrent with a higher utilisation of dental attendance. The gap of caries prevalence between black and white children was reduced in cities with a better profile of socio‐economic status. Cities with higher per‐capita yearly budget, expenditure in health, and provision of public dental services presented reduced indications of ethnic inequality in dental care. Conclusion : The knowledge of conditions associated with a lower ethnic discrepancy in the risk of caries and in the incorporation of dental services can be used to design socially appropriate dental services. An improved community dental service, higher public expenditure in health and per‐capita municipal yearly budget contribute effectively to reducing inequities in oral health by allowing an incorporation of restorative dental treatment more equitably distributed between black and white children.     

The dental therapist movement in the United States: A critique of current trends

Dental therapists are members of the oral health workforce in over 50 countries in the world typically caring for children in publically funded school‐based programs. A movement has developed in the United States to introduce dental therapists to the oral health workforce in an attempt to improve access to care and to reduce disparities in oral health. This article critiques trends in the United States movement in the context of the history and success of dental therapists practicing internationally. While supporting the dental therapist movement, we challenge: a) the use of dental therapists treating adults, versus focusing on children; b) the use of dental therapists in the private versus the public/not‐for‐profit sector; and c) requirements that a dental therapist must also be credentialed as a dental hygienist.     

Addressing disparities in children's oral health: a dental-medical partnership to train family practice residents

Providing oral health care to rural populations in the United States is a major challenge. Lack of community water fluoridation, dental workforce shortages, and geographical barriers all aggravate oral health and access problems in the largely rural Northwest. Children from low-income and minority families and children with special needs are at particular risk. Family-centered disease prevention strategies are needed to reduce oral health disparities in children. Oral health promotion can take place in a primary care practitioner's office, but medical providers often lack relevant training. In this project, dental, medical, and educational faculty at a large academic health center partnered to provide evidence-based, culturally competent pediatric oral health training to family medicine residents in five community-based training programs. The curriculum targets children birth to five years and covers dental development, the caries process, dental emergencies, and oral health in children with special needs. Outcome measures include changes in knowledge, attitudes, and self-efficacy; preliminary results are presented. The program also partnered with local dentists to ensure a referral network for children with identified disease at the family medicine training sites. Pediatric dentistry residents assisted in didactic and hands-on training of family medicine residents. Future topics for oral health training of family physicians are suggested.     

Does Medicaid improve utilization of medical and dental services and health outcomes for Medicaid‐eligible children in the United States?

BACKGROUND: Data are lacking to support the contention that Medicaid services improve utilization of healthcare services and result in better health. OBJECTIVE: To compare sociodemographic, utilization of healthcare services and health status characteristics among Medicaid-eligible children. METHODS: The third National Health and Nutrition Examination Survey included 2821 children 2-16 years of age eligible for Medicaid. The main outcome measures are annual physician visit, annual dentist visit, general health status, oral health status, asthma (second most common childhood disease), dental caries (most common childhood disease), asthma treatment needs, and dental treatment needs. We quantified the association of these outcome measures with Medicaid insurance status and sociodemographic status using multiple logistic regression modeling, taking into account the complex survey design and sample weights. RESULTS: Among Medicaid-eligible children, 27% were uninsured. Among uninsured Medicaid-eligible children, 62% had an annual physician visit, 32% had an annual dentist visit, 10% needed asthma treatment, and 57% needed dental treatment. Among insured Medicaid-eligible children, 81% had an annual physician visit, 39% had an annual dentist visit, 13% needed asthma treatment, and 42% needed dental treatment. After simultaneously taking into account other characteristics, uninsured Medicaid-eligible children were more likely to not have an annual physician visit (OR(NoMDvisit) = 2.21; 1.26-3.90), and to need dental treatment (OR(DentalNeed) = 1.57; 1.13-2.18). CONCLUSIONS: This USA population-based study found disparities exist within Medicaid's services between utilization of dental and medical services. Medicaid insurance improved utilization of medical services, but did not improve the utilization of dental services. This suggests that Medicaid insurance does not improve access to dental services for poor children.     

Increasing dental care utilization by Medicaid-eligible children: a dental care coordinator intervention

Objectives: The aim of this study was to determine the effect of a dental care coordinator intervention on increasing dental utilization by Medicaid-eligible children compared with a control group.
Methods: One hundred and thirty-six children enrolled in Medicaid aged 4 to 15 years at baseline in 2004 who had not had Medicaid claims for 2 years, were randomly assigned to intervention or control groups for 12 months. Children and caregivers in the intervention group received education, assistance in finding a dentist if the child did not have one, and assistance and support in scheduling and keeping dental appointments. All children continued to receive routine member services from the dental plan administrator, including newsletters and benefit updates during the study.
Results: Dental utilization during the study period was significantly higher in the intervention group (43 percent) than in the control group (26 percent). The effect was even more significant among children living in households well below the Federal Poverty Level. The intervention was effective regardless of whether the coordinator was able to provide services in person or via telephone and mail.
Conclusion: The dental care coordinator intervention significantly increased dental utilization compared with similar children who received routine Medicaid member services. Public health programs and communities endeavoring to reduce oral health disparities may want to consider incorporating a dental care coordinator along with other initiatives to increase dental utilization by disadvantaged children.     

Is trust a predictor of having a dental home?

BACKGROUND: Developing a better understanding of sociodemographic variables that predict having a dental home may aid in reducing the disparities in oral health among minorities in the United States. METHODS: The authors used data from a telephone survey of 1,005 randomly selected low-income residents (403 men, 602 women) aged 18 or older in two Florida counties--Miami-Dade and Duval--to examine the sociodemographic characteristics of people who reported having a regular dentist. RESULTS: Bivariate analyses showed that respondents' levels of trust in physicians and dentists were strongly associated with having a dental home. After adjusting for other variables in a multiple logistic regression model, the authors found that respondents with a moderate level of trust in physicians and dentists were 52 percent less likely (odds ratio, or OR, = 0.48; 95 percent confidence interval, or CI, 0.26 to 0.89) and those with low trust were 54 percent less likely (OR = 0.46; 95 percent CI, 0.28 to 0.75) than those with high trust to have a regular dentist. Race/ethnicity, sex, age, education level and employment status remained significant correlates of having a regular dentist in the multivariate model. CONCLUSIONS: The results of this study suggest that efforts to reduce disparities in access to dental care and establish dental homes should include programs to increase patients' trust in dental professionals. CLINICAL IMPLICATIONS: While policy-makers consider ways to improve access to dental care, dental professionals should work at the community level to increase the level of trust of the community in the dental health provider.     

Parental perceptions of unmet dental need and cost barriers to care for developmentally disabled children

PURPOSE: The purpose of this investigation was to describe and assess the disparities, if any, in parental perceived cost barriers to oral health care among developmentally disabled children using a national data set. METHODS: Data from the 1997 National Health Interview Survey (NHIS) were analyzed using a SUDAAN statistical package. RESULTS: After adjusting for age and sex, parental perception of unmet need was significantly associated with developmentally disabled children 2-17 years in lower socioeconomic groups. CONCLUSIONS: Though most children from lower socioeconomic groups are eligible for Medicaid coverage, parents of these children perceive cost barriers to dental care. Children with developmental disabilities face even more perceived barriers to care based on family income.     

Preventive oral health care use for children with special health care needs aged 6 through 12 years enrolled in Medicaid: A mixed methods study

BackgroundThe authors aimed to assess preventive oral health care (POHC) use for children with special health care needs (CSHCN) aged 6 through 12 years enrolled in Medicaid and identify intervention strategies to improve oral health.MethodsIn this sequential mixed methods study, the authors analyzed 2012 Medicaid data for children aged 6 through 12 years in Washington state. They used eligibility and claims data to identify special health care needs status (independent variable) and POHC use (outcome variable). They ran modified Poisson regression models to generate prevalence rate ratios. They coded data from 21 key informant interviews deductively using content analytic techniques.ResultsOf the 208,648 children in the study, 18% were identified as CSHCN and 140,468 used POHC (67.3%). After adjusting for confounding variables, the authors found no difference in POHC use by special health care need status (prevalence rate ratio, 1.00; 95% CI, 0.99 to 1.01; P = .91). In the qualitative analysis, the authors identified 5 themes: caries risk depends on a child’s specific health condition, caries complicates overall health, having a special need creates a bigger barrier to care, legislation alone is “not going to make much of a dent,” and improvements across all fronts are needed to promote the oral health of CSHCN in Medicaid.ConclusionsCSHCN enrolled in Medicaid are just as likely as children without special health care needs to use POHC, although barriers to oral health care access persist for CSHCN.Practical ImplicationsFuture efforts should focus on comprehensive strategies that address the varying levels of dental disease risk and difficulties accessing oral health care within the diverse group of CSHCN.     

Access to care for people with special needs: role of alternative providers and practice settings

Oral Health in America: A Report of the Surgeon General released in 2000 was the first-ever surgeon general's report on the status of oral health in the United States. It clearly outlined a growing set of challenges in such areas as reducing oral health disparities, improving access to oral and dental care, and prevention of common dental diseases. Findings revealed that 75 percent of dental disease is found in 25 percent of the population. California's children have twice as much untreated decay as their national counterparts. For children with special health care needs seeing a dentist, the data is sparse but a survey of general dentists conducted in 2001 showed that only 10 percent see these children often or very often.     

Income gradients in oral health according to child age

This study aimed to confirm whether the well‐known income disparities in oral health seen over the life course are indeed absent in 9‐ to 11‐yr‐old children, and to explore the role of access to dental care in explaining the age‐profile of the income gradient in child oral health. We used data from the 2007 United States National Survey of Children's Health. Income gradients in parental reports of children's decayed teeth or cavities, toothache, broken teeth, bleeding gums, and fair/poor condition of teeth were assessed in stratified analyses according to age of child (1–5, 6–8, 9–11, 12–14, and 15–17 yr), using survey logistic regression to control for family‐, parental‐, and child‐level covariates. Health insurance status and use of preventive dental care were the indicators for children's access to dental care. The adjusted ORs for the effect of family income on having decayed teeth or cavities, toothache, and fair/poor condition of teeth were not significant in 9‐ to 11‐yr‐old children. Different age‐patterns were found for broken teeth and bleeding gums. The attenuation of the income gradients in having decayed teeth or cavities, toothache, and fair/poor condition of teeth, previously seen in 9‐ to 11‐yr‐old children, was also seen in 15‐ to 17‐, 12‐ to 14‐, and 6‐ to 8‐yr‐old children, respectively, after controlling for children's access to dental care. This study supports the attenuation of income inequalities in oral health in 9‐ to 11‐yr‐old children. Access to dental care could attenuate income gradients in oral health in other age groups.     

Increasing minority enrollment utilizing dental admissions workshop strategies

Oral Health in America, the landmark U.S. surgeon general's report, inextricably connects oral health disparities with poor access to oral care by vulnerable populations. Furthermore, the report associates an insufficiently diverse dental workforce with oral health disparities among some minority groups. Successful strategies to curtail oral health disparities and remedy work-force issues require collaboration among all involved in dental education. As gatekeepers to dental programs, admissions committees are significant stakeholders in diversifying the dental workforce. The purpose of this article is to demonstrate that a workshop on diversity in admissions can modify the perceptions of individuals involved in the student recruitment and admissions processes and lead to increased matriculation of underrepresented minority students. Emerging from the workshop were key concepts and action steps for promoting a holistic review of dental applicants. Results since implementing the workshop recommendations have been positive, with underrepresented minority dental student acceptances increasing sixfold. The workshop was cosponsored by the Robert Wood Johnson Foundation and facilitated by two nationally recognized dental educators.