Disparities in dental service utilization among Alabama Medicaid children

OBJECTIVES: Access to oral health care and utilization of available services are important factors in minimizing the oral health disparities among underserved minorities. Our objective was to evaluate the racial and other factors related to 'realized access' to oral health care among Alabama Medicaid children. METHODS: Data were obtained from 308 538 Alabama Medicaid claims submitted in 1995-96 and analyzed using regression analyses. RESULTS: A lower proportion of Blacks (24%) and other racial groups (22%) compared to Whites (31%) and a lower proportion of 15-19-year-olds (15%) compared to younger age groups (30%) obtained dental services (P < 0.05). Odds of males obtaining care were slightly lower compared to females (OR = 0.96; 95% CI = 0.94-0.99). However, there was a significant interaction of race with other factors in determining service utilization. Subjects who were continuously eligible for Medicaid throughout the fiscal year were more likely to obtain care (OR = 2.86; 95% CI = 2.78-2.93). About one-fourth of the visits had an emergency procedure included in the treatment rendered. Availability of a participating dentist within the county of residence and the lower reimbursement-to-charge ratio were among the other related factors for underutilization of services. CONCLUSIONS: There is a significant racial disparity in utilization of dental services even among the Medicaid-eligible children. However, this was not a simple function of race, but a complex interaction of race with other factors such as age, gender, and location. ACKNOWLEDGMENT: Supported by CDC grant #U48/CCU 409679.     

The relationship between body system-based chronic conditions and dental utilization for Medicaid-enrolled children: a retrospective cohort study

Background

Dental care is the most common unmet health care need for children with chronic conditions. However, anecdotal evidence suggests that not all children with chronic conditions encounter difficulties accessing dental care. The goals of this study are to evaluate dental care use for Medicaid-enrolled children with chronic conditions and to identify the subgroups of children with chronic conditions that are the least likely to use dental care services.

Methods

This study focused on children with chronic conditions ages 3-14 enrolled in the Iowa Medicaid Program in 2005 and 2006. The independent variables were whether a child had each of the following 10 body system-based chronic conditions (no/yes): hematologic; cardiovascular; craniofacial; diabetes; endocrine; digestive; ear/nose/throat; respiratory; catastrophic neurological; or musculoskeletal. The primary outcome measure was use of any dental care in 2006. Secondary outcomes, also measured in 2006, were use of diagnostic dental care, preventive dental care, routine restorative dental care, and complex restorative dental care. We used Poisson regression models to estimate the relative risk (RR) associated with each of the five outcome measures across the 10 chronic conditions.

Results

Across the 10 chronic condition subgroups, unadjusted dental utilization rates ranged from 44.3% (children with catastrophic neurological conditions) to 60.2% (children with musculoskeletal conditions). After adjusting for model covariates, children with catastrophic neurological conditions were significantly less likely to use most types of dental care (RR: 0.48 to 0.73). When there were differences, children with endocrine or craniofacial conditions were less likely to use dental care whereas children with hematologic or digestive conditions were more likely to use dental care. Children with respiratory, musculoskeletal, or ear/nose/throat conditions were more likely to use most types of dental care compared to other children with chronic conditions but without these specific conditions (RR: 1.03 to 1.13; 1.0 to 1.08; 1.02 to 1.12; respectively). There was no difference in use across all types of dental care for children with diabetes or cardiovascular conditions compared to other children with chronic conditions who did not have these particular conditions.

Conclusions

Dental utilization is not homogeneous across chronic condition subgroups. Nearly 42% of children in our study did not use any dental care in 2006. These findings support the development of multilevel clinical interventions that target subgroups of Medicaid-enrolled children with chronic conditions that are most likely to have problems accessing dental care.     

Access to dental care in Alabama for children with special needs: parents' perspectives

BACKGROUND: Access to dental care and delivery of quality dental health services are important for children with special needs. The authors surveyed parents of children with special needs in Alabama to determine their perceptions of access and barriers to dental care for their children. METHODS: The authors sent a questionnaire to 2,057 parents of children aged 3 to 13 years with special needs--cleft lip and/or palate; cerebral palsy, or CP; spina bifida; or epilepsy/seizure disorders--who were listed in a database provided by Children Rehabilitation Services of Alabama. The authors conducted univariate and multivariate analyses to calculate odds ratios and 95 percent confidence intervals. RESULTS: The overall response rate was 38 percent (N = 714). Eighty-five percent of respondents reported that their children had received some form of routine dental care. However, 35 percent of respondents reported they had had problems finding dentists willing to treat their children. Among those with problems, significant barriers to dental care included their children's having Medicaid insurance, poor oral health or CP, as well as a shortage of dentists with training in the care of children with special needs. CONCLUSIONS AND PRACTICE IMPLICATIONS: While the majority of respondents said their children had access to dental care, one-third said their children had problems receiving this care. Many of these problems can be ameliorated. Increasing providers' participation in the Medicaid program and improving their knowledge about, empathy for and training in the care of children with special needs is essential in improving access to dental care for this population.     

Preventive dental utilization for Medicaid-enrolled children in Iowa identified with intellectual and/or developmental disability

Objectives: To compare preventive dental utilization for children with intellectual and/or developmental disability (IDD) and those without IDD and to identify factors associated with dental utilization.
Methods: We analyzed Iowa Medicaid dental claims submitted during calendar year (CY) 2005 for a cohort of children ages 3-17 who were eligible for Medicaid for at least 11 months in CY 2005 ( n  = 107,605). A protocol for identifying IDD children was developed by a group of dentists and physicians with clinical experience in treating children with disabilities. Utilization rates were compared for the two groups. Crude and covariate-adjusted odds ratios were estimated using conditional logistic regression modeling.
Results: A significantly higher proportion of non-IDD children received preventive care than those identified as IDD (48.6 percent versus 46.1 percent; P  < 0.001). However, the final model revealed no statistically significant difference between the two groups. Factors such as older age, not residing in a dental Health Professional Shortage Area, interaction with the medical system, and family characteristics increased one's likelihood of receiving preventive dental care.
Conclusion: Although IDD children face additional barriers to receiving dental care and may be at greater risk for dental disease, they utilize preventive dental services at the same rate as non-IDD children. Clinical and policy efforts should focus on ensuring that all Medicaid-enrolled children receive need-appropriate levels of preventive dental care.     

Improving utilization of preventive dental services by Medicaids-enrolled children: focus on the parents

The Access to Baby and Child Dentistry (ABCD) program was implemented in Washington State in 1995 to increase utilization of dental services for children enrolled in Medicaid. The program has increased utilization of services; nevertheless, only 54 percent of Medicaid-enrolled children in ABCD who received care were given a topical fluoride treatment. To gain a better understanding of why children may not be receiving topical fluoride treatment, we interviewed parents. Focus group research found strong parental support for preventive services. Parents were willing to take their children to regular dental visits, but lack of knowledge of benefits was common. This lack of knowledge translated into a failure to fully utilize the topical fluoride benefits. We recommend that the program continue to encourage participation of dentists, regularly update information about program benefits for both dentists and parents, and enhance the visibility of the program in the community.     

Dissatisfaction with dental care among mothers of Medicaid-enrolled children

Objectives: This paper is part of a larger study examining the impact of mothers’ having a regular source of dental care (RSDC) on utilization of dental care and oral health of their preschool children. We describe levels of satisfaction with care among mothers whose preschool children were enrolled in Medicaid in Washington State. We report mothers’ satisfaction related to having a RSDC by type of dental setting/office. Methods: Disproportionate stratified sampling by racial/ethnic group selected 11 305 children aged 3–6 in Medicaid in Washington State. Mothers (n = 4373) completed a mixed‐mode survey. Satisfaction with dental care was measured using the Dental Satisfaction Questionnaire (DSQ). Results: Overall mean DSQ was 57.1 ± 9.9 (range 18–89). A higher score indicates greater satisfaction. There was not evidence of a difference in dissatisfaction by race/ethnicity but Blacks and Hispanics were less satisfied with pain management than Whites. The majority of respondents agreed with the statement that ‘Dentists sometimes act rude to their patients.’ Satisfaction is higher for mothers who have a regular private dentist they see consistently versus having a regular dentist through a public or non‐profit clinic. Conclusions: The satisfaction with dental care for this population is low, and considerably lower than found in other studies for primary medical care. Steps need to be taken to increase dental satisfaction and access to private dental clinics, and to increase perceived quality and pain management of dental care in both private clinics and public/non‐profits serving low‐income populations.     

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.     

The impact of dental benefits on the utilization of dental services by low-income children in western Pennsylvania

PURPOSE: This study examines the impact of dental coverage provided through a health insurance program for low-income children on the use of dental services in Western Pennsylvania. METHODS: A before-after design with a control group was used. Telephone interviews were conducted with the families of newly enrolled children at the time of enrollment, at 6 months and at 12 months after enrollment. Both structured and open-ended questions were asked about the use of health care services, unmet need/delayed care and causes and consequences of unmet need/delayed care. A second group of families were interviewed 12 months after the study group was initially interviewed to form a comparison sample. The study population consisted of 750 children who were continuously enrolled in the program for 12 months and 460 comparison children. RESULTS: After enrollment, the proportion of children with a regular source of dental care increased 42%, while the proportion of those who had a preventive dental visit increased 50%. The proportion of children reporting unmet need/delayed care for dental services fell from 43% to 10%. The program had a larger impact on the use of dental services than on the use of medical services. CONCLUSIONS: The extension of dental benefits to SCHIP-eligible children in Western Pennsylvania had a positive impact on children by increasing their access to dental care and to preventive dental services.     

Inequalities in dental services utilization among Brazilian low-income children: the role of individual determinants

Objectives: To assess the role of the individual determinants on the inequalities of dental services utilization among low‐income children living in the working area of Brazilian's federal Primary Health Care program, which is called Family Health Program (FHP), in a big city in Southern Brazil. Methods: A cross‐sectional population‐based study was performed. The sample included 350 children, ages 0 to 14 years, whose parents answered a questionnaire about their socioeconomic conditions, perceived needs, oral hygiene habits, and access to dental services. The data analysis was performed according to a conceptual framework based on Andersen's behavioral model of health services use. Multivariate models of logistic regression analysis instructed the hypothesis on covariates for never having had a dental visit. Results: Thirty one percent of the surveyed children had never had a dental visit. In the bivariate analysis, higher proportion of children who had never had a dental visit was found among the very young, those with inadequate oral hygiene habits, those without perceived need of dental care, and those whose family homes were under absent ownership. The mechanisms of social support showed to be important enabling factors: children attending schools/kindergartens and being regularly monitored by the FHP teams had higher odds of having gone to the dentist, even after adjusting for socioeconomic, demographic, and need variables. Conclusions: The conceptual framework has confirmed the presence of social and psychosocial inequalities on the utilization pattern of dental services for low‐income children. The individual determinants seem to be important predictors of access.     

Access and use of specific dental services in HIV disease

OBJECTIVES: This study examined factors associated with the use of specific dental services by persons with HIV disease. METHODS: The data were derived from 1,588 adults who participated in a series of up to six interviews as part of the AIDS Cost and Service Utilization Surveys. Use of dental services such as examinations, x-rays, cleaning, fillings, extractions, root canals, crown and bridge or dentures, and periodontal procedures were evaluated using logistic regression and generalized estimating equations were applied. RESULTS: Multivariate analyses showed that medical insurance, an education beyond high school, income higher than $1,300 per month, high ambulatory visits, and receipt of psychological counseling were generally associated with higher service use. Blacks, those with an inpatient admission, and CD4+ cell counts less than 500 cells/microL were significantly less likely to use most types of dental services. CONCLUSIONS: The study concludes that disparities exist in the use of several dental services similar to those seen in the general population.     

Access to dental services for head and neck cancer patients

Dental assessment is important for patients with cancer of the head and neck who are to have radiotherapy, as many of these patients have poor dental health before they start treatment. This, compounded by the fact that radiotherapy to the head and neck has a detrimental effect on oral health, has led the National Institute for Clinical Excellence (NICE) to issue guidance that the dental health of these patients should be assessed before treatment. Unfortunately some multidisciplinary teams, such as the one at United Lincolnshire Hospitals, do not have access to a restorative dentist or a dental hygienist. In a retrospective survey we investigated access to general dental services by patients with head and neck cancer who were to have radiotherapy at our hospital and found that 37/71 (52%) had not been reviewed by a dentist within the past 12 months. A secondary national survey that investigated the availability of restorative dental and dental hygienic services showed that of the 56 multidisciplinary teams that deal with head and neck cancer in England, 19 (34%) do not have access to a restorative dentist and 23 (41%) do not have access to a dental hygienist, suggesting that this problem may be countrywide.     

Trends in toothbrushing and utilization of dental services in Finland

Abstract Prevention and control of common dental diseases highly depends on individual behavior, and during the last decades, individuals have increasingly been required to take responsibility for their own oral health. In Finland the rate of toothbrushing and dental visits were first surveyed nationwide in 1971 by interviews with a sample of 1063 individuals, drawn to represent the total population aged 15 yr and over. At the time, 68% of the 829 dentulous interviewees claimed to brush at least once a day. Using another sample of 1006 interviewees, drawn in the same manner, in 1990 the brushing rate was found to have increased to 91% 853 dentulous subjects. Daily brushing was more frequent among women (98%) than men (83%). The most distinct positive change regarding brushing frequency was found among men and those with only elementary education. In 1971 the interval between the two most recent dental visits was 1 yr or less for 44% of all the interviewees and for 25% it was more than 5 yr. In 1990, 53% of the interviewees had visited a dentist within a year and the visiting interval was more than 5 yr for 16%. The youngest subjects were the most frequent visitors: 60% of them in 1971 and 74% in 1990. The results indicate a clear trend toward more frequent brushing in Finland. However, this trend regarding dental visits does not seem to be equally remarkable.