Infants and very young children (6 months-5 years) can suffer from a significant, painful form of tooth decay known as early childhood caries or ECC. ECC affects the primary or “baby teeth” soon after they erupt and can result in extraction of teeth or extensive restorative work requiring general anesthesia. [i],[ii]
Unfortunately, many children do not receive any treatment for this condition which can negatively affect health, development and school readiness that continues on into adulthood.[iii] Alarmingly, the rates of ECC are rising but the disease itself is entirely preventable.
Primary or “baby teeth” are very important. Premature loss of baby teeth due to ECC can be detrimental to the alignment of the permanent teeth and can impair a child’s ability to chew, speak and smile during the formative years. Prevention and early detection of ECC can save children from unnecessary pain and suffering, reduce their odds of developing significant tooth decay in the future and cut health care costs associated with the expensive treatment needed in cases of advanced disease.
While the disease is still relatively unknown outside the dental community, there are proven interventions that can be coordinated to connect young children at high risk for the disease to proper services. The New York State Oral Health Coalition recommends a multi-faceted approach to preventing ECC:
- Support innovative children’s oral health prevention programs.
- Reform public insurance programs to address barriers to care.
- Develop training opportunities for medical and dental providers.
- Involve healthcare providers in child care and early education settings.
The Facts and Figures
Tooth decay, the number one chronic disease in children is entirely preventable. The oral health of New York State’s children is similar to the nation as a whole, with the most severe tooth decay found in lower income and minority children.
· In 2005, the Centers for Disease Control and Prevention (CDC) reported that the prevalence of cavities in preschoolers age 2-5 increased from 24% to 28%4 where as it decreased in all other age groups.[i]
· Decay rates in Head Start programs range from 30-40% in 3 year-olds and 50-60% in 4 year-olds. Access to oral health services is reported to be the number one health issue affecting Head Start programs.[ii]
· Low-income children in New York had more cavities (60%) than those in higher income groups at (48%).[iii]
· In 2005, 18% of preschool Head Start children in New York who received oral health exams needed treatment; 14% of Head Start children did not have a dental home (regular provider) while only 2% did not have a medical home.[iv]
· In 2005 about 4,000 3-5 year old children in New York State were operated on in a hospital or ambulatory surgical center for treatment of cavities.[v]
· On average, national state Medicaid expenditures for restorative dental care delivered under general anesthesia ranges from $1,500 to $2,000 per child.[vi]
Access to preventive services is often overlooked in the health system and dental care is no exception. In 2004, 75 cents of every dollar spent for dental services in New York was for treatment of cavities, periodontal disease, or for more involved procedures. In contrast, only 25 cents of every dollar was spent for preventive services, with over twice the number of claims filed for treatment vs. preventive services.[i] In 2006, Medicaid expenditures for dental treatment of children ages 0-5 was four times more than for preventive services, with over twice the number of claims filed for treatment vs. prevention.[ii]
The Many Barriers to Care
ral disease and unmet dental needs are more prevalent in children with limited access to services. Dental care in this population is often compromised by the lack of insurance coverage and the inability of families to pay for care out-of-pocket. Even patients with insurance find that local dentists may be unwilling to accept third party reimbursement or Medicaid. Additionally, parents often must miss work for dental appointments or to care for their sick child.
Other barriers faced by families include the lack of services in the community, not having transportation, not speaking English or having low health literacy. Parents who have not been educated on the importance of good teeth to the total health and development of their children may not seek dental care because they do not know about prevention or treatment options.
Finally, the complexity of certain dental and medical conditions or living arrangements may make it more difficult to find a dentist who can provide care. Children who are homeless, homebound, migrant, disabled, and children with special health care needs all have unique problems that further limit their access to oral health services.[i]
Access to providers remains one of the leading reasons children do not receive care. In New York, the distribution of dentists and dental hygienists is geographically uneven, with shortages existing in many rural and inner city areas.10 This creates gaps in access to care for the underserved and for children needing specialty dental services. There is also a relatively low participation rate of dentists in the Medicaid/Child Health Plus programs. Further complicating access, the number of dentists registered to practice in New York State declined almost 10% between 1997 and 2006 while the projected demand for dental professionals will increase by 3.1% for dentists and by nearly 30% for dental hygienists and dental assistants over the next ten years.13
Dental and dental hygiene schools provide a minimum level of training on management of very young children, with very little or no hands-on experience for providers entering the workforce. The number of pediatric dentists trained to treat this population is relatively small compared to those in general practice. In 2004, just over 1% of dentists in New York were pediatric dentists (202 out of 16,082).[ii] Consequently, although general dentists are often reluctant to for very young children because they are not adequately trained to treat this age group, they still treat over 75% of children in the country.[iii]
Access to providers in New York is also complicated by reimbursement policies for public health programs. For dentists, the reimbursement rate for Medicaid and Child Health Plus is relatively low. Dental hygienists are licensed to provide preventive services, education and anticipatory guidance, but cannot directly bill Medicaid for reimbursement. Innovative programs often rely on collaboration among providers, but Medicaid does not reimburse non-dental providers, such as pediatricians, for preventive dental services even if they are properly trained.
New Solutions- Integrated Delivery Systems
he good news is that ECC can be significantly reduced through targeted early intervention and education programs. The American Academy of Pediatric Dentistry, the American Academy of Pediatrics and several other professional organizations now recommend first dental visit as early as 1 year of age. A risk-based approach to dental delivery provides an opportunity to focus existing resources on children who are assessed to be the most vulnerable to dental disease due to multiple family risk factors such as low income, minority status, lack of insurance, low literacy, high-risk feeding practices, homelessness, special health care needs, etc. Studies have shown that the timely delivery of educational information to high-risk families can avoid the need for future surgical intervention.[i]
Sound nutrition and dietary practices and regular self care (oral hygiene) can be promoted by a variety of non-dental resources in an infant or child’s life. Physicians, nurses, child care and early education providers, Head Start and WIC programs can all provide oral health messages and influence healthy behaviors. Training programs have been developed to teach non-dental professionals working with families in these settings about ECC, the importance of baby teeth to overall health, good nutrition and proper tooth brushing practices. Models also exist to help child care and early education programs recruit dental staff to conduct screenings and prevention activities on site.
Community health centers can play a large role in delivery since they often provide services to children who are categorized as high risk, disadvantaged, or who have limited access to care.14 Staff in these settings can coordinate with a dental hygienist for oral health risk assessments, treatment plans and referrals for care based on the assessment. Oral health risk assessment and educational programs for expectant mothers is another successful strategy since women anticipating the birth of their new baby may be more amenable to disease prevention and health promotion interventions.[ii] Education, referrals for treatment and the connection to a dental home (regular provider) can be provided at WIC sites by obstetricians, nurses, or nutrition counselors through home visits or other public health programs.
Primary care physicians and pediatricians can also play a key role in oral health since children are scheduled to have a total of 12-15 well child care visits between birth and age 3.[iii] These visits provide an ideal opportunity to incorporate preventive dental services into medical visits. Models for state-wide, integrated oral health delivery systems exist in Washington, North Carolina, Connecticut and other states. [iv] In the North Carolina project, almost 1,600 medical providers were trained in the first year and preventive dental services increased 300%.[v] This success can be attributed to the collaborative effort of medical and dental providers offering preventive dental services for children (risk assessment, screening and referrals, fluoride varnish application and caregiver counseling). This is just one example of a successful prevention program administered by pediatricians, physician assistants and nurses in a non-dental setting.
There are also national reforms such as the Head Start Dental Home Initiative, a partnership between the Office of Health Start and the American Academy of Pediatric Dentistry (AAPD). This partnership was created to ensure that Head Start children throughout the country are linked with a dental home; a source of comprehensive, continuously assessable coordinated and family-centered oral health care consistent with the AAPD policy “Oral Health Risk Assessment Timing and Establishment of a Dental Home.”17
Next Steps and Reccomendations
arly detection, education and preventive treatment can significantly reduce the incidence of ECC, improve overall health and change oral health behaviors of families. By bringing dental and medical providers together with those who serve the educational needs of young children, ECC can be identified and treated early to reduce the need for more expensive treatment. Reforms that include cavity risk assessment, education, prevention and treatment involving all stakeholders in pediatric health care can reduce barriers to care and improve access to preventive services for infants and very young children. These efforts will ensure that young children have healthier teeth and go on to lead healthier lives.
The New York State Oral Health Coalition proposes that New York adopt these recommendations:
1. Support innovative children’s oral health prevention programs:
· Provide oral health evaluations and education programs for children and families in WIC and Head Start programs;
· Develop a unified system to coordinate dental care through Head Start, WIC and other safety net programs; and
· Encourage use of fluoride varnish and other interventions in these non-traditional settings as fluoride is proven to be effective in significantly reducing cavities.
2. Support reforming public insurance programs to improve access to prevention and treatment:
· Identify reimbursement strategies and financial support for collaborations (i.e., pediatric health team) between Pediatricians, Family Practitioners and General/Pediatric Dentists to establish a dental home, especially for high risk children by age one;
· Expand Medicaid reimbursement policies to include all health care professionals (medical/dental) with proper training to include an annual oral health assessment and fluoride varnish application 3 times/year, with an enhanced reimbursement rate for preventive services;
· Include dental hygienists as recognized providers under Medicaid and support collaborative agreements with dentists to expand access to screening and preventive services; and
· Identify reimbursement strategies that would make it easier for child health care providers to participate as members of the dental team.
3. Develop training opportunities for medical and dental providers:
· Institute pediatric oral health education and training programs for physicians, nurses, physician’s assistants, dentists and registered dental hygienists; and
· Garner support from dental and dental hygiene schools, hospitals and Article 28 facilities to increase competency of dental/dental hygiene students by including advanced training on infant/pediatric oral health and dentistry, including treatment of children with special needs.
4. Involve providers in child care and early education settings:
· Provide information and resources so all early care and education providers have the tools needed to identify high-risk children and assist with enrollment in Child Health Plus;
· Create referral programs that provide educators and parents with information on where they can obtain dental services; and
· Fund demonstration projects that bring dental providers to early childhood educational settings for screening and preventive services.
Additional information on early childhood caries can be found at www.nysohc.org
or contact the NYS Oral Health Technical Assistance Center,
259 Monroe Ave., Rochester, NY 14607, (585) 325-2280 ext 315, nysohc@oralhealthtac.org
The New York State Oral Health Coalition is a membership organization
dedicated to improving the oral health of all New Yorkers.
[i] American Academy of Pediatric Dentistry. Guideline on Infant Oral Health Care.
Reference Manual, Vol 29: 7, 2007-2008.
[ii] Kumar J and Samelson R. eds. Oral Health Care during Pregnancy and Early Childhood. Practice Guidelines. New York State Department of Health, Bureau of Dental Health. Albany, NY, 2006.
[iii] American Academy of Pediatrics. Recommendations for Preventative Pediatric Health Care, Committee on Practice and Ambulatory Medicine. Pediatrics 2000;105(3) 645-646.
[iv] Douglass J, Douglass A, Silk H. Infant Oral Health Education for Pediatric and Family Practice Residents. Pediatr Dent. 2005;27(4):284-91.
[v] Rosier RJ, Sutton BK, Bawden JW, Haupt K, Slade GD, King RS. Prevention of Early Childhood Caries in North Carolina Medical Practices: Implications for Research and Practice. J Dent Educ 2003;67(8): 876-885.
[i] New York State Department of Health. Oral Health Plan for New York State. Albnay, NY, 2005.
[ii] U.S. Department of Labor, Bureau of Labor Statistics; Occupational Employment Statistics, 2004.
[iii] Crall, J. Development and Integration of Oral Health Services for Preschool-age Children, Pediatr Dent 2005;27:323-330.
[i] Center for Disease Control, Morbidity and Mortality Weekly Report: Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism and Enamel Fluorosis-U.S., 1988-1994, 1999-2004, August 2005.
[ii] American Academy of Pediatric Dentistry. The Head Start Dental Home Initiative. Partnering to Provide Dental Homes and Optimal Oral Health for Head Start Children Throughout the U.S. Available at http://www.aapd.org/members/headstart/files/January2008HS.pdf.
[iii] New York State Department of Health. Oral Health Status of Third Grade Children. New York State Oral Health Surveillance System, Albany, NY, 2005.
[iv] Head Start Program Information Report for the 2004-2005 Program Year. Health Services Report. New York.
[v] New York State Department of Health. 2005 SPARCS Data. Albany, NY.
[vi] Kanellis MJ, Damiano PC, Momany ET. Medicaid Costs Associated With Hospitalization of Young Children for Restorative Dental Treatment Under General Anesthesia. Journal of Public Health Dent 2000;60(1): 28-32.
[i]Griffen SO, Gooch BF, Beltran E., Sutherland JN, Barsley R. Dental Services, Costs, and Factors Associated with Hospitalization for Medicaid-Eligible Children, Louisiana 1996-97. Journal of Public Health Dentistry 2000; 60: 21-7.
[ii] Grindefjord M, Daahllof G, Modeer T.,Caries Development in Children, a Longitudinal Study: Caries Res 1995;(29:449-54).
[iii] National Maternal and Child Health Resource Center; Promoting Awareness, Preventing Pain: Facts on Early Childhood Caries.