Tuesday, February 3, 2015

Children SmilingEvery February, the American Dental Association (ADA) sponsors National Children’s Dental Health Month. Developing good habits at an early age and scheduling regular dental visits helps children get a good start on a lifetime of healthy teeth and gums, and works to circumvent tooth decay.

Tooth decay affects U.S. children more than any other chronic infectious disease; it is five times more common than asthma yet is largely preventable. Between 41% and 55% of children ages 2–11 years suffer tooth decay, and more than 34% of this decay is untreated. Consequences of untreated decay can affect development and quality of life and can eventually develop into detrimental and costly long-term effects.1

Nearly half of all children entering kindergarten have had at least one cavity. While prevalence has significantly decreased in recent years among most children, tooth decay is becoming more frequent among those ages 2–5 years. Those “baby teeth” are important: A healthy mouth helps children eat, speak, learn, and play without pain.2 The ADA urges parents to make sure their children brush twice daily with fluoride toothpaste, floss daily, eat a balanced diet, and see their dentist regularly to address tooth decay in its earliest stages.3

Why It Matters

Tooth decay is caused by a bacterial disease (dental caries) that can spread from person to person. Children with cavities in their primary (baby) teeth are three times more likely to develop cavities in their permanent (adult) teeth. The early loss of baby teeth can make it harder for permanent teeth to grow in properly.4 As a result of the increasing prevalence of early childhood caries, Healthy People 2020 revised the nation’s oral health objectives, setting more aggressive goals to reduce dental caries and untreated dental decay in young children through prevention and early detection.5

The Centers for Disease Control and Prevention has dubbed the disparity in children’s oral health “profound.”6 As much as 80% of tooth decay is experienced by only 20%–25% of the population, with children from the lowest socioeconomic groups experiencing issues at significantly higher rates and at younger ages.

Sources of Care

The American Academy of Pediatric Dentistry (AAPD) recommends that the first dental visit occur within 6 months of the appearance of the first tooth and no later than the child’s first birthday.7 However, national data indicate that the majority of young children (2–5 years) do not receive the recommended dental visits.8 In some areas of Michigan, as few as 25% of children have seen the dentist in the past year.9 A number of factors contribute to this discrepancy in accessing care, including lower reimbursement rates, administrative burden, and experience with a high number of appointment no-shows.10, 11

Few general dentists treat children younger than 4 years old.12 In a survey conducted among general dentists in Michigan, 74% of providers are aware of the AAPD recommendations, yet only 36% recommend that their own patients begin routine dental care at age 1.13

Given the low rates of dental visits, oral screening and parental counseling about oral health care for young children may need to come from other child health providers. Engaging in this effort to improve children’s oral health, the American Academy of Pediatrics recommends that children begin receiving oral health risk assessments by 6 months of age by a pediatrician or a qualified pediatric health care professional and has incorporated oral health into its Bright Futures periodicity schedule for pediatric well care.14

Healthy Kids Dental

Michigan has its own unique initiative to address barriers to dentists’ acceptance of Medicaid-enrolled children, the Healthy Kids Dental program, implemented by the Michigan Department of Community Health. It is a public-private partnership with Delta Dental of Michigan managing the dental benefit for Medicaid enrollees ages 0–21 years. This managed care dental service delivery model reimburses providers at significantly higher rates than traditional Medicaid and utilizes an administrative mechanism identical to that of private insurance. As a result, Healthy Kids Dental has increased dental provider participation in Medicaid and resulted in greater utilization of dental care for children in Michigan. Initially implemented in 2000 in 22 counties, Healthy Kids Dental has expanded to 80 of Michigan’s counties, serving more than 600,000 of children insured by Medicaid. However, within these achievements, challenges remain in reaching the youngest children and in expanding the Healthy Kids Dental program to Michigan’s most populous counties (Kent, Oakland, and Wayne) and more than 400,000 children who would be eligible.

Augment What Is Working

Altarum, in collaboration with Delta Dental of Michigan, the University of Michigan School of Dentistry, and the Michigan Department of Community Health, is working on a comprehensive and innovative program to reduce the burden of childhood dental disease. The recently implemented Michigan Caries Prevention Program specifically targets the 1 million Michigan children insured by Medicaid/MIChild to bring about sustained, systemwide improvement in children’s oral health. This collaborative dental project aims to increase the number of children receiving preventive oral health services and advance best practices in both the medical and dental community.

The Centers for Medicare & Medicaid Services data for 2000–2012 show that children’s utilization of preventive dental services increased from 23% to 42% and their access to treatment services grew from 15% to 23%, indicating that a higher proportion of children are receiving dental care but a significant challenge remains.15 While the overall increase of all dental services from 29% to 48% is a tremendous step forward, it remains a concern that more than half (52%) of Medicaid-enrolled children are still not receiving dental care.

At the same time, many Michigan dentists take it upon themselves to donate care for disadvantaged individuals, whether out of a sense of professional service to the community, a feeling that Medicaid funding is inadequate, a desire to avoid the administrative burden, or a combination of all three. According to a 2012 survey released by the Michigan Dental Association, 88% of the 990 dentists who were surveyed report that they donate an average of $45,000 in care annually to uninsured and underinsured adults and children. An additional $17,000 in care is donated by staff members at their practices.16 While this is admirable, it is not a sustainable solution to accessing appropriate care.

Young patients typically see a physician eight times before visiting a dentist.17 The Michigan Caries Prevention Program is building tools to support medical providers in the provision of evidence-based best practices, supporting the expert guidelines for children’s oral health care. The comprehensive and free direct-to-provider technical assistance will support the improvement of the flow of patients (and information) between medical and dental providers. The program will put in place the technology infrastructure needed for value-based care and quality improvement in dentistry that can be expanded to other states, leading the way for medical and dental providers to engage in sustained, systemwide improvement in health care delivery. Recruitment of providers into the Michigan Caries Prevention Program is set to begin in May 2015.

This February: Think Teeth

As mentioned previously, tooth decay is caused by a bacterial disease that is transmissible from person to person, including mother to child. Higher caries prevalence in mothers was significantly associated with increased risk of caries in children.18 Simple changes such as not sharing bites of the same food or using the same utensils, maintaining a healthy diet, brushing teeth, and flossing daily can make a difference in the lives of children and reduce their risk of developing decay. Establishing a dental home is key to starting good behaviors early and to having a place for the child to seek appropriate emergency oral care if needed, rather than seeking help via a costly emergency department visit.1

National Children’s Dental Health Month is a time to be conscious of oral health. Schedule a checkup with your dentist. Encourage loved ones to do the same, especially for their youngest children. In tandem with the comprehensive efforts of the many engaged, talented organizations working to improve children’s oral health, simple changes in our individual health behaviors can help shift the system of oral health care from treatment to prevention and work to eliminate this “silent epidemic.”

Find out the latest NCDHM news on http://ada.org/ncdhm, view the MCPP project page, or follow the conversation on Twitter at #ncdhm.

CMS Disclaimer: This project described was supported by Grant Number 1C1CMS331321 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.


  1. Pew Charitable Trusts. (2012, February). A costly dental destination. Retrieved from http://www.pewtrusts.org/~/media/Assets/2012/01/16/A-Costly-Dental-Destination.pdf.
  2. Children’s Dental Health Project. (2014, April 26). Early childhood caries (ECC). Retrieved from https://www.cdhp.org/resources/312-early-childhood-caries-ecc.
  3. American Dental Association. (2014). American Dental Association. Retrieved from http://www.ada.org/.
  4. Centers for Disease Control and Prevention. (2014, December 16). Dental caries. Retrieved from http://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html.
  5. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2015). Healthy People 2020. Retrieved from https://www.healthypeople.gov/.
  6. Centers for Disease Control and Prevention. (2013, July 1). Oral health disparities. Retrieved from http://www.cdc.gov/OralHealth/oral_health_disparities/.
  7. American Academy of Pediatric Dentistry. (2013). Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Retrieved from http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf.
  8. U.S. Government Accountability Office. (2008, September). Extent of dental disease in children has not decreased, and millions are estimated to have untreated tooth decay. Retrieved from http://www.gao.gov/new.items/d081121.pdf.
  9. Finlayson, T., Siefert, K., Ismail, A., & Sohn, W. (2007). Psychosocial factors and early childhood caries among low-income African American children in Detroit. Community Dentistry and Oral Epidemiology, 35(6), 439–448.
  10. Vargas, C., & Ronzio, C. (2006). Disparities in early childhood caries. BMC Oral Health, 15(6 Suppl 1), S3.
  11. Fisher, M., & Mascarenhas, A. (2007). Does Medicaid improve utilization of medical and dental services and health outcomes for Medicaid-eligible children in the United States? Community Dentistry and Oral Epidemiology, 35(4), 263–271.
  12. Neale, N., & Casamassimo, P. (2003). Access to dental care for children in the United States: A survey of general practitioners. Journal of the American Dental Association, 134(12), 1630–1640.
  13. University of Michigan, Child Health Evaluation and Research Unit. (2014). Oral health needs assessment for Michigan children 0–5 years. Retrieved from http://www.chear.org/oral-health-needs-assessment.
  14. American Academy of Pediatrics. (2014). Recommendations for preventive pediatric health care. Retrieved from http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf.
  15. Steinmetz, E., Bruen, B., & Ku, L. (2014, October). Children’s use of dental care in Medicaid: Federal fiscal years 2000–2012. Retrieved from http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/downloads/dental-trends-2000-to-2012.pdf.
  16. Kent County Oral Health Coalition. (2013, October). Kent County oral health exam. Retrieved from http://firststepskent.org/wp-content/uploads/2014/02/final-2013-Kent-County-Oral-Health-Exam.pdf
  17. American Academy of Pediatrics. Children’s oral health. Retrieved from http://www2.aap.org/commpeds/dochs/oralhealth/index.html.
  18. Reisine, S., Tellez, M., Willem, J., Sohn, W., & Ismail, A. (2008). Relationship between caregiver’s and child’s caries prevalence among disadvantaged African Americans. Community Dentistry and Oral Epidemiology, 36(3), 191–200.

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