Children’s Oral Health & Dental Care Burton L. Edelstein DDS MPH Children’s Dental Health Project, Washington DC Columbia University, New York NY CityMatCH/NACHO PIC Tele-Conference

Children's Dental Health Project2 Charge Provide overview of 1.Children’s Oral Health & Dental Care Status 2.Action to Improve Children’s Oral Health & Dental Care 3.Current Policy Threats to Children’s Dental Care 4.“Opening the Mouth” MCHB Study

Children's Dental Health Project3 Understanding Children’s Oral Health: As Simple as Counting the Black Dots

Children's Dental Health Project4 Context: Oral Health - an MCH Policy Concern Oral Health is a uniquely MCH Issue –By Prevalence: Caries (tooth decay) is the single most prevalent disease of childhood – 5X asthma Caries affects 1-in-5 preschoolers, 1-in-2 second graders An estimated 5 Million children suffer severe, symptomatic dental disease that can disrupt normal daily activities –By Biology: Caries is an infectious & transmissible disease caused by bacteria acquired by children typically from their mothers before age two years –By Importance: Maternal oral disease (periodontitis) is related to unfavorable birth outcomes (Prematurity, LBW) –By Cost/Effectiveness Both pediatric and maternal oral diseases and their consequences can be markedly reduced through relatively low-cost interventions

Children's Dental Health Project5 Context: Growing Policy Concern Evidence of Governmental Interest –Federal reports SG Oral Health in America, National Call to Action Healthy People 2010 –Congress GAO reports, Federal legislation, Hill Hearings, Staff briefings –State Houses NGA Policy Academies, NCSL legislative support, State Summits, ASTHO/ AMCHP/ NASMD/AMCHP activity –Federal Agencies NIH Disparity Centers, HRSA Oral Health Initiative, AHRQ Studies, CDC programs, CMS demonstrations

Children's Dental Health Project6 Context: HRSA/MCHB Concern HRSA/MCHB Oral Health Programming –Oral Health Policy Center at Columbia University –Cooperative Agreement with Association of State and Territorial Dental Directors –National Oral Health Resource Center at Georgetown –New state grant program –Partnerships in Program Planning for Adolescent Health (PIPPAH): Awesome Smiles –Community Integrated Services Systems: Filling the Gaps, Interfaces –Title V Sealant measure –MCH Continuing Education: Opening the Mouth –Support for State Summits

Children's Dental Health Project7 Context: Why Oral Health is of Concern to Policymakers Because –Constituent complaints –Press visibility (see NewsBytes at –Strong data with negative trends –Advocates’ activity –Racial and income disparities –Oral Health/Dental Care is best and worst case Best in public health (fluoridation), past health improvement trends, primary care focus, perceived quality Worst in coverage, unmet need, prevalence of preventable disease, degree of disparity

Children's Dental Health Project8 Players  Federal and State Government MCH agencies and officials keenly aware of dental problems  State Conversion Health Foundations Almost always identify “dental” & “mental” as top two issues  National Health Foundations GIH brief, WKKF Community Voices, RWJF Pipeline & State Initiatives, Kaiser dental stories  Child & Health Advocates National & State level coalitions, Legal Aid  National & Local Press Print & Broadcast: dental focus & inclusion in health pieces  Organized Dentistry

Children’s Oral Health & Dental Care Status

Children's Dental Health Project10 Facts at a Glance Coverage: 2.6x more children have no dental insurance than medical insurance Unmet needs: 3x more parents report unmet needs for dental than medical care Disease prevalence: caries is 5 times more prevalent than asthma Medicaid access: Children in EPSDT are 3-4 times more likely to obtain medical than dental care Disease burden: 1-in-5 preschoolers and 1-in-2 second graders have visible tooth decay Disparities: Low income preschoolers have twice the caries experience as high income preschoolers but obtain care half as often

Children's Dental Health Project11 Coverage CDC NHIS Data 2.6 X more children lack dental than medical coverage

Children's Dental Health Project12 Unmet Need CDC NHIS data Parent-reported unmet need is 3X greater for dental than medical care

Children's Dental Health Project13 Leading Health Problem Dental caries is 5 times more common than asthma CDC NHIS data

Children's Dental Health Project14 Poor Access by Medicaid Kids CMS Data 3-4X more children in Medicaid access medical care than dental care

Children's Dental Health Project15 Disease Burden HP in 5 preschool children have obvious tooth decay 1 in 2 2 nd graders have obvious tooth decay

Children's Dental Health Project16 Disease Disparity by Race Fastest growing population has worst disease

Children's Dental Health Project17 Disease Disparity by Income Low-income young children have double the decay experience… NHANES III data

Children's Dental Health Project18 Treatment Disparities …. But only half as much dental care

Children's Dental Health Project19 Anecdotes Make It Real Wrap around health center lines e.g. Medicaid Commissioner Bob Smedes prior to MI reform Complaints at town meetings e.g. Senators Collins & Feingold prior to Safety Net Amendments Personal Observation / Response to Local Dentist e.g. Senators Bingaman and Cochran prior to Children’s Dental Improvement Act; Secty Shalala prior to Surgeon General’s Report Home institutions e.g. Senator Edwards prior to Children’s Perinatal Dental Health Improvement Act Personal Clinical Experience e.g. HRSA Administrator Earl Fox prior to HRSA/CMS Oral Health Initiative VA and KS “Missions of Mercy”

Children's Dental Health Project20 Dawn – Awaiting Free MOMs Dental Care 2003

Action to Improve Children’s Oral Health & Dental Care

Children's Dental Health Project22 Requirements for effective action: WWWWWH Who : Working, active, regular, ongoing coalitions Strong, visible, empowered ($) leadership What: First: Assess capacities and needs Then: Plan  Implement  Evaluate  Refine Where: Defined locale & population When: As soon as “Who What Where” are known Why: Because it matters, is important, & is doable How: By targeting a clear, measurable, meaningful, and widely accepted goal Essential ingredient Relentless effort by many interests inspired by demanding leadership & tied to ongoing goal assessment.

Children's Dental Health Project23 Inherent Constraints Workforce Declining availability of dentists (numbers, distribution, Medicaid participation) Unrealized potential of hygienists as disease managers No mid-level provider analogous to NP or PA Minimal engagement of non-dental personnel Safety net Small, fragile, understaffed, rarely geared to young children Financing Medicaid, SCHIP, school-based, & public health delivery programs are under-funded & often threatened by policy changes/budgets Prevention/Health Promotion Inadequate development & implementation of risk-based care Minimal adoption of Bright Futures & other guidelines Insufficient attention to key age group – infants and toddlers

Children's Dental Health Project24 A Core Constraint: Chronically Inadequate Financing Source: JJ Crall 2001 Total Dental Spending in US Medicaid Dental spending

Children's Dental Health Project25 SG Framework for Action US Surgeon General’s 5 Action Steps 1.Address perceptions about oral health & dental care 2.Address barriers/ replicate successes 3.Build & apply science 4.Increase workforce capacity 5.Collaborate

Children's Dental Health Project26 Children’s Dental Health Project Application of Framework 1.Collaborate: Develop effective, active, local coalitions 2.Perceptions: –Inform and engage public & private policymakers, advocates, business, faith organizations, academics, health/social providers 3.Remove Barriers: –Address financing: Improve financing by replication, negotiation, advocacy, litigation, experimentation –Address systems of care: e.g. Engage case management, link to existing venues & programs 4.Science: –Implement risk-based interventions & timely disease management 5.Workforce: –Increase safety net capacity through public-private contracting –Expand clinical and sociocultural competencies –Engage non-traditional providers –Address numbers, distribution, diversity, composition, competencies

Children's Dental Health Project27 Current Policy Threats to Children’s Dental Care

Children's Dental Health Project28 Policy Threats Adult dental cuts: Rapidly eroding coverage HIFA ( Health Insurance Flexibility & Accountability1115 Medicaid Waivers ) : UT EPSDT Dental Cap SCHIP losses in elective care: TX Cuts Block Granting: Head Start Precedent? Medicaid Reform: EPSDT Threat? Budgets: Endangered MCH Dental Programs?

Children's Dental Health Project29 “Opening the Mouth” MCHB Study

Children's Dental Health Project30 Opening the Mouth Project Columbia University Goal To assess and enhance “continuing education and development” (CDE) of MCH professionals on children’s oral health Components 1.Assess MCH oral health CDE opportunities 2.Assess MCH professionals’ needs for CDE on children’s oral health 3.Develop web-based CDE materials on children’s oral health for MCH professionals Partners AMCHP, CityMatCH, ATMCH, Mailman School Request Tell us what you need and want in CDE on children’s oral health by responding to our upcoming electronic survey

Children's Dental Health Project31 Visit us at

Children's Dental Health Project32 Thanks to CityMatCH, NACCHO, and Each of You For Engaging CDHP in your efforts to improve the Health and Welfare of Children Throughout our Country