1. Effects of Expanding Preventive Dental Care in Medical Offices for Young Children Covered by Medicaid Sally C. Stearns, PhD R. Gary Rozier, DDS Jeongyoung Park, PhD Bhavna T. Pahel, BDS Rocio Quinonez, DMD The University of North Carolina at Chapel Hill AcademyHealth Annual Research Meeting Orlando, Florida June 4, 2007 Supported by CDC, HRSA, NIDCR, CMS

2. Overview Basic facts: –Fewer than 1 in 5 preschool-aged children on public insurance use preventive dental care –Access exacerbated by declining dental workforce and low rate of provider participation in public insurance Repercussions –Dental decay most common preventable chronic disease among preschool children in US –Rates of decay low at very young ages but accelerate Early childhood caries rates of 1-2% in one year olds 40% of entering kindergartners in NC have had decay

3. For Want of a Dentist: Boy Dies After Bacteria From Tooth Spread to Brain Washington Post, 2/28/07 Twelve-year-old Deamonte Driver died of a toothache Sunday. A routine $80 tooth extraction might have saved him. If his family had not lost its Medicaid. If Medicaid dentists weren't so hard to find.

4. A Possible Solution: Expand the Sites of Early Preventive Care? Physicians already assess teeth and counsel parents on oral health during well-child visits North Carolina started “Into the Mouths of Babes” (IMB), a preventive dental program for Medicaid children from birth through 35 months –IMB offered in medical offices by providers who complete training regarding fluoride application and detecting disease –IMB visits include: Screening, risk assessment, counseling The application of a fluoride varnish to children’s teeth –Children can receive up to six IMB visits up to age 3

5. Study Questions How does IMB affect access to dental care for young children? –Preventive care? –Restorative care? Does IMB reduce need for restorative care? What is the cost-effectiveness of the IMB program?

6. Time Frame for IMB Implementation

7. Study Design, Data Sources, and Methods Pre-post quasi-experimental design Medicaid enrollment & claims file –3 years of claims data (2000 - 2002) –Constructed child-month records for longitudinal analysis of up to ~292,000 children Regression analyses –Controlled for child characteristics (age, gender, race), provider supply, and area characteristics (urban, fluoridation) –Access analyses: Intent to treat analysis –Effectiveness analysis: Effect of treatment among the treated

8. Access to Preventive and Restorative Care Dental Office Medical Office Visits/month per 1,000 kids

9. Why Does IMB Increase Restorative Visits? For 1000 children age 24 months: –Estimates show 6.8 children treated in absence of IMB but that 7.3 children received restorative treatment after IMB implementation Increase occurs for two reasons –Analysis during implementation phase means children with existing decay could not get beneficial effect of IMB –Training of providers leads to increased referrals

10. Will IMB Ultimately Reduce Treatments? Two part regression models used to assess effect of IMB among the treated –Likelihood of dental restoration treatments –Number of treatments conditional upon some Data for 98,411 children with no IMB treatments during study period compared to 1,472 children with 4+ IMB visits Separate estimations for anterior (front) and posterior (back) teeth

11. Effectiveness Increases with Age

12. Significant Reduction in Restorations on Anterior Teeth Effect of 0 versus 4-6 IMB Visits on Expected Dental Treatments Per 1000 Children up to Four Years of Age By Tooth Category Dental Treatments No IMB4-6 IMB Visits Reduction Percentage Reduction All Teeth16971433-26415.6% Anterior Teeth 584356-226*39.0% Posterior Teeth 598527-7011.9%

13. Is IMB Cost-Effective? Cost-savings are unlikely from IMB –Program cost (up to 6 visits) at ~$60 a visit difficult to offset –Discounting works against cost-savings –Issue of primary rather than permanent teeth But IMB may be cost-effective –Dental health is improved –Treatment cost reductions increase with age Additional data being obtained to track effect of IMB for a six year follow-up period

14. Summary and Policy Implications IMB program: –Increased access to dental care But rates of preventive care still modest –Improved health (timely treatment of existing disease) –May reduce total treatments once fully implemented Cost-effectiveness of IMB currently unknown –Program may have additional beneficial effects Increased prioritization of preventive care Could help reduce projected increases in decay and demand for dentist services