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Oral Health Meets State Health Policy: The Case of Young Children



Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Burton L. Edelstein DDS MPH

Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Burton L. Edelstein DDS MPH



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    Oral Health Meets State Health Policy: The Case of Young Children Oral Health Meets State Health Policy: The Case of Young Children Presentation Transcript

    • Oral Health Meets State Health Policy: The Case of Young Children NASHP Meeting October 2007 Burton L. Edelstein DDS MPH Professor of Dentistry and Health Policy & Management, Columbia University Founding Director, Children’s Dental Health Project, Washington DC
    • An organ of – Digestion – Respiration – Communication – Protection – (Sex)
    • Facts Speak for Themselves: Need • Tooth decay is most prevalent disease of children in US – 28% of 2-5 year olds have caries experience. Of those, 72% have untreated disease. • Tooth decay is localized in a small subset of children - those with least access to care – 80% of cavities are in 25% of children of whom ~30% get care in a year • Children with special healthcare needs have high levels of dental disease – 73% of parents of CSHCN who report unmet treatment need report that need as dental (25% of all parents of CSHCN report unmet need for dental care)
    • Facts Speak for Themselves: Care • Unmet dental needs are consequential to children – An estimated 3-4 million children in the US each day have difficulty eating, sleeping, attending to learning, or simply playing nicely with others due to dental pain • Dentists are uniquely qualified to care for children who have significant disease or complications yet few use their training to do so – Typically fewer than 25% of dentists provide care to children in Medicaid • Traditional dental treatment has an excessively and unacceptably high failure rate yet hasn’t changed in concept in the 60 years since the specialty of pediatric dentistry was founded – 40% of children treated for ECC in the OR have recurrence within two years
    • Facts Speak for Themselves: Sequelae • Children and parents lose educational and work productivity because of dental problems. – In the US, children miss x# of school days and parents y# of work days while tending to dental emergencies that could have been prevented • Children die from consequences of ordinary tooth decay. – On average, each year x# of children die from infections that originate as cavities and y# die during dental treatment • The leading reason that new military recruits in the US cannot be deployed is dental problems from tooth decay. – 42% of new recruits to the US Army are “Class III” dental classification upon enlistment
    • ECC Definition & Implications 1. Definition of Early Childhood Caries ECC = any decay in children under six American Academy of Pediatric Dentistry SECC (severe form) = more teeth. 2. Common: ECC 28%+ SECC 5-10% 3. Disparately Distributed: concentrated in low-income children covered by Medicaid/SCHIP, in WIC, HS 5. Nature: virulent, rapid, progressive, painful The Fine Print The So What 7. Consequential: Dentition: Predicts future cavities for life Child: Pain, infection, dysfunction, mood Family: Lost work, cost, stress Community: Loss of performance and productivity; taxing educational & social services Society: Costly in $ and lost productivity
    • Dental Disease Burden US 2-5 year olds 50% 45% 40% 35% 28% 30% 24% 25% 20% 15% 10% 5% 0% 1988-1994 1999-2002 HP 2010
    • Disease Disparity by Race 1.80 1.60 Fastest Growing Population Has Worst Disease 1.40 decayed teeth (dft) x 5 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Overall White Black Hispanic
    • Disease Disparity by Income 1.60 1.40 decayed teeth (dft) x 5 1.20 <200% FPL has 1.00 2X the disease 0.80 0.60 0.40 0.20 0.00 Overall 0- 101-200% 201-300% >300% 100%FPL FPL FPL FPL NHANES III data
    • ECC is Concentrated in Low- Income Medicaid-Eligible Children • 2-5 year olds above 133% of poverty with 12% cavities • 2-5 year olds below 30% 133% of poverty with cavities
    • Treatment Disparities by Income Percent Children with Visit 30.00% 25.00% 20.00% <200% FPL has 15.00% ½ the visits 10.00% 5.00% 0.00% 0-200% FPL 200-400% FPL
    • Harmful Feeding Practices % Preschoolers Exposed to Harmful Feeding Practices 70% 60% 50% 40% 30% 20% 10% 0% Overall Minority Low Education Mothers
    • CDC 2007 Prevalence Report • Caries prevalence in 2-5 year olds is 28%: – over 4 million affected – few 2yo’s affected, therefore prevalence at 5 > 28% • Caries in 2-5 year olds increased 15.2% – additional 600,000 affected • Reasons for increase – Putatively demographic change; Dietary mores change • Concentrated in minority & low-income kids – Combined with demography predicts uptrend – Combined with cariology predicts long term burden
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    • The Nature of ECC: An Extreme Form of Caries 1. ECC is a disease 2. ECC is infectious 3. ECC is transmissible within families when children are infants or toddlers 4. ECC is diet dependent 5. ECC is fluoride mediated 6. ECC is progressive and destructive but reversible 7. ECC is consequential to children’s & families’ lives 8. ECC is highly prevalent among toddlers 9. ECC is inequitably distributed 10. ECC is little affected by dental repair
    • ECC Risk Factors – Early infection with “cariogenic” bacteria – High frequency carbohydrate ingestion – Lack of exposure to fluorides
    • ECC Traditional Treatment
    • When dentists see these…
    • And find this…..
    • They typically think this….
    • And plan this…..
    • And it would be a success…. If it worked to stop disease progression (But it generally doesn’t)
    • Non-Traditional Disease Management
    • Arrested Disease
    • Arrested Disease
    • Children Do Not Exist in a Vacuum P Newacheck Pediatrics 2006
    • Caries is determined at multiple levels Tooth Mouth Child Family Community Society
    • Professional Leverage  Successfully engaging a family in positive oral health behaviors will do more for a child’s oral health than anything that can be done clinically.  Successfully engaging a community and its professionals in promoting oral health will do more than helping a single family.  Successfully engaging policymakers who control society’s resources will do more than engaging a community and its professionals.
    • Promoting All Young Children’s Oral Health 1. Working successfully with others: policymakers, organized dentistry, press, educators, physicians, advocates, CBOs, faith groups... 2. Leadership: Taking visible responsibility for an issue that resonates with the public 3. Advancing public policies: 1. Coverage 2. Licensure & Workforce 3. Program integration 4. Safety net & Partnering 5. Public & Professional Education 6. Prevention 7. Perinatal care with pediatricians
    • Specific State Policy Approaches • Ensure adequate coverage – Ensure dental benefit all young children - best ROI from prevention • SCHIP, State Expansions, in employer mandates & incentives – Update periodicity schedules to include “age 1 dental visit” • Consistent with American Academies of Pediatrics & Pediatric Dentistry – Start early by requiring oral health counseling at birth • Language in “Child Health Insurance Program Reauthorization Act of 2007” – Experiment with risk-based care and disease management • DRA allowances – Prioritize Medicaid payments to children under six and then phase in as prevention provides dividends • Rhode Island experiment • Incentivize performance – Incentivize specially trained providers for early care • RI Medicaid reform, WA “Access to Baby and Child Dentistry” – P4P volume incentives • Designated key practices – Incentive vendors for quality & timeliness of ECC management • Catalyst Institute ECC management experiment in New England
    • Specific State Policy Approaches • Build Systems of Care – Engage MDs in first level screening, prevention, counseling, and referral – Connect Head Start, WIC, early childhood programs with dental care – Apply “perinatal network” and “community integrated service systems” approaches to dental adequacy – Facilitate contracting between health centers and private dentists – Require state-sponsored dental schools to expand curriculum in caries risk assessment, prevention, and management – Experiment with new midlevel dental providers; consider analogs to the certified diabetes educator and the promotore • Leverage licensure – Require “PGY1” training for all dentists and include training in young child care – Add dental & dental hygiene licensure requirement in ECC diagnosis & treatment – Add dental requirement to day care licensing
    • Specific State Policy Approaches • Engage the public – Frame the issue as a core health, education, development, and public good issue in subgroup-appropriate (language, culture, opportunities) way – Partner with traditional and nontraditional entities to get the word out in unanticipated venues – Use multiple new media as well as traditional media – Provide warning labels for baby bottles distributed by drug stores, children’s stores, fast food outlets, health fairs, day care centers etc – Promote proper use of fluorides • Manage the effort – Empower your MCH agency to lead a public-private initiative on ECC with public education, clinical intervention, provider training, financing, and policymaking components – Develop an ECC-specific state oral health plan with defined time-framed objectives and specified responsibilities. – Require a time-specified report to the legislature or governor
    • For more information… Children’s Dental Health Project 2001 L Street NW, Suite 400 Washington DC 20036 202 833 8288 www.cdhp.org, ngralla@cdhp.org Nancy Gralla MPH, Executive Director Meg Booth MPH, Director of Governmental Affairs Jessie Buerlein MSW, Program Manager Perinatal & Infant Oral Health Marci Frosh JD, Program Manager Building State Infrastructure Burton Edelstein DDS MPH, Chair