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