Children’s Oral Health & Dental Care

1. 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 9-18-03

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

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

4. 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 Project

5. Context: Growing Policy Concern Evidence of Governmental Interest • Federal reports SG Oral Health in America, NationalCall 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 Project

6. 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 Project

7. Context: Why Oral Health is of Concern to Policymakers Because • Constituent complaints • Press visibility (see NewsBytes at www.cdhp.org) • 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 Project

8. 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 Dental Health Project

9. Children’s Oral Health & Dental Care Status

10. 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 Project

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

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

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

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

15. Disease Burden 1 in 2 2nd graders have obvious tooth decay 1 in 5 preschool children have obvious tooth decay HP 2010 Children's Dental Health Project

16. Disease Disparity by Race Fastest growing population has worst disease Children's Dental Health Project

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

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

19. 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 Project

20. Dawn – Awaiting Free MOMs Dental Care 2003 Children's Dental Health Project

21. Action to Improve Children’s Oral Health & Dental Care

22. 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 goalassessment. Children's Dental Health Project

23. 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 Project

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

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

26. Children’s Dental Health Project Application of Framework • Collaborate: Develop effective, active, local coalitions • Perceptions: • Inform and engage public & private policymakers, advocates, business, faith organizations, academics, health/social providers • 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 • Science: • Implement risk-based interventions & timely disease management • 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 Project

27. Current Policy Threats to Children’s Dental Care Children's Dental Health Project

28. 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 Project

29. “Opening the Mouth” MCHB Study Children's Dental Health Project

30. Opening the Mouth ProjectColumbia University Goal To assess and enhance “continuing education and development” (CDE) of MCH professionals on children’s oral health Components • Assess MCH oral health CDE opportunities • Assess MCH professionals’ needs for CDE on children’s oral health • 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 Project

31. Visit us at www.cdhp.org! Children's Dental Health Project

32. 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 Children's Dental Health Project