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The state of Little Teeth: Answers About the ACA and Access to Care for Children by Paul Casamassimo, DDS, MS

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To address the nationwide threat to children's health posed by dental caries, the American Academy of Pediatric Dentistry (AAPD) recently introduced its first-ever "The State of Little Teeth Report," exploring key issues related to the oral health of children.

The report draws on the latest scientific research and best available expertise to examine the public-health crisis of tooth decay among young children in the United States, including a look at the impact of the Affordable Care Act (ACA) on children's oral health. In addition to examining the problems and their causes, the report explores what can be done to solve the crisis. This article distills much of the information in the report to explain the current status and the challenges ahead to conquer early childhood caries (ECC).

True or false?
The addition of pediatric dental coverage to the ACA will solve the access-to-care problem. It is too soon to tell if or when. The ACA marked a potential advance for children's oral health by making pediatric dental services one of 10 essential health benefits (EHB) that all plans in the individual and small-group markets must offer. The ACA requires dental benefits to be offered to everyone under the age of 19 through individual and small-employer plans. The plans are sold either within or outside of state health insurance exchanges. In theory, the oral-health EHB in the ACA would help ensure basic coverage for both preventive and restorative care for children who otherwise would not have dental insurance.

According to initial projections, up to 8.7 million children would gain some form of dental benefits by 2018 as a result of the ACA, an increase of 15 percent from 2010. If achieved, this would reduce the number of children without dental benefits by about 55 percent. The increase in children with dental benefits would come from the following sources.
  • 3.2 million children would gain dental benefits through a Medicaid expansion, a 9.9 percent increase over 2010 levels.
  • Three million children would gain dental benefits through the health insurance exchanges by 2018, more than doubling the number of children who have dental benefits purchased through the individual markets.
  • 2.5 million children would gain dental benefits through employer-sponsored insurance as a result of the mandate for pediatric dental benefits in small-employer plans, an increase of about 10 percent compared to 2010 levels.
Consumers have been slow to obtain dental benefits for children in the exchanges, but this may change as problems in the system are addressed. Deeper problems lurk in the structure of the plans, as described in a recent analysis of the dental EHB in the ACA.1, 2 For example, the mandate to purchase was diminished to a mandate to offer dental coverage within the exchanges. Another complication in dental coverage embedded in medical plans is an extremely high, combined deductible in some plans that makes previously covered preventive services now out-of-pocket expenses.

Existing regulations and silence on certain aspects of insurance coverage confound issues such as adequate provider networks and maximum annual and lifetime limits. Because of the inclusion of previously non-enrolled children in Medicaid (a result of the program's expansion and ACA insurance exchanges identifying those eligible), a second element of the ACA's promise of access to dental services faces a reality check as well. The ACA permits a temporary increase in physician fees within Medicaid, but not for dentists.

The inadequacies of Medicaid dental services remain, but now affect even more children. The rise in the number of children who see the dentist has been aided by a 29 percent decline in the percentage of children who are uninsured—from 14.4 percent in 2000 to 10.2 percent in 2010.

Although the percentage of children covered by private insurance fell from 66.2 percent in 1997 to 54.2 percent in 2010, during that same period the percentage of children covered by public insurance (Medicaid/CHIP) doubled from 16.1 percent to 32.2 percent.

While fewer children are uninsured, the use of dental services remains unacceptably low among the most vulnerable to poor oral health—children from poor and minority families, many of whom are on Medicaid. Factors in addition to cost (termed "collectively social determinants of health") shape the utilization of care by Medicaid families. Sometimes it's hard for families to find a dentist who will treat their child. Poor and minority families are discouraged from taking their young children to the dentist by exclusionary practices such as disrespectful treatment by clinic staff, discrimination, long wait times, limitation in provider choice, and difficulties with transportation to appointments. Other reasons may be lack of health literacy, limited English proficiency, and cultural and societal barriers.

Some researchers see a correlation between the low use of dental services by children enrolled in Medicaid, and persistently low rates of participation in Medicaid among general dentists. In response to an ADA survey in 2007, only one in four dentists said they treated Medicaid patients. Many general dentists do not accept Medicaid patients, and even those who take Medicaid patients may decline to see very young children. In contrast, 70 percent of pediatric dentists see Medicaid patients (representing about 25 percent of their patients). Unfortunately, despite a tremendous growth in the specialty over the past 15 years, pediatric dentists are still too few in number to serve the entire population of young children covered by Medicaid. Meanwhile, the ACA has added more children to that population.

It may be too soon to tell if the ACA will be fixed, but it is safe to say that these fixes will take time. Better financing of care and required oral-health benefits are just promises for now and the foreseeable future.

True or false?
Dentistry is doing everything it can to help kids get the dental care they need. The real question is whether society, decision makers, parents and communities are doing all they can—along with dentistry—to foster a system that provides access to care for children. The challenge of getting every child into a dental home is a shared one, not just that of the dental profession. Many with the ability to create change are largely unaware of the problem of ECC and its consequences.

A child with unhealthy teeth is at risk for future oral-health problems as an adult. Additionally, undetected and untreated tooth decay can lead to infection, loss of teeth, and expensive emergency and restorative interventions. In extreme cases, ECC can lead to serious disability and even death.

Caries compromise the health, development and quality of life of young children, both in the short term and over the long term. Caries make a child more vulnerable to infections in other parts of the body, such as the ears, sinuses and the brain, and could have a harmful long-term impact not only on oral health, but also on overall health.

In addition, caries pain may restrain a child's physical growth and diminish overall quality of life. For instance, the pain from tooth decay hinders many children from eating, speaking, sleeping, playing and attending school, or paying attention while they're in class. Children with oral-health problems are three times more likely to miss school due to dental pain than children who do not have oral-health problems. As the child grows older, an unhealthy mouth can be associated with obesity, diabetes and even heart disease.

The social and economic consequences of this epidemic extend far beyond the families of the affected children, to engulf the medical, social and economic health of the greater community. Treatment of severe ECC can cost $10,000 per child, especially if a child needs to be hospitalized and treated under general anesthesia. Hospitalization for infection can cost up to $25,000 in severe cases. Add in mostly preventable emergency and restorative interventions and, in the United States alone, it is estimated that more than $40 billion per year is spent on the treatment of dental caries. The Medicaid program alone pays between $100 million and $400 million each year to treat ECC.

True or False?
Dentistry gets an A in prevention education—it's only kids getting access to restorative treatment that's the problem. Emerging data suggest that this is false. A need for restorative treatment clearly exists. By age 5, about 60 percent of U.S. children will have had caries at some point, including the 40 percent of children who have them when they enter kindergarten. Children aged 2 to 9 living in poverty are twice as likely to suffer tooth decay than their more affluent peers. In addition, their disease is more than twice as likely to go untreated (36.8 percent of poor versus 17.3 percent of non-poor).

However, recent data from the Centers for Disease Control and Prevention suggest that these most-vulnerable poor children are, in fact, receiving care, a trend that began more than a decade ago.3 Similarly, a decade-long look at children's dental visits shows a slow but steady rise, and more children being covered with public funding.4

More children do need access to a dentist, but the first step in addressing access is to reduce the number of children who experience dental caries. This can be achieved with true prevention that starts by age 1. The potential health, social and economic benefits of early visits to the dentist for the child are significant.5 The early visit to the dentist improves the oral health of the child by assessing and treating oral health, including caries, thereby reducing the child's future risk of dental disease and enhancing oral health throughout childhood.

In spite of these critical and potentially lifelong preventive interventions, few children are seeing the dentist in their first year of life. A variety of factors has contributed to restrict access to dental care, especially for poor and minority children. One reason appears to be a lack of understanding of the early dental visit's importance among parents, caregivers and medical professionals. Parents play a critical role in the oral health of their children. Yet, despite growing awareness of the importance of children's oral health, many parents do not follow good dental practices when it comes to their children. They do not understand how to evaluate their child's oral health, nor the importance of their child's oral health.

The lack of understanding of the importance of infant oral-health care is not restricted to parents. It is also all too common among providers in the medical and dental communities. Despite the recommendation from their own professional societies that children see a dentist by age 1, a majority of pediatricians and general dentists do not pass this recommendation on to their patients. The fact that fewer than 25 percent of pediatricians receive oral-health education in medical school, residency or continuing education is likely driving this trend.

The benefits of early visits and the dental home are not available to those who cannot find a dentist. There is evidence, however, that we have too few pediatric dentists. We have already seen that although 70 percent of pediatric dentists see Medicaid patients, there are not enough pediatric dentists to serve the entire population of young children. The AAPD has worked for more than 15 years to increase the supply of pediatric dentists, and this has resulted in a doubling of residency positions. However, more than 40 percent of all applicants for pediatric dentistry training are still turned away each year. It is interesting that this year, the Royal College of Surgeons in the United Kingdom recommended training more pediatric dentists to address their country's epidemic of childhood dental caries.6

Pediatric dentists are specially trained to treat children, and limit their practices to treating children. For instance, pediatric dentists are trained to allay children's fears, treat special-needs children, create a kid-friendly environment and adjust anesthesia dosages. There also is an effort to better identify and assist those with poor health-literacy skills. In fact, evidence supports the idea that children who go to a pediatric dentist get better care, and their parents learn more about pediatric oral health and dental care.

In summary, this article addresses some questions posed about "The State of Little Teeth Report" and adds additional references and emerging science about this national health problem in our children. The AAPD is committed to addressing the oral-health and access problems of children, and will continue to update the report to provide the most recent and accurate information. Through an increased quantity of pediatric dentists, more early preventive visits, ACA modifications and adequate Medicaid/CHIP funding, a greater number of children can enjoy the wide range of benefits that come from having a healthy smile.

"The State of Little Teeth Report" can be accessed at www.AAPD.org/assets/1/7/State_of_Little_Teeth_Final.pdf

References
  1. Orynich CA, Casamassimo PS, Seale NS, Litch CS, Reggiardo P. The Affordable Care Act and Health Insurance Exchanges: Advocacy Effect for Children's Oral Health. Pediatric Dentistry 2015; 37(1): 17-22.
  2. Orynich CA, Casamassimo PS, Seale NS, Reggiardo P, Litch, CS. The Affordable Care Act and Health Insurance Exchanges: Effects on the Pediatric Dental Benefit. Pediatric Dentistry 2015; 37(1): 23-29.
  3. Dye BA, Hsu K-L. Changes in the prevalence and measurement of early childhood caries (ECC). Innovations in the Prevention and Treatment of Early Childhood Caries [conference], October 23-24, 2014, Baltimore, MD.
  4. Nassah K, Vujicic M. Dental Benefits Expanded for Children, Young Adults in 2012. Health Policy Institute, American Dental Association, Chicago, IL, October 2014.
  5. Nowak AJ, Casamassimo PS, Scott J, Moulton R. Do Early Dental Visits Reduce Treatment and Treatment Costs for Children? Pediatric Dentistry 2014; 36: 250-254.
  6. Faculty of Dental Surgery, Royal College of Surgeons of England. The State of Children's Oral Health in England. January, 2015. London, England, UK.



Dr. Paul Casamassimo, DDS, MS, is the director of the AAPD's Pediatric Oral Health Research and Policy Center. He is a member of the Section of Dentistry at Nationwide Children's Hospital and is a professor of pediatric dentistry at The Ohio State University College of Dentistry.


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