Report of the Texas Dental Health Survey
"Make Your Smile Count"
Data Collection Fall 1998
Conducted by Dept of Community Dentistry UTHSCSA
Sponsored by Texas Department of Health

Survey Introduction

The aim of the survey was to assess the impact of enrollment in the Texas Health Steps (EPSDT, Medicaid) program on oral health of children in Texas. Sixteen middle and sixteen adjacent elementary schools, having a high percentage of students enrolled in the free lunch program, were selected randomly for the survey in all eight public health regions of the state. For the survey 1124 children in 2nd grade and 802 students in 8th grade were included by parental consent and questionnaire and a clinical oral examination made by one calibrated dentist according to written protocols.

Also, as specified in the study contract, 110 preschool children (2-3 years of age) enrolled in Texas Health Steps were selected on a random basis for the survey. A consent and questionnaire was completed by a parent or guardian and a dental inspection was conducted by the dental examiner in the home.

Children enrolled currently in Texas Health Steps (35% of Grade 2 and 28% of Grade 8) were compared with those not enrolled for social and clinical aspects of access to dental care.

Key Findings

Schoolchildren in 2nd and 8th Grade

The findings for children in Grade 2 and 8 were generally similar. Ninety percent of the children in the survey were from families with an annual income of less than $30,000 per year. Nearly two-thirds (56-60%) of children surveyed were from families with an income less than $16,000 per year, with 43-50% of these children enrolled in Texas Health Steps. The Grade 8 enrollment rate lagged Grade 2 somewhat. Children from single adult households were more likely to be enrolled in Texas Health Steps.

Enrollment status did not differ by race/ethnicity in Grade 8 but did so for Grade 2 with more Black and fewer Hispanic children enrolled in Medicaid.

Enrollment in Texas Health Steps is significantly associated (p<0.05) with a number of favorable indicators for the dental program:
(i) better parental perception of the child's general health,
(ii) better parental perception of the child's oral health,
(iii) greater likelihood of a dental visit in the past year,
(iv) higher likelihood of last dental attendance for a check up or follow up reason,
(v) lower likelihood of the last visit for pain or a problem,
(vi) lower likelihood of never having had a dental visit,
(vii) greater likelihood of having a usual place for dental care, and
(viii) greater likelihood of attending community health center and private dental office if enrolled.

Those children not enrolled cited cost, no perceived reason to go and not having a dentist as their major reasons for not attending in past year. Enrollees also cited these reasons plus an inability to get to the dental office or clinic because of distance, transportation, or available appointment.

Children enrolled were less likely to have needed but not able to obtain dental care, and also were less likely to have had difficulty with acceptance of their coverage or payment. However more children not enrolled had not tried to access dental care.

That cost was a barrier for enrollees is surprising and should be further studied for both age groups to determine the perceived nature and amount of these costs. Only a quarter of the children not enrolled had private dental insurance, although over a third had private general health coverage.

Dental caries (tooth decay) prevalence in primary teeth did not differ with enrollment for second grade children. In permanent teeth it was higher in enrollees of both ages. Children not enrolled were of a slightly higher average socioeconomic status and thus may be expected to have lower dental caries rates.

Children enrolled had more filled teeth and children not enrolled had more decayed teeth (untreated tooth decay), of either dentition. Also, children enrolled more often had preventive dental sealants with 16-36% of enrollees having sealants on molars. The Healthy People 2000 national goal of 50% of children with dental sealants will not be met by this group of Texas children. There was a notable absence of preventive dental sealants on primary molars.

Dental caries has been experienced by 53-66% of these children. Texas Health Steps enrollment is associated with an enhanced treatment rate and treatment completion rate. This completion rate is greater in Grade 8 than Grade 2. However early professional guidance and periodicity of dental visits are not occurring to the extent needed to prevent and reduce the burden of dental caries. In addition the rate of annual dental visits and the Medicaid enrollment rate are low, so that the proportion of financially qualified children who meet both criteria is only 34% of Grade 2 and 27% of Grade 8 students, from families with income less than $16,000 per year.

Preschool Children (2-3 Years of Age)

Social Survey Findings

Eighty-eight percent of the preschool children were enrolled in Texas Health Steps at the time of the survey.

More parents had a positive perception of their child's general health than their child's oral health. Although two thirds had a dental visit in the past year, one third had not yet had one. Even at this young age seven percent of children attended in pain. Only a third of parents themselves had such a visit, and thirteen percent of them had attended in pain. Six percent of the children needed care but could not get it in the past year. Issues in lack of access included having no reason to go, not having a dentist or being unable to get there, fear and cost. These parents were very reliant on Medicaid for dental care coverage, and utilized public and private dental services.

Etiologic factors for early childhood caries were prominent, including late weaning from a bedtime or naptime bottle, use of sweetened liquids in the bottle at bed time and lack of parental tooth brushing with fluoride toothpaste beginning soon after teeth erupt in the first year. This points to the need for professional guidance and appropriate periodicity of dental visits from twelve months of age.

Clinical Dental Findings

One fifth of these children already had frank tooth decay. Thirteen percent were in need of treatment, one percent urgently. Only 1% had preventive dental sealants. An additional fourteen percent had early enamel dental caries. This early sign of the disease is potentially arrestable and remineralizable by dietary change, parental and professional use of fluoride toothpaste and fluoride varnish and plaque control by tooth brushing.

Through a decision tree devised by a consensus panel of pediatric and public health dental professionals it was estimated that ninety percent of children with dental caries, and 24% overall, could be managed by application of prevention, remineralization and minimal restoration. Success would not be universal, and depends on engagement of parents, caregivers, and dental professional in focused prevention, guidance and periodic re-evaluation. Health behaviors of the parents, caregivers, and practice behaviors of many dentists would be changed to achieve this outcome. There is great potential however for overall reduction in the cost and risk of general anesthesia or sedation and possible hospitalization used to support the restorative treatment approach.

The remaining ten percent of children with dental caries, and three percent overall, had more advanced dental caries indicating need for general anesthesia or sedation and possible hospitalization. Long term success of any treatment schema is dependent on prevention and remineralization of tooth decay, and not merely on overcoming the backlog of restoration of existing frank cavities. It is the disease which must be treated, not just its consequences.

This decision tree provides a schema of alternatives which should be prospectively tested for process, outcome and efficiency.

Selected Recommendations - Opportunities for Action

To improve the oral health of children in Texas the following actions are recommended based on the findings from this statewide survey. In order to attain major improvements in children's oral health coordinated and collaborative efforts will be necessary among a variety of organizations and individuals across Texas. Along with parents and families it will take actions by multiple government agencies, professional organizations, non-profit groups, academic institutions working in tandem at the state and local level with dental professionals, health and social service providers, child care, school personnel, public officials and others to gain improvements in the oral health of children in Texas.

Urge Promotion and Implementation of Community-Based Prevention

Support the initiation and maintenance of community-based prevention efforts like community water fluoridation.

Support local community water fluoridation efforts.

Develop community awareness campaigns for community water fluoridation in non-fluoridated areas.

Support Community-Based and Individual-Based Prevention Strategies to Prevent Tooth Decay in Children Especially Young Children

Integrate a prevention and early intervention orientation and focus into the Texas Health Steps (Medicaid, EPSDT) and Children's Health Insurance Program (CHIP) for all children.

Integrate into the Texas Health Steps (Medicaid, EPSDT) and Children's Health Insurance Program (CHIP) for all children effective measures that are provided by professionals based on risk assessments. Demonstration programs are needed for the prevention of tooth decay in the primary teeth of children. These actions need to start with parents during the prenatal period, continue with infants and toddlers, and throughout the preschool time and elementary school years. Innovative policies, programs, and professional practices need to be developed, implemented, and evaluated to provide early prevention and intervention services with sufficient intensity over time to be effective in preventing tooth decay during early childhood.

Community-Based Strategies

Support innovative campaigns through education, promotion, and community awareness to reach parents, caregivers, the media, and policymakers about practices that can be adopted to prevent early childhood caries.

Increase access to preventive services by maximizing state and local resources to support community-based dental programs. Model preventive dental programs such as as dental sealant programs that are child care center and school-based or linked should be replicated in areas across the state.

Increase fluoride mouthrinse programs in schools in non-fluoridated areas until water fluoridation can be achieved in the community.

Individual-Based Strategies

Promote widespread application of preventive measures such as dental preventive sealants and fluoride varnishes, particularly in children at risk for tooth decay, by reducing professional and personal barriers to their use.

Increase prescription of dietary fluoride supplements by medical and dental professionals in non-fluoridated areas until water fluoridation can be achieved in the community.

In programs supported by TDH such as Texas Health Steps (Medicaid, EPSDT) and Children's Health Insurance Program (CHIP) ensure coverage by all "medically necessary" evaluation, parental guidance and care to allow for the contemporary management of oral disease in children, e.g. dietary guidance, parent and child instructions in fluoride use and plaque control.

Provide waivers at the local level to encourage investigator of innovative programs for oral disease prevention and treatment for individuals and groups.

Improve Access to Dental Cares

Maximize enrollment in public and private insurance programs that include dental coverage (e.g., Texas Health Steps (Medicaid, EPSDT), Children's Health Insurance Program (CHIP), and Texas Healthy Kids Corp. Increase awareness about the availability of no-cost and low-cost health insurance and dental coverage for children.

Increase access to dental care by ensuring that every child has an identified "dental home," a usual place to receive dental care.
Utilize multiple strategies to expand current enrollment and assure continuity and periodicity of dental care by streamlining or reforming policies (e.g., extend Medicaid coverage to one year, etc.) that produce barriers that prevent children from receiving needed regular dental care.

Eliminate barriers that families face in trying to access dental care for their children. Further study is needed to assess why some barriers described in this study contribute to the lack of regular dental visits and to determine effective ways to eliminate these identified barriers, e.g., many parents seem unaware of the benefits of regular preventive dental attendance and said they had no reason to go, some enrolled parents said cost was a barrier and why this would be so is not apparent, and parents of preschoolers were fearful about dental care of their young children.

Decrease barriers to ensure that dental professionals are available and accessible in communities for children and their families (e.g., decrease distances to offices or clinics, increase available appointments, etc.).

Improve transportation to assist families to reach a dental office or dental clinic to assure that children receive needed dental care.
Facilitate collaboration and referral between school-based dental programs (e.g., fluoride mouthrinse programs, dental sealant programs, and screenings) and dental offices and clinics to assure linkages with ongoing dental care.

Increase incentives and decrease disincentives to maximize participation of dentists in Texas Health Steps (Medicaid, EPSDT) and Children's Health Insurance Program (CHIP), and Texas Healthy Kids Corp. (e.g., reimbursement rates at reasonable level, streamlined administrative paperwork, etc.).

Increase capacity of traditional and safety-net providers to provide dental services to children and their families.
Utilize innovative strategies to assure access to dental care by ensuring a sufficient number of dental providers are available in communities to meet the dental care needs of children.

Ensure access to primary dental care of parents so they can attain oral health themselves, be more fully informed oral health teachers of their own children, and have less reason to be fearful about more routine dental care sought early for their children.

Establish performance standards in publicly funded dental programs (e.g., Texas Health Steps (Medicaid, EPSDT), Children's Health Insurance Program (CHIP) to assure evaluation of outcome measures for the improvement of children's oral health.

Develop community awareness campaigns through education and promotion to increase the awareness of the importance of regular dental visits for children to prevent and detect dental problems early. Promote awareness to parents and caregivers about the need for early and periodic screening, diagnosis, prevention, and treatment for children, commencing by one year of age.

Increase the competence of dental and dental hygiene graduates to manage early childhood caries for individuals and communities, at the preventive and interceptive levels, as is provided for under the 1999-2004 Texas State Health Planning, Goal 4 "create a health care workforce framed and equipped to use education and prevention as the primary approach to helping Texas achieve optimal health".

Strengthen Capacity of the Public Sector

Support public health agencies at the state and local level to conduct periodic assessments to track oral health needs of Texas children and their families (e.g., status of oral diseases, dental care needs, evaluation of existing resources, available capacity, gaps in services and resources, effectiveness of interventions, etc.).

Provide support, training, and technical assistance at the local and community levels to assess oral health needs, develop and implement oral health policies, programs, and practices, and evaluate outcomes to assure that identified oral health needs are addressed in local communities.

Assure that necessary oral health services are available and accessible in communities for children and their families that need them. Support the provision of needed private and public dental services in communities and as necessary provide direct dental services in communities where needed dental services are not available or accessible.

Assure that necessary oral health services are available and accessible in communities for children and their families that need them. Support the provision of needed private and public dental services in communities and as necessary provide direct dental services in communities where needed dental services are not available or accessible.

John P. Brown, DDS, PhD
Jane E. M. Steffensen, BS, MPH, CHES
Dennis McMahon, MS

Department of Community Dentistry, Dental School
University of Texas Health Science Center at San Antonio
7703 Floyd Curl Drive
San Antonio, Texas 78229-3900
September 1, 1999
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