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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