Oral health is an extremely important component of overall physical health and well-being for everyone. It is said that "the mouth can be the window to the rest of the body: it often reflects general health and well-being and can indicate disease and dysfunction." Donna Shalala, then Secretary of the Department of Health and Human Services, said in the first Surgeon General’s report on oral health in May 2002, that, “Oral health means more than sound teeth. Oral health is integral to overall health. Furthermore, safe and effective disease prevention measures exist that everyone can adopt to improve oral health and prevent disease.” While the quality of oral health care in Pennsylvania is generally high, access to care is not as readily available for many individuals, particularly those who are uninsured and those insured by Medicaid, indicating the need for an evaluation of access to care as well as utilization of care. This White Paper identifies some access and utilization issues, discusses the current state of oral health care in the Commonwealth, and offers recommendations and actions to improve oral health care in Pennsylvania.
A 2008 report by the U.S. Department of Health and Human Services (HHS) states that illness related to oral health results in 6.1 million days of bed disability, 12.7 million days of restricted activity and 20.5 million lost workdays annually. What is most disturbing about this situation is that much of this is preventable.
A Pew Center on the States report estimates that 17 million low-income children in the United States go without dental care each year, representing about one in five of all those between the ages of one and eighteen. The Medicaid program, called Medical Assistance in Pennsylvania, mandates that eligible children receive dental services to address oral health. The report by the Pew Center describes dental coverage for children under Medical Assistance, including child eligibility requirements, covered services, delivery of care, expenditures, and access to and quality of services.
The tragic story of Deamonte Driver, in early 2007, caused our neighboring state of Maryland to take a very close look at access to dental care. On February 28, 2007, the 12-year-old boy died because of a toothache … a toothache that a routine $80 tooth extraction could have cured. By the time Deamonte got any attention for his aching tooth, the bacteria from the abscess had spread to his brain. After two operations and more than six weeks of hospital care, the Prince George County boy died. The cost of Deamonte’s care totaled about $250,000. We must act now so that something like this never happens in Pennsylvania.
The following are statistics collected by the Pennsylvania Department of Public Welfare (DPW):
More children are affected by dental decay than asthma and hay fever (five times more and seven times more, respectively).
Tooth decay affects forty-eight percent (48%) of children by the age of eight. This figure increases to fifty percent (50%) by the age of fifteen.
In low-income households, thirty-three percent (33%) of children have untreated tooth decay.
Fifty-five (55) areas in PA are experiencing a shortage of dental professionals.
Thirty-one percent (31%) of dental professionals are between the ages of 50-60. Only twenty-six percent (26%) of dental professionals are between the ages of 30-40.
There were 1,729 diagnosed cases of oral cancer and 360 deaths attributed to oral cancer in 2010.
Children in households with an annual income of less than $20,000 are three times more likely to have untreated dental caries than children in households with an annual income of more than $100,000.
Approximately 85% of residents get their water from Community Water Systems.
About half of the population in Pennsylvania does not have fluoridated water.
Effective September 30, 2011, adult Medicaid recipients age 21 and older will be eligible for the following:
One partial upper denture or one full upper denture and one partial lower or one full lower denture per lifetime. Additional dentures require a Benefit Limit Exception (BLE).
One oral evaluation and prophylaxis per 180 days, per adult recipient. Additional oral evaluations and prophylaxis require a BLE.
Crowns and adjunctive services, periodontal and endodontic services if the recipient receives a BLE.
Pennsylvania has created an Expanded Function Dental Assistant (EFDA) position. An EFDA is a dental team member that has completed a specific course of training that includes clinical instruction in restorative techniques. EFDAs are permitted to place restorative materials in cavity preparations, polish teeth and restorations and perform other dental assisting duties under the supervision of a dentist. An EFDA may not perform dental hygiene services.
Act 51 of 2007 was signed into law in Pennsylvania July 20, 2007, creating a new category of dental health professional in the Commonwealth—the Public Health Dental Hygiene Practitioner (PHDHP). Final regulations governing the scope of practice of these professionals were published December 2009. A PHDHP is a dental hygienist with significant supervised clinical experience who has been certified to perform hygiene services without direct supervision by a dentist in certain health settings.
In 2010, Pennsylvania Medical Assistance began reimbursing enrolled physicians and certified registered nurse practitioners for the application of tropical fluoride varnish for eligible children aged zero to four.
Pennsylvania’s Medical Assistance dental fee schedule was last updated on September 20, 2011. This fee schedule reflects the changes related to the limitations on adult dental benefits and the Benefit Limit Exception process.
The last oral health plan by the PA Department of Health was published almost ten years ago (Oral Health Strategic Plan for Pennsylvania – November 2002).
The HealthChoices mandatory managed care program is expanding and will cover all counties statewide by March 2013. Most of the managed care plans have adopted the dental benefit limits implemented by the Department of Public Welfare in 2011.
For 2011, Pennsylvania only met three of the eight Pew Center on the States policy benchmarks aimed at addressing children’s dental health need, resulting in a grade of D. Nevertheless, this was an improvement from 2010, when Pennsylvania only met two of the eight benchmarks and received a failing grade. Forty-one states received a better grade than Pennsylvania.
The Centers for Disease Control and Prevention (CDC) reports that only 54.6% of the population in Pennsylvania receives fluoridated water. This ranks Pennsylvania 41 out of the 50 states. Over the past decades, more than 3,000 studies or reports have been produced about fluoridation or community water fluoridation and the evidence clearly shows that fluoridated water safely and effectively reduces tooth decay in children and adults. Dr. Jayanth Kumar, Director of Oral Health Surveillance and research for the New York State Department of Health, recognizes that while “children living in the under-fluoridated counties had access to fluoride supplements and fluoride-rinse programs in schools … our study found that the people living in these under-fluoridated counties are at a disadvantage.” A 2001 CDC study estimates that for every dollar invested in water fluoridation, communities save $38 in dental treatment costs.
This section will discuss the areas that need to be addressed in order to begin resolving the issues of access to and utilization of oral health care in Pennsylvania. All of the recommendations reflect a need to be more proactive in improving oral health access, care and status in the Commonwealth.
Education – Public education on the importance of oral health care is necessary for individuals to accept it as a priority. Parents of young children under age 3 must be educated to prevent dental disease with proper oral hygiene habits, such as assisting their child with twice daily tooth brushing, limiting sugary beverages and foods in the diet, and visiting the dentist at age 1 for routine preventive care. Along with education comes training. Despite the American Academy of Pediatric Dentistry's recommendation that children see a dentist by their first birthday, few general dentists treat young children between the ages or one and three because they don't have the experience with this population. By educating our communities and training our providers on how to treat children, we will be able to break the current cycle of waiting until the oral health issues escalate to a critical point, when the cost of care is significantly increased.
Water Fluoridation - It has been proven that fluoridation in the water system helps prevent dental caries. As mentioned above, only 54.6% of the state currently receives fluoridated water, below the national average of 66.2%. Recently, Chester County eliminated water fluoridation. A concentrated effort needs to be made to increase this percentage. Having fluoride in our water systems is an easy solution that will benefit everyone without much change in behavior; increased fluoridation means we can focus education on water intake and decreasing juice/soda intake.
Sealant/Fluoride Varnish Program - If fluoride varnish were to be applied on a regular basis, tooth decay could be reduced by one-third, which would provide for significant savings in restorative dental care and hospital visits in the future. Therefore, we must establish a fluoride varnish program that is part of a well-child medical visit. This treatment/program must then be reimbursed more appropriately (see Reimbursement bullet point below). Again, in keeping with our theme of being more proactive, this will ameliorate the need for "restorative" treatments which are much more costly than preventative approaches.
Reimbursement (Adults and Children) - The Pew Center on the States reports that in 2008, Pennsylvania's Medical Assistance reimbursement rates were only 53.2% of the dentists' median retail fees, below the national average of 60.5%, which is also considered low. Pennsylvania's reimbursement rates are also considered low in comparison to other state Medicaid programs. These rates need to be increased not only to more appropriately compensate existing dental providers, but also to encourage other dental providers to enroll in the Medicaid program. Being more proactive now will also help keep costs down in the future. The fact is that dentists are doing more complex procedures, which relates to increased costs to patients as well as the state, because of the current system. A report by CBS News says that “for a growing number of Americans, the hospital is the first line of treatment for dental care, according to new research from the Pew Center. And these patients are probably paying 10 times as much and getting worse treatment than they’d get from a preventive visit to the dentist.”
Innovative Workforce Models - We need to evaluate and support through policy innovative ways to expand access to dental services, to include medical providers, hygienists and other dental professionals, and expand the number of these providers so that care can be provided when a dentist is not available.
This section will discuss each recommendation mentioned above and offer some solutions to address the issues of access to and utilization of oral health care in Pennsylvania.
Education - The state of Pennsylvania must take a more active role in educating the public on the importance of oral health care. A marketing campaign at the state level needs to be established. Dental professionals, schools, community organizations and others will be important partners in a statewide education campaign, both in distribution of marketing materials and in educating the public on the importance of oral health care. Dental disease is preventable and knowledge is a powerful tool in combating the problem. To prevent dental disease early in life, beginning in infancy, all parents and adult caregivers of young children ages birth to five who are enrolled in early childhood education and child development programs, such as Head Start and Early Head Start, infant/toddler programs, childcare programs, pre-K programs, home visiting programs, and preschools, should be educated with accurate and consistent health messages about the “science” of oral health promotion using an evidence-informed curriculum, such as “Cavity Free Kids.” Cavity Free Kids is an educational program developed by the Washington Dental Service Foundation. Cavity Free Kids provides oral health information in five essential learning concepts that organize the curriculum for children and family components. Maryland established a Dental Action Committee (DAC) and Pennsylvania should establish a similar committee. Also, the Oral Health Strategic Plan for Pennsylvania must be updated to identify current issues and trends as well as steps that must be taken to improve oral health in our communities and the Commonwealth.
Water Fluoridation – Legislation needs to be passed requiring all counties to increase the percentage of their population currently receiving fluoridated water. Minimum requirements should be established and enforced.
Sealant/Fluoride Varnish Program - While Pennsylvania now reimburses enrolled physicians for the application of topical fluoride varnish, it needs to take a closer look at the current reimbursement system, collaborate with the provider community to educate providers and parents and implement appropriate changes to increase the utilization of fluoride varnish application during medical visits.
Reimbursement (Adults and Children) - It is incumbent upon our state to increase reimbursement to providers of oral health care, including medical providers applying fluoride varnish. Payment policy does not encourage successful practices and transformation of care delivery. Increasing reimbursement may not only increase the number of providers serving our communities, but actually decrease the cost of overall healthcare by reducing the need for more extensive services in the future and possible hospitalization. Creating a system that is more preventative and prophylactic in nature will help everyone—the state, the providers, and most importantly, the patient.
Innovative Workforce Models - As mentioned above, a committee similar to the one established in Maryland (DAC) needs to look into new innovative models of delivering quality oral health care. Pennsylvania simply doesn't have the number of dentists necessary to meet need and demand.
Oral health is critical to overall health and well being. Pennsylvania must accelerate development and implementation of a plan to improve access to and utilization of quality oral health care. While we have made some strides, much work still needs to be done.
We need to educate our communities on the importance of oral health care, train our dental providers (both medical and dental), increase access to fluoridated water, increase application of fluoride varnish by medical professionals, increase the reimbursement for oral health services and permit dental providers to work to the top of their licensure scope. This multi-pronged approach will help address the fundamental problem of access to oral health care for Pennsylvanians, and particularly vulnerable Pennsylvanians.
We must be more proactive in addressing the issue of oral health. The added benefit of taking the initiative and implementing the recommendations above is that studies show that the cost of an individual’s overall health care will be reduced. It is the right thing to do for the vulnerable individuals whose health and well being is being impacted, it is the right thing to do to control costs, and it is the right thing for policymakers to do as stewards of the Commonwealth’s finances.
U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General (May 2000). Complete report available at: http://www.surgeongeneral.gov/library/reports/oralhealth/
Academy of General Dentistry. White Paper on Increasing Access to and Utilization of Oral Health Care Services (July 2008). Complete report available at: http://www.agd.org/files/newsletter/7025accesstocarewhitepaper7-31-08.pdf
Pennsylvania Department of Public Welfare (DPW). Dental Information for Advocates and Stakeholders. More detailed information can be found at: http://www.dpw.state.pa.us/communitypartners/informationforadvocatesandstakeholders/dentalinformation/index.htm
Pennsylvania Department of State. State Board of Dentistry (http://www.dos.state.pa.us/portal/server.pt/community/state_board_of_dentistry/12509)
Pennsylvania Department of Public Welfare (DPW). Oral Health Strategic Plan For Pennsylvania (November 2002). Complete report available at: http://www.dsf.health.state.pa.us/health/lib/health/oralhealth/FinalStrategicPlan.pdf.
PowerPoint presentation delivered by Paul Westerberg DDS, MBA (Chief Dental Officer with the Pennsylvania Department of Public Welfare) at the Pennsylvania Association of Community Health Centers’ (PACHC) 2012 Medical/Dental Health Integration Summit.
Pew Center on the States. The State of Children’s Dental Health: Pennsylvania. Report can be found at: http://www.pewstates.org/research/state-fact-sheets/childrens-dental-health-pennsylvania-85899373277
PowerPoint presentation delivered by Dr. Harry Goodman (Director, Maryland Office of Oral Health). Maryland Oral Health Reforms: Progress in the Face of Tragedy.
Maryland Dental Action Coalition. Maryland Oral Health Plan 2011-2015. Complete report available at: http://www.mdac.us/wp-content/uploads/2011/02/MOHP-Dental-Action-r4.pdf
Pew Center on the States. Water Fluoridation: What the Science Says. Complete report available at: http://www.pewstates.org/news-room/press-releases/water-fluoridation-what-the-science-says-85899379792#
Department of Health and Human Services – Center for Disease Control and Prevention. 2010 Water Fluoridation Statistics. Complete report can be found at: http://www.cdc.gov/fluoridation/statistics/2010stats.htm
The Washington Post. “For Want of a Dentist” article by Mary Otto on Wednesday, February 28, 2007.
Pew Center on the States. Reimbursing Physician for Fluoride Varnish. Complete report can be found at: http://www.pewstates.org/research/analysis/reimbursing-physicians-for-fluoride-varnish-85899377335
Pew Center on the States. Reimbursing Medical Providers for Preventive Oral Health Services: State Policy Options.
CBS News. “More Americans visit ER for costly and inefficient dental care” article published on February 28, 2012. Complete article can be found at: http://www.cbsnews.com/8301-504763_162-57386846-10391704/more-americans-visit-er-for-costly-and-inefficient-dental-care/
Healthcare Cost and Utilization Project (H-CUP). Statistical Brief #143 – Emergency Department Visits for Dental-Related Conditions, 2009. Complete Brief can be found at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb143.jsp
Pennsylvania Medicaid Policy Center. Dental Coverage for Children Under Pennsylvania Medical Assistance.
Pew Center on the States. The Cost of Decay – State Dental Policies Fail One in Five Children. Complete report can be found at: http://www.pewstates.org/uploadedFiles/PCS_Assets/2010/Cost_of_Delay_web.pdf
National Academy of Sciences – Committee on Oral health Access to Services; Institute of Medicine and National research Council. Improving Access to Oral health for Vulnerable and Underserved Populations.
Pew Center on the States. The State of Children’s Dental Health: Making Coverage Matter. Complete report can be found at: http://www.pewstates.org/uploadedFiles/PCS_Assets/2011/The_State_of_Childrens_Dental_health.pdf
Cavity Free Kids. Tools for Teaching Children and Their Families about Oral Health. More information can be found at http://www.cavityfreekids.org/