Impacts of innovation in dental care delivery and payment in Medicaid managed care for children and adolescents.

BACKGROUND: We evaluated a 14-county quality improvement program of care delivery and payment of a dental care organization for child and adolescent managed care Medicaid beneficiaries after 2 years of implementation. METHODS: Counties were randomly assigned to either the intervention (PREDICT) or control group. Using Medicaid administrative data, difference-in-difference regression models were used to estimate PREDICT intervention effects (formally, "average marginal effects") on dental care utilization and costs to Medicaid, controlling for patient and county characteristics. RESULTS: Average marginal effects of PREDICT on expected use and expected cost of services per patient (child or adolescent) per quarter were small and insignificant for most service categories. There were statistically significant effects of PREDICT (p < .05), though still small, for certain types of service: (1) Expected number of diagnostic services per patient-quarter increased by .009 units; (2) Expected number of sealants per patient-quarter increased by .003 units, and expected cost by $0.06; (3) Total expected cost per patient-quarter for all services increased by $0.64. These consistent positive effects of PREDICT on diagnostic and certain preventive services (i.e., sealants) were not accompanied by increases in more costly service types (i.e., restorations) or extractions. CONCLUSION: The major hypothesis that primary dental care (selected preventive services and diagnostic services in general) would increase significantly over time in PREDICT counties relative to controls was supported. There were small but statistically significant, increases in differential use of diagnostic services and sealants. Total cost per beneficiary rose modestly, but restorative and dental costs did not. The findings suggest favorable developments within PREDICT counties in enhanced preventive and diagnostic procedures, while holding the line on expensive restorative and extraction procedures.

Comparative Effectiveness of Two Nonsurgical Treatments to Reduce Oral Health Disparities From Untreated Tooth Decay in Older Adults: Protocol for a Cluster Randomized Trial.

BACKGROUND: The majority of dental caries lesions in older adults are at the gumline, at the edges of failed fillings and crowns, and in the surfaces of roots after gum recession. These lesions are difficult to restore with conventional surgical treatments using a dental drill and restorations often fail. Clinical guidelines are general and apply treatments that were designed for younger individuals in the dental care of older adults. OBJECTIVE: This study will compare the effectiveness of 2 evidence-based nonsurgical strategies to manage dental caries lesions in adults aged 62 or older: (1) biannual topical application of silver diamine fluoride versus (2) atraumatic restorative treatment + biannual fluoride varnish. METHODS: A cluster randomized clinical trial is being conducted in 22 publicly subsidized and other low-income housing facilities/sites (Arm 1: 11 sites, 275 participants; Arm 2: 11 sites, 275 participants). At baseline, participants will be screened for caries lesions. Those with nonurgent lesions will be treated according to the treatment arm to which the housing site was randomly assigned. The primary outcomes are caries lesion arrest, tooth sensitivity, and tooth pain at 52 weeks after treatment. Analytic methods for the primary aim include a generalized estimating equation approach to determine noninferiority of silver diamine fluoride relative to atraumatic restorative treatment + fluoride varnish treatment. RESULTS: The trial was funded in April 2019. Enrollment began in September 2019 and results are expected in June 2023. CONCLUSIONS: This study will inform the standard of care for treating caries lesions in older adults. If effective, either of these interventions has broad applicability in clinical and community-based settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT03916926; https://clinicaltrials.gov/ct2/show/NCT03916926. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17840.

Changes in Silver Diamine Fluoride Use and Dental Care Costs: A Longitudinal Study.

Purpose: This study evaluated the impact of silver diamine fluoride (SDF) by investigating coverage and reimbursement policies. Methods: We performed a population-level retrospective cohort analysis (N equals 117,599) using claims. We evaluated two policy events: (1) dental board approval permitting SDF use by expanded practice dental hygienists (EPDHs); (2) approval of SDF by Medicaid. Coincident with coverage, Advantage Dental Services instituted EPDH practice algorithms. To evaluate changes, we: estimated CDT code 1354 utilization and average quarterly costs; stratified the population into patients who initiated preventive care from an EPHD or dentist; estimated outcome differences with either policy in quarterly trends; and counted SDF use with claims by quarter and calculated utilization per 1,000 patients. Results: Average per-patient quarterly dental costs (June 2017) ranged from $384 to $423. SDF use grew associated with Medicaid policy: rates increased from $0.32 per 1,000 to $156 per 1,000 in six quarters. Care initiated by EPDHs had lower costs, with quarterly savings of $201 (P=0.011) per patient, without differences in SDF utilization. Conclusions: Policy makers can use our results to improve access and reduce costs. Clinical experts should address more clearly when SDF substitutes for or is used in conjunction with restorative treatment.

Dental health aides in Alaska: A qualitative assessment to improve paediatric oral health in remote rural villages.

OBJECTIVE: Isolated villages in Alaska face disparities in oral health and access to care. Dental health aides such as the primary dental health aide (PDHA) and the dental health therapist (DHAT) fill a critical role for providing dental care in Alaska. Our objective was to describe strengths and barriers to paediatric dental care for children living in remote Alaska villages from the perspectives of the community and the health care system. METHODS: This qualitative study collected data through semi-structured key informant interviews with community members (n = 19) and healthcare workers (n = 19) and focus groups with patients (n = 31 adolescents and 16 caregivers of children under 12 years) living in or providing health care to 3 remote villages in Alaska. Using an inductively developed codebook and a narrative approach, 3 researchers independently read and thematically analysed the transcripts. RESULTS: Two themes emerged: (i) PDHAs and DHATs are perceived as sustainable and strongly positioned to meet the unique dental needs of the rural communities; (ii) PDHAs and DHATs face barriers that limit their effectiveness, and their distinct roles require clarification and administrative support. CONCLUSIONS: Dental health aides, both PDHAs and DHATs, are well accepted in Alaska villages. An innate understanding of cultural norms and continuity of care are key elements driving village satisfaction. The potential exists administratively to strengthen the model with the implementation of clinical and office-system strategies to increase efficiency of the dental team. Culturally adapted implementation strategies will be critical to the successful expansion of new workforce models that are addressing health disparities.

Pay-for-performance incentive program in a large dental group practice.

BACKGROUND: Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance. METHODS: The data come from use of care files and integrated electronic health records, provider and staff member surveys, and interviews and community surveys from 6 counties. Quarterly individual- and team-level incentives focused on 3 performance metrics. RESULTS: The program was challenged by many complex administrative issues. The key issues included designing a P4P system for different types of providers and administrative staff members who were employed centrally and in different communities, setting realistic performance metrics, building information systems that provided timely information about performance, and educating and gaining the support of a diverse workforce. Adjustments are being made in the incentive scheme to meet these challenges. CONCLUSIONS: This is the first report of a P4P compensation system for dental care providers and supporting staff members. The complex administrative challenges will require several years to address. PRACTICAL IMPLICATIONS: Large, capitated dental practice organizations will employ more dental care providers and administrative staff members to care for patients who receive Medicaid and patients who are privately insured. It is critical to design and implement a P4P system that the workforce supports.

Care delivery and compensation system changes: a case study of organizational readiness within a large dental care practice organization in the United States.

BACKGROUND: Dental care delivery systems in the United States are consolidating and large practice organizations are becoming more common. At the same time, greater accountability for addressing disparities in access to care is being demanded when public funds are used to pay for care. As change occurs within these new practice structures, attempts to implement change in the delivery system may be hampered by failure to understand the organizational climate or fail to prepare employees to accommodate new goals or processes. Studies of organizational behavior within oral health care are sparse and have not addressed consolidation of current delivery systems. The objective of this case study was to assess organizational readiness for implementing change in a large dental care organization consisting of staff model clinics and affiliated dental practices and test associations of readiness with workforce characteristics and work environment. METHODS: A dental care organization implemented a multifaceted quality improvement program, called PREDICT, in which community-based mobile and clinic-based dental services were integrated and the team compensated based in part on meeting performance targets. Dental care providers and supporting staff members (N = 181) were surveyed before program implementation and organizational readiness for implementing change (ORIC) was assessed by two 5-point scales: change commitment and efficacy. RESULTS: Providers and staff demonstrated high organizational readiness for change. Median change commitment was 3.8 (Interquartile range [IQR]: 3.3-4.3) and change efficacy was 3.8 (IQR: 3.0-4.2). In the adjusted regression model, change commitment was associated with organizational climate, support for methods to arrest tooth decay and was inversely related to office chaos. Change efficacy was associated with organizational climate, support for the company's mission and was inversely related to burnout. Each unit increase in the organizational climate scale predicted 0.45 and 0.8-unit increases in change commitment and change efficacy. CONCLUSIONS: The survey identified positive readiness for change and highlighted weaknesses that are important cautions for this organization and others initiating change. Future studies will examine how organizational readiness to change, workforce characteristics and work environment influenced successful implementation within this organization.

Costs and Resource Use Among Child Patients Receiving Silver Nitrate/Fluoride Varnish Caries Arrest.

PURPOSE: The purpose of this study was to assess the impact of silver nitrate/fluoride varnish (SN/FV) on care costs. METHODS: A retrospective matched cohort study, using Oregon Medicaid claims (January 1, 2012 to December 31, 2014) for patients younger than 21 years old, compared patients treated with SN/FV to matched patients not treated with SN/FV. The number of services and costs were compared using student's t test and generalized estimating equation (GEE) regression models. RESULTS: Patients treated with SN/FV (n equals 4,612) and matched patients treated conventionally (n equals 13,498) averaged 28±7 (SD) months of continuous eligibility based on initial treatment date. The number of first-year services and total services over an average of 28 months were higher for patients treated with SN/FV (10.6 versus 6.7 in year one; 19.3 versus 8.8 overall; P<0.0001). Excluding diagnostic/preventive services, costs were higher in patients treated conventionally than patients treated with SN/FV in the first year. Overall costs were similar ($698 versus $707; P=.52). The average number of services was 58 percent higher (95 percent confidence interval [CI] 1.54 to 1.63) for patients treated with SN/FV, but costs remained similar. CONCLUSION: Patients treated with silver nitrate/fluoride varnish accrued a greater number of services and higher total costs over approximately 28 months but lower treatment costs than patients treated conventionally.

Oral health and medical conditions among Amish children.

BACKGROUND: The Amish are a growing population who live a traditional, rural way of life, which makes them less accepting of modernism. Most Amish live in poverty and are detached from modern health care. In addition, the recent change of their lifestyle has been reported, such as consuming a nontraditional diet and the usage of electronic devices. As a result, their lifestyle change may have impacted their oral health. However, since only a single report about oral health among Amish children has been published approximately three decades ago it has not yet been updated. This study describes oral health among Amish children and their medical conditions during visits to a mobile dental unit (MDU). MATERIAL AND METHODS: The dental records of all patients (N=216) who visited a mobile dental unit were reviewed, which covers 1 year from May 20, 2011, the first date of service. The following factors were taken into consideration during the review process: parental perceptions of their children's oral health care, dental care experiences, and general health information. RESULTS: Fifty-four (27.8%) children, ages 3 to 17, have never received dental treatment before visiting the MDU; the average number of untreated decayed teeth was 6.8. In spite of this, most parents rated their children's oral health as good or very good (87.7%). The high cost and long distance travel associated with routine, professional dental care makes it difficult for children to maintain good oral hygiene. Our analysis revealed that bleeding disorders were more prevalent among this gene pool compared to the nation at large; however, asthma was less common. CONCLUSIONS: There are oral and general health disparities among Amish children. There is a lack of awareness among Amish parents with regard to their children's oral health. Key words:Amish, child, dental caries, mobile health units.

Population-centered Risk- and Evidence-based Dental Interprofessional Care Team (PREDICT): study protocol for a randomized controlled trial.

BACKGROUND: To improve the oral health of low-income children, innovations in dental delivery systems are needed, including community-based care, the use of expanded duty auxiliary dental personnel, capitation payments, and global budgets. This paper describes the protocol for PREDICT (Population-centered Risk- and Evidence-based Dental Interprofessional Care Team), an evaluation project to test the effectiveness of new delivery and payment systems for improving dental care and oral health. METHODS/DESIGN: This is a parallel-group cluster randomized controlled trial. Fourteen rural Oregon counties with a publicly insured (Medicaid) population of 82,000 children (0 to 21 years old) and pregnant women served by a managed dental care organization are randomized into test and control counties. In the test intervention (PREDICT), allied dental personnel provide screening and preventive services in community settings and case managers serve as patient navigators to arrange referrals of children who need dentist services. The delivery system intervention is paired with a compensation system for high performance (pay-for-performance) with efficient performance monitoring. PREDICT focuses on the following: 1) identifying eligible children and gaining caregiver consent for services in community settings (for example, schools); 2) providing risk-based preventive and caries stabilization services efficiently at these settings; 3) providing curative care in dental clinics; and 4) incentivizing local delivery teams to meet performance benchmarks. In the control intervention, care is delivered in dental offices without performance incentives. The primary outcome is the prevalence of untreated dental caries. Other outcomes are related to process, structure and cost. Data are collected through patient and staff surveys, clinical examinations, and the review of health and administrative records. DISCUSSION: If effective, PREDICT is expected to substantially reduce disparities in dental care and oral health. PREDICT can be disseminated to other care organizations as publicly insured clients are increasingly served by large practice organizations. TRIAL REGISTRATION: ClinicalTrials.gov NCT02312921 6 December 2014. The Robert Wood Johnson Foundation and Advantage Dental Services, LLC, are supporting the evaluation.

Emergency department visits for nontraumatic dental problems: a mixed-methods study.

OBJECTIVES: We documented emergency department (ED) visits for nontraumatic dental problems and identified strategies to reduce ED dental visits. METHODS: We used mixed methods to analyze claims in 2010 from a purposive sample of 25 Oregon hospitals and Oregon's All Payer All Claims data set and interviewed 51 ED dental visitors and stakeholders from 6 communities. RESULTS: Dental visits accounted for 2.5% of ED visits and represented the second-most-common discharge diagnosis in adults aged 20 to 39 years, were associated with being uninsured (odds ratio [OR] = 5.2 [reference: commercial insurance]; 95% confidence interval [CI] = 4.8, 5.5) or having Medicaid insurance (OR = 4.0; 95% CI = 3.7, 4.2), resulted in opioid (56%) and antibiotic (56%) prescriptions, and generated $402 (95% CI = $396, $408) in hospital costs per visit. Interviews revealed health system, community, provider, and patient contributors to ED dental visits. Potential solutions provided by interviewees included Medicaid benefit expansion, care coordination, water fluoridation, and patient education. CONCLUSIONS: Emergency department dental visits are a significant and costly public health problem for vulnerable individuals. Future efforts should focus on implementing multilevel interventions to reduce ED dental visits.

Caregiver's education level and child's dental caries in African Americans: a path analytic study.

The objective of this study was to investigate the influence of caregiver education level on children's dental caries mediated by both caregiver and child oral health behaviors. Participants were 423 low-income African American kindergarteners and their caregivers who were part of a school-based randomized clinical trial. Path analysis tested the hypothesis that caregiver education level affected untreated dental caries and cumulative overall caries experience (decayed or filled teeth) through the mediating influence of frequency of dental visits, use of routine care, and frequency of toothbrushing for both the caregiver and the child. The results supported the hypothesis: caregivers who completed high school were 1.76 times more likely to visit dentists compared with those who did not complete high school (e(0.56) = 1.76, 95% CI: 1.03-2.99), which in turn was associated with 5.78 times greater odds of dental visits among their children (e(1.76) = 5.78, 95% CI: 3.53-9.48). Children's dental visits, subsequently, were associated with 26% fewer untreated decayed teeth compared with children without dental visits (e(-0.31) = 0.74, 95% CI: 0.60-0.91). However, this path was not present in the model with overall caries experience. Additionally, caregiver education level was directly associated with 34% less untreated decayed teeth (e(-0.42) = 0.66, 95% CI: 0.54-0.79) and 28% less decayed or filled teeth (e(-0.32) = 0.72, 95% CI: 0.60-0.88) among the children. This study overcomes important conceptual and analytic limitations in the existing literature. The findings confirm the role of caregiver education in child dental caries and indicate that caregiver's behavioral factors are important mediators of child oral health.

Preventive dental health care experiences of preschool-age children with special health care needs.

PURPOSE: This study examined the preventive dental health care experiences of young children with special needs and determined the feasibility of conducting clinical dental examinations at a community-based early intervention services center. METHODS: Study methods included 90 parent interviews and dental examinations of their preschool-age children. RESULTS: Thirteen percent of the children received optimal preventive care, defined as twice daily tooth brushing with fluoridated toothpaste and two preventive dental visits in the prior 12 months; 37% experienced care that fell short in both areas. Optimal care was more common among children of parents who reported tooth brushing was not a struggle and those with a personal dentist. Parents' opinion of the study experience was generally positive. CONCLUSIONS: Few children with special needs receive effective preventive care early, when primary prevention could be achieved. Barriers to optimal care could be readily addressed by the dental community in coordination with early intervention providers.

Washington state foster care: dental utilization and expenditures.

OBJECTIVES: To identify factors associated with dental utilization and expenditures for children enrolled in Washington State (WA) foster care (FC). METHODS: This cross-sectional study used 2008 Medicaid enrollment and claims files for children ages <18 years enrolled in the WA FC program for ≥11 months (N = 10,177). Regression models were used to examine associations between utilization and expenditures and sex, race, age group, Supplemental Security Income (SSI) (i.e., disability), substance abuse, behavior problems, placement setting (Foster Home Care, Kinship Care, Group Care, Other), and urbanicity. RESULTS: Only 43 percent of the children utilized any dental care; the adjusted mean expenditure was $198.35 [95% confidence interval (CI) $181.35, $215.36]. Fewer utilized diagnostic (41 percent), preventive (39 percent), restorative (11 percent), or complex (5 percent) services. Associated with utilization (P ≤ 0.01) were: female [ARR = 1.05, 95% CI(1.01, 1.10)]; 0-2 years [ARR = 0.18, 95% CI(0.15, 0.21)], [3-5 years ARR = 0.78, 95% CI(0.74, 0.83)]; Native American [ARR = 0.85, 95% CI(0.80, 0.91)]; SSI [ARR = 1.10, 95% CI(1.04, 1.17)]; Kinship Care [ARR = 0.94, 95% CI(0.90, 0.98)]; Group Care [ARR = 1.25 95% CI(1.15, 1.37)]; and urban/rural urbanicity with population <20 K [ARR = 1.20 95% CI(1.12, 1.30)]. Associated with expenditures (P < 0.05) were: ages 0-2 years [-$153.66, 95% CI(-$168.33, -$139.00)], 3-5 years [-$98.71, 95% CI(-$116.78, -$80.65)], 6-11 years [-$16.83 95% CI(-$33.52, -$0.14)]; African American [-$32.05 95% CI(-$47.99, -$16.12)]; Kinship Care [$28.57 95% CI($14.00, $43.15)]. CONCLUSIONS: Most children enrolled in WA FC for ≥11 months during 2008 did not receive dental care. Research is needed to determine the level of unmet need among children in FC and interventions to improve access to oral health of the children. Enforcement of existing federal legislation is needed.

Unmet dental need in community-dwelling adults with mental illness: results from the 2007 Medical Expenditure Panel Survey.

BACKGROUND: Mental illness (MI) affects approximately one in five U.S. adults, and it is associated with oral disease and poor dental treatment outcomes. Little is known about dental care utilization or unmet dental need in this population. METHODS: The authors examined data regarding presence or absence of dental visits and unmet dental need in community-dwelling adults with MI from the 2007 Medical Expenditure Panel Survey. They tested differences between adults with and without MI by using multivariate logistic regression. RESULTS: Eighteen percent of adults (N = 19,368) had MI, and of these, 6.8 percent had unmet dental need. Although people with MI were not significantly more likely to have had a dental visit (46.3 percent) than were those without MI (42.2 percent; odds ratio [OR], 1.09; 95 percent confidence interval [CI], 0.97-1.23), they were significantly more likely to report unmet need (11.0 versus 5.3 percent; OR, 2.00; 95 percent CI, 1.67-2.41). Those with mood or anxiety disorders were most likely to report having an unmet dental need (P < .001 for all values). CONCLUSIONS: Although people with MI did not visit the dentist significantly more often than did adults without MI, their higher level of unmet need suggests that current use of dental services is not addressing their needs adequately. PRACTICAL IMPLICATIONS: Dentists should be familiar with MI conditions as patients with MI may have greater unmet dental need.

Social gradients in dental health among low-income mothers and their young children.

For low-income mothers of children aged 3-6 years, we estimate whether social gradients exist between mothers' income, education, and employment status and mothers' perceptions of self and child dental and general health, and whether these relationships differ by racial/ethnic group. Disproportionate stratified sampling by racial/ethnic group selected 10,909 eligible children aged 3 to 6 in Medicaid in Washington State. Mothers (n=4,373) completed a mixed-mode (web, mail, telephone) survey. Mothers' education had a strong, gradient relationship with mother ratings of self and child dental health that was not explained by other measures. Similar gradients were found for mothers' employment status and income, but some associations were no longer significant (p>.05) after adjusting for oral health beliefs and behaviors, dental insurance, and regular dental care. Associations did not differ significantly by racial/ethnic group.

Oral health in pregnancy: educational needs of dental professionals and office staff.

OBJECTIVE: Dental care during pregnancy is important for pregnant women and their children. Comprehensive guidelines for the provision of dental services for pregnant patients were published in 2006, but there is relatively little information about their use in actual practice. The aim of this study was to examine differences in knowledge and attitudes regarding dental care in pregnancy among dentists, dental hygienists, dental assistants, and nonclinical office staff. A secondary aim was to identify sources of influence on attitudes and knowledge regarding the guidelines. METHODS: A survey was used to collect information from 766 employees of a Dental Care Organization based in Oregon; responses from 546 were included in the analyses reported here. RESULTS: Statistically significant differences in knowledge were found among the professional-role groups. Dentists and hygienists consistently answered more items correctly than did other respondents. Within all professional-role groups, knowledge gaps existed and were most pronounced regarding provision of routine and emergency services. Positive perceptions of providing dental care during pregnancy were associated with higher knowledge scores (z = 4.16, P < 0.001). CONCLUSIONS: Updated dental education and continuing education for all dental office personnel are needed to promote the diffusion of current evidence-based guidelines for dental care during pregnancy.

School screening and parental reminders in increasing dental care for children in need: a retrospective cohort study.

OBJECTIVE: The objective of this study is to assess follow-up dental care received by children given baseline screening and referrals as part of an ongoing clinical trial. METHODS: A retrospective study with two cohorts of kindergarten children who had baseline and follow-up (9 months later) dental exams was used. The parents/caregivers of children with routine restorative or urgent needs at baseline received a referral letter and telephone reminders to seek care for their child. Children with referrals were evaluated at follow-up exam for the receipt of care. A baseline caregiver questionnaire provided information on the individual and family characteristics of the children. RESULTS: A total of 303 children had dental exams at both time periods. At baseline, 42 percent (126/303) received referrals and among the referred group19 percent (24/126) received follow-up care. A greater proportion with urgent referrals (10/30, 33 percent) received care than those with routine referrals (14/96, 15 percent). Baseline dmft decayed, missing, filled primary teeth and DMFT decayed, missing, filled permanent teeth was similar between children who did/did not receive follow-up care (P = 0.178 and 0.491, respectively). Children receiving referrals had caregivers with less education, higher Medicaid participation, fewer routine care visits, poorer self-rating of teeth, and a higher proportion of children reporting tooth pain. Children without receipt of follow-up care had caregivers who were more likely to report not visiting a dentist within the last 5 years and a greater number of missed days from work because of tooth problems. CONCLUSION: The rate of dental utilization was low even with school screening, referral and parental reminders among poor, largely minority inner-city kindergarten children.

A community-based randomized trial of postcard mailings to increase dental utilization among low-income children.

PURPOSE: Increasing awareness about the importance of preventive dental care among low-income families has been considered to be key to overcoming nonfinancial access to care barriers for children. The purpose of this randomized, controlled trial was to measure the impact of postcard mailings on dental utilization by low-income children through a dental society program designed to increase access to dental care. METHODS: Five thousand eight hundred and seven low-income 2- to 4-year-olds were randomly assigned to 1 of 3 groups: (1) Group 1 (n=2,014) received postcards containing information on how to enroll in the Yakima County Access to Baby and Child Dentistry program; (2) Group 2 (n=2,014) received the enrollment information as well as additional information on the availability of fluoride varnish and the need to visit the dentist by the age of 1-year-old; and (3) Group 3 (n=1,779) did not receive postcards. RESULTS: Preventive services utilization rates were not different among the groups: 61% for Group 1, 62% for Group 2, and 60% for Group 3, although rates were high for a Medicaid population. CONCLUSIONS: Postcard mailings did not significantly increase utilization of preventive dental services. Other strategies to increase utilization of preventive oral health measures are needed.

Parents' perspectives on a dental home for children with special health care needs.

The authors surveyed parent-leaders about aspects of a dental home for children with special health care needs (CSHCN). State leaders in two advocacy groups completed the survey; the response rate was 70.6% of all states. Two of the most highly rated aspects of a dental home, endorsed as "essential" by 89% of respondents, pertained to dentist-parent interactions: the dentist listens carefully to the family, and the dentist helps the family feel like a partner in treatment decisions. Likewise, 89% said it was essential that insurance coverage allows the child to see needed providers. Dentists' lack of knowledge or willingness to treat CSHCN and refusal of Medicaid insurance coverage were identified as major barriers to care. More than 84% of respondents reported that parents were unaware of the recommendation to establish dental care by 1 year of age. Establishing policy and educational strategies should help parents meet this dental health goal.

Exploring the potential for foreign-trained dentists to address workforce shortages and improve access to dental care for vulnerable populations in the United States: a case study from Washington State.

BACKGROUND: To address dental workforce shortages in underserved areas in the United States, some States have enacted legislation to make it easier for foreign dental school graduates to become licensed dentists. However, the extent to which foreign dental school graduates will solve the problem of dental workforce shortages is poorly understood. Furthermore, the potential impact that foreign-trained dentists have on improving access to dental care for vulnerable patients living in dental Health Professional Shortage Areas (HPSAs) and those enrolled in public insurance programs, such as Medicaid, is unknown. The objective of this paper is to provide a preliminary understanding of the practice behaviors of foreign-trained dentists. The authors used Washington State as a case study to identify the potential impact foreign dental school graduates have on improving access to dental care for vulnerable populations. The following hypotheses were tested: a) among all newly licensed dentists, foreign-trained dentists are more likely to participate in the Medicaid program than U.S.-trained dentists; and b) among newly licensed dentists who participated in the Medicaid program, foreign-trained dentists are more likely to practice in dental HPSAs than U.S.-trained dentists. METHODS: The authors used dental license and Medicaid license data to compare the proportions of newly licensed, foreign- and U.S.-trained dentists who participated in the Medicaid program and the proportions that practiced in a dental HPSA. RESULTS: Using bivariate analyses, the authors found that a significantly lower proportion of foreign-trained dentists participated in the Medicaid program than U.S.-trained dentists (12.9% and 22.8%, respectively; P = 0.011). Among newly licensed dentists who participated in the Medicaid program, there was no significant difference in the proportions of foreign- and U.S.-trained dentists who practiced in a dental HPSA (P = 0.683). CONCLUSIONS: Legislation that makes it easier for foreign-trained dentists to obtain licensure is unlikely to address dental workforce shortages or improve access to dental care for vulnerable populations in the United States. Licensing foreign dental school graduates in the United States also has ethical implications for the dental workforces in other countries.