The impact of dentists' availability in delivering dental care in Florida Elementary Schools.

OBJECTIVE: This study evaluates the dentists' availability to deliver preventive dental care to children in schools and the impact of school-based programs on access. METHODS: The study population included Florida elementary-school children, differentiated by dental insurance (Medicaid, CHIP, private, or none). We considered the implementation of school-based programs using optimization modeling to (re)allocate the dentists' caseload to schools to meet demand for preventive care under resource constraints. We considered multiple settings for school-based program implementation: (i) school prioritization; and (ii) dentists' participation in public insurance. Statistical inference was used to identify communities to improve access and reduce disparities. RESULTS: School-based programs reduced unmet demand (3%-12%), being more efficient if prioritizing schools in communities targeted to improve access. The access improvement varied by insurance status and geography. Uninsured urban children benefited most from school-based programs, with 15%-75% unmet need reduction. The percentage of urban communities targeted to improve access decreased by 12% against no-school program. Such percentage remained large for suburban (15%-100%) and rural (50%-100%) communities. Disparity in access for public-insured vs. private-insured children persisted under school-based programs (32%-84% identified communities). CONCLUSION: School-based programs improve dental care access; the improvement was however different by insurance status, with uninsured children benefiting the most. Accounting to the dentists' availability in prioritizing schools resulted in effective resource allocation to school-based programs. Access disparities between public and private-insured children did not improve; school-based programs shifted resources from public-insured to uninsured. School-based programs are effective in addressing access barriers to those children experiencing them most.

Oral Cancer Prevalence, Mortality, and Costs in Medicaid and Commercial Insurance Claims Data.

BACKGROUND: This study compared prevalence, incidence, mortality rates, treatment costs, and risk factors for oral and oropharyngeal cancer (OC/OPC) between two large United States adult cohorts in 2012-2019. METHODS: Medicaid and commercial claims data came from the IBM Watson Health MarketScan Database. Logistic regression analyses estimated incidence and risk factors for OC/OPC. Mortality was calculated by merging deceased individuals' files with those of the existing cancer cohort. Summing costs of outpatient and inpatient services determined costs. RESULTS: Prevalence of OC/OPC in Medicaid enrollees decreased each year (129.8 cases per 100,000 enrollees in 2012 to 88.5 in 2019); commercial enrollees showed a lower, more stable prevalence (64.7 per 100,000 in 2012 and 2019). Incidence trended downward in both cohorts, with higher incidence in the Medicaid (51.4-37.6 cases per 100,000) than the commercial cohort (31.9-31.0 per 100,000). Mortality rates decreased for Medicaid enrollees during 2012-2014 but increased in the commercial cohort. OC/OPC treatment costs were higher for commercial enrollees by $8.6 million during 2016-2019. OC/OPC incidence was higher among adults who were older, male, and white; used tobacco or alcohol; or had prior human immunodeficiency virus/acquired immune deficiency syndrome diagnosis and lower among those who had seen a dentist the prior year. CONCLUSIONS: Medicaid enrollees experienced higher OC/OPC incidence, prevalence, and mortality compared with commercially insured adults. Having seen a dentist within the prior year was associated with a lower risk of OC/OPC diagnosis. IMPACT: Expanding Medicaid dental benefits may allow OC/OPC to be diagnosed at earlier stages through regular dental visits.

The 2021 report on oral health in America: Directions for the future of dental public health and the oral health care system.

In the two decades between Oral Health in America: A Report of the Surgeon General and Oral Health in America: Advances and Challenges much good happened but intractable challenges persist. Inequity in oral health status, utilization, and access to care continue to negatively affect the health and economic wellbeing of Americans and their families, local, state, and federal health care systems, and American society overall. To move the nation forward, we argue that: more emphasis is needed in prevention; access to care must be improved to mitigate inequity; newer understandings of oral disease must be leveraged in the service of health and health care; the value that oral health brings to economic wellbeing must be elucidated; better policy choices must be made in all of the above; and more effective oral health care leaders in driving policy change must be trained.

Geographic Distribution of Pediatric Dentists and Community Characteristics of Their Locations in Florida.

Purpose: To describe the geographic distribution of pediatric dentists (PDs) in Florida and the sociodemographic characteristics of communities in which they are located compared with communities without a PD.
Methods: The ratio of PDs to children for each county in Florida and the distribution of PDs in Florida counties at the census tract (CT) level were calculated. Each CT was categorized as having or not having PDs to examine the geographic distribution of PDs, and the sociodemographic differences between CTs with and without a PD were tested by using t-tests. PDs' participation in Medicaid and acceptance of new patients were also investigated.
Results: Of the 67 counties in Florida, 31 had no PD. There were 4,181,677 children younger than 18 years served by 388 PDs, for a statewide ratio of 9.2 PDs per 100,000 population (range 0 to 34.9). Median household income, family income, and education were higher in CTs with PDs, and poverty level, unemployment rate, and percentage of African American population were higher in CTs with fewer PDs. Although 49 percent of PDs accepted Medicaid, only 32 percent accepted new patients.
Conclusion: There are regional and sociodemographic disparities in the distribution of PDs in Florida.

Hospital use for non-traumatic dental conditions among older adults in Florida.

OBJECTIVE: Older Americans are at risk of many oral diseases and conditions, but limited access to dental care may lead to the use of hospital emergency departments (EDs) or inpatient admissions. This study examined the use of hospitals for non-traumatic dental conditions (NTDCs) among persons aged ≥65 years in the Florida. METHODS: We analysed hospital use for NTDCs in Florida in 2018 from health department data sets. We calculated frequencies and rates of ED visits and hospital inpatient admissions, overall and by county, age, sex, race/ethnicity and principal payer. We also examined the source of hospital admission, primary diagnoses and charges. RESULTS: In 2018, there were 4894 ED visits and 747 inpatient admissions for NTDCs among persons aged ≥65 years in Florida. The rate for ED visits was 112.30 per 100 000 population and for hospital inpatient admissions was 17.14; rates varied widely among counties. Medicare was the most common primary payer. Referrals from EDs accounted for 76.2% of inpatient admissions for NTDCs by older adults. Total charges were $21.4 million for ED visits and $40.2 million for inpatient admissions. The most common principal diagnosis for ED visits for NTDCs was "periapical abscess without sinus tract" (K04.7; 26.2%) and for inpatient admissions was "inflammatory conditions of the jaw" (M27.2; 19.1%). Of the 747 inpatient admissions, two people died. CONCLUSIONS: Hospital use for NTDCs in Florida among persons aged ≥65 years is a clinical and financial challenge. Public coverage for basic adult dental services may lead to more effective use of funds and better health outcomes.

Dental Status and Treatment Needs of Children in Foster Care.

Purpose: This study compared the dental status and treatment needs of children in foster care with other children enrolled in Florida Medicaid. Methods: The study was a retrospective dental records review of patients who were associated with a foster care agency and an age-matched group of other Medicaid recipients in 2016. Results: We abstracted the electronic dental records of 548 two- to 18-year-olds in foster care and an age-matched group of 548 Medicaid-enrolled children not in foster care. Compared with other Medicaid-enrolled children, those in foster care were more likely to have experienced dental caries overall (75.7 percent versus 58.8 percent; P<.0001), in the permanent dentition (63.6 percent versus 45.1 percent; P<.0001), and in the primary dentition (32.7 percent versus 18.8 percent; P<.0001). Children in foster care had 1.6 times greater prevalence of pulpitis, 1.4 times as many root canal treatments, 5.8 times more diagnoses of severe gingivitis, 3.5 times more diagnoses of periodontitis, and 1.3 times more treatment-planned extractions. Conclusions: Children in foster care had more dental needs, higher caries prevalence, and received more dental care than other Medicaid-enrolled children. Poor oral health status is a public health concern for children in the foster care system. (Pediatr Dent 2019;41(3):206-10) Received December 18, 2018 | Last Revision March 12, 2019 | Accepted March 14, 2019.

Medicaid caseload for pediatric oral health care.

BACKGROUND: The authors' aims were to compare, according to strata, dentists' participation in Medicaid and Medicaid provider-level caseload measured as the number of patients or visits for preventive or restorative care for 2 comparison years. METHODS: The data sources were the 2012-2013 Medicaid Analytic eXtract claims and 2013 National Plan and Provider Enumeration System data sets. The authors measured Medicaid participation as the proportion of dentists participating in Medicaid among those in the National Plan and Provider Enumeration System. The authors measured provider-level caseload according to the number of patients or visits. The authors stratified oral health care providers according to state; whether practicing in rural, suburban, or urban communities; and provider type. RESULTS: The differences in participation rates for rural versus suburban and versus urban communities ranged from -4% through 27% and -6% through 37%, respectively. The 2012 state median number of patients per provider for preventive care ranged from 99 through 358. The provider-level caseload increased from rural to urban and from other provider to general dentist to pediatric dentist. The difference in caseload from 2012 to 2013 was not statistically significant except for the pediatric dentist type. CONCLUSIONS: This study's results suggest that the realized caseload for children enrolled in Medicaid varies according to provider type and urbanicity. The state median caseload for preventive care is lower than the 500:1 patient to provider ratio used as the minimum caseload in access estimates from other studies. PRACTICAL IMPLICATIONS: This study's results can assist states in gauging the level of oral health care provided to children insured by Medicaid compared with that in other states, with implications for the specification of oral health policies.

Projecting the economic impact of silver diamine fluoride on caries treatment expenditures and outcomes in young U.S. children.

OBJECTIVE: To quantify the economic impact of using silver diamine fluoride (SDF) to arrest the progression of dental caries in Medicaid-enrolled children (aged 1-5 years) relative to the standard restorative treatment from the Medicaid programs' perspective. METHODS: We used Monte Carlo simulation to estimate averted restorative visits and associated expenditures for varying SDF effectiveness and intervention penetration levels. We compared the current standard of care for treating caries to applying SDF. We estimated expenditures from the 2010-2012 Medicaid Analytic Extract files for seven US states and the incremental cost effectiveness ratio for SDF application on averted restorative visits. RESULTS: Across the seven states, averted restorative visits ranged from 2,049 (Vermont) to 60,542 (North Carolina), assuming an SDF penetration level of 50%. Averted per-restorative visit costs ranged from $100 to $350 per-visit. There were higher averted per-restorative visit costs in nonmetropolitan counties than metropolitan counties. CONCLUSIONS: Providing SDF as a caries management strategy can reduce Medicaid program dental care expenditures by averting expensive caries treatment options. It could also prevent stressful restorative procedures. State Medicaid programs should consider reimbursing for SDF to arrest the progression of dental caries in young children.

Women's sense of coherence and its association with early weaning / Senso de coerência da mulher e sua associação com o desmame precoce

Abstract Objective: To investigate whether there is an association between sense of coherence levels and early weaning. Method: This study had a quantitative nature and a cross-sectional design. Factors associated with early weaning (interruption of maternal breastfeeding) were investigated in a sample of 425 women older than 18 years, mothers of children up to 36 months of age who were not twins, with no sensory or motor deficiencies, without distinction of ethnicity or social class. The chi-squared test, with a significance level of 5%, was used to evaluate the association between the dependent variable (early weaning) and the independent variables (socioeconomic, demographic factors and sense of coherence level). Variables with p ≤ 0.20 were tested by the multiple logistic regression model. Odds ratio and the respective 95% confidence intervals were estimated. All statistical tests were performed using the SAS 9.2 software. Results: The results showed that mothers with greater sense of coherence were 1.82 times more likely to maintain breastfeeding for longer periods (p = 0.02). Conclusions: The identification of mothers with low sense of coherence allows the early intervention of health professionals, contributing to decrease the rates of early weaning in the population.

Resumo Objetivo: Investigar se há associação entre níveis de senso de coerência e desmame precoce. Método: O presente estudo tem natureza quantitativa e delineamento transversal. Foram investigados fatores associados ao desmame precoce (interrupção da oferta do leite materno à criança) em uma amostra de 425 mulheres com idade superior a 18 anos, sem distinção de etnia ou classe social, mães de crianças com até 36 meses, que não fossem gêmeos ou apresentassem deficiências sensoriais ou motoras. Foi feito o teste de qui-quadrado, com nível de significância de 5%, para testar a associação entre a variável dependente (desmame precoce) e as variáveis independentes (socioeconômicas, demográficas e nível de senso de coerência). As variáveis que apresentaram p ≤ 0,20 foram testadas no modelo de regressão logística múltipla. Os odds ratio e os respectivos intervalos de 95% de confiança foram estimados. Todos os testes estatísticos foram feitos com o programa SAS 9.2. Resultados: Os resultados apontaram que mães com maior senso de coerência possuem 1,82 vez mais chance de manter o aleitamento por mais tempo (p = 0,02). Conclusões: A identificação de mães com baixo senso de coerência permite a intervenção precoce dos profissionais de saúde, contribui para diminuir as taxas de desmame precoce na população.

ADA Health Policy Institute's methodology overestimates spatial access to dental care for publicly insured children.

OBJECTIVE: This article discusses the sources of overestimation of spatial access as recently provided by the Health Policy Institute (HPI) of the American Dental Association. METHODS: Sources of overestimation of access included estimation of Medicaid participation and capacity and limitations of the access measurement approach. RESULTS: While the HPI analysis used a 30% Medicaid acceptance rate for Florida, 10.2% of dentists accepted ≥100 Medicaid patients in 2015. The nationwide median number of Medicaid-enrolled children per provider ranges from 36 (Nebraska) to 265 (Florida). HPI estimated that 94% of publicly insured children in Georgia lived within 15 minutes of participating dentists. More rigorous modeling for access estimated that 23% of the total child population do not have access within the state access standards in Georgia. CONCLUSIONS: The estimates provided by HPI substantially overestimate access for children with public insurance. The overestimation comes from both the data limitations and the shortcomings of the methodology employed.

Interdisciplinary Community-Based Oral Health Program for Women and Children at WIC.

Objectives To evaluate the women, infants, and children (WIC) Oral Health Program in a county in Florida. Methods The non-traditional interdisciplinary program of the current study was designed to reach at-risk populations with untreated dental diseases and limited access to care; it provides oral health education, dental screenings, preventive dental services, and referrals for women, children, and families at WIC offices. We evaluated the health status of patients enrolled in the program and the services provided. Results From 2013 to 2016, the program provided dental screenings for 576 children and 180 women. Caries prevalence for 3-5 year olds was 46.0%. Only 6.6% (12/114) of pregnant women were eligible for comprehensive dental care under Medicaid (< 21 years). Further, 71.2% (47/66) of all pregnant women had unmet dental care needs. Conclusions for Practice Our results suggested that many children and women had untreated dental diseases and need preventive services and dental care. Also, many pregnant women were not covered by Medicaid. This program demonstrates that collaboration with the WIC program can improve access to oral health services for underserved populations.

Estimating the Cost Savings of Preventive Dental Services Delivered to Medicaid-Enrolled Children in Six Southeastern States.

OBJECTIVE: To quantify the impact of multiyear utilization of preventive dental services on downstream dental care utilization and expenditures for children. DATA SOURCES/STUDY SETTING: We followed 0.93 million Medicaid-enrolled children who were 3-6 years old in 2005 from 2005 to 2011. We used Medicaid claims data of Alabama, Georgia, Mississippi, North Carolina, South Carolina, and Texas. STUDY DESIGN: We clustered each state's study population into four groups based on utilization of topical fluoride and dental sealants before caries-related treatment using machine learning algorithms. We evaluated utilization rates and expenditures across the four groups and quantified cost savings of preventive care for different levels of penetration. DATA EXTRACTION METHOD: We extracted all dental-related claims using CDT codes. PRINCIPAL FINDINGS: In all states, Medicaid expenditures were much lower for children who received topical fluoride and dental sealants before caries development than for all other children, with a per-member per-year difference ranging from $88 for Alabama to $156 for Mississippi. CONCLUSIONS: The cost savings from topical fluoride and sealants across the six states ranged from $1.1M/year in Mississippi to $12.9M/year in Texas at a 10 percent penetration level. Preventive dental care for children not only improves oral health outcomes but is also cost saving.

Women's sense of coherence and its association with early weaning.

OBJECTIVE: To investigate whether there is an association between sense of coherence levels and early weaning. METHOD: This study had a quantitative nature and a cross-sectional design. Factors associated with early weaning (interruption of maternal breastfeeding) were investigated in a sample of 425 women older than 18 years, mothers of children up to 36 months of age who were not twins, with no sensory or motor deficiencies, without distinction of ethnicity or social class. The chi-squared test, with a significance level of 5%, was used to evaluate the association between the dependent variable (early weaning) and the independent variables (socioeconomic, demographic factors and sense of coherence level). Variables with p≤0.20 were tested by the multiple logistic regression model. Odds ratio and the respective 95% confidence intervals were estimated. All statistical tests were performed using the SAS 9.2 software. RESULTS: The results showed that mothers with greater sense of coherence were 1.82 times more likely to maintain breastfeeding for longer periods (p=0.02). CONCLUSIONS: The identification of mothers with low sense of coherence allows the early intervention of health professionals, contributing to decrease the rates of early weaning in the population.

Dental-Related Use of Hospital Emergency Departments by Hispanics and Non-Hispanics in Florida.

OBJECTIVES: To examine differences between Hispanics and non-Hispanics in Florida in the dental-related use of hospital emergency departments (EDs). METHODS: We used ambulatory ED discharge records from 2013 to 2015 to compute rates of ED visits for dental complaints per 10 000 population, by region, age, gender, and the percentage distribution visits by primary payer, day of the week, and hour of arrival. RESULTS: There were 64 100 ED visits for dental complaints by Hispanics and 425 162 by non-Hispanics. Medicaid was the most common primary payer for Hispanics (42.2%) and for non-Hispanics (38.1%). Rates of ED utilization for dental problems per 10 000 population were 45.5 for Hispanics and 95.2 for non-Hispanics. CONCLUSIONS: Rates of ED utilization for dental problems were different between Hispanics and non-Hispanics. Public Health Implications. Effective interventions need to be developed in the context of a social-ecological model to better understand factors such as health, economics, and education, among others. Understanding and intervening with the individual, communities, and policy could help to modify behaviors and improve access to dental care.

The cost-effectiveness of three interventions for providing preventive services to low-income children.

OBJECTIVE: We evaluated the impact of loan repayment programmes, revising Medicaid fee-for-service rates, and changing dental hygienist supervision requirements on access to preventive dental care for children in Georgia. METHODS: We estimated cost savings from the three interventions of preventive care for young children after netting out the intervention cost. We used a regression model to evaluate the impact of changing the Medicaid reimbursement rates. The impact of supervision was evaluated by comparing general and direct supervision in school-based dental sealant programmes. RESULTS: Federal loan repayments to dentists and school-based sealant programmes (SBSPs) had lower intervention costs (with higher potential cost savings) than raising the Medicaid reimbursement rate. General supervision had costs 56% lower than direct supervision of dental hygienists for implementing a SBSP. Raising the Medicaid reimbursement rate by 10 percentage points would improve utilization by <1% and cost over $38 million. Given one parameter set, SBSPs could serve over 27 000 children with an intervention cost between $500 000 and $1.3 million with a potential cost saving of $1.1 million. Loan repayment could serve almost 13 000 children for a cost of $400 000 and a potential cost saving of $176 000. CONCLUSIONS: The three interventions all improved met need for preventive dental care. Raising the reimbursement rate alone would marginally affect utilization of Medicaid services but would not substantially increase acceptance of Medicaid by providers. Both loan repayment programmes and amending supervision requirements are potentially cost-saving interventions. Loan repayment programmes provide complete care to targeted areas, while amending supervision requirements of dental hygienists could provide preventive care across the state.

Measuring quality: caries-related emergency department visits and follow-up among children.

OBJECTIVE: This study validated two Dental Quality Alliance system-level measures of oral healthcare quality for children - caries-related emergency department (ED) visits and timely follow-up of those visits with a dentist - including formal validation of diagnosis codes used to identify caries-related ED visits and measurement of follow-up care. METHODS: The measures were specified for implementation with administrative claims data and validated using data from the Florida and Texas Medicaid and Children's Health Insurance Programs. Measure specification testing and measure score validation used administrative data for 7,007,765 children. We validated the diagnosis codes in claims data by comparisons with manual reviews of 300 records from a Florida hospital ED and calculation of the kappa statistic, sensitivity, and specificity. RESULTS: Overall agreement in caries-related ED visit classifications between the claims data and record reviews was 87.7 percent with kappa = 0.71, sensitivity = 82 percent, and specificity = 90 percent. The calculated measure scores using administrative data found more than four-fold variation between programs with the lowest and highest caries-related ED visit rates (6.90/100,000 member months and 30.68/100,000 member months). The percentage of follow-up visits within 7 days and 30 days ranged from 22-39 percent and 34-49 percent, respectively. CONCLUSIONS: These National Quality Forum endorsed measures provide valid methodologies for assessing the rate of caries-related ED visits, an important system-level outcome indicator of outpatient prevention and disease management, and the timeliness of follow-up with a dentist. There is significant variation in caries-related ED visits among state Medicaid programs, and most ED visits do not have follow-up with a dentist within 30 days.

Costs And Savings Associated With Community Water Fluoridation In The United States.

The most comprehensive study of US community water fluoridation program benefits and costs was published in 2001. This study provides updated estimates using an economic model that includes recent data on program costs, dental caries increments, and dental treatments. In 2013 more than 211 million people had access to fluoridated water through community water systems serving 1,000 or more people. Savings associated with dental caries averted in 2013 as a result of fluoridation were estimated to be $32.19 per capita for this population. Based on 2013 estimated costs ($324 million), net savings (savings minus costs) from fluoridation systems were estimated to be $6,469 million and the estimated return on investment, 20.0. While communities should assess their specific costs for continuing or implementing a fluoridation program, these updated findings indicate that program savings are likely to exceed costs.

Trends in dental-related use of hospital emergency departments in Florida.

OBJECTIVES: The inability to access regular dental care may lead to care seeking at hospital emergency departments (EDs). However, EDs generally are not equipped or staffed to provide definitive dental services. This study examined trends and patterns of hospital ED use for dental-related reasons in Florida, a large, diverse state with serious barriers to accessing dental care. METHODS: Data for this study were drawn from ambulatory ED discharge records compiled by Florida's Agency for Health Care Administration for 2005-2014. Visits for dental-related reasons in Florida were defined by the patient's reported reason for seeking care or the ED physician's primary diagnosis using ICD-9-CM codes. We calculated frequencies, age-specific and age-adjusted rates per 100,000 population, and secular trends in dental-related ED visits and their associated charges. RESULTS: The number of dental-related visits to Florida EDs increased each year, from 104,642 in 2005 to 163,900 in 2014; the age-adjusted rate increased by 43.6 percent. Total charges for dental-related ED visits in Florida increased more than threefold during this time period, from $47.7 million in 2005 to $193.4 million in 2014 (adjusted for inflation). The primary payers for dental-related ED visits in 2014 were Medicaid (38 percent), self-pay (38 percent), commercial insurance (11 percent), Medicare (8 percent), and other (5 percent). CONCLUSIONS: Dental-related visits to hospital EDs in Florida have increased substantially during the past decade, as have their associated charges. Most patients did not receive definitive oral health care in EDs, and this trend represents an increasingly inefficient use of health care system resources.

The effect of Medicaid primary care provider reimbursement on access to early childhood caries preventive services.

OBJECTIVE: To examine receipt of early childhood caries preventive services (ECCPS) in two states' Medicaid programs before and after the implementation of reimbursement to medical primary care providers (M-PCPs). DATA SOURCES: Enrollment and claims data from the Florida and Texas Medicaid programs for children ≤54 months of age during the period 2006-2010. STUDY DESIGN: We conducted time trend-adjusted, difference-in-differences analyses by using modified Poisson regressions combined with generalized estimating equations (GEEs) to analyze the effect of M-PCP reimbursement on the likelihood that an enrollee had an ECCPS visit after controlling for age, sex, health status, race/ethnicity, geographic location, and enrollment duration. DATA EXTRACTION METHODS: Enrollment data were linked to claims data to create a panel dataset with child-month observations. PRINCIPAL FINDINGS: Reimbursement to M-PCPs was associated with an increased likelihood of ECCPS receipt in general and topical fluoride application specifically in both states. CONCLUSIONS: Reimbursement to M-PCPs can increase access to ECCPS. However, ECCPS receipt continues to fall short of recommended care, presenting opportunities for performance improvement.