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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Oral Health Care for Underserved Children in the United States a
b
Linda M. Culyer , Elaine Flagler Brown & Kathleen A. Kelly a
Utica College , Utica , New York
b
St. Elizabeth College of Nursing , Utica , New York
c
c
The Sage Colleges , Troy , New York Published online: 14 Feb 2014.
Click for updates To cite this article: Linda M. Culyer , Elaine Flagler Brown & Kathleen A. Kelly (2014) Oral Health Care for Underserved Children in the United States, Journal of Community Health Nursing, 31:1, 1-7, DOI: 10.1080/07370016.2014.868729 To link to this article: http://dx.doi.org/10.1080/07370016.2014.868729
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Journal of Community Health Nursing, 31: 1–7, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.868729
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Oral Health Care for Underserved Children in the United States Linda M. Culyer Utica College, Utica, New York
Elaine Flagler Brown St. Elizabeth College of Nursing, Utica, New York
Kathleen A. Kelly The Sage Colleges, Troy, New York
Dental caries is the most common chronic disease of childhood with approximately 25% of children from low-income families entering kindergarten without ever having seen a dentist (Larsen, Larsen, Handwerker, Kim, & Rosenthal, 2009). Youth, poverty, and race are characteristics of populations susceptible to oral disease (Dye, Xianfen, & Thorton-Evans, 2012). Services delivering oral health care to underserved populations are referred to as dental safety-net clinics. This article explores the impact of the dental safety-net on improving access to oral health care for underserved children in the United States.
Oral health is vital to general health and well-being; however, not all Americans are afforded the necessary care to achieve optimal oral health. This was the key message of Oral Health in America: A Report of the Surgeon General (US Department of Health and Human Services, Dental and Craniofacial Research, National Institutes of Health, 2000), which called for all levels of society to coordinate efforts and overcome barriers that place certain populations at risk for oral disease. Sadly, specific populations remain susceptible to oral disease despite the existence of safe and effective preventive measures to reduce the incidence of dental caries and periodontal diseases. The most vulnerable populations for oral disease include the poor and the young, especially children of certain racial and ethnic backgrounds, including Black, non-Hispanic, and Mexican American. More dental decay and lack of access to treatment is experienced among individuals living below the poverty level. Poor children between the ages of 2 and 9 are more than twice as likely to have untreated decay of their primary teeth. The highest number of untreated decayed primary teeth is found in poor Mexican American children within this age range, followed by Address correspondence to Linda M. Culyer, Department of Nursing, Utica College, 1600 Burrstone Road, Utica, NY 13502. E-mail: [email protected]
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poor non-Hispanic Blacks and non-Hispanic Whites (US Department of Human Services, Dental and Craniofacial Research, National Institutes of Health, 2000). Poverty, youth, and race continue to be the characteristics that identify populations at risk for oral disease. Dye, Xianfen, and Thornton-Evans (2012) derived this data from the 2009–2010 National Health and Nutrition Examination Survey, which revealed that “14% of children aged 3–5 years and 17% of children aged 6–9 years had untreated dental caries” (p. 2). Amazingly, dental caries is the most common chronic disease of childhood, with approximately 25% of children from low-income families entering kindergarten without ever having seen a dentist (Larsen, Larsen, Handwerker, Kim, & Rosenthal, 2009). Early childhood caries (ECC) is an especially damaging form of tooth decay that attacks primary teeth. The term caries, which originated from the Latin word for rotten, evolved by the last century to mean the condition of having holes or cavities in the teeth. Yet, a cavity is really a late sign of a bacterial infection, caused in part by species of Streptococci mutans. It is important for the public to understand that once teeth erupt, dental caries can occur. In 1997, The US Department of Health and Human Services, National Center for Health Statistics reported that six out of 10 children in the United States had one or more decayed or filled primary teeth by the age of 5. The occurrence of dental caries in children under the age of 6 increased during the 1990s and the proportion of poor children in this age group with severe caries continued to be more than four times greater than for nonpoor children (Rozier, Stearns, Pahel, Quinonez, & Park, 2010). Another contributing factor to caries rates in poor children is the intake of excessive dietary sugar (World Health Organization [WHO], 2003). In 2003, a WHO panel of experts supported evidence connecting frequent intake of simple sugars to an increased risk of caries (The World Oral Health Report). In fact, the most significant determinant of ECC is the prolonged contact of sweetened liquid with developing teeth as is the case when children are allowed a milk bottle feeding at night (Mohebbi, Virtanen, Vahid-Golpayegani, &Vehkalahti, 2008). As children transition to solid foods, some parents role-model healthy eating, whereas other parents may not restrict the inclusion of excessive dietary sugar (Mobley, Marshall, Milgrom, & Coldwell, 2009). The effects of dental caries on the biopsychosocial development of children lead to suffering. The suffering that dental caries inflicts on children includes chronic pain, eating and speaking difficulties, inability to concentrate in school, decreased social and family interaction, diminished self-image and self-esteem (Blevins, 2011; Jackson et al., 2007). Dental disease in children is one of the leading causes of school absenteeism, accounting for the annual loss of more than 51 million school hours (Jackson et al., 2007). This preventable disease can lead to potentially disabling or fatal infections (Rozier et al., 2010). For many, dental care represents the single most common unmet health care need (Mouradian et al., 2009). Barriers that hinder access to oral health were outlined in The Executive Summary of the Surgeon General’s Report - Oral Health in America (US Department of Health and Human Services, Dental and Craniofacial Research, National Institutes of Health, 2000). The most common barriers included lack of awareness of the seriousness of oral health, lack of or insufficient dental insurance, lack of transportation, uncompensated time from work, limited income, low community-to-private provider ratio, dentist nonparticipation with Medicaid/Child Health Insurance Program (CHIP), and low Medicaid program reimbursement rates for dental services. In addition, the report suggested development of a National Oral Health Plan to remove these barriers and promote collaboration among the key stakeholders, including individuals, health
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care providers, policy makers, and local communities, as well as integration of existing initiatives like Healthy People 2010 (US Department of Health & Human Services, 2000a). In a follow-up report to this landmark publication, A National Call to Action to Promote Oral Health (Call to Action) (US Department of Health & Human Services, 2003), these same stakeholders were asked to partner together to develop and implement strategies to overcome barriers and disparities associated with unmet oral health needs. The current Healthy People 2020 (US Department of Health and Human Services, 2010b) initiative builds on the four previous plans aimed at helping individuals of all ages increase their life expectancy and improve their quality of life. Reducing health disparities among different segments of the population is also an aim of this initiative and oral health is one of the identified focus areas. Objectives that focus on the oral health of children include: (a) reducing the proportion of children who have dental caries in their primary teeth or untreated dental decay, (b) increasing the proportion of children who use the oral health system, (c) increasing the proportion of low-income children who receive preventive dental service, (d) increasing the proportion of school-based health centers (SBHCs) and Federally Qualified Health Centers that have oral health programs, and (e) increasing the number of states and the District of Columbia that have an oral and craniofacial health surveillance system (US Department of Health and Human Services, 2010). The purpose of this article is to explore the impact of oral health care programs designed to meet the needs of underserved populations characterized by poverty, youth, and specific ethnic background. Dental care providers whose mission is to deliver oral health care to these populations are referred to as dental safety-net clinics.
DENTAL SAFETY NET PROGRAMS Dental safety-net programs are sponsored by and/or located in public health departments, Indian health service clinics, private not-for-profit social service agencies, dental schools, dental hygiene programs, community health centers, SBHCs with oral health care components, and mobile dental vans (Bailit et al., 2006). Private dental practices play a significant role in providing care to the underserved, but are not factored in as part of the safety-net system (Beazoglou et al., 2005). A quantitative study designed to include all safety-net dental programs in Illinois was conducted by Byck, Cooksey, and Russinof (2005). A goal of these researchers was to promote better understanding of the role of safety-net programs in alleviating dental access problems and barriers. The authors collected data using a cross-sectional survey of all clinics identified by the State Department of Public Health Division of Oral Health, using a confidential, written questionnaire organized into six sections that include dental clinic profile, dental visits, referrals to outside dentists, clinic staffing, funding sources and budgets, and future needs. They found that the programs served populations throughout the state, in urban and rural locations where they treated low-income patients who were either uninsured or covered by public insurance programs, such as Medicaid or the State Children’s Health Insurance Program (SCHIP), and people with personal access problems. The authors concluded that, although the dental safety-net programs in Illinois accounted for less that 2% (about 300,000) of all dental visits in the state, they provided a larger proportion of care for the target population of those facing barriers to accessing dental care. Admittedly, a drawback of this study was the single state sample; however, the authors did
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provide a survey instrument for a longitudinal study in Illinois or for use in other states (Byck et al., 2005). Beazoglou et al. (2005) compared the productivity of safety-net dentists with that of private practitioners in Connecticut. Data was obtained from the State Department of Social Services to investigate the Medicaid and SCHIP relative to enrolled members, utilization rates, and dentist reimbursement rates. The authors obtained a comprehensive list of Connecticut’s safety-net clinics from the State Department of Public Health and examined Medicaid dental claims data for the year 2000–2001, identifying public- and voluntary-sector delivery sites and providers. Comparing the number of patient visits per private practitioner with the number of treatment areas and allied health professionals per safety-net clinic dentist, the authors found the number of visits per dentist was almost the same. This was an unexpected finding, because private practitioners are paid on a fee-for-service basis, but most safety-net clinic dentists are salaried. However, in this study, the fee-for-service payment group saw more patients and produced more services per unit of time than did dentists working for safety-net clinics (Beazoglou et al., 2005). A quantitative research study by Larsen et al. (2009) sought to compare oral health outcomes relative to the productivity and cost-effectiveness of services offered by school-based and community-based dental clinics in New York City. The authors, hypothesizing that school-based clinics would outperform community-based clinics, compared data for fiscal year 2005 from a comprehensive record of dental services provided using encounter forms and expense reports outlining Medicaid reimbursement. The research findings demonstrated that school-based clinics were more efficient than community-based clinics according to the following factors: (a) location of the child, (b) no need for transportation, (c) no need for parent time off work, (d) no need for missed school, (e) little down time secondary to no missed appointments, and (f) little facility-based overhead because of the clinic location within the school. These authors noted that the school-based programs they studied provided almost twice the amount of preventive care to children, as compared with the community-based clinics (Larsen et al., 2009). Further evidence of the positive impact of SBHCs on access to care for children was documented by Guo, Wade, Pan, and Keller (2010). These authors conducted a longitudinal quasi-experimental retrospective study to evaluate the impact of SBHCs on health care disparities in Cincinnati, Ohio. The study used primary data sources and included a cost-benefit analysis. The target population was children in kindergarten through 12th grade who were also insured by Ohio Medicaid or the SCHIP. The authors hypothesized that schools with SBHC would provide students with easier access to primary care, reduce health care disparities in this population, and result in a positive cost-benefit to the community. The study, conducted from 1997 to 2003, compared schools with and without SBHCs and included a total of 5056 students; 3673 in the SBHC and 1383 in schools without SBHC. The authors found that during this time frame, Medicaid spent $30 million on this total number of students. Services paid for were mental health, outpatient care, hospitalizations, prescription medications, doctor appointments and emergency room visits. The cost-benefit analysis over 3 years showed an approximate $1.35 million net social benefit. Furthermore, the authors regarded as unquantifiable the prevention of dental decay or reduction in expensive dental treatment experienced by students who received oral health care in a SBHC (Guo et al., 2010). Rozier et al (2010) studied a program called Into the Mouths of Babes that was instituted in North Carolina in 2000 “to reimburse physicians for up to six preventive oral health visits for Medicaid-enrolled children younger than age three” (p. 2278). The authors proposed that delivery
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of preventive oral health care to young children in the medical setting would have to increase utilization of these services, as they were not previously provided in these settings. Despite this logic, however, there is little evidence of the positive effects of such programs in increasing utilization of oral health care (Rozier et al., 2010). The analysis of data undertaken by Rozier et al. (2010) used files from the North Carolina Medicaid Administration for children from 6 months to 3 years of age enrolled in Medicaid from January 2000 to December 2006. The measure of access to oral health services in medical offices was first the number of preventive visits, and second, the number of well-child visits for the entire group of children aged 6 months to 3 years enrolled in Medicaid. The measure of dental care utilization was the number of visits for any services and those for fluoride applications. Although this quantitative study demonstrated an increase in the utilization of preventive oral health services, the effectiveness of topical fluoride application in preventing dental caries was not demonstrated. In addition, further approaches are needed for underserved populations to provide preventive oral health care (Rozier et al., 2010). Simmer-Beck et al. (2011) studied a collaborative program between the University of Missouri-Kansas City of Dentistry, the Olathe School district, and a dental hygienist with an Extended Care Permit-I (ECP-I). The ECP-I expands the dental hygienist’s scope of practice to include the delivery of preventive oral care and referrals. The Miles of Smiles program targeted low-income children enrolled in Title 4 schools in which more than 40% of the students qualify for reduced-price or free lunches. The program involved dental hygiene faculty that supervised dental hygiene students who had an extended care permit in which underserved children were provided oral health care and counseling regarding nutrition. The students missed an average of approximately 30–60 minutes of time from class. There were no costs to participants, but if they had Medicaid, then it was billed for services. The results demonstrated that a total of 28 dental hygiene students provided oral health care to 339 children during the academic year of 2008–2009. The authors found that this type of SBHC program is effective in meeting the oral health needs of underserved children. Of these children, 63% were referred to a dentist because of active decay; however, a problem found upon reevaluation at the end of the school year was that only 11% of these children were able to transition to a safety-net clinic or dental office (Simmer-Beck et al., 2011). The question of whether disparities in access to, and use of, oral health and medical health services have changed over the years for children of certain race/ethnicity was investigated by Flores and Lin (2013). The authors analyzed secondary data from the 2003 and 2007 National Survey of Children’s Health parental surveys for a total of 193,995 (102,353 in 2003 and 91,642 in 2007) children aged 0–17. In regard to dental health needs, the results revealed that “all minority groups except for multiracial children were more likely than whites to have teeth in suboptimal condition” (p. 11). Although the reason for this disparity is unclear, the authors suggested the need for further study of this finding. In addition, between 2003 and 2007, teeth condition was a disparity that worsened for Latino children and for American Indian/Alaska Native children; this was a new disparity (Flores & Lin, 2013). The findings of the survey suggest that multiple disparities exist and continue to result in unmet oral health needs for children, which necessitate the importance of implementing strategies that will assure each child has a medical and dental home (Flores & Lin, 2013).
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CONCLUSION Despite ongoing research since publication of the first Surgeon General’s Report on Oral Care in America (2000), critical gaps in access to oral health prevail. This article focused on the effectiveness of safety-net dental programs in achieving outcomes for underserved children. These programs’ capacity, productivity, types of services rendered, hours of service, dental personnel, and evidence of improvement in the oral care and quality of life for poor and minority children is sorely lacking. These clinics treat a very small percentage of Americans. However, the Americans who benefit from these programs belong to the most vulnerable patient populations by virtue of age, economic status, race, and ethnicity. The passage of the Patient Protection and Affordable Care Act will introduce into the healthcare system more children who will need oral health care (Discepolo & Kaplan, 2011). However, currently these needs are not being met (Leininger & Meurer, 2011). Implementation of innovative services is needed to break barriers and overcome disparities to improve the ability of children to receive oral health care services.
REFERENCES Bailit, H., Beazoglou, T., Demby, N., McFarland, J., Robinson, P., & Weaver, R. (2006). Dental safety net: Current capacity and potential for expansion. Journal of the American Dental Association, 137, 807–815. Beazoglou, T., Heffley, D., Lepowsky, S., Douglass, J., Lopez, M., & Bailit, H. (2005). The dental safety net in Connecticut. Journal of the American Dental Association, 136, 1457–1462. Blevins, J. Y. (2011). Oral health care for hospitalized children. Pediatric Nursing, 37, 229–35. Retrieved from http:// search.proquest.com/docview/898418784?accountid=13645. Byck, G. R., Cooksey, J. A., & Russinof, H. (2005). Safety-net dental clinics: A viable model for access to dental care. Journal of the American Dental Association, 136, 1013–1021. Discepolo, K., & Kaplan, A. S. (2011). The Patient Protection and Affordable Care Act: Effects on dental care. New York State Dental Journal, 77(5), 34–8. Retrieved from http://search.proquest.com/docview/ 912870464?accountid=13645. Dye, B. A., Xianfen, L. & Thornton-Evans, G. (2012). Oral health disparities as determined by selected Healthy People 2020 Oral Health Objectives for the United States, 2009–2010 (NCHS data brief, no 104). Hyattsville, MD: National Center for Health Statistics, 2012. Flores, G., & Lin, H. (2013). Trends in racial/ethnic disparities in medical and oral health, access to care, and use of services in US children: Has anything changed over the years? International Journal for Equity in Health, 12, 1–16. doi:http://dx.doi.org/10.1186/1475-9276-12-10 Guo, L., Wade, T., Pen, W., & Keller, K. (2010). School-based health centers: Cost-benefit analysis and impact on health care disparities. American Journal of Public Health, 100, 1617–1622. Jackson, D. M., Jahnke, L. R., Kerber, L., Nyer, G., Siemens, K., & Clark, C. (2007). Creating a successful school-based mobile dental program. Journal of School Health, 77(1), 1–6. Larsen, C. D., Larsen, M. D., Handwerker, L. B., Kim, M. S., & Rosenthal, M. (2009). Journal of School Health, 79, 116–122. Leininger, L. J., & Meurer, J. (2011). Access to care for children: Recent progress, remaining challenges. Pediatric Annals, 40, 161–8. doi:http://dx.doi.org/10.3928/00904481-20110217-10 Mobley, C., Marshall, T., Milgrom, P., & Coldwell, S. E. (2009). The contribution of dietary factors to dental caries and disparities in caries. Academic Pediatrics, 9, 410–4. Mohebbi, S. Z., Virtanen, J. I., Vahid-Golpayegani, M., & Vehkalahti, M. M. (2008). Feeding habits as determinants of early childhood caries in a population where prolonged breastfeeding is the norm. Community Dentistry and Oral Epidemiology, 36, 63–69. Mouradian, W. E., Slayton, R. L., Maas, W. R., Kleinman, D. V., Slavkin, H., DePaola, D., . . . Wilentz, J. (2009). Progress in children’s oral health since the surgeon general’s report on oral health. Academic Pediatrics, 9, 374–379.
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National Call to Action to Promote Oral Health. (2003). Retrieved from http://www.nidcr.nih.gov/DataStatistics/ SurgeonGeneral/NationalCalltoAction/. Rozier, R. G., Stearns, S. C., Pahel, B. T., Quinonez, R. B., & Park, J. (2010). How a North Carolina program boosted preventive oral health services for low-income children. Health Affairs, 29, 2278–2285. doi:10.1377/hlthaff.2009.0768. Simmer-Beck, M., Gadbury-Amyot, C., Ferris, H., Voelker, M., Keselyak, N., Eplee, H., . . . Galemore, C. (2011, Summer). Extending oral health care services to underserved children through a school-based collaboration: Part 1— A descriptive overview. Journal of Dental Hygiene, 85, 181–192. Retrieved from http://search.proquest.com/docview/ 900932248?accountid=13645. US Department of Health and Human Services. (2000a). Healthy People 2010. Washington, DC: US Government Printing Office. Retrieved from http://www.healthypeople.gov/. US Department of Health and Human Services. (2010b). Healthy People 2020. Washington, DC: US Government Printing Office. Retrieved June 11, 2013 from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist. aspx?topicId=32. US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, & National Institutes of Health. (2000). Oral health in America: A report of the Surgeon General (NIH publication No. 00-4713). Rockville, MD: National Institutes of Health. Retrieved September 11, 2011 from http://www.nidcr.nih.gov/. World Health Organization. (2003). The World Oral Health Report 2003. Geneva, Switzerland: Author. Retrieved from http://www.who.int/oral_health/media/en/orh_report03_en.pdf
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Oral Health Care for Underserved Children in the United States a
b
Linda M. Culyer , Elaine Flagler Brown & Kathleen A. Kelly a
Utica College , Utica , New York
b
St. Elizabeth College of Nursing , Utica , New York
c
c
The Sage Colleges , Troy , New York Published online: 14 Feb 2014.
Click for updates To cite this article: Linda M. Culyer , Elaine Flagler Brown & Kathleen A. Kelly (2014) Oral Health Care for Underserved Children in the United States, Journal of Community Health Nursing, 31:1, 1-7, DOI: 10.1080/07370016.2014.868729 To link to this article: http://dx.doi.org/10.1080/07370016.2014.868729
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [University of Colorado - Health Science Library] at 08:20 31 March 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Community Health Nursing, 31: 1–7, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.868729
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Oral Health Care for Underserved Children in the United States Linda M. Culyer Utica College, Utica, New York
Elaine Flagler Brown St. Elizabeth College of Nursing, Utica, New York
Kathleen A. Kelly The Sage Colleges, Troy, New York
Dental caries is the most common chronic disease of childhood with approximately 25% of children from low-income families entering kindergarten without ever having seen a dentist (Larsen, Larsen, Handwerker, Kim, & Rosenthal, 2009). Youth, poverty, and race are characteristics of populations susceptible to oral disease (Dye, Xianfen, & Thorton-Evans, 2012). Services delivering oral health care to underserved populations are referred to as dental safety-net clinics. This article explores the impact of the dental safety-net on improving access to oral health care for underserved children in the United States.
Oral health is vital to general health and well-being; however, not all Americans are afforded the necessary care to achieve optimal oral health. This was the key message of Oral Health in America: A Report of the Surgeon General (US Department of Health and Human Services, Dental and Craniofacial Research, National Institutes of Health, 2000), which called for all levels of society to coordinate efforts and overcome barriers that place certain populations at risk for oral disease. Sadly, specific populations remain susceptible to oral disease despite the existence of safe and effective preventive measures to reduce the incidence of dental caries and periodontal diseases. The most vulnerable populations for oral disease include the poor and the young, especially children of certain racial and ethnic backgrounds, including Black, non-Hispanic, and Mexican American. More dental decay and lack of access to treatment is experienced among individuals living below the poverty level. Poor children between the ages of 2 and 9 are more than twice as likely to have untreated decay of their primary teeth. The highest number of untreated decayed primary teeth is found in poor Mexican American children within this age range, followed by Address correspondence to Linda M. Culyer, Department of Nursing, Utica College, 1600 Burrstone Road, Utica, NY 13502. E-mail: [email protected]
Downloaded by [University of Colorado - Health Science Library] at 08:20 31 March 2015
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poor non-Hispanic Blacks and non-Hispanic Whites (US Department of Human Services, Dental and Craniofacial Research, National Institutes of Health, 2000). Poverty, youth, and race continue to be the characteristics that identify populations at risk for oral disease. Dye, Xianfen, and Thornton-Evans (2012) derived this data from the 2009–2010 National Health and Nutrition Examination Survey, which revealed that “14% of children aged 3–5 years and 17% of children aged 6–9 years had untreated dental caries” (p. 2). Amazingly, dental caries is the most common chronic disease of childhood, with approximately 25% of children from low-income families entering kindergarten without ever having seen a dentist (Larsen, Larsen, Handwerker, Kim, & Rosenthal, 2009). Early childhood caries (ECC) is an especially damaging form of tooth decay that attacks primary teeth. The term caries, which originated from the Latin word for rotten, evolved by the last century to mean the condition of having holes or cavities in the teeth. Yet, a cavity is really a late sign of a bacterial infection, caused in part by species of Streptococci mutans. It is important for the public to understand that once teeth erupt, dental caries can occur. In 1997, The US Department of Health and Human Services, National Center for Health Statistics reported that six out of 10 children in the United States had one or more decayed or filled primary teeth by the age of 5. The occurrence of dental caries in children under the age of 6 increased during the 1990s and the proportion of poor children in this age group with severe caries continued to be more than four times greater than for nonpoor children (Rozier, Stearns, Pahel, Quinonez, & Park, 2010). Another contributing factor to caries rates in poor children is the intake of excessive dietary sugar (World Health Organization [WHO], 2003). In 2003, a WHO panel of experts supported evidence connecting frequent intake of simple sugars to an increased risk of caries (The World Oral Health Report). In fact, the most significant determinant of ECC is the prolonged contact of sweetened liquid with developing teeth as is the case when children are allowed a milk bottle feeding at night (Mohebbi, Virtanen, Vahid-Golpayegani, &Vehkalahti, 2008). As children transition to solid foods, some parents role-model healthy eating, whereas other parents may not restrict the inclusion of excessive dietary sugar (Mobley, Marshall, Milgrom, & Coldwell, 2009). The effects of dental caries on the biopsychosocial development of children lead to suffering. The suffering that dental caries inflicts on children includes chronic pain, eating and speaking difficulties, inability to concentrate in school, decreased social and family interaction, diminished self-image and self-esteem (Blevins, 2011; Jackson et al., 2007). Dental disease in children is one of the leading causes of school absenteeism, accounting for the annual loss of more than 51 million school hours (Jackson et al., 2007). This preventable disease can lead to potentially disabling or fatal infections (Rozier et al., 2010). For many, dental care represents the single most common unmet health care need (Mouradian et al., 2009). Barriers that hinder access to oral health were outlined in The Executive Summary of the Surgeon General’s Report - Oral Health in America (US Department of Health and Human Services, Dental and Craniofacial Research, National Institutes of Health, 2000). The most common barriers included lack of awareness of the seriousness of oral health, lack of or insufficient dental insurance, lack of transportation, uncompensated time from work, limited income, low community-to-private provider ratio, dentist nonparticipation with Medicaid/Child Health Insurance Program (CHIP), and low Medicaid program reimbursement rates for dental services. In addition, the report suggested development of a National Oral Health Plan to remove these barriers and promote collaboration among the key stakeholders, including individuals, health
Downloaded by [University of Colorado - Health Science Library] at 08:20 31 March 2015
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care providers, policy makers, and local communities, as well as integration of existing initiatives like Healthy People 2010 (US Department of Health & Human Services, 2000a). In a follow-up report to this landmark publication, A National Call to Action to Promote Oral Health (Call to Action) (US Department of Health & Human Services, 2003), these same stakeholders were asked to partner together to develop and implement strategies to overcome barriers and disparities associated with unmet oral health needs. The current Healthy People 2020 (US Department of Health and Human Services, 2010b) initiative builds on the four previous plans aimed at helping individuals of all ages increase their life expectancy and improve their quality of life. Reducing health disparities among different segments of the population is also an aim of this initiative and oral health is one of the identified focus areas. Objectives that focus on the oral health of children include: (a) reducing the proportion of children who have dental caries in their primary teeth or untreated dental decay, (b) increasing the proportion of children who use the oral health system, (c) increasing the proportion of low-income children who receive preventive dental service, (d) increasing the proportion of school-based health centers (SBHCs) and Federally Qualified Health Centers that have oral health programs, and (e) increasing the number of states and the District of Columbia that have an oral and craniofacial health surveillance system (US Department of Health and Human Services, 2010). The purpose of this article is to explore the impact of oral health care programs designed to meet the needs of underserved populations characterized by poverty, youth, and specific ethnic background. Dental care providers whose mission is to deliver oral health care to these populations are referred to as dental safety-net clinics.
DENTAL SAFETY NET PROGRAMS Dental safety-net programs are sponsored by and/or located in public health departments, Indian health service clinics, private not-for-profit social service agencies, dental schools, dental hygiene programs, community health centers, SBHCs with oral health care components, and mobile dental vans (Bailit et al., 2006). Private dental practices play a significant role in providing care to the underserved, but are not factored in as part of the safety-net system (Beazoglou et al., 2005). A quantitative study designed to include all safety-net dental programs in Illinois was conducted by Byck, Cooksey, and Russinof (2005). A goal of these researchers was to promote better understanding of the role of safety-net programs in alleviating dental access problems and barriers. The authors collected data using a cross-sectional survey of all clinics identified by the State Department of Public Health Division of Oral Health, using a confidential, written questionnaire organized into six sections that include dental clinic profile, dental visits, referrals to outside dentists, clinic staffing, funding sources and budgets, and future needs. They found that the programs served populations throughout the state, in urban and rural locations where they treated low-income patients who were either uninsured or covered by public insurance programs, such as Medicaid or the State Children’s Health Insurance Program (SCHIP), and people with personal access problems. The authors concluded that, although the dental safety-net programs in Illinois accounted for less that 2% (about 300,000) of all dental visits in the state, they provided a larger proportion of care for the target population of those facing barriers to accessing dental care. Admittedly, a drawback of this study was the single state sample; however, the authors did
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provide a survey instrument for a longitudinal study in Illinois or for use in other states (Byck et al., 2005). Beazoglou et al. (2005) compared the productivity of safety-net dentists with that of private practitioners in Connecticut. Data was obtained from the State Department of Social Services to investigate the Medicaid and SCHIP relative to enrolled members, utilization rates, and dentist reimbursement rates. The authors obtained a comprehensive list of Connecticut’s safety-net clinics from the State Department of Public Health and examined Medicaid dental claims data for the year 2000–2001, identifying public- and voluntary-sector delivery sites and providers. Comparing the number of patient visits per private practitioner with the number of treatment areas and allied health professionals per safety-net clinic dentist, the authors found the number of visits per dentist was almost the same. This was an unexpected finding, because private practitioners are paid on a fee-for-service basis, but most safety-net clinic dentists are salaried. However, in this study, the fee-for-service payment group saw more patients and produced more services per unit of time than did dentists working for safety-net clinics (Beazoglou et al., 2005). A quantitative research study by Larsen et al. (2009) sought to compare oral health outcomes relative to the productivity and cost-effectiveness of services offered by school-based and community-based dental clinics in New York City. The authors, hypothesizing that school-based clinics would outperform community-based clinics, compared data for fiscal year 2005 from a comprehensive record of dental services provided using encounter forms and expense reports outlining Medicaid reimbursement. The research findings demonstrated that school-based clinics were more efficient than community-based clinics according to the following factors: (a) location of the child, (b) no need for transportation, (c) no need for parent time off work, (d) no need for missed school, (e) little down time secondary to no missed appointments, and (f) little facility-based overhead because of the clinic location within the school. These authors noted that the school-based programs they studied provided almost twice the amount of preventive care to children, as compared with the community-based clinics (Larsen et al., 2009). Further evidence of the positive impact of SBHCs on access to care for children was documented by Guo, Wade, Pan, and Keller (2010). These authors conducted a longitudinal quasi-experimental retrospective study to evaluate the impact of SBHCs on health care disparities in Cincinnati, Ohio. The study used primary data sources and included a cost-benefit analysis. The target population was children in kindergarten through 12th grade who were also insured by Ohio Medicaid or the SCHIP. The authors hypothesized that schools with SBHC would provide students with easier access to primary care, reduce health care disparities in this population, and result in a positive cost-benefit to the community. The study, conducted from 1997 to 2003, compared schools with and without SBHCs and included a total of 5056 students; 3673 in the SBHC and 1383 in schools without SBHC. The authors found that during this time frame, Medicaid spent $30 million on this total number of students. Services paid for were mental health, outpatient care, hospitalizations, prescription medications, doctor appointments and emergency room visits. The cost-benefit analysis over 3 years showed an approximate $1.35 million net social benefit. Furthermore, the authors regarded as unquantifiable the prevention of dental decay or reduction in expensive dental treatment experienced by students who received oral health care in a SBHC (Guo et al., 2010). Rozier et al (2010) studied a program called Into the Mouths of Babes that was instituted in North Carolina in 2000 “to reimburse physicians for up to six preventive oral health visits for Medicaid-enrolled children younger than age three” (p. 2278). The authors proposed that delivery
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of preventive oral health care to young children in the medical setting would have to increase utilization of these services, as they were not previously provided in these settings. Despite this logic, however, there is little evidence of the positive effects of such programs in increasing utilization of oral health care (Rozier et al., 2010). The analysis of data undertaken by Rozier et al. (2010) used files from the North Carolina Medicaid Administration for children from 6 months to 3 years of age enrolled in Medicaid from January 2000 to December 2006. The measure of access to oral health services in medical offices was first the number of preventive visits, and second, the number of well-child visits for the entire group of children aged 6 months to 3 years enrolled in Medicaid. The measure of dental care utilization was the number of visits for any services and those for fluoride applications. Although this quantitative study demonstrated an increase in the utilization of preventive oral health services, the effectiveness of topical fluoride application in preventing dental caries was not demonstrated. In addition, further approaches are needed for underserved populations to provide preventive oral health care (Rozier et al., 2010). Simmer-Beck et al. (2011) studied a collaborative program between the University of Missouri-Kansas City of Dentistry, the Olathe School district, and a dental hygienist with an Extended Care Permit-I (ECP-I). The ECP-I expands the dental hygienist’s scope of practice to include the delivery of preventive oral care and referrals. The Miles of Smiles program targeted low-income children enrolled in Title 4 schools in which more than 40% of the students qualify for reduced-price or free lunches. The program involved dental hygiene faculty that supervised dental hygiene students who had an extended care permit in which underserved children were provided oral health care and counseling regarding nutrition. The students missed an average of approximately 30–60 minutes of time from class. There were no costs to participants, but if they had Medicaid, then it was billed for services. The results demonstrated that a total of 28 dental hygiene students provided oral health care to 339 children during the academic year of 2008–2009. The authors found that this type of SBHC program is effective in meeting the oral health needs of underserved children. Of these children, 63% were referred to a dentist because of active decay; however, a problem found upon reevaluation at the end of the school year was that only 11% of these children were able to transition to a safety-net clinic or dental office (Simmer-Beck et al., 2011). The question of whether disparities in access to, and use of, oral health and medical health services have changed over the years for children of certain race/ethnicity was investigated by Flores and Lin (2013). The authors analyzed secondary data from the 2003 and 2007 National Survey of Children’s Health parental surveys for a total of 193,995 (102,353 in 2003 and 91,642 in 2007) children aged 0–17. In regard to dental health needs, the results revealed that “all minority groups except for multiracial children were more likely than whites to have teeth in suboptimal condition” (p. 11). Although the reason for this disparity is unclear, the authors suggested the need for further study of this finding. In addition, between 2003 and 2007, teeth condition was a disparity that worsened for Latino children and for American Indian/Alaska Native children; this was a new disparity (Flores & Lin, 2013). The findings of the survey suggest that multiple disparities exist and continue to result in unmet oral health needs for children, which necessitate the importance of implementing strategies that will assure each child has a medical and dental home (Flores & Lin, 2013).
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CONCLUSION Despite ongoing research since publication of the first Surgeon General’s Report on Oral Care in America (2000), critical gaps in access to oral health prevail. This article focused on the effectiveness of safety-net dental programs in achieving outcomes for underserved children. These programs’ capacity, productivity, types of services rendered, hours of service, dental personnel, and evidence of improvement in the oral care and quality of life for poor and minority children is sorely lacking. These clinics treat a very small percentage of Americans. However, the Americans who benefit from these programs belong to the most vulnerable patient populations by virtue of age, economic status, race, and ethnicity. The passage of the Patient Protection and Affordable Care Act will introduce into the healthcare system more children who will need oral health care (Discepolo & Kaplan, 2011). However, currently these needs are not being met (Leininger & Meurer, 2011). Implementation of innovative services is needed to break barriers and overcome disparities to improve the ability of children to receive oral health care services.
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