Bulletin of Dental Education

Five Years Later: A Changing Landscape for Children’s Oral Health Care

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By Nicole Fauteux

On February 22nd, Congressman Elijah E. Cummings (MD-7) convened an event at the University of Maryland School of Law to honor Deamonte Driver, whose tragic death at age 12 provided the catalyst for long needed action on children's access to oral health care. Legislators and others in Maryland have made significant strides in this area, with Congressman Cummings and Senators Ben Cardin and Barbara Mikulski taking the lead at the national level. All three lawmakers were in attendance and spent the morning listening to two panels of experts. Their testimony shed light on what has been accomplished since Deamonte’s death and on the challenges that lie ahead.

At the federal level, the Children's Health Insurance Program (CHIP) now includes a guaranteed dental benefit for CHIP enrollees. The Affordable Care Act (ACA) mandates inclusion of pediatric dental benefits in every insurance package offered through the new health insurance exchanges that states will be creating. And for the first time, Healthy People 2020, the Centers for Disease Control’s (CDC's) framework for improving the health of the American people, lists oral health as one of only12 leading health indicators.

Maryland’s Achievements

At the state level, Maryland is the recognized leader in addressing the problems that led to Deamonte’s death. Maryland has increased its Medicaid reimbursement for dental services to 70% of median retail fees, one of the highest reimbursement rates in the country. As a result, the state has seen an 85% increase in the number of dentists who agree to treat Medicaid enrollees. But as Senator Mikulski, a social worker by training, pointed out, dentists do not see children in a vacuum.

Dr. Harold S. Goodman, Director of the state’s Office of Oral Health and one of the panelists at the event, concurred. He briefly described a case management program that his office has instituted on Maryland's Eastern Shore. The program employs social workers to facilitate the provision of oral health care. "They schedule appointments and make sure the patients arrive," he reported.

Other programs in the state are bringing dental services to children in Head Start programs and in schools and also educating them about proper oral health care. Senator Cardin praised the mobile dental vans he observed treating children in Hagerstown.

"It's one thing to say they are covered,” he remarked. “It's another to provide the care." The senator was also impressed by a child who, when asked if she remembered to brush her teeth, replied, "You also have to brush your gums and your tongue."

This indication of growing oral health awareness among the youngest generation of Maryland residents prompted Congressman Cummings to share a recollection from his own youth. “When I was growing up,” he told the gathering, "many people didn't know there was a connection between the teeth and the body. Toothaches were considered a routine part of life."

According to Dr. Goodman, "In the late 1990s, Maryland had one of the worst records regarding oral health care for its underserved population." He credited Deamonte's death with breaking what he called the cycle of non-action, allowing proponents of oral health to make strides in the state. "Maryland now faces the task of keeping oral health as a top public health priority," he concluded.

What Remains To Be Done: Access

The Pew Children's Dental Campaign has produced two 50-state report cards, which grade states on eight policies related to children's oral health. Shelly Gehshan, the campaign’s Director, appeared on the panel and praised Maryland for its dental sealant programs, community water fluoridation, Medicaid reimbursement and enrollment, and collection of data on children's dental health. She also pointed out that unlike some other states, Maryland does not require a dentist’s exam before a dental hygienist sees a child in a school-based sealant program, eliminating one barrier to care. Ms. Gehshan congratulated the state for receiving an A in the Pew report, but noted that the benchmarks were set very low. "If we had set them where we think they ought to be, every state--including Maryland---would have gotten a much lower grade," she said.

ADEA member Dr. Burton L. Edelstein, Professor at the Columbia University College of Dental Medicine and founding Director of the DC-based Children's Dental Health Project, also appeared on the panel. He began by stating that his testimony would focus on the empty half of the glass, and he emphasized that much more needs to be done to reach the youngest children before they acquire dental disease.

When Senator Mikulski pushed those testifying to offer concrete proposals for further government action, Dr. Edelstein urged lawmakers to look closely at how dental benefits are treated in the insurance plans that the new state health exchanges will offer so that "dental care is affordable as well as covered." He also noted that the Affordable Care Act authorized a $100 million National Oral Health Literacy Campaign, but that funds have yet to be appropriated. He urged active consideration of a $5 million investment in fiscal year 2013 to get the program started, noting, "As Maryland has learned in its public [oral health literacy] campaign, basic knowledge among parents and caregivers is our most powerful tool when it comes to preventing disease and maintaining good oral health."

What Remains To Be Done: Work Force

The lawmakers also expressed concern about shortages of health care providers, student debt, and the need for a more diverse health care workforce—areas where ADEA is well poised to play a leadership role. ADEA President Dr. Leo E. Rouse, Dean of the Howard University College of Dentistry, picked up these themes in his testimony. He urged the federal government to broaden the dialogue concerning the health care workforce beyond the Department of Health and Human Services to include the Department of Labor, the Department of Defense, and others who might play a role in workforce development. "It haunts me every night when I evaluate the class [of Howard students] and see such high levels of debt. Students want to know, will my financial aid be there next year? Will my stipend be available?"

He also stressed the need to engage the entire health care team in ensuring access to oral health care. "We talk about dental homes and medical homes," he said. "It's time to talk about health homes."

Investment Urged

The other panelists described federal efforts, community-based programs including a novel initiative to prepare inner city high school students for oral health careers, and the difficulties of accessing care for children with special needs. Throughout the proceedings, one message came through loud and clear: oral disease is preventable, and with enough political will, the problem can be solved.

Despite budgetary concerns at all levels of government, the panelists urged the lawmakers to increase federal and state investment in the kinds of programs and policies that have produced such positive results in Maryland. Dr. Edelstein used an unabashedly dental metaphor when he implored lawmakers to "take the provisions in the CHIP Reauthorization Act and the ACA and make them into substantive programs with teeth."

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