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Rebecca King, DDS, MPHNC State Dental Director

Section Chief, Oral Health SectionRebecca.King@dhhs.nc.gov

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Most common chronic disease of childhoodAlmost entirely preventable30% of all health care costs for childrenWidespread disparities from lack of prevention and treatment, poor diet, access to care, insurance coverage, financial resources

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Leads to Ch i i d di l li iChronic pain and medical complicationsEarly tooth loss, impaired speech developmentPoor nutrition, failure to thrive/impaired growthInability to concentrate, lost school/work timeReduced self-esteem

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Prevention that decreases costs is cost-saving.

Cost of prevention services plus

treatment services< Cost of treatment

services alone

If benefits are large compared to costs, prevention is cost-effective - even if it doesn’t save money.

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In medicine, we put a cost on lives lost.For dental issues, do not currently quantify:

time lost from work or school inability to sleep at nightdifficulty eatingfewer trips to the dentist f filli / t tifewer fillings/restorationself consciousnessclear speechquality of life

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All water contains fluorideFluoridation adjusting the amount Fluoridation: adjusting the amount of fluoride to the optimal level for preventing decayClassic population-based strategy Focuses on environmental and policy changes, rather than behavioral g ,changesReaches large populations at low cost

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CDC: For most cities, every $1 invested in fluoridation saves $38 in dental treatment costs *saves $38 in dental treatment costs.*Scientists testified before Congress in 1995 that national savings from water fluoridation estimated at $3.84 billion each year.**Texas 2000: the state saved $24/child/year in Medicaid expenditures for children because of the pcavities prevented by drinking fluoridated water.*** (study required by Legislature)

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http://www.cdc.gov/fluoridation/fact_sheets/cost.htm*http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459459/**www.dshs.state.tx.us/dental/pdf/fluoridation.pdf ***

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New York 2010: treatment costs/Medicaid recipient $23 65 hi h f h li i i l fl id d were $23.65 higher for those living in less fluoridated

counties*Colorado 2003:• Saved ~$149 million in unnecessary treatment costs

by fluoridating • A i f ~ $61/ **• Average savings of ~ $61/person.**

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* Public Health Reports (November-December 2010), Vol. 125, 788. ** http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459459/

One of the few public health One of the few public health measures that results in true

cost savings

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Jay Kumar, DDS, MPH

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Build support - internal & external Engage partners and stakeholders Engage partners and stakeholders • State Oral Health Coalition• Rural Water Association• Local Health Departments • State Dental Association

Develop resourcesDevelop resourcesProvide trainingAdvocate for investment

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Document savings in New York StateAdvocate for investing in cost savings interventionDevelop a method for supporting costs of fluoridation equipment, supplies and staff time

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Evaluation to determine if # claims for cavity-related M di id d i d b fl id i Medicaid procedures varied by fluoridation coverageUsed 2006 Medicaid claims dataFinding: # of cavity-related procedures (e.g. fillings, extractions) 33.4% higher in less fluoridated areas. Promotes policies to strengthen fluoridation

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Kumar, Adekugbe, Melnik. Public Health Reports, September –October 2012 Vol 25

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13) Medicaid Coverage of Water Fluoridation: To address disparities in access to dental services the To address disparities in access to dental services the Workgroup recommends that Medicaid funding be made available to support costs of fluoridation equipment, supplies and staff time for public water systems in population centers (population over 50,000) where the majority of Medicaid eligible children reside.

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http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrtcompanion.pdf

On the allowability of Medicaid financing for fluoridation as a strategy to reduce oral disease gyburden while lowering aggregate Medicaid dental expenditures.CMS has recently provided guidance to states regarding Medicaid financing of tobacco cessation quit lines.Medicaid supports administrative activities through the Medicaid Administrative Claiming process.

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Clear plastic coatings painted on the chewing surfaces of teethCan be provided in dental offices or in school-based clinicsCost can depend on where provided Effectiveness depends on risk status of patient p pselectionCost effective, sometimes cost savings

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North Carolina’s Statewide Medicaid Dental Prevention Program for Young Children

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Growing concern over pediatric oral healthStates are experimenting with different modelsPhysicians are being called on to provide dental services• AAP policy statements (2003, 2008)• Maternal and Child Health Bright Futures guidelines, 3rd

ed. 2008• Pew and Kellogg Foundations• National Interprofessional Initiative on Oral Health

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Increase access to preventive dental careReduce prevalence of Early Childhood Caries (ECC)Reduce the burden of treatment needs on the dental care system

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Pilot – volunteer trainerJune 2000 – funding from CMS to Medicaid June 2000 funding from CMS to Medicaid agencies for innovative programs to reduce ECC Partners• NC Medicaid• NC Oral Health program• UNC Schools of Public Health and Dentistry• Community leaders• NC Pediatric Society and Academy of Family Physicians

Additional funding from Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC)

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State Oral Health program provides training for medical providersproviders• Dedicated staff person – central contact

Medicaid reimburses for up to 6 visits before age 3 1/2• Oral evaluation and risk assessment• Referral for dental care• Fluoride varnish application• Caregiver education

U i it f N th C li University of North Carolina Gillings School of Global Public Health does ongoing evaluation

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No reduction in use of dental preventive servicesStatistically significant increase in use of treatment services and improved oral health Services in every county (formerly none in 1/3)At least 4 visits by age 4y g• Statistically significant reduction in need for

treatment of front teeth

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* Research Brief, Evaluation of IMB Program, Rozier et. al. UNC CH School of Public Health, June 2007.

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High adoption rates among medical providers• 450 practices

Increased access to preventive services• Wide geographic distribution• 43% of well-child visits• Physician visits 4 times greater than dentistsy g• Multiple visits 20 times greater in medical offices

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Rozier et al. J Dent Educ 2003;67:876-85. Close et al. Pediatrics. 2008;122:1387-94.Rozier et al. Health Affairs. 2010;29:2278-85.

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*For years 2000-2006 includes 1-2 yr olds only, for 2007 only includes 1-3 year olds.

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Physicians identify disease or not with 93% accuracy

Referral practicesOverall rate = 2.8%; with tooth decay = 33%3-fold increase in dental use (36% vs. 12%)When advised to see a dentist, kids are 2.9 X more likely to have a dental visit

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Pierce et al. Pediatrics. 2002;109:E82-2. Pahel et al. 2008. Beil & Rozier. Pediatrics. 2010;126:e435-41.

Reductions in treatment were substantial (49%) before 18 months of agebefore 18 months of ageFrom about 2 – 3½ years of age, net effectiveness was reduced• Probably because of early detection / referral effect

Overall, program was effective in reducing cavity related treatments through 6 years of agecavity-related treatments through 6 years of age• Net reduction of 18% with >4 visits

28Pahel et al. Pediatrics. 2011:e682-9

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Sample: ~25,000 children with ≥ 4 IMB visits Children had lower Medicaid dental payments from having fewer caries-related treatments and a lower probability of hospitalization. The IMB program is cost-effective with 95% certainty at a willingness to pay • $170 to avoid a dental treatment and $• $2600 to avoid a hospitalization.

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* Stearns, Rozier, Kranz, Pahel, Quiñonez. Poster presentation, AADR Meeting, Tampa, Florida March 2012

At about $35 per IMB visit, in this study sample the IMB program would be cost-saving.Limitations:• Results maybe affected by patient selection• Only treatment can be measured, rather than dental

health

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* Stearns, Rozier, Kranz, Pahel, Quiñonez. Poster presentation, AADR Meeting, Tampa, Florida March 2012

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Involves complex physiological changes that can adversely affect oral health.Emerging evidence shows association between gum infection and adverse outcomes (e.g. premature delivery, low birth-weight)Ideal time to educate women about preventing cavities in young children

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National Center for Education in Maternal and Child HealthAmerican Dental AssociationAmerican Academy of Pediatric DentistryAmerican Academy of PeriodontologyAmerica Academy of pediatricsy pNY State Department of Health

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Convened expert panelD l d d ti f l h lthDeveloped recommendations for oral health• Evidence-based where possible• Expert consensus where controlled studies weren't available

Recommendations for health care professionals• Prenatal• Oral health• Child health

Goals• Bring about changes in health care delivery system• Improve overall standard of care

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Dental care is safe and effective during pregnancypregnancy.Prenatal and oral health care providers need to coordinate.Improve women's health by good oral hygiene and nutrition.Get needed dental treatment before deliveryActions to reduce risk of cavities for children• Proper oral hygiene• Limit sugars• Avoid sharing saliva/germs• Visit dental professional between 6-12 months of age

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Oral Health Care during Pregnancy and Early Childh d (NY) Childhood (NY) http://www.vahealth.org/dental/documents/2008/pdfs/New%20York%20State%20Oral%20Health%20and%20Pregnancy%20Guidelines.pdfOral Health Care During Pregnancy: A Summary of Practice GuidelinesGhttp://www.healthplex.com/pdfs/Oral%20Health%20Care%20During%20Pregnancy%20Guidelines%20for%20Professionals.pdf

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Association of State and Territorial Dental Directors (ASTDD)Directors (ASTDD)

• http://www.astdd.org/state-programs/• http://www.astdd.org/best-practices/ASTDD policy statements

• http://www.astdd.org/docs/Water_Fluoridation_Policy_Statement_April_18_2009_2010-10.pdf

• http://www.astdd.org/docs/Fluoride_Varnish_Policy_Statp // g/ / yement_April_25_2010_New_Logo_2010-10.pdf

• http://www.astdd.org/docs/School-Based_or_School-Linked_Mobile_or_Portable_Dental_Services_Policy_Statement_February_28_2012.pdf

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Prevention is key!First priority is programs that are cost savings, but few procedures are cost savingsIdentify programs that are cost effectiveWhat price is society willing to pay?

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