Reducing early childhood caries in a Medicaid population

A systems model analysis

      Abstract

      Background

      Despite early childhood caries (ECC) being largely preventable, its repair accounts for a disproportionate share of Medicaid expenditures. In this study, the authors model disease reductions and cost savings from ECC management alternatives.

      Methods

      The authors apply system dynamics modeling to the New York State Medicaid population of young children to compare potential outcomes of 9 preventive interventions (water fluoridation, fluoride varnish, fluoride toothpaste, medical screening and fluoride varnish application, bacterial transmission reduction, motivational interviewing, dental prevention visits, secondary prevention, and combinations) and the effect of defluoridating New York City.

      Results

      Model simulations help project 10-year disease reductions and net savings from water fluoridation, motivational interviewing, and fluoride toothpaste. Interventions requiring health professionals cost more than they save. Interventions that target children at high risk, begin early, and combine multiple strategies hold greatest potential. Defluoridating New York City would increase disease and costs dramatically.

      Conclusions

      The variety of population-level and individual-level interventions available to control ECC differ substantially in their capacity to improve children’s oral health and reduce state Medicaid expenditures.

      Practical Implications

      Using Medicaid and health department dollars to deliver ECC preventive and management interventions holds strong promise to improve children’s oral health while reducing state dental expenditures in Medicaid.

      Key Words

      Abbreviation Key:

      CWF (Community water fluoridation), ECC (Early childhood caries), MI (Motivational interviewing), NHANES (National Health and Nutrition Examination Survey), NYC (New York City), NYS (New York State)
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      References

      1. Medicaid.gov. Dental care. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Dental-Care.html. Accessed January 21, 2015.

        • Dye B.A.
        • Tan S.
        • Smith V.
        • et al.
        Trends in oral health status: United States, 1988-1994 and 1999-2004.
        Vital Health Stat. 2007; 11: 1-92
      2. Association of State and Territorial Dental Directors (ASTDD). Early childhood caries policy statement. Available at: http://www.astdd.org/docs/early-childhood-caries-policy-statement-june-26-2012.pdf. Accessed January 21, 2015.

      3. The Reforming States Group. Pediatric dental care in CHIP and Medicaid: paying for what kids need, getting value for state payments. Available at: http://www.milbank.org/reports/990716mrpd.html. Accessed January 21, 2015.

        • Foster T.
        • Perinpanayagam H.
        • Pfaffenbach A.
        • Certo M.
        Recurrence of early childhood caries after comprehensive treatment with general anesthesia and follow-up.
        J Dent Child (Chic). 2006; 73: 25-30
        • Hirsch G.B.
        • Edelstein B.L.
        • Frosh M.
        • Anselmo T.
        A simulation model for designing effective interventions in early childhood caries.
        Prev Chronic Dis. 2012; 9: E66
      4. Centers for Disease Control and Prevention. 2007 National Survey of Children's Health. Maternal and Child Health Bureau of the Health Resources and Services Administration. Available at: http://www.cdc.gov/nchs/slaits/nsch.htm. Accessed February 7, 2015.

        • Beltrán-Aguilar E.D.
        • Barker L.K.
        • Canto M.T.
        • et al.
        Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis: United States, 1988-1994 and 1999-2002.
        MMWR Surveill Summ. 2005; 54: 1-43
      5. Agency for Healthcare Research and Quality. 2004 Medical Expenditure Panel Survey. Department of Health and Human Services. Available at: http://meps.ahrq.gov/mepsweb/about_meps/survey_back.jsp. Accessed February 7, 2015.

        • Nagarkar S.
        • Kumar J.
        • Moss M.
        Early childhood caries-related visits to emergency departments and ambulatory surgery facilities and associated charges in New York State.
        JADA. 2012; 143: 59-65
        • Friedman B.
        • Owens P.
        The cost of “treat and release” visits to hospital emergency departments, 2003.
        US Department of Health and Human Services, Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Rockville, MD2007 (HCUP Methods Series Report 2007, publication #2007-05. Available at:) (Accessed January 21, 2015)
      6. American Academy of Pediatrics. Pediatric cost model. 2012. Available at: http://www.aap.org/en-us/professional-resources/practice-support/pediatric-cost-model/Pages/Pediatric-Cost-Model.aspx. Accessed February 17, 2015.

        • Hettema J.
        • Steele J.
        • Miller W.R.
        Motivational interviewing.
        Ann Rev Clin Psych. 2005; 1: 91-111
        • Kumar J.
        • Adekugbe O.
        • Melnik T.
        Geographic variation in Medicaid claims for dental procedures in New York State: role of fluoridation under contemporary conditions.
        Public Health Rep. 2010; 125: 647-654
        • Marinho V.C.
        • Higgins J.P.
        • Logan S.
        • Sheiham A.
        Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents.
        Cochrane Database Syst Rev. 2003; : CD002782
        • Griffin S.
        • Regnier E.
        • Griffin P.
        • Huntley V.
        Effectiveness of fluoride in preventing caries in adults.
        J Dent Res. 2007; 86: 410-415
        • Centers for Disease Control and Prevention (CDC)
        Water fluoridation and costs of Medicaid treatment for dental decay: Louisiana, 1995-1996.
        MMWR Morb Mortal Wkly Rep. 1999; 48: 753-757
        • Weyant R.J.
        • Tracy S.L.
        • Anselmo T.T.
        • et al.
        Topical fluoride for caries prevention.
        JADA. 2013; 144: 1279-1291
        • Weintraub J.A.
        • Ramos-Gomez F.
        • Jue B.
        • et al.
        Fluoride varnish efficacy in preventing early childhood caries.
        J Dent Res. 2006; 85: 172-176
        • Ng M.W.
        • Torresyap G.
        • White A.
        • et al.
        Disease management of early childhood caries: results of a pilot quality improvement project.
        J Health Care Poor Underserved. 2012; 23: 193-209
        • Pahel B.T.
        • Rozier R.G.
        • Stearns S.C.
        • Quinonez R.B.
        Effectiveness of dental treatments by physicians for young Medicaid enrollees.
        Pediatrics. 2011; 127: e682-e689
        • Söderling E.
        • Isokangas P.
        • Pienihäkkinen K.
        • Tenovuo J.
        • Alanen P.
        Influence of maternal xylitol consumption on mother-child transmission of Mutans streptococci: 6-year follow up.
        Caries Res. 2001; 35: 173-177
        • Köhler B.
        • Bratthall D.
        • Krasse B.
        Preventive measures in mothers influence the establishment of bacterium Streptococcus Mutans in their infants.
        Arch Oral Biol. 1983; 28: 225-231
        • Isokangas P.
        • Söderling
        • Pienihäkkinen K.
        • Alanen P.
        Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0 to 5 years of age.
        J Dent Res. 2000; 79: 1885-1889
        • Köhler B.
        • Andréen I.
        Influence of caries preventive measures in mothers on cariogenic bacteria and caries experience in their children.
        Arch Oral Biol. 1994; 39: 907-911
        • Weinstein P.
        • Harrison R.
        • Benton T.
        Motivating parents to prevent caries in their young children: one-year findings.
        JADA. 2004; 135: 731-738
        • Santos A.P.
        • Oliviera B.H.
        • Nadanovsky P.
        Effects of low and standard fluoride toothpastes on caries and fluorosis: systematic review and meta-analysis.
        Caries Res. 2013; 47 ([published online ahead of print April 6, 2013]): 382-390
        • Beil H.
        • Rozier R.G.
        • Preisser J.S.
        • Stearns S.C.
        • Lee J.Y.
        Effect of early dental visits on subsequent dental treatment and expenditures.
        Med Care. 2012; 50: 749-756
        • Manski R.J.
        • Brown Jr., E.
        Dental Use, Expenses, Private Dental Coverage, and Changes, 1996 and 2004.
        US Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD2007 (MEPS Chart Book No. 17. Available at:) (Accessed January 21, 2015)
        • Edelstein B.L.
        Forward to the background papers from the US Surgeon General’s Workshop on Children and Oral Health.
        Amb Pediatr. 2002; 2: 139-140
        • Chou R.
        • Cantor A.
        • Zakher B.
        • Mitchell J.P.
        • Pappas M.
        Preventing dental caries in children <5 years: systematic review updating USPSTF recommendation.
        Pediatrics. 2013; 132 ([published online ahead of print July 15, 2013]): 332-350
        • Casamassimo P.S.
        • Thikkurissy S.
        • Edelstein B.L.
        • Maiorini E.
        Beyond the dmft: the human and economic costs of early childhood caries.
        JADA. 2009; 140: 650-657
      7. Ad Council Partnership for Healthy Mouths, Healthy Lives. Make sure your kids brush for 2 minutes, twice a day. Available at: http://2min2x.org/. Accessed January 21, 2015.

      8. Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Community water fluoridation: Scientific reviews: assessing the weight of the evidence. Department of Health and Human Services. Available at: http://www.cdc.gov/fluoridation/safety/systematic.htm. Accessed February 8, 2015.

      9. City of New York. Does my water contain fluoride? Available at: http://www.nyc.gov/html/dep/pdf/wsstat00b.pdf. Accessed February 8, 2015.

        • Hanlon C.
        Reimbursing Medical Providers for Preventive Oral Health Services: State Policy Options.
        National Academy for State Health Policy, Washington DC2010 (Available at:) (Accessed January 21, 2015)
      10. Access to Baby & Child Dentistry. Washington Dental Service Foundation. Available at: http://abcd-dental.org/. Accessed February 23, 2015.

      11. I-Smile. Iowa Department of Public Health. Available at: http://www.ismiledentalhome.iowa.gov/. Accessed February 23, 2015.

      12. Into the Mouths of Babes/Connecting the Docs. North Carolina Department of Health and Human Services. Available at: http://www.ncdhhs.gov/dph/oralhealth/partners/IMB.htm. Accessed February 23, 2015.

      13. From the First Tooth. Available at: http://www.fromthefirsttooth.org/. Accessed February 23, 2015.

      Biography

      Dr. Edelstein is a professor of dental medicine and health policy & management, Columbia University Medical Center, New York, NY, and a senior fellow in public policy, Children's Dental Health Project, Washington, DC.

      Biography

      Dr. Hirsch is a proprietor, Learning Environments, Wayland, MA.

      Biography

      Ms. Frosh was a program director, Children's Dental Health Project, Washington, DC, when this article was written. She now is an executive director, Silver Spring Village, Silver Spring, MD.

      Biography

      Dr. Kumar is a director, Bureau of Dental Health, New York State Department of Health, Albany, NY.