Children’s Dental Health Disparities

© The Pew Charitable Trusts

School-based sealant programs allow states to provide more children with the critical preventive dental care they need and often cannot access.

Tooth decay is the most common chronic disease among U.S. children, five times as prevalent as asthma,¹ and dental care is one of the nation’s greatest unmet children’s health needs, especially in low-income, minority, and rural communities.²

Fortunately, two policy solutions proved to increase access to dental care for children are gaining ground across the country: School-based sealant programs have been shown to reduce decay by an average of 60 percent over five years,³ and adding midlevel providers—often called dental therapists—to the dental team can help vulnerable populations get the preventive and routine restorative treatment they need.⁴

With more support at the state level, these strategies can help address the continuing disparities in the dental health of the nation’s children.

Low-income, minority, and rural children suffer disproportionally from problems with dental health and access to care

Research shows that nationwide, these children are more likely to have unmet dental needs and face barriers to care:⁵

• 3 in 4 children with Medicaid across four states did not receive the dental services for which federal law requires coverage, and 1 in 4 did not visit a dentist during a two-year period.⁶
• More than 18 million low-income children went without dental care, including routine exams, in 2014.⁷
• In 2012, more than 4 million children did not receive needed dental care because their families could not afford it.⁸
• Even when controlling for insurance status, low-income and minority children remain less likely than their more well-off peers to receive preventive dental care.⁹ The rate of tooth decay among Hispanic and African-American children ages 2 to 8 was twice that of non-Hispanic white children from 2011 to 2012.¹⁰
• Preschool-age Native American children experience four times as many cases of untreated tooth decay as white children.¹¹
• Rural children are less likely to have dental insurance than their urban counterparts and more likely to seek care for preventable dental problems in overburdened emergency rooms.¹²

A number of factors contribute to the lower levels of preventive care that children in low-income, minority, and rural households receive, including barriers to transportation, a scarcity of dental providers in many communities, and cost.¹³ In a January 2016 report that looked at children’s low rates of dental care across four states, the Department of Health and Human Services identified dental provider shortages as a problem that these states should look to address.¹⁴ Without adequate preventive care, children’s dental issues can worsen and sometimes become urgent. More than 212,000 U.S. children had dental emergency visits in 2012, more than two-thirds of which were covered by Medicaid.¹⁵

School-based dental sealant programs provide essential preventive care

School-based sealant programs, often located in high-need schools with large numbers of low-income students,¹⁶ reliably provide a critical service to at-risk children. Dental sealants—plastic coatings placed on the chewing surfaces of teeth to shield grooved areas—are a powerful and preventive treatment that costs only one-third the price of a filling, can reduce most tooth decay for up to five years, and can even stop early decay from progressing.¹⁷ In light of the compelling research on their performance, the Community Preventive Services Task Force, an independent panel of experts appointed by the Centers for Disease Control and Prevention, issued a strong endorsement in 2001 of school sealant programs.¹⁸

Despite this strong evidence of effectiveness, The Pew Charitable Trusts’ 2015 50-state report revealed that in most states programs have failed to meet national goals for delivery of sealants to low-income and at-risk children. Dental sealants on permanent molars are more common among white 12- to 19-year-olds (47 percent) than their Hispanic (40 percent) and black (30 percent) counterparts.¹⁹

Expanding the dental team can make high-quality care more available to vulnerable populations

Similar to physician assistants in medicine, dental therapists are hired and supervised by dentists and help their practices provide quality care to more of those in need. Research shows that they provide high-quality, cost-effective care and improve access to treatment in parts of the country where dentists are scarce.²⁰ In Minnesota, the state Board of Dentistry and Department of Health reported that dental therapists have been delivering safe, high-quality care in rural and underserved communities, and that clinics employing them are expanding capacity and decreasing travel and wait times for patients.²¹

John Grant directs children’s dental policy and Andrew Peters oversees state campaigns on dental sealants at The Pew Charitable Trusts.

Endnotes

1. National Institutes of Health, U.S. Department of Health and Human Services, “Oral Health in America: A Report of the Surgeon General, National Institute of Dental and Craniofacial Research” (2000), http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/sgr/welcome.htm.
2. Paul W. Newacheck et al., “The Unmet Health Needs of America’s Children,” Pediatrics 105, no. 4 Pt. 2 (2000): 989–97,http://pediatrics.aappublications.org/content/105/Supplement_3/989.full.pdf+html; and Barbara Bloom et al., “Summary Health Statistics for U.S. Children: National Health Interview Survey, 2012,” National Center for Health Statistics, Vital and Health Statistics 10, no. 258 (2013): 5–6 and Tables 13 and 16,http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf.
3. Benedict I. Truman et al., “Reviews of Evidence on Interventions to Prevent Dental Caries, Oral, and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries,”American Journal of Preventive Medicine 23, 1 Suppl. (2002): 21–54, http://dx.doi.org/10.1016/S0749-3797(02)00449-X.
4. The Pew Charitable Trusts, “Expanding the Dental Team” (June 2014), http://www.pewtrusts.org/~/media/assets/2014/06/27/expanding_dental_case_ studies_report.pdf.
5. Jihong Liu et al., “Disparities in Dental Insurance Coverage and Dental Care Among US Children: The National Survey of Children's Health,” Pediatrics  119, Suppl. 1 (2007): S12–S21,http://pediatrics.aappublications.org/content/pediatrics/119/Supplement_1/S12.full.pdf.
6. Office of Inspector General, U.S. Department of Health and Human Services, “Most Children With Medicaid in Four States Are Not Receiving Required Dental Services” (2016), http://oig.hhs.gov/oei/reports/oei-02-14-00490.pdf.
7. U.S. Department of Health and Human Services and Centers for Medicare & Medicaid Services, Annual EPSDT participation report (Form CMS-416 (national) fiscal year 2014), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html. This figure includes children through age 20 who are eligible for the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.
8. Bloom et al., “Summary Health Statistics for U.S. Children.”
9. Liu et al., “Disparities in Dental Insurance Coverage and Dental Care Among US Children.”
10. Bruce A. Dye et al., “Dental Caries and Sealant Prevalence in Children and Adolescents in the United States, 2011–2012,” National Center for Health Statistics,NCHS Data Brief, no. 191 (2015), http://www.cdc.gov/nchs/data/databriefs/db191.pdf.
11. Kathy R. Phipps and Timothy L. Ricks, “The Oral Health of American Indian and Alaska Native Children Aged 1-5 Years: Results of the 2014 IHS Oral Health Survey,” data brief, Indian Health Service (2015), http://www.ihs.gov/doh/documents/IHS_Data_Brief_1-5_Year-Old.pdf. These figures refer to the 2014 Indian Health Service oral health survey of American Indian and Alaska Native children ages 1 to 5 and the National Health and Nutrition Examination Survey, 1999-2002.
12. Liu et al., “Disparities in Dental Insurance Coverage and Dental Care Among US Children.”
13. National Association of Dental Plans, “Who Has Dental Benefits,” http://www.nadp.org/Dental_Benefits_Basics/Dental_BB_1.aspx#_ftn1; Health Resources and Services Administration, “Shortage Designation: Health Professional Shortage Areas & Medically Underserved Areas/Populations,” http://www.hrsa.gov/shortage; and General Accountability Office, “Dental Services: Information on Coverage, Payments, and Fee Variation,” GAO-13-754 (September 2013),http://www.gao.gov/assets/660/657454.pdf.
14. Office of Inspector General, U.S. Department of Health and Human Services, “Most Children With Medicaid in Four States Are Not Receiving Required Dental Services.”
15. T. Wall and M. Vujicic, “Emergency Department Use for Dental Conditions Continues to Increase,” Health Policy Institute Research Brief, American Dental Association (April 2015), http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/ HPIBrief_0415_2.ashx. This figure includes charges for dental-related emergency department visits by children ages zero to 18 who were not admitted to the hospital.  
16. Centers for Disease Control and Prevention, “Oral Health Fact Sheet: School-Based Dental Sealant Programs,”http://www.cdc.gov/oralhealth/dental_sealant_program.
17. American Dental Association, Health Policy Institute, “2013 Survey of Dental Fees” (2014) http://success.ada.org/en/practice/operations/financial-management/2013-survey-of-dental-fees. The national median (50th percentile) charge among general practice dentists for a sealant (procedure code D1351) is $48, and the national median (50th percentile) charge for a one surface posterior composite filling (procedure code D2391) is $160; Susan O. Griffin et al., “Use of Dental Care and Effective Preventive Services in Preventing Tooth Decay Among U.S. Children and Adolescents—Medical Expenditure Panel Survey, United States, 2003-2009, and National Health and Nutrition Examination Survey, United States, 2005-2010,” Morbidity and Mortality Weekly Report 63, no. 2 (Sept. 12, 2014): 54–60,http://www.cdc.gov/mmwr/preview/mmwrhtml/su6302a9.htm?s_cid=su6302a9_w; Anneli Ahovuo-Saloranta et al., “Sealants for Preventing Dental Decay in the Permanent Teeth,” Cochrane Database of Systematic Reviews 3 (2013), doi:10.1002/14651858.CD001830.pub4; and Susan O. Griffin et al., “The Effectiveness of Sealants in Managing Caries Lesions,” Journal of Dental Research 87, no. 2 (February 2008): 169–74, http://www.ncbi.nlm.nih.gov/pubmed/18218845.
18. Centers for Disease Control and Prevention, “School-Based Dental Sealant Programs,” http://www.cdc.gov/oralhealth/dental_sealant_program.
19. Dye et al., “Dental Caries and Sealant Prevalence.” This figure applies to children ages 6 to 11.
20. David A. Nash et al., “Dental Therapists: A Global Perspective,” International Dental Journal 58 (2008): 61–70, http://www.ncbi.nlm.nih.gov/pubmed/18478885; and Scott Wetterhall et al., “Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska,” RTI International (2010),https://www.rti.org/pubs/alaskadhatprogramevaluationfinal102510.pdf.
21. Minnesota Department of Health and Minnesota Board of Dentistry, “Report to the Minnesota Legislature 2014: Early Impacts of Dental Therapists in Minnesota” (February 2014), http://www.health.state.mn.us/divs/orhpc/workforce/dt/dtlegisrpt.pdf.