Moving Minnesota Government Policies From a "C" to an "A": Helping Children Grow Up Caries Free

Moving Minnesota Government Policies From a "C" to an "A": Helping Children Grow Up Caries Free

Patricia Glasrud, M.P.H.*:

Introduction
Minnesota has often been touted as one of the healthiest states — and as having one of the most progressive state dental practice acts — in the country. So how did we earn only a “C” grade in the recent Pew Center on the States report called “The Cost of Delay: State Dental Policies Fail One in Five Children”?1 Furthermore, should we care?


The purpose of this article is not to give undue credence to the Pew report, but to remind us about how our continued advocacy is actually moving Minnesota closer to an “A”. The Pew report is about government policies that help ensure dental health and access to care for children: It is not a statement about the performance of dentists or dental associations.

Background
The Pew Charitable Trusts is a non-profit organization that provides a wide variety of grants to inform the public and support community service through public opinion. This particular project was funded by the W.K. Kellogg Foundation and DentaQuest Foundation, and focuses on public policies related to children’s oral health care (www.pewcenteronthestates.org). Some readers may recall that the organization called Oral Health America, funded in part by The Robert Wood Johnson Foundation, produced state “report cards” on oral health in the past, using some but not all of the same criteria used in the Pew report.2,3 One of the authors of these reports testified before the 2009 Minnesota legislature in support of the dental therapy legislation. It is reasonable to assume that key legislators will be paying attention to the Pew Report, so it is in dentists’ best interests to know what is influencing lawmakers’ decisions.


Such state “report cards” can be helpful in calling attention to policies that state officials, lawmakers, and dentists can work on for the benefit of their constituents and patients. One shortcoming acknowledged by the researchers is that not all states collect oral health status data on their populations — including Minnesota until recently — so policy recommendations are exactly that: recommendations, not mandates.

Policy Benchmarks:
How Were States “Graded”?
The Pew report gave each state and the District of Columbia a grade of A through F based on eight government policy benchmarks:
1. State has sealant programs in at least 25% of high-risk schools;
2. State does not require a dentist’s exam before a hygienist sees a child in a school sealant program;
3. State provides optimally fluoridated water to at least 75% of citizens on public water supply;
4. State meets or exceeds the national average (38.1%) of children ages 1-18 on Medicaid (Medical Assistance) receiving dental services;
5. State pays dentists who serve Medicaid-enrolled children at least the national average (60.5%) of Medicaid rates as a percentage of dentists’ median retail fees;
6. State Medicaid program reimburses medical care providers for preventive dental health services;
7. State has authorized a new primary care dental provider, and
8.State submits basic screening data to the National Oral Health Surveillance System database.


In order to earn a “C”, a state had to meet at least four of those benchmarks. Minnesota’s “C” grade was based on having achieved the following:
• Dental hygienists are allowed to place sealants without a dentist’s prior exam;
• Minnesota demonstrates 98.7% of our state’s population is on community water fluoridation;
• Minnesota pays medical providers for early preventive dental health care, and
• Minnesota has authorized the licensure of a new primary dental provider (the dental therapist).
That’s right: We are the only state that received a checkmark for having a new primary dental provider, and without it we would have gotten a “D”. There were only six states who received an “A” (that is, they got at least six of the eight benchmarks), including our neighbor to the south, Iowa.

Minnesota Government Policies That Pew Says Need Work
Some would argue that literally all of Minnesota’s government policies related to dental care need work for one reason or another, while others say our policies do not go far enough to promote oral health for children at high risk. Generally speaking, high risk children are those from low-income families, the under- and uninsured, and those who qualify for free school lunch programs.


The issue of children suffering from dental caries becomes particularly frustrating knowing that caries is preventable when multiple approaches are used. Reducing decay in those “one in five” children who government policies are failing requires the work of private practice health care professionals, along with community-based prevention strategies. The Pew report makes the point that states need to have all eight benchmarks in place to best work toward creating “cavity-free” children. Having just one (or four as in Minnesota) doesn’t cut it.


Let’s look at the four benchmarks where the Pew report’s authors claimed Minnesota falls short, and see what is being done in each one.


Benchmark #1: Share of Dentists’ Median Retail Fees Reimbursed by Medicaid
Minnesota dentists know all too well that our state has one of the lowest reimbursement rates in the country for dental services rendered to Minnesota Health Care Program enrollees. Wisely, the Pew report supports the need for state governments to step up to the plate and do the right thing by increasing reimbursements to dental providers at least up to the national average of 60.5% of dentists’ retail fees (as the Pew authors determined it to be). Because Minnesota’s reimbursement level has always been low - and is now at about 35% of dentists’ fees - this issue has been a perennial priority for the Minnesota Dental Association’s legislative agenda.


Increasing dentists’ reimbursement rates is one of the surest ways to increase dentists’ participation in public assistance programs. Furthermore, the Pew authors state that “ensuring that children have access to dental care should be non-controversial. Proven policy solutions exist. They are relatively inexpensive and can save taxpayers money. (page 51)”1 Surely this is a message we — along with other taxpayers and caregivers — can and will continue to bring to our legislators.

Benchmark #2: Share of High-Risk Schools with Sealant Programs
Dental professionals have used sealants successfully in private practice for years, but use in school-based programs that reach high-risk children has not been widespread across Minnesota. One of the oldest programs, Children’s Dental Services (CDS), is a non-profit organization that originated in 1919 to meet the needs of underserved families. Today, CDS operates more than 100 fixed or mobile dental clinics in schools and Head Start centers in the Twin Cities, Duluth, and St. Cloud, with plans to branch out into other areas of Greater Minnesota (www.childrensdentalservices.org). CDS offers more than sealants and is widely recognized as a school-based oral health program.


For years, dentists have questioned whether children should be assessed to determine level of caries risk before sealant application; whether radiographs need to be obtained before sealants are applied; whether incipient carious lesions should be sealed; whether sealants should be checked periodically, and so on. For many reasons, these questions become even more debatable when sealant application in schools is being considered. It is reasonable to examine the cost-effectiveness of such programs, particularly given the transience of low-income families, along with ever-dwindling government funding.


A comprehensive review of the scientific literature on the effectiveness of school-based sealant programs was published in the Journal of the American Dental Association in 2009.4 The authors’ recommendations update previous guidelines and support policies and practices for school-based sealants programs that are appropriate, feasible, and consistent with current scientific information. Among several recommendations are the following: Radiographs are unnecessary solely for sealant placement; tooth brushing before placing sealants is acceptable for preparing teeth for sealant placement; children should receive sealants even when follow-up cannot be ensured; and sealant retention should be evaluated after one year.


As authors Gooch, Griffin, Gray et al point out, dentists in private practice need to be aware of such programs because it is likely that they “will see children who have received sealants in school-based programs and might themselves be asked to participate in or even implement such programs. (page 1,357).”4 In addition, a March 2010 paper titled “Best Practice Approach: Improving Children’s Oral Health through Coordinated School Health Programs”5 from the American Association of State and Territorial Dental Directors shows why and how school programs can target high-risk children and offer not only sealants but also various fluorides and professional dental care. This information demonstrates that school-based sealant programs help get high-risk children off to a good start oral health-wise — and they have the important potential of linking children to comprehensive clinical dental care.

Benchmark #3: Share of Medicaid-Enrolled Children Getting Dental Care
According to Pew, only 37.7% of Minnesota children enrolled in Medicaid (Medical Assistance) receive dental care, just below the national average of 38.1%. Both statistics show that changes are badly needed to reach more disadvantaged children. This becomes even more evident when we realize that significantly more children who are covered by commercial dental insurance (rather than government insurance) receive dental care.


As reported in the March-April issue of Northwest Dentistry,6 Minnesota is actively working to get all children established in a “dental home” by the age of one year. This requires the joint efforts of dentists and of medical professionals such as family physicians and pediatricians, who typically see the babies before dentists do. General dentists and medical professionals need to perform infant oral exams, fluoride application, and provide anticipatory guidance with parents/caregivers. (Recall that the Pew report gave Minnesota a point for reimbursing medical providers for preventive oral health care.)


The Minnesota Dental Association, the Minnesota Academy of Pediatric Dentists, and other community partners continue to support the use of collaborative practice dental hygienists in Head Start programs in assessing, triaging, and referring high risk preschoolers for comprehensive dental care. This initiative is helping to prioritize and target children’s dental needs, and that should lead to a wiser use of public funding.


Although our state budget is in woefully bad shape, legislators and the governor have managed to maintain children’s dental care for Medical Assistance. Nevertheless, we need to ensure that this continues so that many more than 37% of children get the dental care they need.

Benchmark #4: Tracks Data on Children’s Dental Health
Right now, the Minnesota Department of Health Oral Health Program is gathering data on caries and sealants by screening third graders from a selected sample of high-risk schools across the state.7 This information will be used to create a Minnesota Oral Health Plan that lays out a strategy for improving the oral health of all Minnesotans. For the past several years, largely due to budget cuts, the Minnesota Department of Health saw the decline of its once-thriving oral health program. With new federal funding and a broad-base of community stakeholders, we are well on our way to putting a sound infrastructure in place as several other states have — complete with timely oral health data upon which to base goals and measure progress over time. The data will allow much better planning for future oral disease prevention and restorative measures by targeting groups most in need.

Conclusion
A basic premise upon which the Pew report was written is this:
Unlike so many of America’s other health care problems, the challenge of ensuring disadvantaged children’s dental health and access to care is one that can be overcome. There are a variety of solutions, they can be achieved at relatively low cost, and the return on investment for children and taxpayers will be significant.1


When stated like that, how can we not feel encouraged to seek new solutions toward creating cavity-free communities for kids? Remember the old adage: It’s always easier and more possible to tackle a big project when the project is divided into smaller parts. So let’s work locally in our own communities, share the results, and Minnesota’s overall picture of oral health may well be something for all to brag about in the not-too-distant future.

References
1. “The Cost of Delay: State Dental Policies Fail One in Five Children.” The Pew Center on the States, Feb. 2010. www.pewcenteronthestates.org.
2. “Keep America Smiling: Oral Health in America.” The Oral Health America National Grading Project 2003. (www.oralhealthamerica.org).
3. “A for Effort: Making the Grade in Oral Health.” An Oral Health America Special Grading Project, Feb. 2005. (www.oralhealthamerica.org)
4. Gooch, BF, Griffin, SO, Kolavic Gray, S et al. Preventing Dental Caries Through School-Based Sealant Programs: Updated Recommendations and Reviews of Evidence. JADA 2009;140:1,356-1,365.
5. “Best Practice Approach: Improving Children’s Oral Health through Coordinated School Health Programs.” www.astdd.org, March 5, 2010.
6. Carroll, C and Fong, T: Right from the start: A New Initiative for Children’s Oral Health. Northwest Dentistry 2010, Mar-Apr; 89(2):
12-18.
7. “MN Health Department conducts third grader screenings.” MDA News, Feb.2010, page 2.


*Pat Glasrud is the Director of Policy Development for the Minnesota Dental Association. Email is pglasrud@mndental.org.