Well-Baby Dental Checks by Physicians Cut Hospitalizations

Jenni Laidman

August 28, 2012

August 28, 2012 — Children are less likely to be hospitalized for tooth decay when pediatricians are enlisted to perform dental care during well-baby visits, according to results from a study published online August 27 in the Archives of Pediatric and Adolescent Medicine. But whether a North Carolina program to encourage the practice saves money is a matter of how you look at it.

Sally C. Stearns, PhD, professor, Department of Health Policy and Management, University of North Carolina at Chapel Hill, and colleagues show that infants with 4 or more physician-conducted oral health exams by age 3 years saw a small but statistically significant reduction in hospitalizations for dental caries by their sixth birthday. An earlier study of this same population (all participants in the North Carolina Into the Mouths of Babes [IMB] program) showed that children with 4 or more IMB visits saw a 17% reduction in dental caries–related treatment up to 6 years of age compared with children with no IMB visits.

The North Carolina Medicaid program reimburses physicians an average of $54.81 for each IMB visit for up to 6 visits by the time the infant is 35 months old. During each visit, the physician examines the baby's mouth, provides parental counseling, applies a fluoride varnish to infant teeth, and makes referrals to dentists when needed.

Moving in the Right Direction

"It's a very positive thing," Joel Berg, DDS, president of the American Academy of Pediatric Dentistry and dean of the University of Washington School of Dentistry, Seattle, told Medscape Medical News. Dr. Berg, who was not involved in the study, has been following the success of the North Carolina program almost since its start in 2000. "The reality is, pediatricians and family physicians see these children much more often than dentists do during the first 3 years of life."

The study shows "[w]e're going in the right direction," Dr. Berg said, but it is a direction that needs to be bolstered by more training. "In medical school and residencies, [physicians] don't get as much training on teeth. We're looking at ways to improve that. We want to raise the bar on physician ability to assess disease."

The study looked at Medicaid claims for 209,285 children enrolled in Medicaid at 6 months from 2000 to 2006. It found that 4 or more IMB visits in this group resulted in 0.036 fewer dental caries–related hospitalizations up to age 6 years compared with children without an IMB visit.

Children with 4 or more IMB visits were hospitalized 2936 times (95% confidence interval, 2035 - 3247 times) between age 6 months and 6 years compared with children with no IMB visits, who were hospitalized 3051 times in that period (95% confidence interval, 2150 - 3362).

Cost-Benefit Analysis

The authors report that this small but significant reduction led to a cumulative drop in Medicaid payments for dental care of $231 in the group with more IMB visits. However, at $242, the cost of physician reimbursement for IMB was $11 higher than the savings.

A traditional cost-benefit calculation shows IMB has a 32% chance of resulting in a cost savings, the article reports, but in another kind of analysis, the chance of savings is increased to 47.9%. If one adds to the calculation the reduction in pain and suffering brought about by the IMB program, as well as the indirect cost of lost parental earnings, the authors say, the savings is far greater.

The problem is that preventive healthcare is rarely cost-effective in a traditional analysis because of discounting, Dr. Stearns said in an interview with Medscape Medical News. Discounting dictates "a dollar today is worth more than a dollar in the future," she said.

"With preventive intervention, discounting always works against it," Dr. Stearns said. "I was thrilled when it was even a 32% cost savings."

When Dr. Stearns removed discounting from the formula, the picture improved. "We find if we don't discount cost or benefit, the program is more likely to break even," Dr. Stearns told Medscape Medical News.

A certain way to have the program break even is to reimburse physicians $34 per visit rather than the nearly $55 per visit currently used, the authors note. But perhaps a better way of assessing benefits is to include a consideration for the reduction in pain and suffering in any calculation, they suggest.

Hospitalization for dental caries is a "very expensive and traumatic event," study author R. Gary Rozier, DDS, professor in the Department of Health Policy and Management, University of North Carolina at Chapel Hill, told Medscape Medical News. Toddlers with severe tooth decay are in pain, cannot eat, and often cannot sleep. "The question becomes, how much are you willing to pay to prevent all that pain and suffering? That's where value judgments come in. In our assessment, it is worth paying this amount of money," Dr. Rozier stated.

Dr. Berg says he sees an even greater cost benefit.

"We know that there's just a small percentage of children who end up with most of the disease, and that's with any disease. To the extent that we target those children, and maximize the benefit for them, and the better physicians are at assessing which babies are at risk for more severe disease and referring them to dentists for aggressive prevention intervention, the more money you save."

The study was supported by the National Institute of Dental and Craniofacial Surgery. The authors and Dr. Berg have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. Published online August 27, 2012. Abstract

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