US Oral Health Improving, Surveys Show

Laird Harrison

December 18, 2013

Cuteness counts.

You can talk all day about the cost savings of prevention and about social responsibility, but in the end, there is nothing like big eyes in a little face to influence legislation.

That is one of the lessons Burton Edelstein, DDS, MPH, from the College of Dental Medicine and Mailman School of Public Health, Columbia University, New York City, has taken away from decades of work on oral health policy. It helps explain why children are gaining more oral healthcare while adults are losing it, the founder of the Children's Dental Health Project told Medscape Medical News.

"Children are regarded as vulnerable, they are regarded as dependent, and they are cute," he said.

The disparity stands out in several recent studies on dental care in the United States.

In the first of the new studies, published in the December 5 issue of in Preventing Oral Disease, Mahua Mandal, MPH, PhD, also from the College of Dental Medicine and Mailman School of Public Health, and colleagues examined the National Survey of Children's Oral Health.

They found that 71.9% of 90,555 parents surveyed in 2011 and 2012 thought their kids were in good or excellent oral health, up from 67.7% of the 96,510 parents surveyed in 2003.

"Even the poor kids did better," said Dr. Edelstein.

In addition, the proportion of parents who reported that their kids had a preventive dental visit in the previous year increased from 71.5% in 2003 to 77.0% in 2011/2012.

In the second new study, published online December 17 in Frontiers in Public Health, researchers looked at statistics on adults from a different survey, the Behavioral Risk Factor Surveillance System.

Bei Wu, PhD, from the School of Nursing, Global Health Institute, Duke University, Durham, North Carolina, and colleagues showed that in 2008, less than 77% of US adults at least 50 years old had a dental cleaning in the previous year. Significantly, that rate had barely improved in the previous decade.

The databases, timelines, and questions asked in the 2 studies differ enough that a direct comparison would not be meaningful. However, earlier studies by the American Dental Association (ADA) support the notion that age groups are heading in different directions.

Looking at the National Health Interview Survey for an article published in the August 2012 issue of the Journal of Dental Education, the ADA researchers found that the percentage of children aged 2 to 20 years who had visited a dentist (for any reason) increased from 71.6% in 1999 to 77.0% in 2010. In contrast, the percentage of adults aged 65 years and older with a visit declined from 73.1% to 69.6%, and the percentage of adults aged 21 to 64 years with a visit dropped even more steeply, going from 66.8% to 61.8%.

Digging deeper, the ADA researchers found that the increase in dental visits among children occurred mostly among those in poverty. The corresponding decrease among adults was also sharpest among those in poverty.

At least part of this difference could be attributed to insurance coverage. The ADA researchers found that dental coverage by private insurance declined among both adults and children as many employers dropped their healthcare plans. Meanwhile, public insurance through Medicaid expanded, but this federal–state partnership does not mandate dental benefits for adults, and many states do not provide them. The Children's Health Insurance Program, which is exclusively for children, also expanded its dental coverage in the last decade.

As more provisions of the Affordable Care Act take effect, the difference between adults and children looks likely to widen even further. The act expands Medicaid but still does not mandate adult dental benefits. In addition, it requires that private insurers offer dental benefits for children, but not adults, through exchanges in the individual market.

Utah Dental Director Kim Michelson, DDS, has observed this difference in his own state. Utah provides full dental coverage through Medicaid for indigent children. A state program also encourages pediatricians, but not physicians treating adults, to provide fluoride varnish to their patients. As a result, untreated caries among Utah children declined from 22.1% in 2000 to 17.0% in 2010, according to data from the Utah Department of Health.

But the state has no similar programs in place for adults.

"Currently, here in Utah, the only adult dental care is for pregnant women," Dr. Michelson told Medscape Medical News. "For all the other adults, the only care is an emergency-type visit where an extraction is done, and there have been years when we don't even have that. I'm not sure what all the reasons are. It's sad that that's the way it is."

Good News in Some Areas

The news about dental care is not all bad. Adults as well as children in Utah may have benefited from a big increase in the percentage of the state's community water supplies that are fluoridated, and fluoridation across the country might explain why the some trends in oral health for adults are positive.

The most recent survey by the Centers for Disease Control and Prevention (CDC), published in May, show a decline in untreated dental caries among all age groups from 1971-1974 to 2007-2010 (although data are missing for some age groups in the more recent surveys).

A lower prevalence of caries could help explain why adults are going to the dentist less often.

The Frontiers in Public Health study turned up some other good news as well: it showed that the gap in dental visits between whites and ethnic minorities was narrowing, with particular progress among Asians and American Indians.

In 2008, 76.69% of Asians had their teeth cleaned in the previous year, up from 62.84% in 1999. They were followed by whites (76.18% in 2008, up from 75.34% in 1999), Hispanics (62.33%, up from 61.26%), American Indians/Alaskan Natives (61.85%, up from 57.49%), and blacks (56.52%, up from 55.88%).

"For Asian-Americans there are potential changes in culture and awareness," first author Dr. Wu told Medscape Medical News. However, Dr. Wu said she was speculating on this point.

In addition, the problem remains that many American adults are not getting the oral healthcare they need. The CDC's 2005-2008 survey showed that 23.7% of adults 20 to 64 years old had untreated caries compared with 16.2% of children aged 6 to 19 years.

Even among children, the Affordable Care Act may not help many who need dental care the most, Lawrence Hill, DDS, MPH, executive director of the American Association of Community Dental Programs in Cincinnati, Ohio, told Medscape Medical News.

In many states, Medicaid reimburses dentists less than the cost of caring for a patient, so it is difficult to find dentists willing to see Medicaid patients, he said. "We have a Medicaid program that doesn't work well. So if we have more children eligible for a program that doesn't work well, that's not going to fix the problem."

He advocates school-based dental care and the expansion of licensing programs for midlevel providers who are not as extensively trained as dentists but who can provide many of the same services as dentists at a lower cost.

Meanwhile, Dr. Edelstein has spent a lot of time pondering how to get legislators to focus on the problem of unmet dental needs at all.

In an analysis published online January 4 and in the July/August print issue of Special Care in Dentistry, Dr. Edelstein explains that dental care has remained on the sidelines of public health conversations for generations because of the historical separation of dentists from medical physicians, a perception that oral health is relatively unimportant, and resistance to public insurance programs by some groups of organized dentists.

He adds that the Children's Dental Health Project and other advocates have succeeded in expanding public oral health programs for children through the following strategy: "(1) [A]rticulate their issue with clarity, urgency, and articulation of significant consequence; (2) tie their issue to some policy agenda that is 'moving;' (3) obtain significant levels of consensus within the oral health and general health communities and related communities of interest in order to avoid dissention and competing voices; and (4) commit to doing the 'heavy lifting' of day-to-day engagement in the policymaking process."

Dr. Edelstein believes it might be possible to enlist legislator's interest in the oral needs of disabled adults because they, similar to children, are vulnerable and dependent. However, it will not be easy. In 2007, Dr. Edelstein points out, Mary Keel, an adult with Alzheimer's disease died from the sequelae of a dental infection after a 19-month stay in a Petaluma, California, nursing home, where she received no dental care. The case got little attention outside the State Legislature, which pulled the plug on adult Medicaid dental benefits soon afterward.

In contrast, when 12-year-old Deamonte Driver died from a spreading tooth infection the same year in Prince George's County, Maryland, the Washington Post picked up the story. The US Congress held hearings on the Driver case, and significant improvement in Maryland's oral health programs for children followed.

Older patients, it seems, just do not have the same emotional pull as children.

Dr. Mandel's article was funded by the National Institute of Dental and Craniofacial Research. Dr. Wu's study was funded by the National Institutes of Health/National Institute of Dental and Craniofacial Research. Dr. Edelstein, Dr. Michelson, Dr. Wu, and Dr. Hill have disclosed no relevant financial relationships.

Prev Chronic Dis. 2013;10:130187. Full text

Front Public Health. Published online December 17, 2013. Full text

J Dent Ed. 2012;76:1020-1027. Full text

Health, United States, 2012. CDC. Published online May 2013. Full text

Spec Care Dent. 2013;33:198-203. Abstract

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