State Medicaid Early and Periodic Screening, Diagnosis, and Treatment guidelines: Adherence to professionally recommended best oral health practices

doi:10.14219/jada.archive.2013.0117

The Journal of the American Dental Association

Volume 144, Issue 3, March 2013, Pages 297-305

https://doi.org/10.14219/jada.archive.2013.0117 Get rights and content

ABSTRACT

Background

The authors evaluated the adherence of state Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) guidelines to recommended best oral health practices for infants and toddlers.

Methods

The authors obtained state EPSDT guidelines via the Internet or from the Medicaid-CHIP State Dental Association, Washington. They identified best oral health practices through the American Academy of Pediatric Dentistry (AAPD), Chicago. They evaluated each EPSDT dental periodicity schedule with regard to the timing and content of seven key oral health domains.

Results

Thirty-two states and the District of Columbia (D.C.) had EPSDT dental periodicity schedules. With the exception of the dentist referral domain, 29 states (88 percent) adhered to the content and timing of best oral health practices, as established by the AAPD guideline. For the dentist referral domain, 31 of the 32 states and D.C. (94 percent) required referral of children to a dentist, but only 11 states (33 percent) adhered to best oral health practices by requiring referral by age 1 year.

Conclusions

With the exception of the timing of the first dentist referral, there was high adherence to best oral health practices for infants and toddlers among states with separate EPSDT dental periodicity schedules.

Practical Implications

States with low adherence to best oral health practices, especially regarding the dental visit by age 1 year, can strengthen the oral health content of their EPSDT schedules by complying with the AAPD recommendations.

Section snippets

EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT DENTAL SERVICES

As a joint federal and state program, Medicaid is operated by states within broad federal requirements. States “can elect to cover a range of optional populations and services, thereby creating programs that differ substantially from state to state.―⁷ Although adult dental benefits are optional, all states are federally mandated under EPSDT to cover comprehensive dental services for children younger than 21 years.⁷ According to the Centers for Medicare and Medicaid Services (CMS), Baltimore,

METHODS

We identified state-level (and District of Columbia [D.C.]) EPSDT dental periodicity guidelines by using two approaches. In the first approach, we accessed many guidelines online, which is testament to their wide availability to EPSDT staff members, health care practitioners and parents. One of us (J.M.H.) performed the Internet searches in January 2012 by using the following search terms: state dental periodicity, state oral health periodicity, state dental EPSDT, state EPSDT periodicity,

RESULTS

Although all 50 states and D.C. had a dental component to their EPSDT guidelines, 33 of 51 (65 percent) maintained separate dental EPSDT periodicity schedules (Table 1 ¹², 17, 18, 19, 20, 21) and 18 (35 percent) did not (Table 2). For states that did not adopt a separate dental EPSDT periodicity schedule, five incorporated dental information into their Medicaid policy from the American Academy of Pediatrics (AAP), Elk Grove Village, Ill., periodicity schedule for medical screening,¹⁸ and one

DISCUSSION

Medicaid programs provide many oral health services for children in low-income families who otherwise would not have access to dental care. We identified state EPSDT dental periodicity schedules because of their potential to influence the oral health of children enrolled in Medicaid. We found that only 32 states and D.C. had EPSDT oral health guidelines, but the majority of those that did included more than 85 percent of recommended best oral health practices in their guidelines. EPSDT dental

CONCLUSIONS

The results of our study show that only 32 states and D.C. (65 percent) had a separate EPSDT oral health guideline. Most states with EPSDT oral health guidelines included more than 85 percent of the recommended best oral health practices, which are based on the AAPD guideline.¹² Conversely, none of the states without a separate EPSDT dental periodicity schedule adopted the AAPD guideline. The age at which children are first referred to a dentist was the most divergent issue among state

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A comparative analysis of public and private dental benefit payer types for the provision and outcomes of root canal therapy on permanent teeth of children and adolescents in Massachusetts
2023, Journal of the American Dental Association
Despite substantial increases in dental benefits and improvements in the use of dental services among children and adolescents in the United States, oral health disparities according to dental insurance payer type persist.
The authors used an all-payer claims (2013-2017) database to perform a comparative analysis of the provision and treatment outcomes of an endodontic procedure (root canal therapy) in the permanent teeth of a pediatric population aged 6 through 18 years, according to dental insurance payer type. Statistical analyses, including logistic regression, Cox proportional hazards regression, and the Kaplan-Meier method, were performed at person and tooth levels.
Compared with privately insured children and adolescents, public-payer children and adolescent beneficiaries were more likely to have had root canal therapy (adjusted odds ratio, 1.91; 95% CI, 1.73 to 2.11) and had poorer treatment outcomes associated with the procedure (adjusted hazard ratio, 2.19; 95% CI, 1.53 to 3.14; P < .0001) during the study period. Those enrolled in private insurance were more likely to receive treatment from an endodontist (specialist in providing root canal therapy) (P < .0001). Amounts allowed and paid by the insurer were significantly higher for private payers (P < .001).
There were significant differences in the provision and outcomes of endodontic treatment between privately and publicly insured children and adolescents.
Despite ostensibly equal access to care, differences in the provision of oral health care exist between privately and publicly insured patients. These differences may be contributing to persisting oral health disparities.
Comparative analysis of dental procedure mix in public and private dental benefits programs
2022, Journal of the American Dental Association
Citation Excerpt :
CMS grants autonomy to each Medicaid program to determine the services and associated frequencies that will meet minimum objectives for oral health among the eligible children living in their state.29 As state programs have refined their benefits for children in adherence of EPSDT over time, public coverage for oral health care has grown to look remarkably similar to private coverage for children’s oral health care, with more dentist participation and greater oral health care use.28,30,31 The Patient Protection and Affordable Care Act reinforced the essentialism of children’s oral health care with the inclusion of pediatric oral health care as an essential health care benefit; the same was not done for adults.31-33
There is little published research on whether public and private dental benefits plans affect the types of oral health care procedures patients receive. This study compares the dental procedure mix by age group (children, working-age adults, older adults), dental benefits type (Medicaid and Children’s Health Insurance Program, private), and level of Medicaid dental benefits by state (emergency only, limited, extensive).
The authors extracted public dental benefits claims data from the 2018 Transformed Medicaid Statistical Information System. To compare procedure mix with beneficiaries who had private dental benefits, the authors used claims data from the 2018 IBM MarketScan dental database. The authors categorized dental procedures into specific service categories and calculated the share of procedures performed within each category. They analyzed procedure mix by age, plan type (fee-for-service, managed care), and adult Medicaid benefit level.
Aside from orthodontic services, the dental procedure mix among children with public and private benefits is similar. Among adults with public benefits, surgical interventions make up a higher share of dental procedures than routine preventive services.
Children with public benefits have a procedure mix comparable with those with private benefits. There are substantial differences in procedure mix between publicly and privately insured adults. Even in states that provide extensive dental benefits in Medicaid, those programs primarily finance invasive surgical treatment as opposed to preventive treatment.
There is a need to assess best practices in publicly funded programs for children and translate those attributes to programs for adults for more equitable benefit design and care delivery across public and private insurers.
Pediatric dental care use and parent- or caregiver-rated oral health among Alabama children enrolled in Medicaid
2020, Journal of the American Dental Association
Reducing caries and improving access to dental care is a public health challenge. Understanding low use of dental care is of critical importance. This study estimated parent- or caregiver-reported prevalence and identified factors associated with children’s dental care use, including the association with children’s oral health.
A cross-sectional analysis of children enrolled in Medicaid in Alabama, using data from the 2017 statewide Consumer Assessment of Healthcare Providers and Systems Health Plan Survey, was conducted. Associations were measured using adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) from logit regression and generalized linear model postestimation of least-squares means.
The 6-month prevalence of children receiving dental care was 70.4%. Children aged 0 through 3 years (aPR, 0.72; 95% CI, 0.53 to 0.91) had lower prevalence of care than other age groups. The prevalence of low-rated oral health was 9.2%. Low-rated oral health was associated with not receiving dental care (aPR, 1.50; 95% CI, 1.12 to 1.87) and parental education of 8th grade or less (aPR, 2.59; 95% CI, 1.20 to 3.98). Falsification tests determined that dental care use was not associated with ratings for overall health (aPR, 1.18; 95% CI, 0.83 to 1.52) or emotional health (aPR, 1.06; 95% CI, 0.79 to 1.33).
It was observed that children not receiving dental care had low-rated oral health; however, as a cross-sectional study, it was not possible to assess the temporality of this relationship.
Oral health care providers should continue to recognize their role in educating parents and providing anticipatory guidance on children’s oral health.
Trends in Pediatric Dental Care Use
2018, Dental Clinics of North America
Citation Excerpt :
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program was created in 1967 as a means to combat the effects of poverty on the health of children.8 This preventive services benefit program is mandated for children receiving Medicaid, but there is variability by states in the application of the EPSDT guidelines.9 Although the EPSDT services are mandated, access through provider participation in Medicaid is not guaranteed.10
Infant Oral Health: An Emerging Dental Public Health Measure
2018, Dental Clinics of North America
Citation Excerpt :
This requirement fits in with IOH, and over the decades since Medicaid’s inception, states have adopted schedules that permit reimbursement for early dental intervention. The 2013 study by Hom and colleagues41 revealed that all 50 states and the District of Columbia had a dental component to their EPSDT program. However, only 32 states and the District of Columbia had established a separate periodicity schedule.
Topical silver diamine fluoride for dental caries arrest in preschool children: A randomized controlled trial and microbiological analysis of caries associated microbes and resistance gene expression
2018, Journal of Dentistry
The Stopping Cavities Trial investigated effectiveness and safety of 38% silver diamine fluoride in arresting caries lesions.
The study was a double-blind randomized placebo-controlled superiority trial with 2 parallel groups. The sites were Oregon preschools. Sixty-six preschool children with ≥1 lesion were enrolled. Silver diamine fluoride (38%) or placebo (blue-tinted water), applied topically to the lesion. The primary endpoint was caries arrest (lesion inactivity, Nyvad criteria) 14–21 days post intervention. Dental plaque was collected from all children, and microbial composition was assessed by RNA sequencing from 2 lesions and 1 unaffected surface before treatment and at follow-up for 3 children from each group.
Average proportion of arrested caries lesions in the silver diamine fluoride group was higher (0.72; 95% CI; 0.55, 0.84) than in the placebo group (0.05; 95% CI; 0.00, 0.16). Confirmatory analysis using generalized estimating equation log-linear regression, based on the number of arrested lesions and accounting for the number of treated surfaces and length of follow-up, indicates the risk of arrested caries was significantly higher in the treatment group (relative risk, 17.3; 95% CI: 4.3 to 69.4). No harms were observed. RNA sequencing analysis identified no consistent changes in relative abundance of caries-associated microbes, nor emergence of antibiotic or metal resistance gene expression. Topical 38% silver diamine fluoride is effective and safe in arresting cavities in preschool children. Clinical Significance: The treatment is applicable to primary care practice and may reduce the burden of untreated tooth decay in the population.

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Disclosure. None of the authors reported any disclosures.

This research was supported by grant T32DE017245 from the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md., and by the American Academy of Pediatric Dentistry Samuel D. Harris Research and Policy Fellowship.

¹: Dr. Hom is a pediatric dentistry resident, Department of Pediatric Dentistry, School of Dentistry, and a doctoral candidate, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill.

²: Dr. Lee is a distinguished professor, Department of Pediatric Dentistry, School of Dentistry, and Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill.

³: Ms. Silverman is assistant director, Pediatric Oral Health Research and Policy Center, American Academy of Pediatric Dentistry, Chicago.

⁴: Dr. Casamassimo is a professor and chief, Department of Dentistry, Nationwide Children’s Hospital, Columbus, Ohio; chair, Division of Pediatric Dentistry and Community Oral Health, College of Dentistry, The Ohio State University, Columbus; director, Pediatric Oral Health Research and Policy Center, American Academy of Pediatric Dentistry, Chicago.

View full text

Oral Health GuidelinesState Medicaid Early and Periodic Screening, Diagnosis, and Treatment guidelines: Adherence to professionally recommended best oral health practices

ABSTRACT

Background

Methods

Results

Conclusions

Practical Implications

Section snippets

EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT DENTAL SERVICES

METHODS

RESULTS

DISCUSSION

CONCLUSIONS

JADA

Acad Pediatr

Medicaid and the Uninsured. Medicaid matters: Understanding Medicaid’s role in our health care system

Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health Screening Services

Crossing the Medicaid-private insurance divide: the case of EPSDT

Health Aff (Millwood)

EPSDT: Medicaid’s critical but controversial benefits program for children

Issue Brief George Wash Univ Natl Health Policy Forum

Beyond access: the role of family and community in children’s oral health

J Dent Educ

Advancing Oral Health in America

Oral Health: Dental Disease Is a Chronic Problem Among Low-income Populations

Guide to Children’s Dental Care in Medicaid

The unmet health needs of America’s children

Pediatrics

Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling and Oral Treatment for Infants, Children, and Adolescents

Oral Health Guidelines
State Medicaid Early and Periodic Screening, Diagnosis, and Treatment guidelines: Adherence to professionally recommended best oral health practices