By Dr. Paul S. Casamassimo, Homa Amini

 

Most dentists are familiar with the concept of a dental home¹, a physical metaphor for the ongoing relationship between a patient and a dentist offering care, information, and collaborative management of oral health. In the case of children, the traditional dental home embraces the family in recognition of the triangular constellation of parent, child, and provider. Not as familiar, or perhaps even unknown, is the concept of spatial justice which, very simply stated, is the recognition of the impact of where one lives on health.² Intuitively, and in fact, this concept explains aspects of access and availability of quality care. Distance is a very understandable aspect of spatial justice, but concepts such as nearby availability of services, comprehensiveness of locally available care, and the values and health care practices of that community are other aspects of the concept. Overwhelmed small community hospitals during the COVID-19 pandemic vividly illustrate the concept, along with vaccination obstacles due to ultra-refrigeration requirements in early versions.  

See the full editorial here.

By Dr. Paul S. Casamassimo, C. Scott Litch, Dr. John S. Rutkauskas, Dr. Robin Wright 

 

Can we use science without first paying attention to the vulner-ability and dependence of children? No, not if we act to best protect the patients we serve. 

In the history of pediatric dentistry, science has always been tempered by compassionate caring, and these two concepts will continue to coalesce in pursuit of optimal oral health for chil-dren. This has been the American Academy of Pediatric Dentis-try’s (AAPD) approach for at least four decades. Collectively, we four co-authors have more than 100 years of experience observing pediatric dentists doing what is best for children. We feel prompted to speak about the enduring marriage of science and benevolence in the Academy’s history. We acknowledge our many members, past and present, who have served on committees and councils and worked hard to balance science with caring in developing positions for the Academy. 

See the full editorial here.

By Dr. Paul S. Casamassimo, Chief Policy Officer

Persons with special health care needs (PSHCN) in this country would benefit tremendously from a universal adult dental benefit in Medicaid. As in many aspects of our society, they are the forgotten 20 percent of Americans.¹ In actuality, one in three persons in Medicaid are those with disabilities. In the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program, younger PSHCN covered by Medicaid enjoy access to oral health care, but at adulthood enter the limbo of the Affordable Care Act and many, eventually, the purgatory of unpredictable coverage or the hell of none. Alternative sources of funding for poor special needs adults vary by state. Those with mild disability who may be under- or unemployed and without health coverage, as well as those with acquired disabilities, may not have access to oral health care. Many adult PSHCN without a source of oral health care end up in the vast queue of Americans who: (1) rely on emergency medical management of preventable dental problems, (2) often require hospitalization to achieve that care, and (3) upon returning to society, have no source of rehabilitation and restoration of function, much less oral health supervision. The downward cycle begins again.

An adult dental benefit in Medicaid offers both beneficial human and fiscal outcomes. Reduction in suffering and health equity should be benefit enough. The return on investment from EPSDT-supported care should be another motivator to those who pay for and have to manage acute needs. A third more subtle benefit is safety. Many special needs patients have medical conditions kept at bay with advances in medical care in childhood and adolescence, but who in adulthood suffer from accumulated systemic effects that can be exacerbated by dental disease and compromise its treatment. An adult benefit would offer the opportunity to many patients to prevent risks associated with decades of dental neglect and accumulated need, capped with significant medical problems.

Another major good that would emerge from an adult benefit would be, at last, some compensation for care to institutions, training programs, and safety net clinics that have carried the burden for dentistry for both poor and special needs adults. Case management compensation is at least a decade or more away from being routine, but even Medicaid’s meager compensation for dental procedures will help defray some cost of direct care and case management of social obstacles to care for these safety nets.

Sadly, it is unlikely that dentistry will immediately embrace adults in Medicaid, much less those with special needs, even with dental benefits. Medicaid’s history with dentistry isn’t rosy. Pervasive misconceptions within the profession, along with likely continued low reimbursement, will make this an uphill trek. The lack of trained generalists is another confounder, as only recently have predoctoral dental education standards moved past a “referral competency” related to people with special needs. It will take decades to amass a general dental community capable of caring for people with special needs, irrespective of coverage. Pediatric dentists reading this commentary are all too familiar with the “white coat ceiling” when trying to refer patients with special needs who need adult dental homes.² Sadly, too few programs like the NYU Dentistry Oral Health Center for People with Disabilities ³ exist in dental schools to immerse predoctoral students in care of special needs patients. History has shown us that general practice residencies have not been able to generate adequate numbers of dentists willing to and capable of treating those with special needs, and lack of compensation exacerbates to that shortage.

Other unknowns are the expectations and promotion by state and the federal government toward expenditures aimed at an adult Medicaid population. Dental programs in general are a low priority in Medicaid, accounting for about four percent of expenditures,⁴ and it is estimated that an adult benefit adds only one percent to a state’s burden.⁵ Yet even with the negative fiscal and human toll of oral health problems noted above, dentistry barely gets noticed in many states, and it is the state that bears most of the cost. The oral health needs of the special needs population are at risk of being caught in the widespread disinterest in a Medicaid adult dental benefit, despite its low cost.

Lastly, with all but a handful of states engaged in the managed care Medicaid experiment, it is unclear how an adult benefit would fit into the fiscal model of payer organizations. With an adult benefit in place, managed care organizations would inherit an EPSDT-groomed population with minimal needs, but still at risk. A robust adult benefit would be needed to support health and deter a second standard of care for those covered. The balance of oral health with corporate and government fiscal health is already a juggling act in managed care Medicaid dentistry; an adult benefit, especially one that addresses the challenges of those with special needs, adds another ball. The fact that the emergency and inevitable medical costs of dental neglect often fall outside the dental administrator’s responsibility doesn’t help to move the needle forward.

In summary, an adult benefit in Medicaid would be a large step forward in oral health equity for America’s poor and particularly those with special needs. States that have already provided an adult benefit offer guidance and impact measures on how an adult benefit would affect states. Now, a meaningful dental benefit in Medicare is a competing priority of organized dentistry. Oral health coverage in Medicare would enable those who have had employer-supported or self-paid oral health coverage to extend access to oral health care into their senior years. What is missing in the discussion is that a large cohort of poor older Americans, denied adult benefits in Medicaid, would come to Medicare with a lifetime of accumulated dental needs. If that happens, it is not hard to see the outcome become one of “dentitions of despair” to borrow a concept from medicine,⁶ with services focused on and unintentionally encouraging an inevitable, unavoidable and less expensive decline to policy-facilitated edentulism. For the special needs population, even with a Medicare benefit, dentitions damaged by neglect over a lifetime will be accompanied by accumulated medical issues complicating treatment and limiting treatment goals for future oral health.

A universal adult Medicaid benefit is a means-tested path to oral health equity and compassion for those with special needs and a way to maximize the return on investment of EPSDT’s opportunity to provide oral health to a large segment of our society.

References

1. Kaiser Family Foundation. Medicaid in the United States. October, 2019.
2. Nowak AJ, Casamassimo PS, Slayton R. Facilitating the transition of patients with special health care needs from pediatric to adult oral health care. JADA 2010;14(11):1351-1356. https://pubmed.ncbi.nlm.nih.gov/21037193/. Published November 2010.
3. New York University College of Dentistry, Evolution of oral health for persons with disabilities, Global Health Nexus. 2020; 21(1): 16-19.https://dental.nyu.edu/content/dam/nyudental/‌‌‌‌‌documents/Nexus_S2020.pdf.  Published Spring 2020. Accessed August 14, 2021.
4. Crall JJ, Vujicic M. Children’s oral health: progress policy development and priorities for continued improvement. Health Aff (Millwood). 2020;39(101):1762-1769. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.00799 Published October 2020.
5. Health Policy Institute, American Dental Association. Infographic. Medicaid expansion and dental benefit coverage. https://www.ada.org/~/media/ADA/Science%20and%20‌Research/HPI/Files/HPIgraphic_1218_3.pdf?la=en Published December 2018. Accessed August 15, 2021.
6. Leonhardt D. The Morning Newsletter: Life Expectancy, Falling. The New York Times. July 22, 2021. https://www.nytimes.com/2021/07/22/briefing/life-expectancy-falling-covid-pandemic.html. Accessed July 22, 2021.

By Paul Casamassimo, Charles Czerepak and Jessica Y. Lee 

Published in the July, 2021 issue of the Journal of the American Dental Association, this commentary proposes first steps in moving closer toward oral health care equity within the existing vehicle of Medicaid. Negative social determinants of health remain prominent obstacles to oral health care equity, but incremental improvement can be made, beginning with fundamental changes in public insurance programs providing oral health access to low-income families. 

See the full editorial here.

By Dr. Paul S. Casamassimo, Chief Policy Officer 

A recent report by the Health Services and Resource Administration (HRSA) on dental and dental hygiene workforce projections for 2030 predicts a fifty percent increase in the pediatric dentistry workforce by 2030.¹ That percentage is in general agreement with the projection in a report commissioned by the American Academy of Pediatric Dentistry (AAPD).²  The AAPD projects a 62% increase in pediatric dentistry full-time equivalents from 2016 to 2030. The percentage difference can be attributed to the starting provider populations in respective reports and modeling differences. Both reports make assumptions regarding population growth, patterns of utilization, retirements and entering new providers. 

The similar findings related to growth are encouraging support for AAPD’s policy and legislative efforts to focus the future pediatric dental workforce. The AAPD study, done by a group known for health workforce studies of medical and dental professionals, went beyond the HRSA report in detailing location, busyness, and under-service. It also provides more direction for workforce management than HRSA’s and has already influenced AAPD’s legislative priorities to address mal-distribution, health inequity, and sustainability of pediatric services to special populations.³

HRSA’s generic view of general dental providers and specialists falls short of addressing many areas that influence children’s oral health in an equitable and responsible fashion. In the AAPD report, shortage areas - geographic and population-related - suggest the need for a focused workforce policy beyond simple manipulation of numbers. The AAPD report uses both numerical and opinion-based responses to validate areas of need. For example, its busyness estimates jibe with population density, confirming the need for pediatric dentists in less populated and less urbanized parts of the US. AAPD legislative priorities are already addressing this.³

The essential role of pediatric dentists is well-established. The American Dental Association’s Health Policy Institute recognizes that about three-quarters of the pediatric dentistry workforce is engaged in care of Medicaid children, far above any other group in dentistry.⁴ Further, almost 100 percent of pediatric dentists see children and adults with special health care needs.⁵  Less is known about access to integrated comprehensive health services for children who have both medical and dental needs, but pediatric dentists have traditionally filled that niche. Early studies suggest that large gaps in availability of comprehensive integrated care exist for children with inherited and acquired conditions across the US^6,7 with pediatric dentists filling that demand. What’s missing is the impact of increasing numbers of children with these needs.  No other component of the dental profession can substitute for pediatric dentistry’s contribution, and it remains unclear how the predicted increases will affect the movement toward better medical-dental integration.

Another change meriting further research is the association between the increase in pediatric dentists over the last two decades with (1) a rise in the number of Medicaid children seen⁸, and (2) the reduction in untreated dental caries in children under 5 years of age.⁹ These parallel curves over time suggest a relationship worth investigating.

Other areas deserving of deeper investigation are the importance of pediatric dentists to programs like Head Start, school-health, and contracts with federally qualified health centers - all links with the greater public health community. The oral health care system will likely continue its reliance on private practice pediatric dentistry to care for young, poor, and special needs children of this country.  The viability of multi-dentist, multi-office pediatric dental practices that can perform well financially, yet provide care to medically and financially challenging populations with surgical, non-surgical, and case management services, needs further scrutiny.

The role of an increasing number of dual-trained pediatric – public health dentists in the care of children - another result of AAPD legislative efforts - is another area begging for research. The specialty of dental public health has stagnated in terms of growth. The combination of pediatric dentistry with public health offers new opportunities to integrate public and private sector approaches to care.   The role of women providers, the fastest growing part of pediatric dentistry, who tend to be more likely to see children receiving Medicaid, deserves attention⁴. The specialty is also dentistry’s most diverse.¹⁰ This diversity has increasing value as the link between health and system inequity emerges more clearly from lessons learned from the COVID-19 pandemic. Will pediatric dentistry’s embrace of diversity be adequate to provide new approaches to solving age-old disparities? The character and complexion of the growth in pediatric dentists will likely be as important to watch as the numbers.

The AAPD has promoted a thoughtful approach to growth. Its current legislative priorities continue that introspection and creative directions. Research and analysis will continue as public health challenges press for solutions to growing poverty, improved survivorship in childhood health conditions, increasing indebtedness of new graduates contributing to potential loss of Medicaid providers11, and the need for its unique skills in community and school health.

The AAPD has offered the above and other perspectives to HRSA as that agency moves to revise its Health Profession Shortage Area (HPSA) guidelines. The attention to dental workforce is a national and professional responsibility for all of dentistry, and the AAPD has already demonstrated its prospective, responsible posture to help shape a workforce that best meets the needs of today’s and tomorrow’s children.

References

1. Health Services and Resource Administration. Oral Health Workforce Projections, 2017-2030: Dentists and Dental Hygienists, December, 2020. https://bhw.hrsa.gov/national-center-health-workforce-analysis   Accessed January 20, 2021.
2. Langelier M, Simona S, Dall T, Reynolds R, et al. The Pediatric Dental Workforce in 2016 and Beyond. Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany, November, 2017.
3. Council on Government Affairs, American Academy of Pediatric Dentistry (AAPD). 2021 Legislative and Regulatory Priorities. https://www.aapd.org/advocacy/legislative-and-regulatory-issues/ Accessed January 15, 2021.
4. Health Policy Institute, American Dental Association (ADA). Dentist participation in Medicaid or CHIP. Chicago, IL: ADA, August, 2020.
5. American Academy of Pediatric Dentistry (AAPD), Pediatric Oral Health Research and Policy Center and the Center for Health Workforce Studies, SUNY at Albany. The 2017 Survey of Pediatric Dental Practice. Chicago, IL: AAPD, 2017.
6. Kerins CA, Casamassimo PS, Ciesla D, Lee Y, Seale NS. A Preliminary Analysis of the U.S. Dental Health Care System to Care for Children with Special Health Care Needs. Pediatric Dentistry 2011; 33(2): 107-112.
7. Ciesla D, Kerins CA, Seale NS, Casamassimo PS. Characteristics of Dental Clinics in U.S. Children’s Hospitals: Pediatric Dentistry 2011; 33(2): 100-106.
8. American Dental Association, Health Policy Institute. Dental Care Use Among Children: 2016. Chicago, IL: American Dental Association, 2018. https://www.ada.org/en/science-research/health-policy-institute/publications/infographics   Accessed February 1, 2021.
9. Dye B, Mitnik GL, Iafolla TJ, Vargas CM. Trends in dental caries in children and adolescents according to poverty status in the U.S. from 1999-2004 and from 2011-2014. JADA 2017 48(8):550-565.
10. American Dental Association, Health Policy Institute. Survey of Advanced Dental Education, 2019-20. Chicago, IL: American Dental Association, 2020.  https://www.ada.org/en/science-research/health-policy-institute/data-center/dental-education    Accessed February 1, 2021.