Infant Oral Health: The Unrealized Cost of Waiting
Much consideration has been given to the cost ramifications of beginning dental care at age one versus beginning at age three to five. Proponents of the age-one dental visit often site a North Carolina study that demonstrated a significant cost savings when dental care began at one year of age as compared to patients who received care beginning at three years of age. Detractors are quick to point out that most of the cost savings are lost when those cases requiring hospital/operating room care are removed from the patient pool. As hospital/OR care can be quite expensive, (e.g., $15,000/case), the removal or inclusion of these patients, although small in number, significantly impacts the cost of care delivery to a patient population.
In fact, comparing the cost of oral health care from cohorts receiving dental care from one to six years of life versus three to six years of life (utilizing current NHANES data), revealed an approximate savings of only $50 per patient. This cost analysis did not include those patients that required their care to be delivered in a hospital setting; therefore, although there is a cost savings associated with early, preventive oral health care, profound cost savings are only realized by a small percentage of patients who, through early intervention, are able to avoid being treated in a hospital setting. Additionally, when the cost savings of ‘Infant Oral Health Care’ are multiplied by large-scale implementation, (e.g., 1,000 patients = $50,000 savings), the realized cost savings are said to be “less than significant” when cast against the economy of scale defined by our overall health care expenditures.
When viewed in the cold light of dollars and cents, the rational for the “age-one dental visit” lacks the glitz one hopes for when attempting to implement a new paradigm of early, preventive dental care. In fact, one is left with the question, “What is the unrealized cost of waiting until age three to begin dental care?”
The most obvious cost is that of compromised or undelivered care. Current NHANES data indicates that nearly 30% of three to five year olds have dental decay; and that percentage is growing. Distribution studies indicate that 80% of all decay is suffered upon 20% of patients; therefore, roughly 20% of children with decay have significant decay. The more significant the decay the less likely it is that that patient will receive definitive and successful treatment by less than specialty level, pediatric care. Limited numbers of pediatric dental specialists, and geographic distribution issues amongst the specialty when compared to the sheer number of patients with pathology, dictate that a majority of these patients be treated by general dentists that are less than comfortable treating complex restorative cases in young children. All of these factors contribute to: care that is potentially emotionally difficult for the patient or family, long and challenging procedures, long-term restorative results that fall short of the practitioner’s expectations and, in many instances, care that is delayed to the point of “never being delivered.”
Young children with high decay rates predictably grow up to be older children with high decay rates. This yields adolescents and young adults who have lived with unaddressed dental needs or those that were addressed in a less than successful manner. The unavoidable results: a percentage of our youth with compromised oral health. And at what cost?
Behavioral evidence suggests lowered self-esteem that produces young adults who are less likely to pursue higher education and more likely to experiment in risk behaviors (e.g., sex, drugs, over-eating and alcohol). Though it would be an overstatement to suggest that poor oral health is a causal predictor of these outcomes, its role as a pernicious contributor is undeniable as is its long-term cost to the community and society.
However, the real reason for starting dental care by age one is not simply the incalculable cost-savings. The principal reason to begin early oral health intervention is the compounding effect of prevention over time. The one-year dental visit provides an opportunity to delay, ameliorate, mitigate and/or prevent very young children from experiencing decay. Although dental decay must be addressed, from the perspective of the child patient operative dentistry is rarely enjoyable and often times a devastating ordeal. Every Dentist who brings a frightened child through a painful procedure will wear the scars of that experience his or her entire career and into retirement -- as will the patient. Dentistry on children is challenging and it is unconscionable to do less than everything in our power as healthcare providers to prevent and/or delay that experience. Beginning dental care by age one is the most humane thing we can do short of administering a cure for caries (which we have yet to stumble upon). Every child should have a "Dental Home" beginning in infancy. Not because it will save us a few dollars but because it is the right thing to do!
Kevin J. Hale, DDS, FAAPD
Executive Director, Points of Light project
POL in West Michigan
The West Michigan District Dental Society has created a Points of Light workgroup with the goal of increasing the network of West Michigan practices willing to accept infants, Head Start children and children with Special Healthcare Needs. Led by Dr. Colette Smiley, the impetus for this workgroup was a collaboration between WMDDS and the Kent County Oral Health Coalition. The Kent County Oral Health Coalition is a partnership of over 40 individuals and 20 organizations working together to improve awareness of the need for dental health in the community and to coordinate oral health clinical and educational resources.
According to Dr. Smiley, "Once a tipping point of Points of Light providers is achieved, our workgroup plans to approach the medical and Head Start communities in West Michigan to stimulate early referrals. The oral and overall health of the community, starting with the youngest members, will improve as a shift occurs from a surgical caries intervention to prevention."
As a general dentist in private practice for 25 years, Dr. Smiley has seen the benefits of preventive dental care and early diagnosis and treatment. She serves as an allied dental educator at Grand Rapids Community College and Ferris State University and currently sits on the Michigan Dental Association's Board of Trustees.
POL Head Start Article
Getting a Head Start on Oral Health
The American Academy of Pediatric Dentists recommends infants have an oral health screening either when their first tooth erupts or before they turn 1, in order to establish good preventive practices to fight tooth decay and create a solid foundation for future oral health. Oral health and dental services are important concerns for Head Start and Early Head Start Programs (HS/EHS). The highest rates of dental caries is observed in economically disadvantaged and racial and ethnic minority children- conditions that describe children enrolled in HS/EHS. Finding dentists in Michigan to serve this group of children can be challenging for Head Start health coordinators and parents. We need your help.
What is Head Start?
Head Start is a federally funded early childhood program serving young children ages 3 to 5. Head Start promotes school readiness by providing a comprehensive early childhood program including education; physical, oral and mental health; parent education; community services; literacy promotion; transportation; nutrition; and physical activity. Early Head Start serves children from birth to 3 years of age. EHS provides support to low-income infants, toddlers, pregnant women and their families.
Head Start in Michigan
38,417 children are served through HS programs annually in Michigan. It is estimated that only 50% of eligible children in Michigan are funded for enrollment. Head Start serves children and families living at 100% of poverty or below. 97% of all Head Start children have insurance. With the addition of 10 new Healthy Kids Dental Counties added this past October, reimbursement for services is increased. 10% of HS enrollment is required for children with a disability. There are Head Start programs in all 83 counties and with an Early Head Start program in most counties.
Head Starts have certain oral health requirements that must be met annually in order to receive federal and state financial support. Michigan uses the Periodicity Table from Bright Futures and the American Academy of Pediatrics. http://brightfutures.aap.org/pdfs/aap%20bright%20futures%20periodicity%20sched%20101107.pdf
As part of the Head Start Dental Home Initiative, the MI-AAPD has helped make connections with local dentists and Head Starts. If you are willing to provide a dental home for any Head Start children, or help participate in annual health fairs with local Head Starts please contact:
Susan Deming, RDH, RDA, B.S.
Michigan Department of Community Health
Oral Health Program
201 Townsend, PO Box 30195
Lansing MI 48909
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The Points of Light Project
For more information regarding our project, or to register as a participant, please visit our website: pointsoflightonline.org.
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