Chapter 1:
The EPSDT Dental Registry and
Dentists' Views on
Treating Young Children

Over the last twenty years, the oral health status and utilization of dental services for the general population has improved significantly (National Center for Health Statistics, 1995). Access to dental care, however, remains an important issue for segments of the population who have not experienced the same declines in dental caries or increases in utilization of dental services. For example, children from low income families are known to experience higher rates of dental disease, have a higher percentage of unmet dental needs and have significantly lower rates of utilization than children not living in poverty (Call 1989, National Institute of Dental Research 1989). Lower income is also associated with decreased utilization of dental services among adults (National Center for Health Statistics 1994). Among the elderly, there remain serious barriers to accessing dental care for both home bound seniors and nursing home residents (Strayer and Ibrahim 1994; Kiyak, Grayston and Crinean 1993).

The Title XIX dental program was designed to provide underserved populations with financial access to dental services primarily within the private dental care delivery system. State Title XIX programs are required to provide comprehensive dental services to children through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. Dental services for adults, however, are optional. States can receive federal matching funds for any level of dental coverage they provide to adult recipients. Iowa has one of the most complete dental Title XIX programs in the country, covering comprehensive dental care for both children and adults.

Dental Screening of Children

Children who live in families meeting specific federal poverty guidelines are eligible for medical and dental services under Title XIX. Every Title XIX enrolled child is eligible to participate in the EPSDT program, and therefore eligible for a comprehensive program of dental services.

The federal EPSDT guidelines require that an oral health assessment be completed by a child's primary medical or health care provider at frequent intervals during infancy and that each enrolled child be referred to a dentist by their primary care provider by three years of age. States are given the option of requiring earlier referrals, and Iowa guidelines require referral to a dentist for annual exams at ages one and two, with exams twice a year beginning at age three (Table 1-1).

Table 1-1. EPSDT oral health screening and referral schedule

Although EPSDT services are mandated by the federal government, compliance with these mandates has been low. In an attempt to improve compliance, the Omnibus Budget Reconciliation Act of 1989 (OBRA '89) included a provision mandating that 80 percent of children enrolled in Title XIX in each state receive an EPSDT screening by September 1, 1995.

To improve recipient participation in the EPSDT program, the state of Iowa implemented a statewide EPSDT case management program on August 1, 1995. This program established a system of care coordinators in Iowa to improve the rates of EPSDT screenings and referrals. Care coordinators, while not required to provide comprehensive care to enrolled participants, are required to remind recipients when screening exams are due, provide assistance in scheduling needed exams, and assist in linking families with further diagnostic and treatment services. Care coordinators can be providers participating in the Title XIX managed care program (MediPASS), providers in the Title XIX HMO, or Iowa Department of Public Health designated agencies .

For dental referrals and treatment, the role of the care coordinator is to assist with the scheduling of dental appointments, assist with transportation needs, and to remind participants of upcoming appointments. In addition, it is the responsibility of the care coordinator to follow up on missed dental appointments.

EPSDT Dental Registry

Shortly before the implementation of Iowa's Case Management Program, a new problem concerning access to oral health care was identified. Physicians in some parts of the state, when attempting to refer children to the dentist (especially those as young as age 1), reported difficulty locating dentists willing to accept these referrals. Some Iowa dentists prefer to not see very young children on Title XIX mainly for these reasons: 1) some dentists remain unconvinced of the need for a dental visit at age one; 2) some simply prefer not to see very young children, primarily because of difficulties in managing the behavior of young children, and/or because of an individual preference relating to the scope of their practice; and 3) some dentists in Iowa do not participate in Title XIX, or are currently limiting the number of new Title XIX patients they are seeing for a variety of reasons that will be discussed in more detail later in this report.

To address this problem, a statewide EPSDT dental registry was established. The EPSDT dental registry acts as a reference guide for social service agencies, physicians, dentists and other health care professionals attempting to identify dentists willing to provide EPSDT dental services to children as early as age one. Interested health care professionals can call the University of Iowa Department of Pediatric Dentistry, and receive the name of the closest dentist who has agreed to participate. Agreement to participate has no specific requirements for the dentists other than having their name distributed as accepting Title XIX enrolled children as young as age one. A current geographical distribution of dentists included in the EPSDT dental registry can be seen in Figure 1-1. Currently included in this registry are 189 dentists from 67 Iowa counties and four bordering states.

Dentists were recruited to participate in the EPSDT dental registry and were educated in several ways about the need for children to receive a dental examination by age one. In March of 1995, a letter was sent to all dentists with a current Iowa Title XIX provider number, inquiring whether they would be willing to have their name placed on the registry of providers and receive referrals of Title XIX enrolled children as early as one year of age. Dentists who indicated a willingness to participate were sent additional information about the EPSDT program and were informed that their names would be included in the registry. (Some dentists were willing to see one-year-old Title XIX enrolled children but did not want to have their name placed on the registry).

Figure 1-1. Geographical distribution of dentists in the EPSDT dental registry
(map not intended to indicate access to dental services)

Second, educational activities concerning the EPSDT program and the need to see children enrolled in Title XIX at one year of age were conducted around the state. A table clinic presentation featuring the EPSDT dental program was presented at the annual meeting of the Iowa Dental Association in Des Moines in May 1995. During this statewide meeting, information sheets were given to dentists interested in learning more about EPSDT and dentists were encouraged to have their names added to the EPSDT dental registry.

During the summer of 1995, every dentist and physician in the state of Iowa received a copy of the EPSDT "Care for Kids" Newsletter , that focused on oral health care issues. The purpose of the newsletter was to inform physicians and dentists about the oral health component of the EPSDT program. The oral health topics covered in the newsletter included: the physician's role in oral health care, what is involved in the EPSDT dental screening, prevention of nursing caries, anticipatory guidance and oral health, and an update on the new fluoride supplementation schedule. The newsletter also repeated information regarding how to sign up for the EPSDT dental registry.

In the October 1995 edition of the Iowa Dental Journal , an article appeared entitled "Care For Kids: Iowa's EPSDT Program". This article announced that the Department of Pediatric Dentistry at the University of Iowa College of Dentistry was working with the Iowa Department of Human Services to inform health professionals about Iowa's EPSDT program, and to identify Iowa dentists who were willing to see children enrolled in Title XIX as young as one year of age. The goal of the article was to provide more information about EPSDT to Iowa dentists, and to offer them another opportunity to have their names added to the statewide registry.

Both the Summer newsletter and the Iowa Dental Journal article included a list of recommended activities to be carried out at EPSDT dental screenings by the Iowa Department of Human services (IDHS) (Figure 1-2). The provision of comprehensive dental services was not required in order to be included in the registry. Significant caries found during an EPSDT screening in a child too young to be cooperative could be referred elsewhere for treatment.

Additional educational activities included the development of a slide program about dental care and the EPSDT program that was then presented at local dental society meetings, continuing education courses for Iowa dentists and to third and fourth year dental students at the University of Iowa College of Dentistry. The educational/recruitment portion of this project is continuing with more presentations scheduled.

Additional statewide publicity for this project was obtained through a variety of sources. The University of Iowa College of Dentistry featured the program on the front page of the Dental Link , the dental alumni newsletter. A press release about this project reached a statewide newspaper audience while a videotaped segment reached a statewide television audience.

Iowa Dentists' Treatment of Young Children

Historically, it has been common practice to recommend that a child's first visit to the dentist take place at age three. The current guidelines of the American Academy of Pediatrics are consistent with this recommendation (although they acknowledge that earlier visits may be indicated). The American Academy of Pediatric Dentistry, however, recommends that a child's first visit to the dentist occur by one year of age. Educational efforts associated with this project have been aimed at increasing the awareness among dentists of the importance of dental visits at age one.

Age of the Child 6-12 months … Clinical oral examination and appropriate diagnostic tests to assess oral growth and development and pathology. … Oral hygiene counseling for parents, guardians, caregivers. … Assessment of fluoride supplementation needs, if indicated, following drinking water analysis. … Assessment of topical fluoride status and parental counseling. … Assessment of appropriateness of feeding practices and potential effects of prolonged bottle use. … Dietary counseling related to oral health. … Injury prevention counseling for orofacial trauma (play objects, pacifiers, car seats, etc.). … Treatment of any oral disease or injury (or referral to appropriate dentist for treatment). … Counseling for oral habits (digit, pacifiers, etc.). 12-24 months … Repetition of 6-12 month procedures every six months or as indicated by the patient's susceptibility to disease and other special needs. … Injury prevention counseling for dento-facial trauma (learning to walk, run, etc.). 2-6 years …Repetition of 12-24 months procedures every six months, or as indicated by the patient's susceptibility to disease and other special needs. … Radiographic assessment of pathology and growth and development, as indicated for individual patient's needs, as determined by the dentist. … Prophylaxis twice a year or as determined by the dentist. … Topical fluoride treatments twice a year or as determined by the dentist. … Pit and fissure sealants as indicated by individual patient's needs, as determined by the dentist. … Counseling for oral habits (digit, pacifiers, etc.). … Injury prevention counseling for dento-facial trauma (play, sports, etc.). … Assessment and treatment of developing malocclusion, as indicated by individual patient's needs. … Treatment of dental diseases, habits, or injuries, as indicated.

Figure 1-2. Recommended activities for EPSDT
dental screening of infants and young children

To investigate the attitudes and current practices of Iowa dentists concerning the treatment of very young children, a series of questions was included in the 1995 Survey of Iowa Dentists, a questionnaire mailed to all actively practicing licensed dentists in Iowa (for more information about the survey, please see Chapter 3). Nearly all responding dentists (98 percent) reported that they treat children under the age of 14 in their practice. Only eleven percent of responding dentists, however, thought that children should be seen by age one (Table 1-2), 35 percent thought children should be seen by age two and 84 percent believed that children should visit a dentist by age three. Not until five years of age was there 100 percent agreement that children should be seen by a dentist.

Table 1-2. Recommended age for first dental visit

Age in years	Cumulative percent
1	11%
2	35%
3	84%
4	87%
5	100%

The age of the youngest patients Iowa dentists said they were willing to accept in their practice is shown in Table 1-3. Twenty-six percent of dentists reported they were willing to accept patients as young as one year of age, while nearly half of the responding dentists were willing to accept patients at two years of age. Over 80 percent were willing to see three-year-olds in their practice. These responses indicate that at least some dentists who do not recommend routine dental visits as early as one or two would be willing to see these patients in their practice if necessary.

Table 1-3. Youngest age of patient
dentists are willing to see

Age in years	Cumulative percent
1	26%
2	47%
3	82%
4	90%
5	93%

Dentists were also asked how often they believed children under the age of six need to be seen for routine exams. The results are presented in Table 1-4. Seventy percent of the respondents believe that children under six should be seen every six months.

Table 1-4. Iowa dentists' recommended intervals
of routine dental exams for children under six years of age

Interval	Percent response
Every 3 months	0%
Every 6 months	70%
Yearly	23%
Other	7%

When dentists were asked whether they were familiar with the Iowa Title XIX EPSDT program by name, almost 70 percent responded that they were not familiar with the program. Of the 31 percent who said they were familiar with the EPSDT program, 48 percent said their familiarity was because they received a recent informational brochure about the program. The survey also asked dentists to indicate how many dental patients under the age of 14 who were enrolled in Title XIX had been referred to them by physicians during the past year. About two thirds of dentists (68 percent) indicated that they had not received such a referral in the past year. Fifteen percent had received between one and five referrals, eight percent had received six to ten referrals and another eight percent had received over ten referrals.

Summary

To date, 189 dentists have agreed to participate in the EPSDT dental registry as a way to improve the access to dental care for very young children enrolled in Title XIX. Educational activities have been undertaken to improve both physicians' and dentists' understanding of the need for dental care for very young children. Dentists in Iowa generally believe that children should be receiving care between the ages of two and three which is later than the current Iowa EPSDT guidelines. About one in four Iowa general dentists and pediatric dentists are willing to accept a child at age one in their practice. Increasing the number willing to accept one-year-olds will be an important step toward improving the rate at which one-year-olds are successfully referred for dental care following an EPSDT screening.

MediPASS is the primary care case management program operating in 82 of the 99 counties. Title XIX recipients are assigned to a primary care physician 'gatekeeper' who must approve use of emergency room and specialty services. Dental care is not a managed service.

Six different HMOs contract with the Title XIX program to provide services on a capitated basis to Title XIX recipients in 43 of the 99 counties. Dental care is not covered in the HMO contract.

Local public health departments have contracted with the Department of Human Services to be the care coordinator in areas where no physicians have agreed to participate as care coordinators.