Study

First Preventive Dental Exam: Disparities in Needs, Costs & Behavioral Insights

This study investigates the predictors and outcomes of the age at which Medicaid-enrolled children receive their first preventive dental exam (AFPDE). Age at first dental check-up helps establish a dental home for the child and provides important preventive counseling for the mother. Medicaid-enrolled children are known to have less access to dental care.



Of particular interest in this study are five Medicaid subpopulations at high risk of disparities in access to dental care and resulting oral health status:

  1. Racial and ethnic minority children
  2. Rural children
  3. Children in federally designated Dental Health Professions Shortage Areas (HPSAs)
  4. Children with less access to medical care and associated well child visits
  5. Children who receive care at a Community Health Center (CHC)

Since one in four children in the U.S. are enrolled in Medicaid, this study could impact a large population of the most vulnerable children in the country. It is supported by NIDCR/NIH Challenge Grant 5RC1DE020303-02.

The project has four separate but related components:

[collapsed title="Study 1: Determinants of the age at which Medicaid-enrolled children receive their first preventive dental exam"]

This study investigates the predictors of age at first preventive dental exam using Iowa Medicaid claims data for preschool-age children. We will follow these children in the claims database until they have their first preventive dental exam, are no longer enrolled in Medicaid, or turn six years old. Factors previously identified in dental use models will be included in these analyses with the added factor of utilization of well-child visits. We will use survival analyses to model these relationships.



    Related publications:

  • IADR Abstract: Medical Well-Baby Examinations and First Dental Examinations for Medicaid-Enrolled Infants

    Medical Well-Baby Examinations and First Dental Examinations for Medicaid-Enrolled Infants



    Presented at the IADR/AADR Annual meeting, San Diego, CA:

    Thursday, March 17, 2011: 10:45 a.m. - 12:15 p.m.

    Presentation Type: Oral Session

    D.L. CHI 1, E.T. MOMANY 2, G.L. WEHBY 2, K. CARTER 3, M.P. JONES 2, R.A. KUTHY 4, N.M. ASKELSON 2, and P.C. DAMIANO 4, 1Dental Public Health Sciences, University of Washington, Seattle, WA, 2University of Iowa, Iowa City, IA, 3College of Dentistry, University of Iowa, Iowa City, IA, 4Dept. of Prevent & Comm Dentistry, University of Iowa, Iowa City, IA



    Objective: To examine the relationship between medical well-baby examinations (WBEs) and the age at first dental examination (FDE) for Medicaid-enrolled infants.



    Methods: We analyzed Iowa Medicaid data for infants who were: a) born in 2000; and b) continuously-enrolled in Medicaid from birth to age ≥16 months (N=5,880). The main independent variables were whether the infant had each of the first seven WBEs, as recommended by the American Academy of Pediatrics. The outcome variable was the age at FDE. Model covariates included: sex, race/ethnicity, adverse health condition, participation in MediPASS, residing in a dental health professional shortage area, and rurality. We used Cox proportional hazard regression models to test the hypothesis that infants who had WBEs were more likely to have an earlier FDE (¦Á=0.05).



    Results: Almost all infants had at least one WBE; 29.7% had 6 or 7 WBEs. About 70% of infants had a FDE (n=3,986). After adjusting for covariates, infants who had a 2-month WBE were more likely to have an earlier FDE (hazard ratio [HR]: 1.13; p=0.036). There was no significant difference in the age at FDE for the remaining six WBEs. Infants with an adverse health condition were less likely to have an earlier FDE (HR: 0.85; p=0.002) and male infants were more likely to have an earlier FDE (HR: 1.08; p=0.047). Conclusion: Infants who had a 2-month WBE were significantly more likely to have an earlier FDE. Other factors associated with an earlier FDE included not having an adverse health condition and male sex. These findings suggest heterogeneity in the age at FDE for Medicaid-enrolled infants that may be rooted in medical care utilization, systemic health status, and other demographic factors.





    Also available at: http://iadr.confex.com/iadr/2011sandiego/webprogram/Paper143987.html

[/collapse] [collapsed title="Study 2: An evaluation of the effectiveness of earlier first preventive dental exams on the need for dental care at the first visit and the successful completion of treatment plans for Medicaid-enrolled children who sought care at a CHC in Iowa"]

Chart reviews are being used to investigate the dental needs of children at the time of their first dental exam and whether the age at which they receive the exam affects outcomes, including completion of the treatment plan. The chart reviews are being performed at 7 Community Health Centers (CHCs) with electronic health records for 270 children in Iowa.



    Related publications:

  • IADR Abstract: First Dental Episode: Preventive and Corrective Services at CHCs

    First Dental Episode: Preventive and Corrective Services at CHCs



    Presented at the IADR/AADR Annual meeting, San Diego, CA:

    Thursday, March 17, 2011: 2:00 p.m. - 3:15 p.m.

    Presentation Type: Poster Session

    R.A. KUTHY 1, B. PENDHARKAR 1, E.T. MOMANY 2, M.P. JONES 3, N.M. ASKELSON 4, D.L. CHI 5, G.L. WEHBY, 6 and P.C. DAMIANO 1, 1Dept. of Prevent & Comm Dentistry, University of Iowa, Iowa City, IA, 2Public Policy Center, University of Iowa, Iowa City, IA, 3Biostatistics, University of Iowa, Iowa City, IA, 4Community and Behavioral Health, University of Iowa, Iowa City, IA, 5Dental Public Health Sciences, University of Washington, Seattle, WA, 6Health Management and Policy, University of Iowa, Iowa City, IA



    Objective: To determine mix of preventive and corrective treatment services, by age, provided to Medicaid-eligible children at their first dental episode. Since community health centers (CHCs) see a disproportionate number of lower-income families, it is important to determine extent of corrective treatment required and preventive services provided at the first and subsequent dental episodes.



    Methods: Sampling frame was Iowa's CHCs that provided child dental care prior to 2007 (n=6). Statewide Medicaid claims data were used to address four child inclusion criteria: Medicaid-eligible within two months of birth; continuously Medicaid-eligible; less than 6 years of age at First Preventive Dental Visit (FPDV); and not seen elsewhere for an initial dental examination (CDT=00150). Chart reviews (n=40) were conducted on randomly selected children at each site. Date for each preventive service was recorded as well as number of teeth that required and subsequently received care. Additionally, number of visits and date of last visit was documented for this first episode.



    Results: Age was positively associated with dental prophylaxis (p < 0.001); whereas there was no statistically associated relationship with topical fluoride application, dietary counseling, and oral hygiene instruction. 11.3% received all four preventive services and 15.8% received no preventive services at this first episode. Only 6.6% of this population had any caries noted on treatment plan at FPDV; however, two children were referred for operating room for corrective care. Mean number of restorations planned was 0.30 (1.44); mean number of restorations received was 0.21 (0.78). The ratio of minor restorations (1-2 surfaces) to more extensive restorations (3+ surfaces) for this first episode was 2.4:1. Conclusion: On average, children who are seen early for a FPDV had relatively few restorative needs. However, there were few exceptions.





    Also available at: http://iadr.confex.com/iadr/2011sandiego/webprogram/Paper143987.html

  • IADR Abstract: Time to First Preventive Dental Visit (FPDV) at Iowa CHCs

    Time to First Preventive Dental Visit (FPDV) at Iowa CHCs



    Presented at the IADR/AADR Annual meeting, San Diego, CA:

    Thursday, March 17, 2011: 2 p.m. - 3:15 p.m.

    Presentation Type: Poster Session

    B. PENDHARKAR 1, R.A. KUTHY 1, E.T. MOMANY 1, M.P. JONES 2, N.M. ASKELSON 3, D.L. CHI 4, G.L. WEHBY 1, and P.C. DAMIANO 1, 1Dept. of Prevent & Comm Dentistry, University of Iowa, Iowa City, IA, 2Department of Biostatistics, University of Iowa, Iowa City, IA, 3Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, 4Dental Public Health Sciences, University of Washington, Seattle, WA



    Objective: To assess demographics and behavioral variables which may be associated with time to first preventive dental visit (FPDV) at the Iowa community health centers.



    Methods: Forty chart reviews were performed per site on randomly selected Medicaid-eligible children at six Iowa community health centers for calendar years 2000-2006. Data regarding initial oral examination and dental preventive and treatment services rendered were entered and analyzed for 240 children, all of whom were less than 6 years of age at entry.



    Results: Mean age for first preventive dental visit was 26.8 months (SD 13.7). Seventy-three percent of the children had their FPDV by 3-years of age. Fifty-three percent were males, 37% were white non-Hispanic and 23% required translation services. Each of these three variables was not statistically associated with time to first dental visit. However, there was a statistically significant association between age at FPDV and the community health center where the child received care initially (Chi-Square=98.64,df=45,p=0.0001). About 62% received oral prophylaxis, 73% received topical fluoride applications,14% received dietary counseling and 63% received oral hygiene instructions during their first visit. Of the 98% who had a documented treatment plan, 86% completed this plan. Ninety-seven percent of children saw the same provider throughout the first episode. Conclusion: More than 70% Medicaid-eligible children made their first preventive dental visit prior to their third birthday. However, there is variation among community health centers for when a child is first seen.





    Also available at: http://iadr.confex.com/iadr/2011sandiego/webprogram/Paper143987.html

[/collapse] [collapsed title="Study 3: Impact of the age at first preventive dental exam on future dental and medical care utilization and costs"]

Iowa Medicaid claims and administrative data are being used to determine if age at first dental exam affects future dental and medical care costs for children. Using instrumental variable analyses, we are modeling the factors related to dental use and cost.

[/collapse] [collapsed title="Study 4: Using the Health Belief Model and the Extended Parallel Process Model to determine factors associated with mothers’ decision-making and preventive dental care-seeking behavior related to first preventive dental exam"]

Focus groups with mothers of Medicaid-enrolled children have been used to investigate the factors that encourage and discourage parents from taking their children for comprehensive dental care. The results of these groups will serve to inform the contents of a survey of parents with children in Medicaid. Previous results will help us to include the most critical factors and tailor the surveys to issues important to parents with children in Medicaid. These surveys will be designed to find out what prompts parents to take their children to the dentist for their first preventive dental visit and what might discourage them from preventive dental care. The data will be analyzed with OLS regression to determine what psycho-social factors are related to AFPDV.



    Related publications:

  • IADR Abstract: Health Behavior Models and Parents' Decision-making about Preventive Dental Visits

    Health Behavior Models and Parents' Decision-making about Preventive Dental Visits



    Presented at the IADR/AADR Annual meeting, San Diego, CA:

    Friday, March 18, 2011: 2 p.m. - 3:15 p.m.

    Presentation Type: Poster Session

    N.M. ASKELSON 1, E. MOMANY 2, D.L. CHI 3, R.A. KUTHY 4, M.P. JONES 5, and P.C. DAMIANO 4, 1Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, 2Preventive and Community Dentistry, University of Iowa, Iowa City, IA, 3Dental Public Health Sciences, University of Washington, Seattle, WA, 4Dept. of Prevent & Comm Dentistry, University of Iowa, Iowa City, IA, 5Department of Biostatistics, University of Iowa, Iowa City, IA



    Objective: This qualitative study uncovered factors that influence parents' decision-making about preventive dental care for preschool-aged children enrolled in Medicaid. The Health Belief Model and the Extended Parallel Process Model were used to guide this formative inquiry.



    Methods: A random sample of children enrolled in Medicaid under age 6 in Iowa was drawn, including children from Spanish-speaking households. Parents were recruited to participate in focus groups via a letter and phone calls. Forty-one parents participated in 11 focus groups, which were recorded, transcribed and translated. Transcripts were analyzed by 3 coders who employed open and closed strategies.



    Results: Over half of the children were white, 9.8% were black, and 22.0% were Hispanic. The key finding was parents felt strongly about the importance of preventive dental care and were aware of the recommendations for young children. They believed children should receive preventive care before age one. The findings were consistent with the health behavior models. Parents' response efficacy for preventive care was high. They believed preventive care could deter illness and poor appearance. Parents' self-efficacy was high, but they were concerned about barriers like the lack of dentists, especially dentists who are good with children. Parents had low perceived susceptibly to dental problems for their children. This was a result of most children already receiving preventive care, which the parents thought was highly efficacious. Parents' perceptions of severity were very high. Parents were concerned about negative health and appearance outcomes. Parents listed many benefits to early care. Cues to action for parents included doctors, childcare providers, and the belief that a dental visit was required for school. Conclusion: Parents understand early preventive visits are important and effective. Policies should address barriers parents face.





    Also available at: http://iadr.confex.com/iadr/2011sandiego/webprogram/Paper143987.html

[/collapse]

This research is designed to help us understand the impact of earlier receipt of a first preventive dental check-up. The ultimate goal is to inform the design of an intervention with parents and providers to encourage the effective timing of children’s first preventive dental exams.