South Dakota Enhances Access to Oral Health Care for Young Children

Summary: South Dakota's Partners for Prevention Project seeks to enhance access to dental care for its youngest and poorest children. The project gives medical primary care providers training to detect dental disease and to provide parents with prevention information and tools they need to ensure better oral health for their children. It also trains general dentists in pediatric dental techniques so they can better meet the needs of very young children. The state's goal is to increase the number of Medicaid-enrolled children ages 1 to 5 that have access to dental services by 25% over five years.

The Issue
Throughout the nation, access to oral health services is frequently limited or unavailable, especially for low-income families. In the private sector, many employers and health insurers are looking for ways to constrain escalating health costs, and dental coverage is often one of the first services to be curtailed—through higher cost-sharing for dental services; decreased payments to providers, leading to fewer dentists participating; or elimination of dental benefits entirely.

In the public sector, state budget crises have led to significant cuts in state Medicaid programs, with dental care a primary casualty. With the recent improvement in the economy, some states have been able to restore dental services that had been cut or scale back the cost-sharing that affected access to care, and several states have even been able to expand coverage or services in significant ways. A few states, including North Carolina, Washington, Minnesota, and Connecticut, are using innovative approaches to enhance access to oral health care, particularly to children, by developing training curriculums for primary care providers and/or general dentists. South Dakota uses an innovative approach that uses local dentists to train medical providers.

Background
Many children in South Dakota are not seen by a dentist until they are more than five years old. The state's Partners for Prevention Project seeks to change that by enhancing access to dental care for its youngest and poorest children. The project is funded by a five-year, $250,000 grant provided through the Healthy Tomorrows Partnership. Healthy Tomorrows is a partnership between the Health Resource Services Administration and the American Academy of Pediatrics. The project focuses on very young children due to the fact that five major national medical organizations, including the American Dental Association and the American Academy of Pediatrics, recommend that children now be seen by a dentist by age 1.

The state's goal is to increase the number of Medicaid-enrolled children ages 1 to 5 that have access to dental services by 25% over five years. To achieve this, local dentists train children's primary care providers in how to perform a basic oral health assessment. This includes consideration of clinical factors such as infection, untreated dental decay, and developmental problems as well as risk factors such as lack of a dental home, poor diet, previous tooth decay experience, and poor oral hygiene.

In addition, pediatric dentists will train non-pediatric general dentists in techniques such as making a child comfortable, using new restorative dental treatment techniques for primary teeth, and providing anticipatory guidance to the family.

The state aims to train 95% of pediatricians, 80% of other primary care providers, and 200 general dentists.

South Dakota's Partners for Prevention Program is administered by the South Dakota Dental Association (SDDA) on behalf of the South Dakota Oral Health Coalition. It received funding through the Health Resources and Services Administration and the American Academy of Pediatrics (AAP) via the Healthy Tomorrows Partnership for Children Program. AAP awards the five-year grants and provides technical assistance. The South Dakota Departments of Health and Social Services (Medicaid) are members of the Oral Health Coalition and are on the advisory board for the grants.

Programs in other parts of the country that have similar goals generally have been initiated by medical or pediatric groups. By comparison, the Partners for Prevention Program uses local dentists to provide oral health training to medical providers in their community, thus creating an interface between the medical and dental professional at a local level.

Process of Change
The program began in June 2004. The SDDA formed an advisory committee made up of dentists, medical providers, child advocates, and representatives from social service agencies and state government. David Krol, M.D., M.P.H., a senior policy research consultant at the Children's Dental Health Project in Washington, D.C., and a professor at Columbia University, designed a training curriculum.Curriculum
While the providers' training curriculum is basically consistent across regions, it can be adjusted to the needs of each participating community. The training takes an hour and is often presented as a lunchtime session—factors that have helped to achieve participation by physicians. Pocket guides designed by the National Maternal and Child Oral Health Resource Center are distributed to providers at the end of the training. These guides provide an overview of pediatric dentistry and are concise, easy-to-use, and can fit inside a pocket.

The training presents the rationale for medical providers to participate by emphasizing the connection between oral health and broader health. It provides information about dental disease, including infections, tooth decay, and other conditions; and instructs the providers on how to conduct risk assessments, teaching them what to look for when examining children's mouths as well what questions they should ask to determine whether a child is at risk for oral health issues. Finally, it discusses anticipatory and preemptive guidance that providers can use to involve children and their families in dental health care.

The Network
South Dakota's Partners for Prevention program seeks to build a network from the community level upward. Four communities have been identified as pilot sites. In each of these sites, one or two local dentists have been recruited to implement the Partners for Prevention Program, reach out to local pediatricians, and present the curriculum to them through the training course.

In this way, the program aims to promote camaraderie and cooperation among dentists and physicians and thereby improve children's access to oral health. Using the program's inter-professional referral system, doctors will be able to make appointments for their patients with dentists, regardless of whether the children have had a regular, or any previous, dental provider. The referrals are informal: at the training session, each medical provider is given a pad of referral slips that they can use to refer patients to participating dentists for emergency treatment, non-emergency treatment, or routine check-ups.

The program is expected to result in a greater number of referrals to dentists from primary care providers—one reason why it employs pediatric dentists to train general dentists in pediatric dental techniques for children ages 1 to 5. As an incentive to undergo the training, general dentists will gain certification as "Access to Baby and Child Dentistry" (ABCD) providers and receive an enhanced Medicaid reimbursement from the state for certain services.

Next Steps
As of November 2005, trainings had been completed in two of the four pilot communities and had begun in a third community.

Due to South Dakota's small population, word has spread rapidly about the Partners for Prevention Program. SDDA has been asked to make presentations to a state conference of nurse practitioners, a state public health conference, and various communities and private health centers throughout the state. According to Randy Sachau, D.D.S., president of SDDA, "For years, the dental profession has known that good dental health is founded on prevention of disease. Partners for Prevention is just the beginning of an effort by the South Dakota Dental Association and the Oral Health Coalition to improve the dental health of South Dakotans by renewing our focus on preventive dentistry."

The SDDA has begun to evaluate the training sessions and is developing ways to assess outcomes of the program. An evaluation component already in place uses a pre- and post-training test to gauge how well the curriculum communicates information to the providers. Ultimately, an evaluation will examine dental service utilization rates for children with Medicaid coverage before and after the trainings. It also will likely track how many dental referrals are filed and completed and the number of primary care providers performing oral evaluations before and after the training.