As our health system moves to pay for value, highly-effective but low-cost preventive medicine becomes increasingly vital. Dental sealants provide a low-cost intervention to prevent tooth decay, a health condition with serious consequences. A $48 sealant placed on a permanent molar of a child at the right time can reduce decay by 80 percent in the first two years and continue to block decay for nearly five years. In the world of public health, these outcomes are stunning.
Despite this compelling evidence, in 2010 less than one-third of five- to 19-year-olds had sealants on any of their teeth. Only 25 percent of low-income children of these ages had sealants. This is of particular concern because they are twice as likely to have untreated tooth decay and one-third less likely to see a dentist than other children. States can increase access to sealants for low-income children, but most are lagging in this effort, according to a new report by The Pew Charitable Trusts.
Tooth Decay’s Serious Consequences
Throughout my 27-year career as a public health dentist, and more recently as Iowa’s dental director, I have seen oral health problems not receive the attention they deserve in the larger health policy arena. Surgeon General David Satcher referred to dental and oral diseases as a “silent epidemic.” That’s unfortunate.
Tooth decay is one of the most common conditions among children and dental care remains their greatest unmet health need. The longer tooth decay remains untreated, the more trouble children have eating, talking, socializing, sleeping, and learning. The consequence of doing nothing leads to unnecessary and costly emergency room (ER) visits and hospitalizations. In 2008, children went to the ER more than 215,000 times for preventable dental issues at a cost of more than $104 million.
In rare cases, untreated tooth decay causes infections that lead to death, such as in the case of Deamonte Driver, a boy in Maryland who died in 2007 when bacteria from an untreated tooth abscess traveled to his brain. More recent studies show that Deamonte’s case was not an isolated incident. From 2008 through 2010, more than 100 people who went to hospital emergency rooms with dental conditions died from these ailments.
The sad irony is that unlike many health conditions, tooth decay is largely preventable.
Cost-effective Prevention
Dental sealants are plastic coatings that are painted onto molars, which are the most cavity-prone teeth for children. The procedure, which takes just a few minutes, is often done by a dental hygienist. Research confirms that sealants, at one-third the cost of a filling, are the most powerful clinical strategy for preventing tooth decay.
State oral health policy has focused on getting sealants to low-income children because we know they face obstacles to receiving care to detect and treat decay. In 2011, less than 40 percent of children below the poverty line received dental care. With only about one-third of dentists in the U.S. accepting Medicaid, visit rates are not much higher for Medicaid children – nearly half (more than 16 million Medicaid children) did not visit a dentist in 2013.
School sealant programs are a very effective means of reaching low-income children. Studies find that programs targeting high-need students can reduce decay by 60 percent. Programs draw from a variety of funding sources including state and local health departments, the Maternal and Child Health Block Grant, nonprofit agencies, and philanthropy. Many programs reduce the need for such funding by billing Medicaid for sealant placement.
Challenges Reaching High-need Children
While school sealant programs can be found in 48 states and the District of Columbia, the Pew reportnoted that in 2014, 39 states and D.C. lacked sealant programs in most of their high-need schools, often defined as those with at least 50 percent of students qualifying for free or reduced-price lunch. In fact, 10 states reported reaching fewer high-need schools today than in 2012.
In 2014, 39 states and the District of Columbia lacked sealant programs in most of their high-need schools. Two states—Missouri and Wyoming—reported having no sealant programs in any high-need schools.
The report also identified policy barriers that hinder efforts by states to expand school sealant programs. For instance, in 13 states and D.C., children must be examined by a dentist before a hygienist can seal their teeth at a school program. This rule runs counter to the experience in dozens of states that a hygienist alone can assess which teeth to seal. Studies show that such requirements increase the cost of school sealant programs and lower the number of children served.
In addition, Medicaid payment policies are not always friendly to school sealant programs. Pew’s report found that in several states, Medicaid does not allow hygienists to bill for sealants provided in schools, some Medicaid agencies do not reimburse for portable dentistry and in other states, Medicaid managed care vendors do not reimburse for sealants provided in schools.
In my state of Iowa, we’ve made slow but steady strides over the past decade to reach more low-income children with sealants. In 2004, the Iowa Dental Board removed our prior exam rule. Iowa then expanded the range of locations that public health hygienists could practice to schools and preschools. Finally, we streamlined Medicaid policies so that public health agencies using school-based hygienists could bill Medicaid without needing to employ a dentist to supervise the hygienist.
The state also increased funding for school sealant programs using dollars from the Centers for Disease Control and Prevention State Oral Health Improvement Grant and private philanthropy. As a result, we’ve added 11 school sealant programs across the state since 2012 and expanded sealants to an additional 18,000 low-income students, which marks a 78 percent increase in students sealed over the past three years.
At relatively little cost, we can do more to help children avoid pain while spending less on unnecessary health care. Sealants work. Low-income children, especially, need them. We need more sealant programs in our nation’s high-need schools.