Programs and Policies Targeted to Improve Access to Dental Care for Low Income Adults and Children in the US: An Integrative Literature Review

  

    
Study
    
Primary Intervention Assessed
    
Study Design
    
Sample/Study Population
    
Outcome measured
    
Principal Finding
  
  

    
Arthur & Rozier, 2016
    
Oral health services in non-traditional settings
    
Time series
    
Medicaid-enrolled children
    
Use of oral health services
    
Implementation of Medicaid reimbursement policies    for non-traditional providers to administer preventive oral health services    can improve access
  
  

    
Bailit & D’Adamo, 2012
    
Oral Health Education
    
Narrative review
    
-
    
-
    
Several states have promising programs to reduce    disparities but most are still at the demonstration level and have not been    adequately evaluated.
  
  

    
Batliner, 2016
    
Dental therapists
    
Narrative
    
-
    
-
    
The Dental Health Aide Therapists are a potential    solution to dental access scarcity
  
  

    
Beazoglou et al., 2015
    
Medicaid reimbursement
    
Pre-post
    
Children enrolled in Medicaid
    
Dental care utilization
    
Increased Medicaid reimbursement rates for dental    providers resulted in reduction of dental access disparities
  
  

    
Berdahl et al., 2016
    
-
    
Descriptive
    
Children aged 0-18
    
Dental care utilization
    
Access disparities were based on insurance    status, race, income, educational attainment and overall health status
  
  

    
Bethel et al., 2014
    
Dental residency programs; Oral health services    in non-traditional settings
    
Narrative
    
-
    
-
    
Offering oral health care services in alternative    settings, such as senior centers, places that are familiar to older adults is    a key strategy to increase access
  
  

    
Blue & Kaylor, 2016
    
Dental therapists
    
Cross-sectional
    
Four dental practices in Minnesota
    
Changes in dentists’ practice patterns
    
Dentists performed fewer restorative and    preventive procedures after a DT was hired.
  
  

    
Brickle et al., 2016
    
Dental therapists
    
Narrative
    
-
    
-
    
Preliminary findings are positive regarding the    public health impact of Dental Therapists in Minnesota
  
  

    
Chalmers & Compton, 2017
    
Medicaid reimbursement
    
Cross-sectional
    
50 states and the District of Columbia
    
Access to dental care
    
Reimbursement rates and access to dental care    were directly related at the state level
  
  

    
Chalmers, 2017
    
-
    
Cross-sectional
    
Maryland residents
    
ED utilization and costs
    
Dental/oral health-related conditions discharges    are not evenly distributed by race
  
  

    
Dolce, 2014
    
Oral health services in non-traditional settings
    
Narrative
    
-
    
-
    
Inter-professional education is requisite to    improving oral health care outcomes
  
  

    
Dudovitz et al., 2018
    
Community-based dental access programs
    
Longitudinal
    
Low-income urban children
    
Oral health status
    
A school-based universal screening and fluoride    varnishing program can improve the oral health of children with a high burden    of untreated dental diseases
  
  

    
Flynn et al., 2014
    
ACA, Medicaid expansion
    
Cross-sectional
    
Adult Medicaid enrollees
    
Receipt of timely dental care
    
The ACA will not reduce barriers to dental care    for adult Medicaid enrollees.
  
  

    
Guo et al., 2014
    
Oral Health Literacy
    
Survey
    
Adults aged 25+ in rural Florida
    
Oral health status
    
Higher levels of health literacy were associated    with better oral health status
  
  

    
Gupta et al., 2017
    
Medicaid reimbursement
    
Descriptive
    
All US states
    
Medicaid reimbursement rates
    
There is considerable variation across states in    Medicaid fee-for-service reimbursement rates
  
  

    
Horowitz et al., 2015
    
Oral health education
    
Qualitative
    
Low-income parents
    
Knowledge and understanding of prevention and    control of dental caries
    
Most participants had limited understanding of    and extensive misinformation about how to prevent dental caries
  
  

    
Johnson et al., 2017
    
Loan support
    
Cross-sectional
    
Children aged =19 years
    
Cost-effectiveness of three preventative    interventions
    
Loan repayment programs are potentially    cost-saving interventions.
  
  

    
Kranz et al., 2014
    
Oral health services in non-traditional settings
    
Cross-sectional
    
Medicaid enrollees under three years old
    
Access to dental care
    
For young Medicaid enrollees, oral health    services provided in medical offices can improve access and increase use
  
  

    
Laniado et al., 2017
    
Medicaid coverage
    
Pre-post
    
All individuals who presented to the ED with a    dental problem
    
Number of NTDC visits
    
The increase in Medicaid dental benefits through    the ACA significantly decreased NTDC visits
  
  

    
Lee et al., 2014
    
-
    
Cross-sectional
    
Adults 65 years or

      older
    
Dental care utilization
    
County-level dentist-to-population ratio has    independent effects on older adults’ dental care utilization
  
  

    
Li et al, 2018
    
-
    
Descriptive
    
Adults aged 20+ years
    
Self-reported oral health
    
Self-reported oral health improved from 1999 to    2014
  
  

    
Macek et al., 2016
    
Oral health education
    
Descriptive
    
Adult dental patients
    
Dental visits, oral health functioning, and    dental self-efficacy
    
The relationship between health literacy and oral    health is not straightforward, depending on patient characteristics
  
  

    
Maxey et al., 2017
    
Oral health services in non-traditional settings
    
Comparative case study
    
Primary care physicians at federally qualified    health centers
    
Roles for physicians in oral health
    
Family physicians can contribute a great deal to    the success of integrated health care delivery models
  
  

    
McKernan et al., 2015
    
Medicaid participation
    
Survey
    
General dentists in Iowa
    
Factors affecting Medicaid participation
    
Dentists who accepted Medicaid patients had more    positive attitudes about Medicaid and altruistic attitudes
  
  

    
Nasseh & Vujicic, 2015
    
Medicaid reimbursement
    
Pre-post
    
Medicaid-eligible children in Connecticut,    Maryland and Texas
    
Access to dental care
    
Increasing Medicaid dental fees closer to private    insurance fee levels has a significant impact on dental care utilization
  
  

    
Nebeker et al., 2012
    
Medicaid
    
Cross-sectional
    
Dentists practicing in Michigan
    
Dentists’ attitudes toward Medicaid and an    alternative public dental insurance system in Michigan
    
Practitioners were more satisfied with the    alternative public dental insurance program than they were with Medicaid
  
  

    
Pathman et al., 2012
    
Loan support
    
Descriptive
    
Clinicians serving in the NHSC’s loan repayment    programs
    
Changes in the disciplinary composition of the    NHSC’s workforce
    
With increased funding, the NHSC’s workforce has    become larger and more diverse
  
  

    
Phillips et al., 2016
    
Dental therapists
    
Cross-sectional
    
Adult patients and their waiting room companions
    
Patient-reported comfort with mid-level dental    providers
    
Patients lacking regular care appear to be    comfortable with the introduction of mid-level dental providers
  
  

    
Ramos-Gomez, 2014
    
Oral health services in non-traditional settings
    
Narrative
    
-
    
-
    
The Infant Oral Care Program could reduce    disparities in oral health care access and disease among vulnerable    populations
  
  

    
Rodriguez et al., 2013
    
Community dental health coordinators, dental    therapists
    
Narrative
    
-
    
-
    
Mid-Level Dental Providers could increase access    to care to underserved populations
  
  

    
Rowland et al., 2016
    
Community-based dental access programs
    
Time series
    
Maryland residents
    
Impact of community dental program
    
Effective ED dental diversion programs can result    in cost savings and more appropriate care
  
  

    
Sen et al., 2016
    
Preventive dental visits
    
Retrospective cohort study
    
Low-income children
    
Use of restorative or emergency dental services
    
Dental sealants reduced the likelihood of using    restorative and emergency services and costs
  
  

    
Shariff & Edelstein, 2016
    
Medicaid, access to care
    
Cross-sectional
    
Publicly and privately insured children
    
Oral health status, dental care use
    
Publicly insured children had poorer oral health    status; No differences in use of dental care
  
  

    
Shoffstall-cone & Williard, 2013
    
Dental therapists
    
Narrative
    
-
    
-
    
Dental therapists can improve access to oral    health care and address health disparities
  
  

    
Simmer-Beck et al., 2017
    
Public health dental hygienists
    
Narrative
    
-
    
-
    
Expanding dental hygienists’ scope of practice    can increase access to care
  
  

    
Singhal et al., 2017
    
Medicaid, access to care
    
Trend study
    
Low income adults
    
Access to dental care
    
Improved access associated with an expansion of    Medicaid benefits
  
  

    
Singhal et al., 2015
    
Medicaid, access to care
    
Interrupted time-series
    
Adult Medicaid enrollees
    
Dental-related ED visits
    
Medicaid’s dental coverage elimination increased    dental-related ED use
  
  

    
Townsend & Chi, 2017
    
Loan support
    
Case studies
    
Junior pediatric dentistry faculty
    
Loan repayment
    
Loan repayment programs make an academic career    in pediatric dentistry financially viable
  
  

    
Warder & Edelstein, 2017
    
Medicaid, dentist participation
    
Cross-sectional
    
Dentists participating in Medicaid
    
Medicaid participation rates for dentists
    
ADA’s 2015 analysis was the most rigorous source
  

Table 1: Studies included in the integrated literature review.

Innovations in community-based public health dental access programs

Our literature search identified multiple models of communitybased workforce innovations using allied dental health workers with varying levels of training and expertise to increase access to care and utilization of dental services in low-income and vulnerable populations [9-12]. The Community Dental Health Coordinators (CDHCs) program was developed by the American Dental Association (ADA) to address oral health disparities in underserved rural, urban, and Native American communities [9]. CDHCs have been shown to be effective in providing oral health education and promotion, community outreach and engagement, case management, and patient navigation services to patients. Community health workers deployed to screen applicants, educate residents to adopt good oral hygiene practices, coordinate follow up care, and ensure that patients had transportation to appointments have been successful in diverting patients seeking urgent dental care in emergency departments to private practice providers or community dental clinics [10]. Another model employed an oral health nurse to coordinate services and oversee a school-based district-wide oral education and health promotion program that provided preventive services in schools, and intensive, restorative services for individual patients in need [11]. Although the long-term impact on oral health of the children was inconclusive at the end of the pilot, the program demonstrated that collaborations between school-based oral health programs and the community have the potential to reduce oral health disparities in populations with a high burden of dental disease [11]. Many states have also revised their dental practice acts to permit Registered Dental Hygienists (RDHs) to practice outside of the traditional dental office and the direct supervision of a dentist to provide a range of preventive oral health services in schools and community-based public health settings [12].

Policies related to medicaid reimbursement and expansion of dental coverage

Studies have shown that utilization rates and access to dental care is increased, particularly among publicly insured children, when Medicaid Fee-For-Service (FFS) reimbursement rates are adjusted closer to market levels [13,14]. Chalmers, et al. estimated that 1.8 million more children would have had access to dental care in 2014 if states with low reimbursement rates had raised their rates in 2013 [15]. Such increase is premised on the assumption that higher rates encourage provider participation which results in increased network capacity. Modest increases in regular dental care use and the subsequent cost savings associated with use – among Medicaidenrolled children have also been attributed to reforms to state Medicaid programs, such as managed care carve-outs for dental services, better customer service, implementation of a missed appointment tracker, and expansion of the provider network [16,17]. Further, this expansion must be adjudicated using clinically meaningful metrics – such as the proportion of caseload attributable to Medicaid enrollees in order to see improvement in utilization numbers [18]. Disparities in oral health in children associated with socioeconomic and racial minority status may persist, even when reimbursement rate increases are implemented, unless the fundamental social determinants of health, such as housing and food insecurity, are addressed [19].

While several individual, provider, and system-level barriers were projected to hinder the effectiveness of expansion, states that opted to expand their Medicaid programs under the Affordable Care Act (ACA) to provide coverage beyond emergency services, saw a resultant increase in low-income adults receiving dental care [20]. Low-income adults residing in states with a non-emergency dental benefit also had a greater probability of having seen a dentist compared to low-income adults residing in states without such dental benefits [21].

Without access to preventive dental care, patients in urgent need of oral health care services increasingly seek treatment of dental conditions in hospital emergency departments [22]. Laniado et al. found that states that opted to expand Medicaid dental benefits to adults are likely to see reductions in the number of emergency department visits for preventable dental conditions, particularly in populations of young adults [22]. Conversely, the elimination of adult dental benefits resulted in a substantial increase in emergency departments visits by Medicaid enrolled adults for dental problems due to a decline in access to dental care in primary care settings [23]. In addition, significant differences across racial and socioeconomic groups in emergency department utilization for dental conditions have been noted [10,24]. An adult Medicaid dental benefit would allow adult Medicaid enrollees to access primary care through a dental provider, eliminate the necessity to seek routine medical care in hospital emergency departments, and begin to erode some of the racial and socio-economic disparities in poor populations.

Loan Support

Dental loan repayment programs vary in scope and size, ranging from total student loan forgiveness after a specified period of time to a fixed amount per year in exchange for dentists commitment to practice in dental professional shortage areas [25-27]. Studies have shown that while these programs may provide only modest per child cost savings to the Medicaid program, they provide an incentive to newly licensed providers to locate their practice in areas with higher needs or to serve primarily uninsured or publicly insured populations [25-27]. In addition, dental school graduates who have an interest in pursuing a career in academic pediatric dentistry may be able to take advantage of numerous state and federal loan repayment programs designed to reduce the student debt burden for junior faculty. These programs provide a pathway for young dentists to care for underserved populations, engage in challenging clinical research and scholarship, and to teach and mentor the next generation of clinicians and researchers [27].

Dental residency and externship programs and primary care physician-based oral health services

Various interdisciplinary patient-centered health care models integrate preventive dental care in medical practices and other nontraditional dental practice settings to improve access and address disparities in oral health in adult and pediatric patients [28-33]. Pediatric primary care physicians are well situated to educate parents about basic oral health practices, provide screening for early childhood caries, and deliver preventive oral health services (e.g. fluoride varnish) during a child’s first two years of life [28]. In addition, patients who seek treatment for non-traumatic dental conditions in hospital emergency departments typically are not treated for the underlying condition, usually receiving only antibiotics and prescription pain relief [34]. Research suggests that the high costs associated with providing dental care in emergency departments nationwide can be mitigated by integrating oral health professionals on staff in hospital emergency departments [34]. Studies have shown that primary care physicians and nurses who have received oral health training tend to provide better emergency care to their patients and have a better appreciation for the ways in which oral health can affect overall health [29,31].

Expansion of public education programs to improve oral health literacy

Health literacy is the degree to which a patient understands basic health information and the importance of oral health disease prevention and treatment [35]. Education and income are indicators of self-reported good oral health status among adults [36]. Higher health literacy skills lead to improved patient-dentist communication, better self-care habits, such as regular brushing and flossing, as well as a greater likelihood of being a regular dental care seeker [37]. Community-based health education and literacy programs [5,38,39] have been shown to have a positive effect on overall oral health status and outcomes. In addition, inter-professional education such as training nurses in oral health – has been found to support efforts in improving oral health literacy [31]. While these and other models of oral health education programs have been shown to have an impact on oral health outcomes [12,36,40,41], the relationship between health literacy and oral health is complex [40]. Further studies have been called for to fully understand the extent to which health literacy skills impact access and utilization of health care services, providerpatient communications, and self-care [40].

Expanding the use and scope of practice of dental therapists

Similar to physician assistants in medicine, mid-level dental practitioners known as dental therapists provide preventive and routine restorative oral health care services to patients. Dental therapists practice under the general supervision of a licensed dentist and provide a limited scope of primary oral health care services to patients in a range of settings, including Federally Qualified Health Centers (FQHCs) and community clinics, private practices, nursing homes, and school-based health centers [42].

In Alaska, Dental Health Aide Therapists (DHATs), the first mid-level dental providers in the nation, have provided culturally competent care to more than 40,000 people with extremely limited access to care for over a decade [38,39]. Evaluations of the DHAT workforce model concluded that DHATs operate safely within their scope of practice and have improved access to oral health services [38,39]. In Minnesota, preliminary data indicate that dental therapists have shortened waiting times and travel distances for patients, reduced costs, and improved the utilization of dental services [43] and that the majority of patients treated by the dental therapists are either uninsured or on public insurance [42]. As a relatively new profession in the U.S., dental therapy is not well understood as a workforce model. Patients with perceived need, who lack access to care, viewed dental therapy in a favorable light [44]. Further, studies have shown that dental therapy has the potential to “effectively, safely, and efficiently contribute to the U.S. oral health care delivery system, particularly in dental safety net programs and nonprofit community based practices whose primary mission is caring for the underserved” [9].

Discussion

For advocates and policymakers tasked with prioritizing improvements in an oral health policy agenda, this integrative literature review yields important information. Fundamentally, our research suggests that a holistic and multifaceted approach to strengthening the oral health care safety net is necessary if the oral health status of vulnerable children and adults is to be improved. Ensuring access to basic preventive care and comprehensive dental care for all children and adults should be the guiding principle behind all policy reforms. Policy levers should work, not in isolation, but rather in complementary fashion to one another. Public health interventions that address socioeconomic factors and the contextual influences that make individual decision-making easier tend to have the greatest population impact, while interventions that are more clinical in nature or are designed to achieve individual behavior changes may realize a significant impact to public health, but require greater resources to accomplish the desired result [45].

The conceptual framework presented in the Figure 1 describes programmatic and policy interventions that have the potential to change the ecological context of the oral health safety net. Policies with the broadest capacity to reduce the burden of disease and to affect oral health outcomes are represented at the top of the circle and proceed clockwise in increasing order of intensity of focus on individual patients.

    

    

    Figure 1: Conceptual Framework to Improve Access to Dental Care.