Oral Health in the District of Columbia

Oral Health has important implications for children's overall health status and well-being. In the District, parents are more likely to report that their children have fair or poor oral health than parents of children nationwide. Wards 1, 7, and 8 have particularly high percentages of children with fair or poor oral health status. There is a shortage of oral health providers who serve persons insured by Medicaid, children, and populations east of the Anacostia River. Wards 7 and 8, as well as several clinics that serve high numbers of children insured by Medicaid, have been designated as dental health professional shortage areas.

The District of Columbia Pediatric Oral Health Coalition is a community-driven alliance of multidisciplinary public and private stakeholders, convened to address access to oral health for District of Columbia children. Motivated by a 2009 health and health care needs assessment of District youth that noted significant barriers to oral health care in the city (Chandra et al., 2009), the coalition commissioned this report on the oral health of District children receiving Medicaid benefits. This report assesses the perspectives of Washington, D.C., stakeholders—parents, medical and oral health clinicians, and school health nurses—regarding the oral health of children in the city.

Data for this report were collected from three focus groups with parents (n=26) and three focus groups with providers, including dentists and school health nurses (n=25). In addition, data were collected at an oral health forum of various stakeholders (n=30) and from an oral health provider survey with pediatricians, dentists, and other oral health clinicians (n=37).

Key Findings from Focus Groups

• Providers believe that there is a general lack of parental awareness of the importance of preventive oral health care.
  While the parents in the focus groups felt that oral health for children is important, many providers stated that, in their experiences, parents do not always view oral health as a priority. In particular, providers felt that parents do not prioritize preventive oral health care, instead only bringing in children for the required completion of the DC Oral Health (Dental Provider) Assessment Forms or urgent complaints.*
• Access to care, particularly for specialty services, is a challenge for parents seeking oral health services for children who are Medicaid beneficiaries.
  Specialty care (such as endodontics and orthodontics) is particularly challenging, as few specialty providers accept Medicaid. Low reimbursement and administrative hurdles are barriers to provider participation in Medicaid.
• Some parents perceive quality to be lower at sites that treat patients insured by Medicaid.
  Many parents expressed the perception that the care they get at clinics serving populations insured by Medicaid is of lower quality, often because of lack of continuity of care by the same provider at such clinics.
• Providers report that parents often do not obtain follow-up for children who have urgent oral health needs identified at their bi-annual preventive oral health visits.
  According to providers, while many parents are motivated to bring children to the dentist for an initial oral health appointment to have the DC Oral Health (Dental Provider) Assessment Form completed, if an oral health problem requiring urgent follow-up is identified, the recommended follow-up visits are often not completed. This may be due to a lack of parental understanding of the importance and urgency of such follow-up. In addition there is no mandate that requires follow-up care to be completed.
• There is little coordination of care among school health nurses, pediatricians, and oral health providers.
  Although school nurses do enter information from the DC Oral Health (Dental Provider) Assessment Forms into a database, there is little care coordination among the nurse, dentist, or pediatrician to ensure that parents get appropriate follow-up care for urgent oral health problems identified at their child's preventive visit.
• Oral health education in schools is limited, with great variation across school sites.
  Some school nurses do organize sessions on oral health education for students. In general, such sessions are limited and are not consistent across all schools. Parents expressed interest in having their children learn about proper oral health care in the school setting.
• There are few oral health education initiatives that target parents in schools.
  Although few oral health educational initiatives target parents in schools, both parents and providers agreed that this would greatly enhance parental education and follow-up for children's oral health.

Key Parental and Provider Recommendations from Focus Groups

• Incentives to encourage dentists to accept Medicaid and to serve in underserved communities are needed.
  Providers who participated in the focus groups expressed concern about administrative rates and hurdles associated with Medicaid. Many stated that Medicaid reimbursement rates for oral health should be increased. They also felt that loan repayment programs and other incentives to encourage providers to practice in underserved communities should be expanded.
• Provider insurance information should be made readily available to parents.
  Often, parents may not be aware of what oral health benefits are covered by their insurance. Improved and up-to-date resource lists are needed to help inform parents of their coverage benefits and provider availability by insurance type.
• Expanded hours for oral health care are needed.
  Oral health appointments set during weekday hours may be prohibitive for parents who work, or for children enrolled in school. Parents and providers felt that expanded hours during afterschool time periods would make appointments more readily accessible.
• Interventions to improve follow-up are needed.
  Both parents and providers felt that reminders for appointments are helpful. Suggested potential interventions include automated reminders via calls (robocalls), text messaging, email reminders, and phone calls.
• Providers viewed the revised oral health forms as favorable.
  The revised DC Oral Health (Dental Provider) Assessment Forms were viewed as favorable by providers, specifically, the removal of the tooth map, shortening the length to one page, and the box that allowed identification of problems requiring follow-up as urgent.
• Better communication between local oral health providers and schools is needed to improve collaboration.
  A mechanism in which school nurses can notify pediatricians of the need for further care, as well as report back to dentists about the receipt of follow-up care, is also needed to help reinforce the need for follow-up by parents.
• Oral health stakeholders should work across disciplines to improve care.
  Providers felt that, to promote good oral health, it is important for multiple stakeholders to come to the table to work together. Such stakeholders should include the Department of Health and the D.C. Public School system, as well as parents, providers, insurers, nutritionists, medical societies, and community organizations.
• Schools should incorporate oral health as part of the standard health curriculum.
  Although many school nurses offer limited school educational sessions that focus on oral health, most participants felt that this education should be expanded. Education should incorporate practical aspects of oral health care and principles of good nutrition.
• Education should focus on the entire family.
  Both parents and providers agreed that, while it is important to educate children about the importance of oral health, education should be targeted to the entire family. Events such as parent-teacher conferences and health fairs can serve as outlets in which parents can be educated. Educating parents to take a greater role in their children's oral health would lead to improvement in follow-up of children's oral health issues.
• Medical education should stress the incorporation of oral health care education as part of general pediatric practice.
  Focus group participants felt that medical school education should be expanded to teach medical students and residents how to provide basic oral health education. In addition, providers should be educated to encourage patients to engage in oral health prevention at all stages of the life continuum.
• Improved community-based and culturally appropriate outreach is needed.
  Community-based outreach focusing on oral health should include media campaigns that reach a broad audience. Participants noted that it would be important for such outreach to be culturally and linguistically appropriate to appeal to the diverse communities who use the DC Public School System.
• The concept of an oral health home should be considered.
  The concept of an oral health home, similar to a medical home, would promote continuity of care, with parents and children linked to a consistent provider, and could potentially improve perceptions of quality as well as increase rates of follow-up care.
• The District government should enforce completion of the DC Oral Health (Dental Provider) Assessment Form.
  Participants felt that the DC Oral Health (Dental Provider) Assessment Form should have more consistent enforcement by the District of Columbia Public Schools system and the Department of Health.
• More data are needed about oral health trends in the District.
  There are few data available about oral health care and access in the District. Such data can guide promotion efforts and target priority geographic areas.

Note

* The District of Columbia uses the school system to encourage oral health prevention by requiring parents to complete the DC Oral Health (Dental Provider) Assessment Form, which indicates that an oral health screening exam has been conducted within 150 days of starting the school year.

The research was completed by RAND Health, a division of the RAND Corporation, and by the District of Columbia Pediatric Oral Health Coalition.