Summary: A program in rural Oregon designed to reduce cavities in children provided expectant mothers in the state’s Medicaid program with education and dental care in hopes of preventing the transmission of cavity-causing bacteria from mother to child. The women who participated in the program typically had eight decayed, missing, or filled teeth. A study of the intervention found that 85 percent of 2-year-olds in the Klamath County sample were cavity-free, compared with 58.9 percent in the comparison county samples.
By Sarah Klein
Recognizing that cavity-causing bacteria can be passed from mothers to their children, the Klamath County Early Childhood Cavities Prevention Program launched a program in 2004 to find expectant mothers covered by the state’s Medicaid program and provide them with dental care and education.
As in other parts of rural Oregon, Klamath County’s water supply was not artificially fluoridated. The county’s median income was about 20 percent lower than the state’s median, and over half of expectant mothers there were covered by the Medicaid program when the initiative was launched. Back then, only 8.8 percent of low-income pregnant women in Oregon saw a dentist.
To improve those numbers, the Klamath County Health Department, with funding from the Robert Wood Johnson Foundation, created a community-wide collaborative that brought together dental care organizations that provided care to the Medicaid population on a capitated basis, safety-net providers including those serving the Klamath Tribes, and community agencies that had frequent contact with Medicaid beneficiaries. One of the most important collaborators proved to be the Women, Infants, and Children (WIC) program, a federally funded health and nutrition program that reached significant numbers of pregnant women and their children.
At the outset the program, experts in dentistry educated WIC and Head Start staff and local obstetricians, among others, about the importance of treating tooth decay and gum disease. They also stressed the importance of encouraging good hygiene, including regular brushing with fluoride toothpaste.
In order to enhance dental provider capacity, dental hygiene students from the Oregon Institute of Technology Dental Hygiene Clinic provided initial assessments and X-rays, as well as patient education. A program coordinator served as a liaison between patients, obstetricians, and dentists, which helped to improve communication among them and reduced no-show rates for dental appointments from 40 percent to 9 percent for patients that needed restorative, periodontal, and oral surgical services. The dental plans subsequently agreed to pay $38 per patient for dental hygienists’ services.
Another goal of the initiative was to create universal access to a dental home for all poor children before their first birthday. Staff and expectant mothers also were educated about how untreated oral health problems have been linked to low birth weight and preterm babies.
In its first two years, 503 women were identified as eligible for the program; of them, 421 were contacted, and 80.5 percent of that group received a counseling visit from a hygienist and 55.8 percent received dental care. The program found the typical woman had eight decayed, missing, or filled teeth. Ninety percent had untreated cavities, with an average of six. The majority had gingivitis.1
A separate evaluation found that 85 percent of 2-year-olds were cavity-free in the Klamath County sample, compared with 58.9 percent in the in the comparison county samples. The mean number of teeth with any decay in 2-year-old children was .75 in the test population compared with 1.6 in the comparison group.2
Medicaid enrollees in Oregon are four times more likely than commercially insured residents to visit an emergency department for dental problems.
Although Klamath County no longer has funding to continue this work, providing dental care to pregnant women and their children has become a central part of Oregon's Strategic Plan for Oral Health, which will be executed through the state’s Coordinated Care Organizations (CCOs).3 CCOs in Oregon oversee the provision of medical, dental, and behavioral health services for Medicaid patients, and are required to meet state-designated quality improvement and cost containment goals. All health care providers, including dentists, participating in the state's Medicaid program are required to join a CCO.
Dental health insurers such as Advantage Dental Plan also are testing whether financial incentives, such as rewarding dentists that increase screening rates for pregnant women, help, says R. Michael Shirtcliff, D.M.D., Advantage Dental’s president and CEO, who helped evaluate the Klamath County program. “We said we’ll set some money aside and if you increase the rate of screening by 10 percent, you will get some of the extra money. Every single one of them made it,” he says.
1 P. Milgrom, S. Ludwig, R. M. Shirtcliff et al., “Providing a Dental Home for Pregnant Women: A Program to Address Dental Care Access,” Journal of Public Health Dentistry, Summer 2008 68(3):170–73.
2 P. Milgrom, M. Sutherland, R. M. Shirtcliff et al., “Children’s Tooth Decay in a Public Health Program to Encourage Low-Income Pregnant Women to Utilize Dental Care,” BMC Public Health, published online Feb. 18, 2010.
3Strategic Plan for Oral Health in Oregon, 2014–2020, http://www.orohc.org/sites/default/files/Strategic%20Plan%20for%20Oral%20Health%20