The Dental Care System in California: An Analysis.

among children residing in El Monte, Calif., a low-income area 16 miles east of Los Angeles. In an attempt to decrease oral health disparities, Western University of Health Sciences, College of Dental Medicine established schoolbased oral health centers in El Monte and implemented a modified caries risk assessment protocol. Results showed a statistically significant decrease in caries risk following disease management interventions. Josih T. Hostetler, MSW,is the director of communityoutreach in the College ofDental Medicine at WesternUniversity of HealthSciences. He overseesthe administration andpartnerships of fourth-yearexternships and grantprojects. Conflict of Interest Disclosure: None reported. Yesha M. Patel, MPH,is a statistician in thedepartment of preventivemedicine at the Universityof Southern California, KeckSchool of Medicine. Conflict of Interest Disclosure: None reported.Jessica M. Vergel deDios, MS, is a 2017 DMDcandidate in the College ofDental Medicine at WesternUniversity of HealthSciences. Conflict of Interest Disclosure: None reported. Marc A. Bernardo, MPH,is a 2019 DMD candidatein the College of DentalMedicine at WesternUniversity of HealthSciences. Conflict of Interest Disclosure: None reported.Mary E. Foley,RDH, MPH, is theexecutive director of theMedicaid|Medicare|CHIPServices Dental Association(MSDA). She serves as aconsulting programevaluator for the Collegeof Dental Medicine atWestern University ofHealth Sciences’ First 5LA CDCP project. Conflict of Interest Disclosure: None reported. C DA J O U R N A L , V O L 4 4 , No 6 368 J U N E 2 01 6In an effort to align with therecommendations of the reports andeffectively address the growing lackof adequate preventive and treatmentservices for vulnerable underservedchildren living in El Monte, an urbanarea of East Los Angeles County, WesternUniversity of Health Sciences, Collegeof Dental Medicine (WesternU CDM)established a comprehensive dentalhome model, school-based oral healthcenters (SBOHCs). The goal of theWesternU CDM SBOHC model wasto assure that all children living in ElMonte received essential risk-based oraldisease preventive and treatment services.By increasing access to routine risk-based oral health care services throughthe SBOHCs, it was anticipated that adecrease in caries risk, caries experienceand ultimately a healthier child andstudent population would be observed.Using the free and reduced lunchprogram as a relative proxy for childrenwho were Medicaid eligible, it wasdetermined that 82.79 percent ofchildren ages 5 to 17 in the El MonteCity and El Monte Union High SchoolDistricts were eligible for the free andreduced lunch program.2 Based on thehighest rates of children enrolled inthe free and reduced lunch programby school, WesternU CDM selectedGidley Elementary School in 2012 asthe fi rst site for the SBOHC. In 2015,WesternU CDM moved the GidleyElementary SBOHC to the Jeff SeymourFamily Center (JSFC) to allow forthe expansion of dental services.As part of program planning,development, quality improvement andevaluation, WesternU CDM established aquality improvement (QI) project. Specificrisk-based care quality improvementstrategies were established. Thesepreliminary strategies focused on reducingcaries risk among children who receiveddental care at the Gidley ElementarySBOHC and the JSFC dental clinic.Project data from September 2013 throughSeptember 2015 revealed that earlychildhood, preschool and school-agedchildren who received routine preventiveand treatment services experienced asignificant reduction in caries risk.The focus of this article is to highlightWesternU CDM’s improvement strategiesand the outcomes associated with thedelivery of risk-based dental care tochildren attending the Gidley ElementarySBOHC and the JFSC dental clinic. Oral Health Disparities and DiseaseOutcomesIn 2012, Dye et al. published a NationalCenter for Health Statistics (NCHS) databrief summarizing the key findings fromthe 2009 to 2010 National Health andNutrition Examination Survey (NHANES)published by the U.S. Department ofHealth and Human Services. Dye reported“approximately one in four children ages3 to 5 and 6 to 9 living in poverty haduntreated dental caries.” Furthermore, Dyeindicated that oral health disparities existedbecause of poverty status, race and ethnicity.Specifically, children ages 3 to 5 and 6 to9 who came from lower-income familieshad significantly higher untreated cariesamong the Hispanic population. Moreover,Dye suggested that Hispanic children wereless likely to utilize available preventivedental care services when compared totheir African-American or Caucasiancounterparts. This fact further demonstratedthe increased disease risk among thisparticular ethnic minority group.3According to the U.S. CensusBureau, 24.3 percent of El Monte’spopulation lived at or below the povertylevel compared to 15.9 percent acrossCalifornia (2009-2013). This paralleledthe comparison of El Monte’s medianhousehold income of $39,535 (2009-2013) to California’s $61,094.4 With 28.4percent of El Monte’s 113,475 populationunder the age of 18 and 69 percentof its population of Hispanic/Latinodescent,4 the demographics in El Montesuggested a potential heightened risk oforal disease. Applying together the U.S.Census demographics and the key findingsfrom the NCHS data brief regarding theassociation among caries disease, povertyand race, families in El Monte might bemore vulnerable to dental disease.3,4Additionally, according to demographicsocioeconomic status (SES), it was furtherestimated that families in El Monte weremore likely to be eligible for Medicaiddental benefits (Denti-Cal). Based on the2011 Milgrom study on Medicaid utilizationand reimbursement, “larger proportions ofchildren in states with higher Medicaiddental reimbursement rates see a dentistmore often than children in states withlower reimbursement rates.” This impliedthat in states with lower reimbursementrates, fewer children received neededservices.5 In 2013, California ranked 49out of 50 states, with one of the lowestMedicaid fee-for-service pediatric dentalreimbursement schedules in the country.6Drawing from the Medicaid assessments,the NHANES report and demographics,El Monte was a niche in which an SBOHCmight provide essential services to reducethe risk of disease and improve the healthof the children in the community.r i s k b a s e d c a r e In 2013, California ranked49 out of 50 states, with oneof the lowest Medicaidfee-for-service pediatricdental reimbursementschedule in the country. C DA J O U R N A L , V O L 4 4 , No 6 J U N E 2 01 6 369Patient PopulationWith full support from the El MonteCity School District, an agreementfor dental services memorandum ofunderstanding (MOU) was establishedbetween the El Monte City School Districtand WesternU CDM. This MOU includedservices for children in the El Montecommunity and/or attending elementary,junior high or high school within the ElMonte City and El Monte Union HighSchool Districts during the time of themeasurement, September 2013 throughSeptember 2015. El Monte students fromall of these schools and any other childrenliving in the community were eligible toreceive care at the Gidley ElementarySBOHC or the JSFC dental clinic. Establishing a Caries Risk AssessmentProtocolAs part of the SBOHC standardoperating procedures to improve cariesrisk, WesternU CDM adopted theDentaQuest Institute Early ChildhoodCaries Collaborative (ECC) Phase IIIdefinitions of high, moderate and low cariesrisk. TABLE 1 describes the DentaQuestInstitute ECC Phase III definitions forhigh, moderate and low caries risk.7 Administrative and Clinical ProtocolThe WesternU CDM SBOHCsimplement standard operating proceduresas well as administrative protocols,consistent with the WesternU CDMmain campus dental center. Parents andcaretakers of children living near theSBOHCs receive marketing brochuresexplaining the dental services provided.Parents call the school or walk into theclinics to schedule appointments for theirchildren. The community health assistants,EMCSD school administrators or HeadStart programs schedule the patient’sfirst visit into the universal health carescheduler either by phone or in person.A comprehensive patient health careinformation packet is hand delivered tothe parents/caregivers either at the timeof scheduling or at the beginning of thepatient’s first oral examination. The patienthealth information packet (translatedin Spanish, Chinese and Vietnamese)includes a health history questionnaire,as well as general information and aparental consent form. The signedinformed parental consent is requiredfor all patients seen at these SBOHCs.Unlike some school-based programs whereinformed consents are disseminated tothe whole school population and onlya subset are returned, 100 percent ofthe WesternU CDM SBOHC parentalconsent forms are completed and returned.Parents/guardians are required to bepresent at the beginning and end of alldental examinations. During this time,clinic staff review the caries risk assessment(CRA) protocol, dietary evaluation,oral hygiene instruction and provideanticipatory guidance. As part of all oralhealth examinations, caries risk is assessedusing a WesternU CDM modified versionof the CRA protocol previously describedin the literature.8 In an effort to eliminatecaries-risk error by socioeconomic status(SES), WesternU CDM modified theCRA ages 0 to 5 and ages ≥6 protocol byeliminating the SES risk factor. The reasonfor this change is due to the potential ofover classification of high caries risk amongchildren enrolled at the Gidley ElementarySBOHC and JSFC dental clinic due totheir SES status (FIGURES 1 and 2). Themodified-CRA protocol helps to identifyindividual contributing conditions,general health conditions and clinicalconditions that contribute to dental cariesrisk in children ages 0 to 5 and ages ≥6.8All WesternU CDM dental studentsand faculty providers who participate in thecommunity-based dental education programundergo calibration exercises in the use ofthe modified-CRA protocol, motivationalinterviewing, and standardized languagefor use in parent/guardian counseling.Such calibration exercises address cariesrisk factors associated with diet, generalhealth and oral conditions such ascavitation, plaque and missing teeth, etc.In determining dental caries risk,WesternU CDM dental student providersand faculty assess the clinical findingsof cavitated and noncavitated clinicallesions. WesternU CDM incorporatesthe International Caries Detectionand Assessment System (ICDAS)into the curriculum. This system offersmethodology for documenting cariesprogression beginning from soundenamel to the development of largeactive decay. Below are the ICDASclassification codes and associateddefinitions as defined by Jenson et al.:■ 0 = Sound tooth surface withno evidence of caries afterfive seconds of air-drying.■ 1 = First visual change in enamelsurface with opacity or discoloration(white/brown) visible at theentrance to a pit or fissure afterfive seconds of air-drying.TABLE 1 DentaQuest Institute ECC Phase III Definitions7 HighA “patient currently has clinical caries (demineralization or cavitation) or radiographic caries, or has a history of caries within the past six months.” Moderate A “patient does not have clinical or radiographic caries but has dietary or oral hygiene habits that increase the caries risk. Also, a previously ‘high-risk’ patient who has demonstrated improved diet, protective factors and/or presence of remineralization and absence of new demineralization and cavitation for the past six months.” LowA “patient does not have clinical or radiographic caries and has good dietary habits, oral hygiene and protective factors or a previously ‘high-risk’ or ‘moderate-risk’ patient who has demonstrated improved diet, protective factors and/or presence of remineralization and absence of new demineralization and cavitation for the past 12 months.” C DA J O U R N A L , V O L 4 4 , No 6 370 J U N E 2 01 6WesternU CDM — AxiUm Electronically Modified-Caries Risk Assessment Form 0–5 Years of Age Contributing conditions1. Are you exposed to fluoride (through drinking water, toothpaste, professional applications, supplements, etc.)?a. Yes (low)b. No (moderate) 2. Frequency of sugary or starchy foods or drinks (including juice, carbonated or noncarbonated soft drinks, energy drinks, medicinal syrups, etc.)a. Primarily at mealtimes (low)b. Frequently between meals (moderate)c. Bottle or sippy cup with anything but water (high) 3. †Caries experience of mother, caregiver and/or other siblingsa. No carious lesions in last 24 months (low)b. Carious lesions last seven to 23 months (moderate)c. Carious lesions in the last six months (high) 4. Dental home: Established patient of record, receiving regular dental care in dental office.a. Yes (low)b. No (moderate) General health conditions1. Special health care needs (including developmental, physical, medical or mental disabilities that prevent or limit adequate oral care)?a. No (low)b. Yes (high) Clinical conditions1. ‡Visual or radiographically evident cavitated lesionsa. No active cavitated lesions in one year (low)b. No active cavitated lesions or restorations in last six months (moderate)c. Presence of lesions/restorations in last six months (high) 2. ‡Non-cavitated ACTIVE carious lesions (e.g. active brown/white spot lesions)a. No incipient active lesions in one year (low)b. No incipient active lesions in last six months (moderate)c. Presence of incipient noncavitated active lesions in last six months (high) 3. Teeth missing due to cariesa. No (low)b. Yes (high) 4. Visible plaquea. Yes (moderate)b. No (low) 5. Dental/orthodontic appliances (fixed or removable)a. No (low)b. Yes (moderate) 6. Salivary flowa. Visually adequate (low)b. Visually inadequate (high) TOTAL (auto-calculates electronically): High, moderate or low caries risk assessment.†If the child showed improvement after six months with no change in the parent’s caries experience, the child was noted as “moderate” risk.‡DentaQuest ECC Phase III definition of low, moderate and high caries risk assessment associated with cavitated or noncavitated lesions. FIGURE 1.r i s k b a s e d c a r e