HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Improving the Oral Health of CSHCN through the lifespan

EDWARD STERLING: In this title slide, I put Lifespan in quotes and there’s a reason for that. Because I think, I’m not really sure, but I think the lifespan goes beyond 22 or 44, last time I checked, at least mine has.

And that’s a major part of the problem when we start talking about the issue of oral health, the issue of a lot of different aspects of health care. Particularly as it relates to Children and Adults with Special Health Care Needs.

And I realize Intelligent Design is one of the issues being bandied about nationally, but it’s hard to evolutionary to argue the point that these are also obviously the offspring of red-eyed drosophila. But these are four of my five grandsons. The fifth one isn’t here because by the time this picture was taken, he wasn’t around yet. The curly haired one in the middle there is the reason I’m losing my voice quickly, because he was in a soccer tournament this weekend, which came down to the last five seconds of the final game when they scored a goal and won the tournament. It was a busy weekend.

In talking about dental care for children and adults with disabilities, and I am going to talk about adults. Because that’s a very significant part of it and if anything, the issues get magnified. If I were doing this talk 30 plus years ago, when I first got started with this stuff, when I was in Oregon, and even when I came to Ohio in 1971, I would have said the biggest factor was one of fear. Fear on the part of the professional, fear on the part of the dental professional, because you had little to no exposure, little to no experience children or adults with special health care needs, or people with disabilities. Today, the issue is more one of economics, not even really economics. It’s not necessarily the poor reimbursement rate from Medicaid. It goes deeper than that and it’s more difficult to deal with. There’s a basic animus that exists and I guess I’ll limit my comments of that to Ohio, because that’s one I’m most familiar with. But unfortunately, I don’t think it’s limited to Ohio. It’s basically an adversarial relationship between Medicaid and the private practicing dentists. Neither one trusts the other, put it plain and simple. It’s only taken the better part of 40 years for Medicaid to standardize, to use the standard dental codes. So you’re asking practioners to take 35-40 cents on the dollar reimbursement, use special codes, which means, everyone’s computerized today, so you have to have a different program in order to do the billing. And on top of it, not even talking about the limitations, but just the, all the difficulties, all the barriers, that exist between the dentist and the Medicaid system. I’ve maintained for a long time that Medicaid will never be a responsive system until the state employees that operate it that that is their HMO, their PPO. Then they’ll have a vested interest. And then they’ll get off their butts and do something.

But everyone thinks they’re doing someone a favor. Whether it’s that third Thursday of the odd-numbered months when the moon is full from 12-1, or whatever. But everyone thinks they’re doing someone a favor and that’s unfortunate.

In dentistry, we talk about a dental home as well. As well as the medical home, and it’s really an offshoot of that. And the official American Academy of Pediatric Dentistry notion of the dental home is that the official first dental appointment should occur by one year of age or six months after the first tooth erupts.

Now, what are we really after? Are we really looking to see child? The answer is no. We’re really wanting to deal with those parents; we’re really wanting to talk to them to begin to establish things like anticipatory guidance. What can you expect next? Begin to establish some oral hygiene practices. Eliminate some poor practices, which might include taking a bottle to bed, or having a child fall asleep at the breast. The packaging is different, but the problem is the same. Those children can end up with a lot of early dental decay. And also to alleviate concerns and answer questions. So that’s really what the intent of that first visit is about and why we talk about it at age one, or six months after the first tooth comes in. But, big but, the minority, in fact, of pediatric dentists, don’t really agree with this concept. And if you as a parent would call most any dental office and say, “I have a one year old child, and I’ve read where they should be seen at this point for an initial dental examination, evaluation, assessment,” whatever we want to call it. Odds are you’ll be told, “Why don’t you call me back in about two years”?

However, and it’s a big however, a big but, if that request came from another professional, if that request came from a physician, there’s no dentist that’s going to turn away a physician. There’s no dentist who’s going to turn down a physician. That dentist will see that child. At the same time, it’s also critical to realize that very few family practioners, dental family practioners have any experience whatsoever with very young children. And to add to it with some of the materials that have been presented already, the most recent data that’s come out of MMWR in the Hanes data is that actually there is an increase, there’s some argument as to how great the increase is. But there’s actually an increase in what we call early childhood carries. Early childhood dental decay, and that’s children age 2-5.

What about parent-professional relationship? What do we need? Well, what we need, first of all, is for people to make appointments and keep them. Ask questions, very important part of it. Another significant piece that I find is don’t make promises that I can’t keep. And that certainly happens. And if you’re unsure of a child, ask a question of a parent, or another professional, if you’re not sure of the answer, defer it. Defer it to that dentist; let the dentist answer the question. And also to let that pediatric dentist and my obvious bias would be toward pediatric dentists, but they’re not available everywhere, would be to let that dentist, or that pediatric dentist know the things that your child likes, the things your child doesn’t like. Some children are orally defensive and even then, I don’t really buy that very much. There are a few, but not nearly as many as are professed to be. Most of the time, it’s the way people approach the child.

So what can we do to prevent dental disasters? That was one of the things that Jay had asked me to talk about. And one of the very basic ones would be early referral. I don’t need physicians necessarily to be looking into children’s mouths. What I need them to be doing is picking up the phone. That will go a lot further. There’s, Toni, I think it was Toni, was talking about putting together some materials for physicians and other primary care providers related to oral health. The American Academy of Pediatrics has put out a very good one, a CD/DVD that will walk you through it. The only thing it doesn’t seem to show is picking up the phone and that would go a lot further. Because I’m not looking to that person to be a diagnostician. Because when I was in Oregon, because I was the new kid on the block, I had the dubious honor of giving the lectures to the medical students on dental health and early care and things of that sort. This is circa 1969 and this was in Oregon, it was Friday afternoon at 3 o’clock during ski season. So I can vouch for the fact that there is, that there are a whole group of physicians and if they know anything about oral health and dental health, they learned it as on the job training and not from me, because they weren’t there.

So what can we do? Early referral would be my number one thing. Communication between and among providers, and I would add, communication between and among agencies would be nice as well. So that MCH talks to ADD and talks to the adult providers and that they can find some reasonable common ground. We have things like fluoride supplements, and fluoride varnishes that can be used to help reduce decay, arrest decay, do things of this sort. We have sealants, which are primarily used with permanent teeth, but are used occasionally with baby teeth, primary teeth as well. The issue of silver fillings versus plastic fillings is one, about the only time I run into it, it most frequently is with parents of children with autism. There’s a significant contingent of parents with--I find the parents of autism as being the people who are seeking.

Seeking answers, seeking solutions, probably more than any other group within this whole group that we call disabled. And they’ve latched on, must like the measles, mumps, rubella thing, to the notion of the mercury in silver fillings and how this, will cause or has caused their child’s autism and there is absolutely no evidence for any of that. But certainly when we can, we’ll use plastic fillings or composite fillings. But it isn’t necessarily the answer for all situations. And then regular check ups and regular reassessment of risk. Is this is a child that needs to be seen more frequently? Is it a child who can be seen less frequently? There are far more resources for children than there are for adults. The situation for adults, actually overall has improved from when I first started in this field. But that’s a relative statement and you have, at each seat I put one of the folders regarding the Grottoes of North America and I’ll come back to that. But recent Medicaid cuts will reduce, or already have reduced, or eliminated adult dental services in many states. You can’t avoid talking about Medicaid and adult care, if we’re really talking about life span and if we’re really talking about continuity of services.

In Ohio, dental service’s total dental budget is less than one percent of the entire Medicaid budget. Yet, in Ohio, adult dental services have been slated for elimination three times in the last two years, most recently, in the last four months. Our governor, Governor Taft, who is one of the few people who has a lower approval rating than the sitting president at this time, stated that when he was talking about eliminating adult dental services, and this was for anyone covered under Medicaid, we’re not even talking about people with disabilities, but the vast majority of those people as adults are covered under Medicaid, so we have to talk about it. But Governor Taft’s response when he was talking about eliminating dental services was that volunteerism would take care of the situation, would solve the problem. Now, this was a system that was not adequate to begin with. So volunteerism now was going to take its place. And he wonders why he’s never been invited to a MENSA meeting.

To the credit of the Ohio Dental Association and many other people, adult dental services in Ohio has been maintained, and has been retained with some new limitations in which I’ll go into, it hasn’t been officially approved, it’s going to happen, and it will be maintained with new limitations beginning January 1st. Reality is that in Ohio, that there were five programs that were up for elimination in the last two years. Three of the five have been eliminated. The Big Kahuna in the Medicaid budget in Ohio were the nursing homes. And when I actually got numbers in terms of what monies are allocated to these various programs, when I discovered in doing a little bit of math, because the nursing homes had the wonderful built in seven percent increase in their reimbursement. If that reimbursement were decreased from seven percent to four percent, a three percent change, all five of those programs that were slated for elimination, not only could have been maintained, but could have had an increase in their budget. Gives you an idea of the relative size of the budgets.

In the proposed program in Ohio that will take over January 1st, children and adult services reimbursement has been reduced 2 percent with no further reductions on the child’s side. With the adult side, for prosthetics, for replacement of missing teeth, that’s been reduced another five percent. Again, given the fact that the average reimbursement is about 35 to 40 cents on the dollar. And now to substitute for that, there is a three-dollar co-pay for adults per visit. And they’ve also reduced the regular checkups from six months to once a year. And this is a population, again, as adults, that if anything, the majority of patients that we see are people that really need to be seen more than once every six months, let along once a year.

The issues are there, the problems are there. When you start talking adult care. Periodontal disease is far more difficult to manage. One of the great advantages that I have as a dentist when it comes to things like this, is when you come in with a cavity, you leave with a filling, you no longer have a cavity. You come in with periodontal disease, with gum disease, no matter what I do, when you leave, you still have gum disease. And it’s what happens between appointments and what goes on at home or in the group home or wherever that will determine how successful or unsuccessful I am in at least, if not stopping, if not improving, the disease process.

There are guardianship issues as well that we don’t really have time to get into, but when you start talking adults, you starting getting into guardianship issues. And then there’s a Special Olympics Special Smiles program which I’ll come back to if Jay doesn’t give me the hook.

The Grottoes of North America, the Grottoes are a mason organization, or a mason related organization and their humanitarian foundation has a particular interest in dental care for children with disabilities, and in this case, particular disabilities, mainly cerebral palsy, muscular dystrophy, mental retardation, those undergoing organ transplant. It’s essentially gap coverage. It doesn’t augment. It’s not there to supplement whatever Medicaid doesn’t pay. Among other things, that would be against the law. But it is there to fill in the blanks, and it will even cover those children who do require treatment under general anesthesia that it would even pick up the hospital costs and those are, the fees, the reimbursement rates, are very close to what we call UCR, Usually customary and reasonable fees. What they use are the national statistics on what the fees are and then go, to the 85 th or 90 th percentile of that.

The Special Smiles, Special Olympics Special Smiles program that’s out there, that I’ve been involved with, is part of the healthy athletes program. And it is not an oral health, it is an oral health assessment, it is not treatment. It may include referrals for care. And usually, the people involved with that aren’t familiar with resources around that particular state or certainly that particular area. But the primary intent is to collect consistent data. Whether this screening is going on in Maine, California, Hawaii, or Slovakia, that the same kind of information is being gathered, so that we have something that’s comparable that we can look at and see what is the status of things. And it’s also been used to try to influence national and state policies. But even more significant than that is the opportunity that it presents for community involvement. Whether it’s practitioners in the community, whether it’s students, whether it’s middle school and high school students, to get them involved with this whole issue and this whole problem. And this was just a slide from one that was held in Ohio, and one of our dental hygiene students who’s doing an oral health assessment. And what I do quote, because it’s the number six of the six critical indicators of progress that been put out by the Maternal and Child Health Bureau, is all Youth with Special Health Care Needs will receive the services necessary to make appropriate transitions to adult health care work and independence. And I think that sixth one is one that’s kind of flying off the ground there at the end. But hopefully, we can get them grounded and we can deal with some of these issues. At that point, I’m going to stop, because I have a feeling that Jay is ready for me, too.