ANNUAL MEDICAL AUDIT:
Children’s Oral Health Visits
Performance Improvement Project Baseline Measurement
Prepared by the Division of Health Care Management
July 2004
Anthony D. Rodgers
Director, AHCCCS

Arizona Health Care Cost Containment System (AHCCCS)

ANNUAL MEDICAL AUDIT:
Children’s Oral Health Visits
Performance Improvement Project Baseline Measurement

TABLE OF CONTENTS

EXECUTIVE SUMMARY .………………………………….................................................. i
I. INTRODUCTION
Background ………………………………………………………........................................... 1
AHCCCS and Healthy People Goals ……………………………………………………….... 3
Purpose ……………………………………………………….................................................. 3
II. QUALITY INDICATORS ...................…………..………....………….……………....… 4
III. METHODOLOGY
Population …......................………………………...................………………….………....... 4
Measurement Period …......................………………………………………….……….......... 4
Data Collection …......................…………………………………………................……....... 4
Data Validation …......................…………………………………………................……....... 4
IV. RESULTS
Baseline Measurement ..................................………...……….…………...…………………. 5
Data Validation ..................................………………………….…………...……..…………. 6
V. ANALYSIS
Overall Results .......................................…………….…….…………….....…….…………... 6
Comparisons with Other Benchmarks ...................................................................................... 7
Preventive Care vs. Treatment .................................................................................................. 7
VI. CONCLUSIONS AND RECOMMENDATIONS
Overall Performance ................................................................................................................. 7
Children with Special Health Care Needs ................................................................................. 8
Interventions to Improve Quality .............................................................................................. 8
Performance Improvement Goals ........................................................................................... 10
VII. REFERENCES ................................................................................................................ 10
VIII. TABLES AND FIGURES .............................................................................................. 24
IX. APPENDIX ...................................................................................................................... 28

Arizona Health Care Cost Containment System (AHCCCS)

ANNUAL MEDICAL AUDIT:
Children’s Oral Health Visits
Performance Improvement Project Baseline Measurement

EXECUTIVE SUMMARY
Background
Tooth decay is one of the most common infectious diseases among children today.1
Nationally, children lose more than 51 million school hours each year due to dental disease or
dental visits.2
According to the Arizona Office of Oral Health, at 2 years of age, 5 percent of all Arizona
children have some tooth decay. By the time they reach 8 years old, 60 percent of all Arizona
children will have tooth decay. This compares with a national rate of 52 percent of all children
8 years old who have tooth decay.3
A number of studies point to disproportionately low use of dental services among some racial
or ethnic groups and low-income people, as well as high rates of dental disease relative to the
rest of the population. 1,2,4-9 Increased access to oral health services, such as the application of
topical fluorides and dental sealants, as well as patient/caregiver education, are key to
reducing the rate of tooth decay and other oral diseases among children.1,4
AHCCCS and Healthy People Goals
AHCCCS has established long-range goals, or benchmarks, for Contractors to achieve in
ensuring annual dental visits among children and adolescents, based on the objective set by
the United States Department of Health and Human Services (DHHS) in Healthy People
2010. The Healthy People 2010 objective is to increase the proportion of children and adults
who use the oral health care system each year (i.e., have an annual dental visit) to 56 percent.
Likewise, AHCCCS has established a benchmark of 56 percent for children’s annual dental
visits. This benchmark applies to acute-care Contractors and the Department of Economic
Security’s two programs that serve AHCCCS-eligible children, the Comprehensive Medical
and Dental Program (CMDP) and the Division of Developmental Disabilities (DDD).
Purpose
The purpose of the Oral Health Performance Improvement Project (PIP) is to increase the rate
of annual dental visits among AHCCCS members 3 through 20 years old, in order to make
more progress toward AHCCCS and national Healthy People 2010 goals. As a first step,
AHCCCS established a baseline measure of annual dental visits overall and by Contractor
from which to measure improvement. This baseline measure also serves as the AHCCCS
Annual Medical Audit.

i

The project will specifically focus on children who are 3 through 8 years old for the acutecare, CMDP, KidsCare (the state Children’s Health Insurance Program or SCHIP) and DDD
populations. As previously noted, literature suggests that the rate of tooth decay increases
dramatically between the ages of 3 through 8; thus, this appears to be a critical time in a
child’s life to ensure that he or she receives regular preventive dental care. All members 3
through 20 years who are enrolled in the Arizona Long Term Care System (ALTCS) are
included in the measurement, in order to have an adequate number from which to draw valid
conclusions for that population.
Methodology
Using methodology developed by the National Committee for Quality Assurance (NCQA) for
the Health Plan Employer Data and Information Set (HEDIS®), AHCCCS measured annual
dental visits among members ages 3 through 8 (ages 3 through 20 years if enrolled in
ALTCS) who were continuously enrolled during the measurement period. Data for the
baseline measurement were collected from AHCCCS administrative data (i.e., records of
claims paid by Contractors known as encounters). The measurement period was the contract
year from October 1, 2001, through September 30, 2002.
As part of this project, AHCCCS also validated dental visits found in AHCCCS
administrative data against members’ dental or medical charts. A validation sample was
selected from the baseline numerator, stratified by program (Medicaid acute-care, KidsCare,
etc.) and by Contractor (because of the relatively small ALTCS population, all children in the
baseline numerator were included in the validation sample). Sample selection was calculated
to provide a 95-percent confidence level and a 5-percent confidence interval. After receiving
their samples, Contractors submitted to AHCCCS documentation of dental visits from
members’ records.
Overall Findings
The total number of members selected for the baseline measurement, including all programs,
was 76,702. Of these members, 39,423 members (51.4 percent) had at least one encounter for
a dental visit during the measurement period.
Rates by type of program were as follows:
For children enrolled with acute-care Contractors under Medicaid, the baseline rate was
51.3 percent.
•
For children enrolled with acute-care Contractors under KidsCare, the baseline rate was
59.5 percent.
•
For children enrolled with DES/CMDP, the baseline rate was 61.4 percent.
•
For children enrolled with DES/DDD, the baseline rate was 30.9 percent.
•
For children enrolled with ALTCS Contractors, the baseline rate was 24.3 percent.
•

Data Validation
Encounters for 97.2 percent of the validation sample were validated against dental or medical
charts. For the remaining 2.8 percent, encounters could not be validated because no dental
service within the measurement period was found in members’ records or the charts could not
be obtained by Contractors.

ii

Analysis and Conclusions
Data analysis using Pearson’s Chi-square revealed that children enrolled in AHCCCS under
CMDP or KidsCare were more likely to have an annual dental visit than children enrolled
under Medicaid, DDD or ALTCS (p<.001 for all comparisons). Children in Maricopa County
were more likely to have an annual dental visit than those living in Pima County or the rural
counties combined (p<.001).
AHCCCS also calculated the percent of children who had only preventive dental services
during the year, compared with treatment only or both preventive and treatment services. Of
all children with a dental visit, 40.3 percent received preventive services only, 2.5 percent had
treatment services only, and 57.2 percent had both preventive and treatment services.
Overall, the baseline study for this project indicates that more than half of AHCCCS members
had at least one dental visit within the measurement year. Rates of annual dental visits for
children enrolled under KidsCare and DES/CMDP exceeded the Healthy People 2010
objective of 56 percent.
However, there is room for improvement in ensuring children have access to dental services
and better oral health. AHCCCS already has provided baseline data from this study to all
Contractors, who further analyzed their data and identified interventions to improve rates of
annual dental visits. In the contract year ending September 30, 2004, Contractors are focusing
interventions to improve the use of dental services and oral health among children enrolled in
their plans.
To assist AHCCCS Contractors in improving or enhancing those interventions, the AHCCCS
Clinical Quality Management Unit synthesized research and literature on oral health
initiatives from a variety of sources. The Chronic Care Model, developed by Wagner, et al, of
the MacColl Institute for Healthcare Innovation at Group Health Cooperative, was adapted for
use in organizing various interventions for improving oral health. This model identifies
essential elements of a health care system that encourage high-quality care. By ensuring that
each of these elements is adequately addressed, health care organizations can expect healthier
patients, more satisfied providers, and cost savings.10
Through this Performance Improvement Project, all Contractors are expected to increase their
rates of annual dental visits. Contractors should strive to meet or exceed the Healthy People
2010 goal or the AHCCCS overall average for their respective program (i.e., Medicaid Acutecare, KidsCare, etc.). A Contractor will show improvement when:
•
It meets or exceeds the next highest threshold (e.g., the AHCCCS overall average) above
its baseline rate (the increase must be statistically significant),
•
It “narrows the gap” between its baseline rate and the next highest threshold by at least 10
percent (the increase must be statistically significant), or
•
It maintains a rate above the highest threshold, which is the Healthy People 2010 goal, if
its baseline rate already exceeds that level.
AHCCCS will work with Contractors, especially those with the lowest rates, to assist them in
making progress toward these goals for performance improvement.

iii

References
1

U.S. Department of Health and Human Services. Oral health in America: A report of the surgeon general.
Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute
of Dental and Craniofacial Research, September 2000
2
U.S. Department of Health and Human Services. National call to action to promote oral health. Rockville, MD:
U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National
Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, Spring 2003. Available at
http://www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.htm
3
Arizona Department of Health Services. Arizona oral health update. Phoenix, AZ: Arizona Department of
Health Services, Office of Oral Health, May 2000
4
U.S. Department of Health and Human Services. Oral health 2000: facts and figures. Rockville, MD: U.S.
Department of Health and Human Services, Office of Public Health and Science, Office of the Surgeon General,
May 2000
5
U. S. Department of Health and Human Services. Healthy People 2010: Objectives for improving health, Vol.
II. U. S. Department of Health and Human Services, Office of Public Health and Science, November 2000.
Available at http://www.healthypeople.gov/document/tableofcontents.htm#Volume2
6
General Accounting Office. Oral health: Factors contributing to low use of dental services by low-income
populations. U.S. General Accounting Office, Report to Congressional Requesters. HEHS-00-149, September
2000. Available at http://www.gao.gov/new.items/he00149.pdf
7
General Accounting Office, Medicaid: stronger efforts needed to ensure children’s access to health screening
services. U.S. General Accounting Office, Report to Congressional Requesters. GAO-01-749, July 2001.
Available at
http://frwebgate.access.gpo.gov/cgibin/useftp.cgi?IPaddress=162.140.64.21&filename=d01749.pdf&directory=/
diskb/wais/data/gao
8
State of New York Department of Health. New York state managed care plan performance 2001. State of New
York Department of Health, April 2002
9
General Accounting Office. Oral health: Dental disease is a chronic problem among low income populations.
U.S. General Accounting Office, Report to Congressional Requesters. HEHS-00-072, April 2000. Available at
http://www.gao.gov/new.items/he00072.pdf
10
Improving Chronic Illness Care. Overview of the Chronic Care Model. Available at
http://improvingchroniccare.org/change/model/components.html

iv

Arizona Health Care Cost Containment System (AHCCCS)

ANNUAL MEDICAL AUDIT:
Children’s Oral Health Visits
Performance Improvement Project Baseline Measurement

I. INTRODUCTION
Background
Oral health is inseparable from overall health status.1,2 Oral diseases are progressive and
cumulative and become more complex over time. They can affect our ability to eat, the foods
we choose, how we look, and the way we communicate. These diseases can affect economic
productivity and compromise our ability to work at home, at school, or on the job.3
Most oral diseases are preventable. For example, cavities (known as dental caries) are
primarily caused by a bacterial infection that is transmitted from mother or other caregiver to
child. Thus, reducing the bacterial infection in the mother or other caregiver and preventing
its transmission can significantly improve the oral health of young children.4,5
Yet, tooth decay is one of the most common infectious diseases among children today.1 It is
five times more common than asthma in children 5 to 17 years old. Nationally, children lose
more than 51 million school hours each year due to dental disease or dental visits.3
The Arizona Department of Health Services (ADHS) has reported that 31 percent of all
children younger than 18 in the state have never had a dental check up. At 2 years of age, 5
percent of all Arizona children have some tooth decay, according to the Arizona Office of
Oral Health. By the time they reach 8 years old, 60 percent of all Arizona children will have
tooth decay. This compares with a national rate of 52 percent of all children 8 years old.2
A number of national and state studies point to disproportionately low use of dental services
among some racial or ethnic groups and low-income people, as well as high rates of dental
disease relative to the rest of the population. 1,2,6-11 According to the U.S. Department of
Health and Human Services (DHHS), Hispanic and black children ages 6 to 8 years have
higher rates of untreated dental decay than non-Hispanic white children.6 Only 20 percent of
children and adolescents in families with incomes at or below 200 percent of the federal
poverty level received any dental service in 1996. Among all children age 2 to 17 years, 48
percent had a dental service during that year.1
Increased access to oral health services, such as the application of topical fluorides and dental
sealants, as well as parent/caregiver education in preventing the transmission of bacteria that
cause caries, tooth brushing and good diet, are keys to reducing the rate of tooth decay and
other oral diseases among children.1,6

1

A growing number of research projects,
conferences, and publications nationally
emphasize the need for greater attention to
improving children’s dental care and oral
health.

The Burden of Oral Diseases
and Disorders Among Children
Oral diseases are progressive and
cumulative and become more complex
over time. A child’s ability to learn and
articulate can be affected by problems of
the teeth and gums. The following are
some key facts about oral health and
children:
•
Over 50 percent of 5- to 9-year-old
children have at least one cavity or filling,
and that proportion increases to 78
percent among 17-year-olds.
•
There are striking disparities in dental
disease by income. Poor children suffer
twice as much caries (tooth decay) as
their more affluent peers, and their
disease is more likely to be untreated.
These differences continue into
adolescence.
•
Tobacco-related oral lesions are
prevalent in adolescents who currently
use smokeless (spit) tobacco.
•
Professional care is necessary for
maintaining oral health, yet 25 percent of
poor children have not seen a dentist
before entering kindergarten.
•
Nationally, fewer than one in five
Medicaid-covered children received a
single dental visit in a recent year-long
study period.
•
The social impact of oral diseases in
children is substantial. Poor children suffer
nearly 12 times more restricted-activity
days than children from higher-income
families. Pain and suffering due to
untreated diseases can lead to problems
in eating, speaking, and learning.

Healthy People 2010, published by DHHS
in November 2000, stated that, “to promote
oral health and prevent oral diseases, oral
health literacy among all groups is
necessary. In addition, oral health services
— preventive and restorative — should be
available, accessible, and acceptable to all
persons in the United States. In areas
where different languages, culture, and
health care beliefs would otherwise be
barriers to care, a cadre of clinically and
culturally competent providers must be
available to provide care.”7
In 2003, the Office of the Surgeon General
published a “Framework for Action” to
improve oral health among all Americans.
This plan is aimed at broadening public
understanding of the importance of oral
health and its relevance to general health
and well-being, as well as ensuring that
existing and future preventive, diagnostic,
and treatment measures for oral diseases
are made available to all Americans. The
principal components of the plan are
included in this report as Appendix A.
Building on this momentum, the
Association of State and Territorial Health
Officials researched and detailed five
states’ initiatives to improve children’s
access to oral health services. The
initiatives involve collaborations with
Medicaid, educational institutions and
private partners, and include addressing
workforce issues and providing oral health
education to communities.12

Source: U.S. Department of Health and
Human Services. Oral Health in America: A
Report of the Surgeon General, 2000.

2

Using methodology developed by the National Committee for Quality Assurance (NCQA) for
the Health Plan Employer Data and Information Set (HEDIS®), AHCCCS collects and reports
a rate of annual dental visits for children and adolescents enrolled with acute-care health plans
(Contractors). In contract year ending (CYE) 2002, approximately 48 percent of members 3
through 20 years old who were eligible under Medicaid and continuously enrolled with an
acute-care Contractor during the measurement period had at least one visit to a dentist. This
compares with an average of approximately 37 percent for annual dental visits for all
Medicaid health plans reporting their rates to NCQA in 2002. The rate of annual dental visits
among members enrolled in AHCCCS under KidsCare (the State Children’s Health Insurance
Program or SCHIP) was approximately 57 percent in CYE 2002.
AHCCCS and Healthy People Goals
AHCCCS has established long-range goals, or benchmarks, for Contractors to achieve in
ensuring annual dental visits among children and adolescents, based on the objective set by
the United States Department of Health and Human Services (DHHS) in Healthy People
2010. The Healthy People 2010 objective is to increase the proportion of children and adults
who use the oral health care system each year (i.e., have an annual dental visit) to 56 percent.
Likewise, AHCCCS has established a benchmark of 56 percent for children’s annual dental
visits. This benchmark applies to acute-care Contractors and the Department of Economic
Security’s two programs that serve AHCCCS-eligible children, the Comprehensive Medical
and Dental Program (CMDP) and the Division of Developmental Disabilities (DDD).
Purpose
The purpose of the Oral Health Performance Improvement Project (PIP) is to increase the rate
of annual dental visits among AHCCCS members 3 through 20 years old, in order to make
more progress toward the AHCCCS benchmark and national “Healthy People 2010” goal. As
a first step, AHCCCS established a baseline measure of annual dental visits overall and by
Contractor from which to measure improvement. This baseline measure also serves as the
AHCCCS Annual Medical Audit.
While all AHCCCS members up to 21 years of age should have an annual dental visit, the
project specifically focuses on those who are 3 through 8 years old for the acute-care, CMDP,
KidsCare and DDD populations. As previously noted, literature suggests that the rate of tooth
decay increases dramatically between the ages of 3 through 8; thus, this appears to be a
critical time in a child’s life to ensure that he or she receives regular preventive dental care.
All members 3 through 20 years who were enrolled in the Arizona Long Term Care System
(ALTCS) are included in the measurement, in order to have an adequate number from which
to draw valid conclusions for that population.
Because of differences between program populations, each was analyzed separately. For
example, children enrolled in ALTCS and DDD have special health care needs and may
experience unique challenges or barriers in accessing dental care.

3

II. QUALITY INDICATORS
1. The number of members ages 3 through 8 years who were enrolled with acute-care
Contractors under Medicaid (Title XIX) and had at least one dental visit for preventive or
treatment purposes during the measurement period.
2. The number of members ages 3 through 8 years who were enrolled with CMDP under
Medicaid and had at least one dental visit for preventive or treatment purposes during the
measurement period.
3. The number of members ages 3 through 8 years who were enrolled with acute-care
Contractors under KidsCare (Title XXI) and had at least one dental visit for preventive or
treatment purposes during the measurement period.
4. The number of members ages 3 through 8 years who were enrolled with DDD and had at
least one dental visit for preventive or treatment purposes during the measurement period.
5. The number of members ages 3 through 20 years who were enrolled with ALTCS
Contractors as physically disabled or ventilator-dependent and had at least one dental visit
for preventive or treatment purposes during the measurement period.
III. METHODOLOGY
Population
The study population consisted of all members who met the following criteria:
•
For the acute-care, CMDP, KidsCare and DDD populations, children ages 3 through 8
who were continuously enrolled during the measurement period; or for the ALTCS
population, members ages 3 through 20 who were continuously enrolled during the
measurement period,
•
who were enrolled as of September 30, 2002, and
•
who had no more than one break in enrollment, not exceeding 31 days.
Measurement Period
The measurement period was October 1, 2001, through September 30, 2002.
Data Collection
All data were collected from AHCCCS administrative data. Recipient enrollment data were
used to identify members who met the denominator criteria, and encounter data (claims paid
by Contractors known as encounters) were used to identify members who received dental
services.
Data Validation
As part of this project, AHCCCS also validated dental visits found in AHCCCS
administrative data against members’ dental or medical charts, using a double-blind process.
A validation sample was selected from the baseline numerator, stratified by program
(Medicaid acute-care, KidsCare, etc.) and by Contractor (because of the relatively small
ALTCS population, all children in the baseline numerator were included in the validation
sample). Sample selection was calculated to provide a 95-percent confidence level and a 5percent confidence interval.

4

Contractors verified from dental service records or medical charts that each member in the
sample received at least one dental service during the measurement period. Contractors were
provided up to five different dates of service for each member, but needed to verify only one
date of service during the measurement period. Contractors provided to AHCCCS a copy of
the pertinent section of the dental or medical chart for validation of the encounter. If a
Contractor could not locate a record for any of the dates of service provided for a member in
the sample, the Contractor was asked to provide documentation of any date of dental service
within the measurement period by providing a copy of the pertinent section of the dental or
medical chart. AHCCCS randomly verified that copies of the pertinent sections of medical or
dental services records provided by Contractors corresponded to services selected for the
baseline numerator from the AHCCCS encounter system.
IV. RESULTS
Baseline Measurement
The total number of members selected for the baseline measurement, including all programs,
was 76,702. Of these members, 39,423 members (51.4 percent) had at least one encounter for
a dental visit during the measurement period.
Children enrolled with Acute-care Contractors under Medicaid
For the baseline measurement, 65,115 members met the sample frame criteria (Table 1).
Encounters for one or more dental visits during the measurement period were found in
AHCCCS administrative data for 33,374 children (51.3 percent). The highest percentage of
dental visits was in Maricopa County, at 53.5 percent, compared with Pima County (47.6
percent) and the combined rural counties (49.2 percent).
By Contractor, rates ranged from 48.9 percent to 54.0 percent (Table 2).
Children enrolled with Acute-care Contractors under KidsCare
For the baseline measurement, 7,873 members met the sample frame criteria (Table 3).
Encounters for one or more dental visits during the measurement period were found in
AHCCCS administrative data for 4,685 children (59.5 percent). The highest percentage of
dental visits was in Maricopa County, at 62.5 percent, compared with Pima County (53.4
percent) and the combined rural counties (56.4 percent).
By Contractor, rates ranged from 54.0 percent to 66.0 percent (Table 4).
Children enrolled with DES/CMDP
For the baseline measurement, 722 members met the sample frame criteria (Table 5).
Encounters for one or more dental visits during the measurement period were found in
AHCCCS administrative data for 443 children (61.4 percent). The highest percentage of
dental visits was in Pima County, at 63.6 percent, compared with Maricopa County (60.0
percent) and the combined rural counties (60.7 percent).

5

Children enrolled with DES/DDD
For the baseline measurement, 2,918 members met the sample frame criteria (Table 6).
Encounters for one or more dental visits during the measurement period were found in
AHCCCS administrative data for 903 children (30.9 percent).
The highest percentage of dental visits was in Pima County, at 35.9 percent, compared with
Maricopa County (31.2 percent) and the combined rural counties (26.4 percent).
Children enrolled with ALTCS Contractors
For the baseline measurement, 74 members met the sample frame criteria (Tables 7).
Encounters for one or more dental visits during the measurement period were found in
AHCCCS administrative data for 18 children (24.3 percent).
By Contractor, rates ranged from 16.7 percent to 50.0 percent (Table 8). However, because
only a small number of ALTCS members met the criteria for inclusion in this study, valid
conclusions can only be made overall, not by county or by Contractor.
Data Validation
From all programs, 2,023 members were selected from the baseline numerator and sent to
Contractors for validation (Table 9). Encounters for 97.2 percent of the validation sample
were validated against dental or medical charts. For the remaining 2.8 percent, encounters
could not be validated because no dental services within the measurement period were found
in members’ records or the charts could not be obtained by Contractors.
By program, the percent of dental encounters validated against dental or medical charts were
as follows: acute-care members enrolled under Medicaid, 97.3 percent; members enrolled
under KidsCare, 98.0 percent; members enrolled with DES/CMDP, 97.4 percent; members
enrolled with DES/DDD, 92.5 percent; and members enrolled with ALTCS Contractors, 88.9
percent. These results demonstrate a high degree of validity of the baseline measurement, as
obtained from the AHCCCS encounter system.
V. ANALYSIS
Overall Results
Data analysis using Pearson’s Chi-square revealed that children enrolled in AHCCCS under
CMDP or KidsCare were more likely to have an annual dental visit than children enrolled
under Medicaid, DDD or ALTCS (p<.001 for all comparisons). Overall, children in Maricopa
County were more likely to have an annual dental visit than those living in Pima County or
the rural counties combined (p<.001).

6

Comparisons with Other Benchmarks
Rates for dental visits among children 3 through 8 years old who were enrolled with acutecare Contractors under both Medicaid and KidsCare were slightly higher than overall rates for
members 3 through 20 years old, as measured by the AHCCCS Performance Indicator for the
same measurement period. For CYE 2002, 47.8 percent of members 3 through 20 years old
who were enrolled under Medicaid had dental visits (compared with 51.3 percent of children
3 to 8 years), and 57.3 percent of members enrolled under KidsCare had visits (compared with
59.5 percent of children 3 to 8 years).
The lower rate among members 3 through 20, compared with younger children only, probably
reflects a pattern of decreasing dental utilization among adolescents. Other data collected by
AHCCCS show the proportion of members receiving dental services peaks in the age range of
6 to 9 years and progressively declines in the 10- to 14-, 15- to 18- and 19- to 20-year-old
groups.13
Rates for 3- through 8-year-olds enrolled in AHCCCS under Medicaid, CMDP and KidsCare
compare favorably to national rates measured under HEDIS. Rates for AHCCCS children
enrolled in DDD and ALTCS were lower than the 2002 Medicaid HEDIS averages for
members 3 through 20. As previously noted, the mean for all Medicaid plans reporting rates
for annual dental visits in 2002 was 37.4 percent. The best performing Medicaid plans (90th
percentile) nationally recorded a rate of 53.4 percent.
Preventive Care vs. Treatment
AHCCCS also analyzed the percent of children who had only preventive dental services
during the measurement period, compared with treatment only or both preventive and
treatment services (Table 10). Of all children with a dental visit, 40.3 percent received
preventive services only, 2.5 percent had treatment services only, and 57.2 percent had both
preventive and treatment services.
The majority of children enrolled under Medicaid and KidsCare received both preventive and
treatment services (57.1 percent and 61.3 percent, respectively). More than half of children
enrolled in CMDP, DDD and ALTCS received preventive services only (rates were 52.8
percent, 50.7 percent and 77.8 percent, respectively).
VI. CONCLUSIONS AND RECOMMENDATIONS
Overall Performance
Overall, the baseline study for this project indicates that more than half of AHCCCS members
had at least one dental visit within the measurement year. Rates of annual dental visits for
children enrolled under KidsCare and DES/CMDP exceeded the Healthy People 2010
objective of 56 percent.

7

The higher rate of visits among KidsCare members could be due to the fact that parents of
many of those children pay a premium for coverage and thus may be more likely to ensure
that their children utilize benefits, including dental services. Likewise, children enrolled with
CMDP may be more likely to receive dental care because they are in a foster-care system in
which case managers and conscientious foster parents ensure that these members receive
dental services.
Children with Special Health Care Needs
Eligibility criteria for children who are developmentally or physically disabled allow these
members to quality for AHCCCS, even though they may have another source of medical
coverage, such as private insurance. The low rates of dental visits among DDD and ALTCS
members, as measured through this study, may be due to the fact that many of these children
received services that were covered by another payer; thus, those encounters were not
reported to AHCCCS.
In addition, the low rates may reflect the challenges faced by special needs children and their
families in obtaining dental services: complex physical problems that demand integrated
dental and medical care, a lack of dental provider capacity to meet these complex needs, and
difficulty in simply getting children with physical or developmental disabilities to the
dentist’s office because of special equipment needed or behavioral issues. ADHS and the
Arizona Dental Association are working to improve the number of dentists able to serve this
group of patients by providing continuing education. AHCCCS Contractors may want to
consider providing enhanced reimbursement to dentists who are treating members with
special needs, as has been done in other states.
It should be noted that dental visit rates among children with special health care needs were
higher in Pima County than in Maricopa or the combined rural counties. This is an area that
warrants further examination to determine if there are differences in the dental network or
overall accessibility in Pima County.
Interventions to Improve Quality
As shown in the baseline measurement for this project, there is room for improvement in
ensuring children have access to dental services and better oral health. AHCCCS has provided
baseline data from this study to all Contractors, who further analyzed their data and identified
interventions to improve rates of annual dental visits. In the contract year ending September
30, 2004, Contractors are focusing interventions to improve the use of dental services and oral
health among children enrolled in their plans.
To assist Contractors in improving or enhancing those interventions, the AHCCCS Clinical
Quality Management Unit synthesized research and literature on oral health initiatives from a
variety of sources (Table 11). The Chronic Care Model, developed by Wagner, et al, of the
MacColl Institute for Healthcare Innovation at Group Health Cooperative, was adapted for
use in organizing various interventions for improving oral health. The model identifies
essential elements of a health care system that encourage high-quality care.

8

The Chronic Care Model

From Wagner EH. Chronic disease management: What will it take to improve care for
chronic illness? Effective Clinical Practice 1998;1:2-4. Copyright ACP-ASIM Journals
and Books. Reprinted with permission.

Elements of the model include:
•
Community resources and policies. Care can be improved by making the most of existing
community programs and resources, as well as raising community awareness about
preventive health, specific diseases, and chronic illnesses.
•
Health system organization. Changes in the health care system, including positive
incentives for physicians, nurses and other providers to change their practices, is another
element of improving care.
•
Self-management support. Patients must take better care of themselves to prevent disease
or keep their chronic illness under control, and need to be trained in proven methods of
minimizing complications, symptoms and disabilities.
•
Delivery system design. Improving health requires not only determining what care is
needed, but ensuring a patient gets that care; for example, designating provider staff to
call patients with reminders that they are due for a preventive-care service.
•
Decision support. This element includes explicit, proven treatment guidelines based on
scientific research, ensuring that patients understand these guidelines and the principles
behind their care, ongoing provider education, and better feedback to primary care
physicians or joint consultation when a patient is referred to a specialist.
•
Clinical information systems. Effective care requires information systems that track
individual patients as well as populations.
By ensuring that each of these elements is adequately addressed, health care organizations can
expect healthier patients, more satisfied providers, and cost savings.14

9

Performance Improvement Goals
Through this Performance Improvement Project, all Contractors are expected to increase their
rates of annual dental visits. Contractors should strive to meet or exceed the Healthy People
2010 goal or the AHCCCS overall average for their respective program; i.e., Medicaid acutecare, KidsCare, etc. (Figures 1 through 4). A Contractor will show improvement when:
•
It meets or exceeds the next highest threshold (e.g., the AHCCCS overall average) above
its baseline rate,
•
It “narrows the gap” between its baseline rate and the next highest threshold by at least 10
percent, or
•
It maintains a rate above the highest threshold, which is the Healthy People 2010 goal, if
its baseline rate already exceeds that level.
AHCCCS will work with Contractors, especially those with the lowest rates, to assist them in
making progress toward these goals for performance improvement. Remeasurements to
evaluate progress will occur in contract years 2004 and 2005.
VII. REFERENCES
1

U.S. Department of Health and Human Services. Oral health in America: A report of the surgeon general.
Rockville, MD: Department of Health and Human Services, National Institutes of Health, National Institute of
Dental and Craniofacial Research, September 2000
2
Arizona Department of Health Services. Arizona oral health update. Phoenix, AZ: Arizona Department of
Health Services, Office of Oral Health, May 2000
3
U.S. Department of Health and Human Services. National call to action to promote oral health. Rockville, MD:
DHHS, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial
Research. NIH Publication No. 03-5303, Spring 2003. Available at
http://www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.htm
4
Phipps K. Dental careies: A transmissible bacterial infection. Inscriptions, Journal of the Arizona Dental
Association 2004; 18(8).
5
Linke HAB, Kuyinu EO, Ogundare B, et al. Microbiological composition of whole saliva and caries experience
in minority populations. Dent Clin N Am 2003; 47:67-85
6
U.S. Department of Health and Human Services. Oral health 2000: facts and figures. Rockville, MD: DHHS,
Office of Public Health and Science, Office of the Surgeon General, May 2000
7
U. S. Department of Health and Human Services. Healthy People 2010: Objectives for improving health, Vol.
II. DHHS, Office of Public Health and Science, November 2000. Available at
http://www.healthypeople.gov/document/tableofcontents.htm#Volume2
8
U.S. General Accounting Office. Oral health: Factors contributing to low use of dental services by low-income
populations. General Accounting Office, Report to Congressional Requesters. HEHS-00-149, September 2000.
Available at http://www.gao.gov/new.items/he00149.pdf
9
U.S. General Accounting Office. Medicaid: stronger efforts needed to ensure children’s access to health
screening services. GAO, Report to Congressional Requesters. GAO-01-749, July 2001. Available at
http://frwebgate.access.gpo.gov/cgibin/useftp.cgi?IPaddress=162.140.64.21&filename=d01749.pdf&directory=/
diskb/wais/data/gao
10
State of New York Department of Health. New York state managed care plan performance 2001. State of New
York Department of Health, April 2002
11
U.S. General Accounting Office. Oral health: Dental disease is a chronic problem among low income
populations. GAO, Report to Congressional Requesters. HEHS-00-072, April 2000. Available at
http://www.gao.gov/new.items/he00072.pdf
12
The Association of State and Territorial Health Officials. Children’s oral health: State initiatives and
opportunities to address the silent epidemic. Washington, DC.
13
Arizona Health Care Cost Containment System. Annual EPSDT Participation Report (Form CMS-416), for
the federal fiscal year 2003. March 2004.
14
Improving Chronic Illness Care website. Overview of the Chronic Care Model. Available at
http://improvingchroniccare.org/change/model/components.html

10

Table 1
Arizona Health Care Cost Containment System (AHCCCS)
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Members Enrolled with Acute-care Contractors under Medicaid
Measurement Period: October 1, 2001, to September 30, 2002

County

Number with

Percent with

Number of

One or More

One or More

Members

Dental Visits

Dental Visits

Maricopa County

35,296

18,889

53.5%

Pima County

11,851

5,642

47.6%

Rural Counties

17,968

8,843

49.2%

TOTAL

65,115

33,374

51.3%

11

Table 2
Arizona Health Care Cost Containment System (AHCCCS)
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Members Enrolled with Acute-care Contractors under Medicaid
Measurement Period: October 1, 2001, to September 30, 2002

Contractor

Number with

Percent with

Number of

One or More

One or More

Members

Dental Visits

Dental Visits

AZ Physicians IPA

25,075

12,428

49.6%

Health Choice AZ

6,521

3,248

49.8%

Maricopa Health Plan

4,468

2,186

48.9%

18,170

9,746

53.6%

Phoenix Health Plan/CC

7,861

4,242

54.0%

Pima Health System

1,057

542

51.3%

University Family Care

1,963

982

50.0%

65,115

33,374

51.3%

Mercy Care Plan

TOTAL

12

Table 3
Arizona Health Care Cost Containment System (AHCCCS)
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Members Enrolled with Acute-care Contractors under KidsCare
Measurement Period: October 1, 2001, to September 30, 2002

County

Number with

Percent with

Number of

One or More

One or More

Members

Dental Visits

Dental Visits

Maricopa County

4,722

2,949

62.5%

Pima County

1,389

742

53.4%

Rural Counties

1,762

994

56.4%

TOTAL

7,873

4,685

59.5%

13

Table 4
Arizona Health Care Cost Containment System (AHCCCS)
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Members Enrolled with Acute-care Contractors under KidsCare
Measurement Period: October 1, 2001, to September 30, 2002

Contractor

Number with

Percent with

Number of

One or More

One or More

Members

Dental Visits

Dental Visits

AZ Physicians IPA

2,946

1,591

54.0%

Health Choice AZ

733

425

58.0%

Maricopa Health Plan

580

367

63.3%

Mercy Care Plan

2,176

1,398

64.2%

Phoenix Health Plan/CC

1,111

709

63.8%

94

62

66.0%

233

133

57.1%

7,873

4,685

59.5%

Pima Health System
University Family Care
TOTAL

14

Table 5
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Members Enrolled with DES/CMDP
Measurement Period: October 1, 2001, to September 30, 2002

County

Number with

Percent with

Number of

One or More

One or More

Members

Dental Visits

Dental Visits

Maricopa County

340

204

60.0%

Pima County

247

157

63.6%

Rural Counties

135

82

60.7%

TOTAL

722

443

61.4%

15

Table 6
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Members Enrolled with DES/DDD
Measurement Period: October 1, 2001, to September 30, 2002

County
Maricopa County

Number with

Percent with

Number of

One or More

One or More

Members

Dental Visits

Dental Visits

1,922

599

31.2%

Pima County

432

155

35.9%

Rural Counties

564

149

26.4%

2,918

903

30.9%

TOTAL

16

Table 7
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Members Enrolled with ALTCS
Measurement Period: October 1, 2001, to September 30, 2002

County

Number with

Percent with

Number of

One or More

One or More

Members

Dental Visits

Dental Visits

Maricopa County

21

4

19.0%

7

2

28.6%

Rural Counties

46

12

26.1%

TOTAL

74

18

24.3%

Pima County

17

Table 8
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Members Enrolled with ALTCS
Measurement Period: October 1, 2001, to September 30, 2002

Contractor

Number with

Percent with

Number of

One or More

One or More

Members

Dental Visits

Dental Visits

Evercare Select

41

7

17.1%

Maricopa Health Plan LTC

5

1

20.0%

Mercy Care Plan LTC

4

2

50.0%

Pima Health System LTC

7

2

28.6%

Pinal/Gila County LTC

6

1

16.7%

Yavapai County LTC

11

5

45.5%

TOTAL

74

18

24.3%

Cochise Health Systems is not included because no members meeting the enrollment criteria were
selected for this Contractor.

18

Table 9
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Data Validation Results
ALL PROGRAMS
Measurement Period: October 1, 2001, to September 30, 2002

Program

Number of

Number

Number

Number with

Percent

Members in

for whom

with Visits

Visits

Visits

Validation

No Record

Not Found

Validated by

Validated by

Sample

was Found

in Records

Chart Review

Chart Review

Medicaid

995

24

3

968

97.3%

KidsCare

760

14

1

745

98.0%

DES/CMDP

117

0

3

114

97.4%

DES/DDD

133

0

10

123

92.5%

ALTCS

18

0

2

16

88.9%

TOTAL

2,023

38

19

19

1,966

97.2%

Table 10
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP):
CHILDREN'S ORAL HEALTH VISITS
Dental Services by Type
ALL PROGRAMS
Measurement Period: October 1, 2001, to September 30, 2002

Program

Number of

Number

Percent

Number

Percent

Members

with

with

with

with

with

Preventive

Preventive

Treatment

Treatment

Number with

Percent with

both Preventive both Preventive

Dental Visits Services Only Services Only Services Only Services Only

and Treatment

and Treatment

Services

Services

Medicaid

33,374

13,457

40.3%

849

2.5%

19,068

57.1%

KidsCare

4685

1709

36.5%

103

2.2%

2873

61.3%

DES/CMDP

443

234

52.8%

11

2.5%

198

44.7%

DES/DDD

903

458

50.7%

23

2.5%

422

46.7%

ALTCS

18

14

77.8%

0

0.0%

4

22.2%

TOTAL

39,423

15,872

40.3%

986

2.5%

22,565

57.2%

20

Table 11

Possible Health Plan Interventions to Improve Rates of Annual Dental Visits by Children
The following table includes interventions that are under way or that should be considered by AHCCCS Contractors to improve
children’s access to oral health services and rates of annual dental visits. The Chronic Care Model, developed by Wagner, et al, of the
MacColl Institute for Healthcare Innovation at Group Health Cooperative, was adapted for use in organizing various interventions for
improving oral health. The model identifies essential elements of a health care system that encourage high-quality care. By ensuring
that each of these elements is adequately addressed, health care organizations can expect healthier patients, more satisfied providers,
and cost savings.1 Interventions in bold are those that could be considered by Contractors as new strategies for quality improvement.

Community
Linkages
Collaborate with
Arizona Department
of Health Services
Office of Oral
Health (OOH) on
RWJ Foundation
grant activities;
utilize as a resource
for provider and
member education
Participate on
AHCCCS work
group to increase
the number of
children 6 years
and younger who
have all necessary
well-child visits, per
State School
Readiness Board
recommendation

Health System
Create a culture at
all levels of the
organization to
reinforce the
importance of wellchild/adolescent
screenings and
services, with oral
health as an
integral part of
those services
Adapt “Take Five”
campaign, which
encouraged all
dentists in
Georgia to accept
five new Medicaid
patients each
year; could be
done at the plan
level, with
provider
incentives

Self-Management
Support
Utilize
promotoras/lay
health outreach
workers for
community dental
outreach and
education
Reinforce
messages (mail,
phone, etc.) to
members/parents
regarding:
• the importance
of good oral health
and its relationship
to overall health
• the positive
outcomes of
preventive dental
care
• address fears
associated with
dental procedures

Delivery System
Design
Improve education of
Primary Care
Providers
(physicians, PAs,
NPs) and office/
clinic staff about oral
health issues:
• early detection of
dental disease
• EPSDT
requirements/
referral for treatment
or preventive visits
• education of
parents about the
importance of regular
dental care
Ensure care and
information are
understood by
patients and are
culturally relevant
21

Decision Support
Promote CME
course for PCPs to
improve oral
health screening
skills (available
from OOH via
internet)
Reinforce PCP
use of guidelines
for oral health
screening during
exams and referral
based on those
findings, per the
AHCCCS Medical
Policy Manual
Develop utilization
profiles and
provide feedback
to dental providers
on visit rates

Clinical
Information
Systems
Monitor dental
performance
indicator/utilization
rates quarterly:
• overall
• by county/
geographic area
• by provider
group
• by population
Develop dental
tracking database
(i.e., electronic
registry) that is
proactive in
nature (e.g.,
anticipates when
visits are due) and
ensures treatment
is completed;
could be shared
by Contractors
and providers

Community
Linkages
Participate/
collaborate with
programs such as
Head Start (Health
and Disabilities
subcommittee), the
Arizona Early
Intervention
Program, WIC and
Health Start or
Healthy Start
community
programs for
pregnant women
and mothers with
young children to
assist in reaching/
educating
members;
Refer/encourage
members to
participate in these
programs
Tie in outreach
efforts with related
activities/events
(e.g., National
Children’s Dental
Health Month)
and/or coordinating
media campaigns
with other Health
Plans to reinforce
messages

Health System
Ensure
reimbursement
rates reflect
marketplace levels
Reduce “hassle
factor” for dentists
(e.g., contracting,
prior authorization
and billing
procedures)
Take dental
screening/services
into community
(e.g., contract with
OOH school dental
screening/sealant
program; sponsor
medical/dental
screening and
health fair with
contracted dentists)
Utilize ”pay-forperformance”
strategies to
reward PCPs
and/or dentists
who meet specific
benchmarks for
dental services

Self-Management
Support
Consider ways to
improve
members’ “health
literacy”
Offer incentives
that are valued by
members to
encourage them to
seek dental care
Organize internal
and community
resources to
provide ongoing
self-management
support to
members,
including following
up with members
who miss
appointments and
arranging for
transportation
when necessary
Make or
collaborate with
organizations that
make home visits
to reinforce
education about
oral health and
importance of
regular dental care

Delivery System
Design
Provide case
management
services for families
at risk (i.e.:
numerous children,
poor dental history,
non-compliant,
serious health
issues)
Ensure continuity
and regular follow up
by the care team
Monitor provider’s
use of EPSDT
tracking forms
Support incentives
to dental providers
to extend office
hours and/or days
to assist members
in making dental
appointments
Support systems
for information flow
and coordination of
care between
dentists and PCPs;
(e.g., send dental
visit reports
through
Contractors
22

Decision Support
Utilize dental
consultants to
review utilization
patterns, practice
guidelines and/or
treatment plans for
specific members
Train/empower
Health Plan staff
(provider
representatives,
MCH/EPSDT
specialists) to
reinforce
education and
clinical practice
guidelines with
providers

Clinical
Information
Systems
Incorporate medical
and/or dental chart
audits into
performance
monitoring
processes
Capture dental
referral data from
EPSDT Tracking
Forms for follow up
to ensure that
appointment was
completed

Community
Linkages
Collaborate with
Arizona Dental
Association,
American
Academy of
Pediatrics, the
Arizona Medical
Association
Committee on
Maternal and
Child Health and
other professional
organizations to
reinforce provider
education and
identify/
address barriers
to dental care

Health System
Evaluate standard
outreach methods
(mailings, postcard
reminders, and
phone calls),
including use of
member or provider
focus groups to
identify barriers to
dental care and
effectiveness of
specific outreach
strategies

Self-Management
Support
Use Contractor
staff and/or dental
providers to make
educational
presentations in
schools, provide
educational
materials and other
items, such as
toothbrushes, to
take home

Delivery System
Design
Consider employing
a dental director at
the Contractor and
AHCCCS levels

1

Improving Chronic Illness Care. Overview of the Chronic Care Model. Available at:
http://improvingchroniccare.org/change/model/components.html

23

Decision Support

Clinical
Information
Systems

Figure 1
Arizona Health Care Cost Containment System (AHCCCS)
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT: BASELINE MEASUREMENT
CHILDREN’S ORAL HEALTH VISITS
Members Enrolled with Acute-Care Contractors under Medicaid
Measurement Period: October 1, 2001, to September 30, 2002
100%

Percent of Children with One or More Dental Visits

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
APIPA

Health Choice

Maricopa Health
Plan

Mercy Care Plan

Phoenix Health
Plan/CC

Medicaid Acute-care Average
Healthy People 2010 Goal

24

Pima Health
System

University Family
Care

Figure 2
Arizona Health Care Cost Containment System (AHCCCS)
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT: BASELINE MEASUREMENT
CHILDREN’S ORAL HEALTH VISITS
Members Enrolled with Acute-Care Contractors under KidsCare
Measurement Period: October 1, 2001, to September 30, 2002
100%

Percent of Children with One or More Dental Visits

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
APIPA

Health Choice

Maricopa Health
Plan

Mercy Care Plan

Phoenix Health
Plan/CC

KidsCare Average
Healthy People 2010 Goal

25

Pima Health
System

University Family
Care

Figure 3
Arizona Health Care Cost Containment System (AHCCCS)
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT: BASELINE MEASUREMENT
CHILDREN’S ORAL HEALTH VISITS
Members Enrolled with DES
Measurement Period: October 1, 2001, to September 30, 2002

Percent of Children with One or More Dental Visits

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

CMDP

DDD

DES Average
Healthy People 2010 Goal

26

Figure 4
Arizona Health Care Cost Containment System (AHCCCS)
CYE 2003 PERFORMANCE IMPROVEMENT PROJECT: BASELINE MEASUREMENT
CHILDREN’S ORAL HEALTH VISITS
Members Enrolled with ALTCS Contractors
Measurement Period: October 1, 2001, to September 30, 2002
100%

Percent of Children with One or More Dental Visits

90%

80%

70%

60%

50%
40%

30%

20%

10%

0%

Evercare Select

Maricopa LTC

Mercy Care LTC

Pima Health System

Pinal/Gila LTC

ALTCS Average
Healthy People 2010 Goal

27

Yavapai LTC

APPENDIX

A FRAMEWORK FOR ACTION
Oral Health in America: A Report of the Surgeon
General, is the first report by the Surgeon General of the
United States Public Health Service to focus exclusively
on oral, dental, and craniofacial health. The report was
commissioned by the Secretary of Health and Human
Services upon the recommendation of the Surgeon
General, on April 9, 1997.
The major message of this report is that oral health
is essential to the general health and well-being of all
Americans and can be achieved through community,
provider, and personal services and programs. The
following are the principal components of the plan.

Change perceptions regarding oral health and disease so that oral health
becomes an accepted component of general health.

Change public perceptions. Many people consider oral signs and symptoms to
be less important than indications of general illness. As a result, they may avoid
or postpone needed care, thus exacerbating the problem. If we are to increase
the capacity to improve oral health and reduce health disparities, we need to
enhance public understanding of the meaning of oral health and the relationship
of the mouth to the rest of the body. These messages should take into account
the multiple languages and cultural traditions that characterize American diversity.
•

•

Change policymakers’ perceptions. Informed policymakers at the local, state,

and federal levels are critical in ensuring the inclusion of oral health services in
health promotion and disease prevention programs, care delivery systems, and
reimbursement schedules. Raising awareness of oral health among legislators
and public officials at all levels of government is essential to creating effective
public policy to improve oral health. Every conceivable avenue should be used to
inform policymakers — informally through their organizations and affiliations and
formally through their governmental offices — if rational oral health policy is to be
formulated and effective programs implemented.

APPENDIX
•

Change health providers’ perceptions. Too little time is devoted to oral

health and disease topics in the education of nondental health professionals. Yet
all care providers can and should contribute to enhancing oral health. This can be
accomplished in several ways, such as including an oral examination as part of a
general medical examination, advising patients in matters of tobacco cessation
and diet, and referring patients to oral health practitioners for care prior to medical
or surgical treatments that can damage oral tissues, such as cancer
chemotherapy or radiation to the head and neck. Health care providers should be
ready, willing, and able to work in collaboration to provide optimal health care for
their patients. To prepare providers for such a role will involve, among other
factors, curriculum changes and multidisciplinary training.
Accelerate the building of the science and evidence base and apply science
effectively to improve oral health. Continued investment in research is critical for
the provision of new knowledge about oral and general health and disease for
years to come, and needs to be accelerated if further improvements are to be
made. The challenge is to understand complex diseases caused by the
interaction of multiple genes with environmental and behavioral variables — a
description that applies to most oral diseases and disorders — and translate
research findings into health care practice and healthy lifestyles.
Future data collection must address differences among the subpopulations
making up racial and ethnic groups. More attention must also be paid to
demographic variables such as age, sex, sexual orientation, and socioeconomic
factors in determining health status. Clearly, the more detailed information that is
available, the better can program planners establish priorities and targeted
interventions.
Progress in elucidating the relationships between chronic oral inflammatory
infections, such as periodontitis, and diabetes and glycemic control as well as
other systemic conditions will require a similar intensified commitment to
research. Improvements in oral health depend on multidisciplinary and
interdisciplinary approaches to biomedical and behavioral research, including
partnerships among researchers in the life and physical sciences, and on the
ability of practitioners and the public to apply research findings effectively.
Build an effective health infrastructure that meets the oral health needs of all
Americans and integrates oral health effectively into overall health.
Although the Healthy People 2010 objectives provide a blueprint for outcome
measures, a national public health plan for oral health does not exist.
Furthermore, local, state, and federal resources are limited in the personnel,
equipment, and facilities available to support oral health programs.

APPENDIX
There is a lack of racial and ethnic diversity in the oral health workforce. Efforts to
recruit members of minority groups to positions in health education, research, and
practice in numbers that at least match their representation in the general
population not only would enrich the talent pool, but also might result in a more
equitable geographic distribution of care providers.
A closer look at trends in the workforce discloses a worrisome shortfall in the
numbers of men and women choosing careers in oral health education and
research. Government and private sector leaders are aware of the problem and
are discussing ways to increase and diversify the talent pool, including easing the
financial burden of professional education, but additional incentives may be
necessary.
Remove known barriers between people and oral health services. Data indicate
that lack of dental insurance, private or public, is one of several impediments to
obtaining oral health care and accounts in part for the generally poorer oral health
of those who live at or near the poverty line, lack health insurance, or lose their
insurance upon retirement. The level of reimbursement for services also has been
reported to be a problem and a disincentive to the participation of providers in
certain public programs. Professional organizations and government agencies are
cognizant of these problems and are exploring solutions that merit evaluation. In
addition, individuals whose health is physically, mentally, and emotionally
compromised need comprehensive integrated care.
Use public-private partnerships to improve the oral health of those who still suffer
disproportionately from oral diseases. The collective and complementary talents
of public health agencies, private industry, social services organizations,
educators, health care providers, researchers, the media, community leaders,
voluntary health organizations and consumer groups, and concerned citizens are
vital if America is not just to reduce, but to eliminate, health disparities. Increased
public-private partnerships are needed to educate the public, to educate health
professionals, to conduct research, and to provide health care services and
programs. These partnerships can build and strengthen cross-disciplinary,
culturally competent, community-based, and community-wide efforts and
demonstration programs to expand initiatives for health promotion and disease
prevention. Examples of such efforts include programs to prevent tobacco use,
promote better dietary choices, and encourage the use of protective gear to
prevent sports injuries. In this way, partnerships uniting sports organizations,
schools, the faith community, and other groups and leaders, working in concert
with the health community, can contribute to improved oral and general health.