Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits?

AM Kranz; RG Rozier; BD Stein; AW Dick

doi:10.1177/0022034520916161

. 2020 Apr 23;99(8):891–897. doi: 10.1177/0022034520916161

Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits?

AM Kranz ^1,^✉, RG Rozier ², BD Stein ³, AW Dick ⁴

PMCID: PMC7346745 PMID: 32325007

Abstract

In the United States, state Medicaid programs pay for medical and dental care for children from low-income families and support nondental primary care providers delivering preventive oral health services (POHS) to young children in medical offices (“medical POHS”). Despite the potential of these policies to expand access to care, there is concern that they may replace dental visits with medical POHS. Using Medicaid claims from 38 states from 2006 to 2014, we conducted a repeated cross-sectional study and used linear probability regression to estimate the association between the annual proportion of children in a county receiving medical POHS and the probability that a child received 1) dental POHS and 2) a dental visit in a given year. Models included county and year fixed effects and controlled for child- and county-level factors, and standard errors were clustered at the state level. In a weighted population of 45.1 million child-years (age, 6 mo to <6 y), we found no significant nor substantively important association between the proportion of children in a county receiving medical POHS and the probability that a child received dental POHS or a dental visit. Additionally, we found an almost zero probability (<0.001) that the reduction in dental POHS was at least as large as the expansion in medical POHS (full substitution) and a 0.50 probability that increased medical POHS was associated with an increase in dental POHS of at least 6.6% of the expansion of medical POHS. Results were similar when receipt of dental visits was examined. This study failed to find evidence that medical POHS replaced dental visits for young children enrolled in Medicaid and, in fact, offers evidence that increased medical POHS was associated with increased utilization of dental care. Given lower-than-desired rates of dental visits for this population, delivery of medical POHS should be expanded.

Keywords: Medicaid, pediatrics, preventive dentistry, pediatric dentistry, health policy, health services research

Introduction

Integration of oral health services into primary medical care is promoted as a strategy to improve oral health globally (Watt et al. 2019). In the United States, delivery of preventive oral health services (POHS) in medical offices to children younger than 6 y has support from medical and dental stakeholders (Clark et al. 2014; Moyer 2014; “Policy on Early Childhood Caries” 2016; “Recommendations for Preventive Pediatric Health Care” 2019). POHS delivered in medical offices most commonly includes fluoride varnish applications, less often also caries risk assessment, oral evaluation, and parental counseling (Arthur and Rozier 2016). Some state Medicaid programs, which provide health insurance to children from low-income families, have encouraged fluoride varnish applications in medical offices since the early 21st century, and rates of these fluoride varnish applications vary considerably across states, ranging from <1% to >20% (Arthur and Rozier 2016). Delivery of POHS in medical offices (hereafter, medical POHS) increases utilization (Okunseri et al. 2009; Herndon et al. 2015), improves oral health (Kranz, Preisser, and Rozier 2015; Kranz et al. 2019), and reduces restorative treatments for caries, hospitalizations, and Medicaid expenditures for dental care (Stearns et al. 2012).

Medical POHS is intended to complement and not substitute for dental visits, because dental visits are essential for conducting comprehensive examinations, assessing caries risk, and monitoring and treating problems (“Periodicity of Examination” 2018). Medical POHS could lead to a reduction in dental visits if families defer or delay them, believing that medical POHS provides all dental care needed. Some evidence suggests that this is happening. Following the introduction of a medical POHS policy in Florida, there was evidence of decreased provision of POHS by dentists (Herndon et al. 2015). In North Carolina, dental visit rates in later childhood were lower for children who first received POHS in medical offices as compared with children who first received POHS in dental offices (Kranz, Rozier, et al. 2015). A second North Carolina study examining referral practices of pediatric medical providers found that they underreferred to dentists in scenarios where immediate referral was recommended (Zhu et al. 2018). Because this evidence is limited to studies in 2 states, it is uncertain whether medical POHS is substituting for dental visits.

This study’s objective was to test the hypothesis that widespread adoption of state Medicaid policies supporting medical POHS may have unintentionally reduced dental visits. We tested this using Medicaid claims data from 38 states and estimated the probabilities that 1) medical POHS completely replaced dental visits, 2) medical POHS replaced some dental POHS, and 3) medical POHS expanded dental visits.

Methods

Sample

We analyzed Medicaid Analytic eXtract (2019) enrollment and claims data from 2006 to 2014 for 38 states (average of 6 y per state). We obtained data for 45 states based on data availability and high-quality managed care encounter data (Byrd and Dodd 2012). We subsequently dropped 7 states due to inability to confidently identify medical POHS. The states and years analyzed in this study are listed in Appendix Table 1. Our sample was limited to 1) the universe of Medicaid-enrolled children <6 y of age in 38 states who ever received medical POHS and 2) a stratified random sample of Medicaid-enrolled children <6 y old who never received medical POHS, weighted to be representative of all Medicaid-enrolled children <6 y in each state in each year. Starting with an unweighted sample of 11,593,940 child-year observations for Medicaid enrollees aged 6 mo to <6 y, we excluded children enrolled in Medicaid for <6 mo in a year (63% of the dropped observations) and those for whom the data were missing county of residence, rurality, sex, or race—resulting in an analytic sample of 8,711,192 child-year observations.

Variables

Our main dependent variable was a dichotomous indicator that a child received a dental visit with POHS (hereafter, dental POHS) during a given year, which is consistent with the measurement approach used by the US government’s Healthy People 2020 quality measurement initiative (Healthy People 2020). Dental POHS was identified with Current Dental Terminology codes for oral evaluation, prophylaxis, and topical application of fluoride and fluoride varnish (listed in Appendix Table 2). Because some dental procedure codes are used by dental and medical providers, we excluded POHS claims delivered by medical providers. Medical providers were defined as having <10% of all their procedure codes for dental procedures (D0100 to D9999) and <1% of all their procedure codes for dental treatment procedures (D0200 to D9999). For a secondary analysis, we constructed a dichotomous variable indicating that a child had a dental visit for any reason during a given year (inclusive of Current Dental Terminology codes D0000 to D9999 and not delivered by a medical provider).

Our key explanatory variable was the proportion of Medicaid-enrolled children in a county receiving medical POHS in a calendar year. The denominator for this variable was the count of Medicaid-enrolled children <6 y old in a county in a calendar year. The numerator was the count of Medicaid-enrolled children <6 y old receiving medical POHS in a county in a calendar year. Medical POHS was identified with state-specific procedure codes obtained from the American Academy of Pediatrics. All states had codes for fluoride varnish, and fewer states had codes for risk assessment, oral evaluation, and counseling. Children receiving medical POHS were identified by first excluding claims for dental services and then identifying medical POHS procedure codes provided by 1) physicians or nurse practitioners or 2) a medical provider based on our aforementioned definition.

Additional child-level variables included sex, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and other), age (<1, 1, 2, 3, ≥4 y), and indicator of Medicaid enrollment <12 mo in a given year. Because we include only those months prior to a child’s sixth birthday, we included indicators for total months enrolled in a year to account for the fact that children will have fewer months of study enrollment in the year that they turn 6 y old. Medical POHS is encouraged to be delivered during well-child medical visits; thus, we identified children receiving these visits via Current Procedural Terminology codes for a new or established well-child visit (99381, 99382, 99383, 99391, 99392, 99393).

County-level characteristics were obtained from the Area Health Resource Files and merged to child-level claims per county and year. County rurality was defined according to the 2013 Rural-Urban Continuum Codes (RUCC; Economic Research Service 2016) and categorized as metropolitan (RUCC = 1 to 3), nonmetropolitan adjacent to metropolitan (RUCC = 4, 6, 8), and nonmetropolitan not adjacent to metropolitan (RUCC = 5, 7, 9), consistent with prior studies (Geiger et al. 2019; Luu et al. 2019). Additional county-level covariates included size (total area in square miles), dichotomous indicators of living in a county with the highest quartile of rates of unemployment and poverty, and indicators of whether the county was a full or partial health professional shortage area (HPSA; primary care or dental). Information on HPSAs was missing for 2014, so we applied 2013 information. The HPSA variables serve as proxies for access to care; however, they may obscure important individual-level access challenges.

Analysis

All analyses were conducted with Stata MP (version 15.1; StataCorp) and approved by the corresponding author’s Institutional Review Board. The study used deidentified observational data; thus, patient consent was neither required nor obtainable. We estimated linear probability models at the child-year level to predict the likelihood of a child receiving dental POHS and the likelihood of a child receiving any dental visits in a calendar year. The models included the aforementioned child- and county-level variables, year and county fixed effects, robust standard errors clustered at the state level (Huber 1992), and probability weights to account for the sampling of children in each year. We conducted 2-tailed hypothesis tests with a significance level of 0.05 to test whether the proportion of children in a county receiving medical POHS was associated with the dependent variables. Recognizing that this research question requires additional evidence beyond the P values generated from the aforementioned tests (Wasserstein and Lazar 2016), we calculated probabilities for the following scenarios: 1) dental POHS fell by at least as much as medical POHS increased; 2) dental POHS fell by at least some fraction of medical POHS; and 3) dental POHS increased by at least some fraction of medical POHS. To do so, we used the cumulative probability function given by the medical POHS point estimate and standard error from our regression results to identify the probability that our dependent variables (receipt of any dental POHS or dental visits in a year) would increase or decrease by at least a given fraction of the medical POHS expansion. This study conforms to the STROBE guidelines.

Results

Our final weighted sample included 45,107,240 child-year observations for Medicaid-enrolled children aged 6 mo to <6 y in 2,609 counties in 38 states. Approximately half (51.0%) were male; 40.3% were white; and 27.0% were ≥4 y of age (Table 1). Most children lived in metropolitan counties (79.4%) and in full or partial HPSAs (primary care, 78.5%; dental, 84.7%).

Table 1.

Characteristics of Child-Years Analyzed from a Pooled Sample of Young Medicaid Enrollees from 38 States, 2006 to 2014.

	% or Mean (SD)
Child characteristics
Race/Hispanic ethnicity
White, non-Hispanic	40.3
Black or African American, non-Hispanic	25.6
Hispanic	20.9
Other	13.2
Male	51.0
Months enrolled in Medicaid in a given year	11.0 (4.1)
12 mo of Medicaid coverage	68.9
Age, y
<1	26.8
1	15.7
2	15.4
3	15.2
≥4	27.0
Year
2006	10.2
2007	11.3
2008	12.3
2009	13.9
2010	14.6
2011	15.0
2012	13.5
2013	6.9
2014	2.3
County characteristics
Rurality
Metropolitan	79.4
Nonmetropolitan adjacent to metropolitan county	13.0
Nonmetropolitan not adjacent to metropolitan county	7.6
Total area in square miles	94,721 (364,496)
Lives in county with highest quartile of
Child poverty rate (≥28.4%)	23.3
Unemployment rate (≥8.6%)	24.1
Lives in full or partial HPSA
Dental	84.7
Primary care	78.5

Open in a new tab

Weighted count of child-years = 45,107,240. Sample includes children aged 6 mo to <6 y enrolled in Medicaid for at least 6 mo in a sample of 38 states from 2006 to 2014. Results are weighted to be representative of all children aged <6 y in each state in each year.

HPSA, health professional shortage area.

The percentage of states with policies allowing for medical POHS increased over time, from 17% in 2006 to 82% in 2012 (Appendix Table 3). Fewer than half of all children received POHS in medical or dental offices (38.3%; Fig. 1). Receipt of dental POHS was more common (36.4%) than medical POHS (2.8%). Among children receiving any POHS in medical or dental offices, 8.9% received POHS in medical and dental offices; 20.7%, only medical POHS; and 70.4%, only dental POHS. There was variation in the county percentage of children receiving medical POHS in a calendar year (25th percentile, 0%; 50th percentile, 0.1%; 75th percentile, 3.2%).

Figure 1. — Utilization of preventive oral health services (POHS) for young Medicaid enrollees from 2006 to 2014. Sample includes children aged 6 mo to <6 y enrolled in Medicaid for at least 6 mo in a sample of 38 states from 2006 to 2014. Results are weighted to be representative of all children <6 y in each state in each year.

We did not find an association between the proportion of children in a county receiving medical POHS and the probability of a child receiving dental POHS (Table 2, model 1). A 5–percentage point higher county rate of POHS in medical offices (roughly 1 SD) was associated with a nonsignificant 0.35–percentage point higher probability of a child receiving POHS in a dental office (95% CI, –0.87 to 1.57). Similarly, we did not find an association between the proportion of children in a county receiving medical POHS and the probability of a child receiving any dental visit (Table 2, model 2).

Table 2.

Results of Regression Models Examining Factors Associated with a Medicaid-Enrolled Child’s Receipt of a Dental Visit in a Given Year.

	Coefficient (SE)
Variable	Model 1: Receipt of Dental POHS	Model 2: Receipt of Dental Visit for Any Reason
Proportion of children in county receiving medical POHS	0.066 (0.117)	−0.019 (0.110)
Race (reference: White, non-Hispanic)
Black or African American, non-Hispanic	0.012 (0.008)	0.014 (0.009)
Hispanic	0.092 (0.015)^a	0.095 (0.014)^a
Other	0.042 (0.004)^a	0.046 (0.004)^a
Male	−0.004 (0.001)^a	−0.004 (0.001)^a
Age, y (reference: <1 y)
1	0.176 (0.022)^a	0.191 (0.025)^a
2	0.330 (0.014)^a	0.351 (0.015)^a
3	0.428 (0.018)^a	0.456 (0.016)^a
≥4	0.473 (0.019)^a	0.507 (0.018)^a
Year (reference: 2006)
2007	0.012 (0.004)^b	0.014 (0.003)^a
2008	0.041 (0.005)^a	0.043 (0.006)^a
2009	0.067 (0.010)^a	0.065 (0.008)^a
2010	0.089 (0.014)^a	0.084 (0.012)^a
2011	0.103 (0.014)^a	0.097 (0.012)^a
2012	0.102 (0.012)^a	0.096 (0.010)^a
2013	0.110 (0.012)^a	0.106 (0.011)^a
2014	0.109 (0.018)^a	0.098 (0.015)^a
Lives in county with highest quartile of
Child poverty rate	−0.004 (0.004)	−0.0037 (0.004)
Unemployment rate	−0.000 (0.004)	0.002 (0.004)
Lives in full or partial HPSA
Dental	−0.001 (0.009)	−0.004 (0.008)
Primary care	−0.018 (0.008)^c	−0.016 (0.008)^c
Any well-child visits	0.116 (0.007)^a	0.116 (0.006)^a
Intercept	0.026 (0.022)	0.024 (0.020)
Observations, n
Unweighted	8,711,192	8,711,192
Weighted	45,107,240	45,107,240

Open in a new tab

Table shows results of linear probability models, which also included county and year fixed effects, standard errors clustered at the state level, and probability weights to account for the sampling of children in each year. Sample includes children aged 6 mo to <6 y enrolled in Medicaid for at least 6 mo in a sample of 38 states from 2006 to 2014.

HPSA, health professional shortage area; POHS, preventive oral health services.

P < 0.001.

P < 0.01.

P < 0.05.

Figures 2 and 3 illustrate the cumulative probability functions derived from the results from the aforementioned regression models estimating a child’s receipt of dental POHS and any dental visit. There was a probability of almost zero (<0.001) that the reduction in dental POHS was at least as large as the expansion in medical POHS (full substitution; Fig. 2, result 1). There was a 0.30 probability that increased medical POHS was associated with reduced dental POHS (Fig. 2, result 2), with a corresponding 0.70 probability that dental POHS increased. Furthermore, there was a 0.50 probability that increased medical POHS was associated with an increase in dental POHS of at least 6.6% of the expansion of medical POHS (the model’s point estimate; Fig. 1, result 3).

Figure 2. — Probability that preventive oral health services (POHS) in medical offices replaces or increases rates of POHS in dental offices for young Medicaid enrollees from 2006 to 2014. Figure uses the cumulative probability function given by the medical POHS point estimate and standard error from our regression results to identify the probability that receipt of dental POHS in a year would increase or decrease by at least a given fraction of the medical POHS expansion. Sample includes children aged 6 mo to <6 y enrolled in Medicaid for at least 6 mo in a sample of 38 states from 2006 to 2014.

Results were similar upon examination of these scenarios for children’s receipt of any dental visits in a year. As Figure 3 illustrates, we found an almost zero probability (<0.001) that the reduction in receipt of any dental visits was at least as large as the expansion in medical POHS (full substitution; result 1); a 0.55 probability that increased medical POHS was associated with a reduction in children’s receipt of any dental visits (result 2); and a probability of 0.20 that children’s receipt of any dental visits increased by >10% of the medical POHS increase (result 3).

Discussion

Integration of oral health services in medical offices is promoted as a strategy to improve oral health globally (Moyer 2014; Watt et al. 2019). However, if this integration reduces dental visits, it may lead to negative outcomes due to increased unmet treatment needs. Using an individual-level data set with 38 states and >45 million child-year observations for children enrolled in Medicaid for at least 6 mo annually, we found 1) a high probability (0.70) that expansions in medical POHS were not associated with reductions in dental POHS and 2) a 0.50 probability that expansions in medical POHS were associated with an increase of dental POHS (by up to 6.6% of the expansions of medical POHS). These results, with research that medical POHS improves oral health (Kranz, Preisser, and Rozier 2015; Kranz et al. 2019) and reduces hospitalizations and payments for dental care (Stearns et al. 2012), supports the expansion of POHS in medical offices.

Few children, however, receive medical POHS. In our study, <3% of children received POHS in medical offices. Evidence from a 2012 national survey of oral health practices of pediatricians reported that while 41% of pediatricians agreed that they should apply fluoride varnish, 7% reported applying it to most patients eligible to receive it (Quinonez et al. 2014). Strategies to increase the delivery of medical POHS include providing oral health training to primary care providers (Bernstein et al. 2016; Dooley et al. 2016; Clark et al. 2017; Silk et al. 2018), emphasizing the importance of POHS to providers (Dooley et al. 2016), offering incentives to motivate staff to incorporate POHS into medical visits (Bernstein et al. 2016), and reducing clinical workflow demands (Sengupta et al. 2017). These strategies are most successful when tailored to a practice’s specific needs and when implemented together, addressing multiple barriers simultaneously (Bernstein et al. 2016; Dooley et al. 2016; Clark et al. 2017; Silk et al. 2018). Given that medical POHS and overall POHS rates are lower than desired, more primary care medical providers should begin providing POHS.

While our models provide evidence that it is extremely unlikely that medical POHS fully substituted for dental POHS, it is possible that expansions of medical POHS may be associated with fewer children receiving dental care. We estimated a 0.30 probability that dental POHS would be reduced by any amount by expansions in medical POHS and a 0.55 probability that receipt of any dental visits in a year would be reduced by any amount due to expansions in medical POHS. Studies conducted in Florida and North Carolina suggest that delivery of POHS in medical offices may be associated with fewer children having dental visits (Herndon et al. 2015; Kranz, Rozier, et al. 2015). Our results are consistent with this phenomenon, as <10% of children who received POHS in a calendar year received it from medical and dental offices. However, we found that about one-fifth of children who received POHS in a year received it only in medical offices. Taken with our finding about the limited role of substitution, this is evidence that medical POHS is helping some children receive POHS who otherwise may not receive it.

Because our models rely on a county-level measure of medical POHS, we cannot distinguish for an individual child when medical POHS substituted for dental POHS, led to a referral to a dentist, or filled an unmet need. Evidence is not compelling that higher rates of medical POHS were associated with higher rates of dental POHS or dental visits overall, suggesting that referrals from medical providers to dentists are not frequently occurring. Factors associated with increased odds of dental referral among medical providers include confidence in ability to perform screenings and low difficulty of referral (dela Cruz et al. 2004), suggesting that provider training and enhancing connections between dentists and medical providers may help increase referrals to dentists. For example, colocating medical and dental services may help to increase referrals and access to dental care. A study of California health centers found that 33% had colocated medical and dental services, enabling patients to have same-day medical and dental visits and enabling medical and dental providers to manage complex cases together (Pourat et al. 2015). Additionally, a sample of Los Angeles County health centers with colocated medical and dental services that received financial support and technical assistance to better integrate medical and dental care reported a threefold increase in delivery of POHS for children <6 y old after 2 y (Crall et al. 2016).

This study should be interpreted within the context of its limitations. Although we failed to reject the null hypothesis that medical POHS had no effect on dental POHS, we did find a positive point estimate (i.e., a positive association between medical POHS and dental POHS) with enough precision to be confident that dental POHS fell by, at most, about 12% of the increase in medical POHS—which translates to a decrease in dental POHS visits of <1%. Policies in some states limiting POHS payments annually may have led to missing information in our data set about services received. If this differentially affected dentists, then we may understate the probability of the expansion of dental visits. Although all nonexperimental studies have threats to the validity of causal interpretations, use of county-level fixed effects helps to mitigate threats to internal validity by identifying effects based on intracounty changes in medical POHS rates over time, eliminating the fixed idiosyncratic differences in rates across states as a source of spurious correlation. Additionally, our data do not provide information about POHS service quality or its effects on children’s clinical outcomes, important topics for future research. POHS is one of many biological, behavioral, and societal factors affecting oral health (“Policy on Early Childhood Caries” 2016). A recent systematic review and meta-analysis suggested that fluoride varnish may be less effective for young children than previously suggested (de Sousa et al. 2019); however, prior studies were not adjusted for risk, suggesting that fluoride varnish is still highly effective in high-risk populations, such as Medicaid enrollees. Finally, medical and dental providers in some states use the same procedure codes for POHS, in which case we could have misidentified services as POHS in medical offices when they were actually POHS in dental offices. We sought to address this by identifying POHS in medical offices by type of service code and by using an algorithm to identify providers unlikely to be dentists. Our approach led to estimated rates of POHS that were similar to those previously published (Arthur and Rozier 2016).

In conclusion, we found that there is very little risk for substantively meaningful decreases in dental POHS resulting from the introduction of medical POHS. Given the low probability that medical POHS replaced dental visits and the high need for POHS among young children enrolled in Medicaid, efforts should be made in the United States to expand the delivery of POHS in medical offices, which currently has low uptake among providers and has been shown to have a range of benefits (Stearns et al. 2012; Kranz et al. 2019). Moreover, this result is important for all countries seeking to broaden access to POHS without reducing dental visits. Researchers argue that integration of POHS into medical offices may promote more equitable access to care in high-income countries and may partially address dental workforce shortages in low- and middle-income countries, and our results support expanding integration.

Author Contributions

A.M. Kranz, A.W. Dick, contributed to conception, design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript; R.G. Rozier, contributed to conception, design, data analysis, and interpretation, critically revised the manuscript; B.D. Stein, contributed to conception and data acquisition, critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of the work.

Supplemental Material

DS_10.1177_0022034520916161 – Supplemental material for Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits?

Click here for additional data file.^{(87.4KB, pdf)}

Supplemental material, DS_10.1177_0022034520916161 for Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits? by A.M. Kranz, R.G. Rozier, B.D. Stein and A.W. Dick in Journal of Dental Research

Footnotes

A supplemental appendix to this article is available online.

This study was supported by the National Institute of Dental and Craniofacial Research (grant R01 DE026136-03). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Dental and Craniofacial Research or the National Institutes of Health. The funding source had no involvement in study design; collection, analysis, and interpretation of data; the writing of the report; or in the decision to submit the article for publication.

The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

ORCID iD: A.M. Kranz Inline graphic https://orcid.org/0000-0003-0507-7800

References

Arthur T, Rozier RG. 2016. Provision of preventive dental services in children enrolled in Medicaid by nondental providers. Pediatrics. 137(2):e20153436. [DOI] [PubMed] [Google Scholar]
Bernstein J, Gebel C, Vargas C, Geltman P, Walter A, Garcia RI, Tinanoff N. 2016. Integration of oral health into the well-child visit at federally qualified health centers: study of 6 clinics, August 2014–March 2015. Prev Chronic Dis. 13:E58. [DOI] [PMC free article] [PubMed] [Google Scholar]
Byrd VLH, Dodd AH. 2012. Assessing the usability of encounter data for enrollees in comprehensive managed care across MAX 2007–2009. Princeton (NJ): Mathematica Policy Research; [accessed 2020 Feb 14]. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/Downloads/MAX_IB_15_AssessingUsability.pdf [Google Scholar]
Clark M, Quinonez R, Bowser J, Silk H. 2017. Curriculum influence on interdisciplinary oral health education and practice. J Public Health Dent. 77(3):272–282. [DOI] [PubMed] [Google Scholar]
Clark MB, Slayton RL; Section on Oral Health. 2014. Fluoride use in caries prevention in the primary care setting. Pediatrics. 134(3):626–633. [DOI] [PubMed] [Google Scholar]
Crall JJ, Pourat N, Inkelas M, Lampron C, Scoville R. 2016. Improving the oral health care capacity of federally qualified health centers. Health Aff (Millwood). 35(12):2216–2223. [DOI] [PubMed] [Google Scholar]
de Sousa FSO, Dos Santos APP, Nadanovsky P, Hujoel P, Cunha-Cruz J, Oliveira BH. 2019. Fluoride varnish and dental caries in preschoolers: a systematic review and meta-analysis. Caries Res. 53(5):502–513. [DOI] [PubMed] [Google Scholar]
dela Cruz GG, Rozier RG, Slade G. 2004. Dental screening and referral of young children by pediatric primary care providers. Pediatrics. 114(5):e642–e652. [DOI] [PubMed] [Google Scholar]
Dooley D, Moultrie NM, Heckman B, Gansky SA, Potter MB, Walsh MM. 2016. Oral health prevention and toddler well-child care: routine integration in a safety net system. Pediatrics. 137(1). doi: 10.1542/peds.2014-3532. [DOI] [PMC free article] [PubMed] [Google Scholar]
Economic Research Service. 2016. 2013 rural-urban continuum codes. Washington (DC): US Department of Agriculture; [accessed 2019 July 6]. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/ [Google Scholar]
Geiger CK, Kranz AM, Dick AW, Duffy E, Sorbero M, Stein BD. 2019. Delivery of preventive oral health services by rurality: a cross-sectional analysis. J Rural Health. 35(1):3–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
Healthy People. 2020. Oral health. Washington (DC): US Department of Health and Human Services; [accessed 2020 Feb 14]. https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Oral-Health/data. [Google Scholar]
Herndon JB, Tomar SL, Catalanotto FA, Vogel WB, Shenkman EA. 2015. The effect of Medicaid primary care provider reimbursement on access to early childhood caries preventive services. Health Serv Res. 50(1):136–160. [DOI] [PMC free article] [PubMed] [Google Scholar]
Huber PJ. 1992. Robust estimation of a location parameter. In: Kotz S, Johnson NL, editors. Breakthroughs in statistics. New York (NY): Springer; p. 492–518. [Google Scholar]
Kranz AM, Duffy E, Dick AW, Sorbero M, Rozier RG, Stein BD. 2019. Impact of Medicaid policy on the oral health of publicly insured children. Matern Child Health J. 23(1):100–108. [DOI] [PMC free article] [PubMed] [Google Scholar]
Kranz AM, Preisser JS, Rozier RG. 2015. Effects of physician-based preventive oral health services on dental caries. Pediatrics. 136(1):107–114. [DOI] [PMC free article] [PubMed] [Google Scholar]
Kranz AM, Rozier RG, Preisser JS, Stearns SC, Weinberger M, Lee JY. 2015. Examining continuity of care for Medicaid-enrolled children receiving oral health services in medical offices. Matern Child Health J. 19(1):196–203. [DOI] [PMC free article] [PubMed] [Google Scholar]
Luu H, Slavova S, Freeman PR, Lofwall M, Browning S, Bush H. 2019. Trends and patterns of opioid analgesic prescribing: regional and rural-urban variations in Kentucky from 2012 to 2015. J Rural Health. 35(1):97–107. [DOI] [PubMed] [Google Scholar]
Medicaid Analytic eXtract. 2019. Minneapolis (MN): Research Data Assistance Center; [accessed 2019 July 6]. https://www.resdac.org/cms-data/files/max-ot. [Google Scholar]
Moyer VA. 2014. Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement. Pediatrics. 133(6):1102–1111. [DOI] [PubMed] [Google Scholar]
Okunseri C, Szabo A, Jackson S, Pajewski NM, Garcia RI. 2009. Increased children’s access to fluoride varnish treatment by involving medical care providers: effect of a Medicaid policy change. Health Serv Res. 44(4):1144–1156. [DOI] [PMC free article] [PubMed] [Google Scholar]
Periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. 2018. Chicago (IL): American Academy of Pediatric Dentistry; [accessed 2019 July 6]. http://www.aapd.org/media/Policies_Guidelines/BP_Periodicity.pdf. [PubMed] [Google Scholar]
Policy on early childhood caries: classifications, consequences, and preventive strategies. 2016. Chicago (IL): American Academy of Pediatric Dentistry; [accessed 2019 July 6]. https://www.aapd.org/globalassets/media/policies_guidelines/p_eccclassifications.pdf. [PubMed] [Google Scholar]
Pourat N, Martinez AE, Crall JJ. 2015. Better together: co-location of dental and primary care provides opportunities to improve oral health. Los Angeles (CA): UCLA Center for Health Policy Research; [accessed 2019 July 6]. http://healthpolicy.ucla.edu/publications/Documents/PDF/2015/Dental-brief-sep2015.pdf [PubMed] [Google Scholar]
Quinonez RB, Kranz AM, Lewis CW, Barone L, Boulter S, O’Connor KG, Keels MA. 2014. Oral health opinions and practices of pediatricians: updated results from a national survey. Acad Pediatr. 14(6):616–623. [DOI] [PMC free article] [PubMed] [Google Scholar]
Recommendations for preventive pediatric health care. 2019. Itasca (IL): Bright Futures / American Academy of Pediatrics; [accessed 2019 July 6]. https://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf. [Google Scholar]
Sengupta N, Nanavati S, Cericola M, Simon L. 2017. Oral health integration into a pediatric practice and coordination of referrals to a colocated dental home at a federally qualified health center. Am J Public Health. 107(10):1627–1629. [DOI] [PMC free article] [PubMed] [Google Scholar]
Silk H, Sachs Leicher E, Alvarado V, Cote E, Cote S. 2018. A multi-state initiative to implement pediatric oral health in primary care practice and clinical education. J Public Health Dent. 78(1):25–31. [DOI] [PubMed] [Google Scholar]
Stearns SC, Rozier RG, Kranz AM, Pahel BT, Quinonez RB. 2012. Cost-effectiveness of preventive oral health care in medical offices for young Medicaid enrollees. Arch Pediatr Adolesc Med. 166(10):945–951. [DOI] [PMC free article] [PubMed] [Google Scholar]
Wasserstein RL, Lazar NA. 2016. The ASA’s statement on P-values: context, process, and purpose. Am Stat. 70(2):129–133. [Google Scholar]
Watt RG, Daly B, Allison P, Macpherson LM, Venturelli R, Listl S, Weyant RJ, Mathur MR, Guarnizo-Herreño CC, Celeste RK, et al. 2019. Ending the neglect of global oral health: time for radical action. Lancet. 394(10194):261–272. [DOI] [PubMed] [Google Scholar]
Zhu Y, Close K, Zeldin L, White B, Rozier RG. 2018. Implementation of oral health screening and referral guidelines in primary health care. JDR Clin Trans Res. 4(2):167–177. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

DS_10.1177_0022034520916161 – Supplemental material for Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits?

Click here for additional data file.^{(87.4KB, pdf)}

[bibr1-0022034520916161] Arthur T, Rozier RG. 2016. Provision of preventive dental services in children enrolled in Medicaid by nondental providers. Pediatrics. 137(2):e20153436. [DOI] [PubMed] [Google Scholar]

[bibr2-0022034520916161] Bernstein J, Gebel C, Vargas C, Geltman P, Walter A, Garcia RI, Tinanoff N. 2016. Integration of oral health into the well-child visit at federally qualified health centers: study of 6 clinics, August 2014–March 2015. Prev Chronic Dis. 13:E58. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr3-0022034520916161] Byrd VLH, Dodd AH. 2012. Assessing the usability of encounter data for enrollees in comprehensive managed care across MAX 2007–2009. Princeton (NJ): Mathematica Policy Research; [accessed 2020 Feb 14]. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/Downloads/MAX_IB_15_AssessingUsability.pdf [Google Scholar]

[bibr4-0022034520916161] Clark M, Quinonez R, Bowser J, Silk H. 2017. Curriculum influence on interdisciplinary oral health education and practice. J Public Health Dent. 77(3):272–282. [DOI] [PubMed] [Google Scholar]

[bibr5-0022034520916161] Clark MB, Slayton RL; Section on Oral Health. 2014. Fluoride use in caries prevention in the primary care setting. Pediatrics. 134(3):626–633. [DOI] [PubMed] [Google Scholar]

[bibr6-0022034520916161] Crall JJ, Pourat N, Inkelas M, Lampron C, Scoville R. 2016. Improving the oral health care capacity of federally qualified health centers. Health Aff (Millwood). 35(12):2216–2223. [DOI] [PubMed] [Google Scholar]

[bibr7-0022034520916161] de Sousa FSO, Dos Santos APP, Nadanovsky P, Hujoel P, Cunha-Cruz J, Oliveira BH. 2019. Fluoride varnish and dental caries in preschoolers: a systematic review and meta-analysis. Caries Res. 53(5):502–513. [DOI] [PubMed] [Google Scholar]

[bibr8-0022034520916161] dela Cruz GG, Rozier RG, Slade G. 2004. Dental screening and referral of young children by pediatric primary care providers. Pediatrics. 114(5):e642–e652. [DOI] [PubMed] [Google Scholar]

[bibr9-0022034520916161] Dooley D, Moultrie NM, Heckman B, Gansky SA, Potter MB, Walsh MM. 2016. Oral health prevention and toddler well-child care: routine integration in a safety net system. Pediatrics. 137(1). doi: 10.1542/peds.2014-3532. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr10-0022034520916161] Economic Research Service. 2016. 2013 rural-urban continuum codes. Washington (DC): US Department of Agriculture; [accessed 2019 July 6]. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/ [Google Scholar]

[bibr11-0022034520916161] Geiger CK, Kranz AM, Dick AW, Duffy E, Sorbero M, Stein BD. 2019. Delivery of preventive oral health services by rurality: a cross-sectional analysis. J Rural Health. 35(1):3–11. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr12-0022034520916161] Healthy People. 2020. Oral health. Washington (DC): US Department of Health and Human Services; [accessed 2020 Feb 14]. https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Oral-Health/data. [Google Scholar]

[bibr13-0022034520916161] Herndon JB, Tomar SL, Catalanotto FA, Vogel WB, Shenkman EA. 2015. The effect of Medicaid primary care provider reimbursement on access to early childhood caries preventive services. Health Serv Res. 50(1):136–160. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr14-0022034520916161] Huber PJ. 1992. Robust estimation of a location parameter. In: Kotz S, Johnson NL, editors. Breakthroughs in statistics. New York (NY): Springer; p. 492–518. [Google Scholar]

[bibr15-0022034520916161] Kranz AM, Duffy E, Dick AW, Sorbero M, Rozier RG, Stein BD. 2019. Impact of Medicaid policy on the oral health of publicly insured children. Matern Child Health J. 23(1):100–108. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr16-0022034520916161] Kranz AM, Preisser JS, Rozier RG. 2015. Effects of physician-based preventive oral health services on dental caries. Pediatrics. 136(1):107–114. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr17-0022034520916161] Kranz AM, Rozier RG, Preisser JS, Stearns SC, Weinberger M, Lee JY. 2015. Examining continuity of care for Medicaid-enrolled children receiving oral health services in medical offices. Matern Child Health J. 19(1):196–203. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr18-0022034520916161] Luu H, Slavova S, Freeman PR, Lofwall M, Browning S, Bush H. 2019. Trends and patterns of opioid analgesic prescribing: regional and rural-urban variations in Kentucky from 2012 to 2015. J Rural Health. 35(1):97–107. [DOI] [PubMed] [Google Scholar]

[bibr19-0022034520916161] Medicaid Analytic eXtract. 2019. Minneapolis (MN): Research Data Assistance Center; [accessed 2019 July 6]. https://www.resdac.org/cms-data/files/max-ot. [Google Scholar]

[bibr20-0022034520916161] Moyer VA. 2014. Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement. Pediatrics. 133(6):1102–1111. [DOI] [PubMed] [Google Scholar]

[bibr21-0022034520916161] Okunseri C, Szabo A, Jackson S, Pajewski NM, Garcia RI. 2009. Increased children’s access to fluoride varnish treatment by involving medical care providers: effect of a Medicaid policy change. Health Serv Res. 44(4):1144–1156. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr22-0022034520916161] Periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. 2018. Chicago (IL): American Academy of Pediatric Dentistry; [accessed 2019 July 6]. http://www.aapd.org/media/Policies_Guidelines/BP_Periodicity.pdf. [PubMed] [Google Scholar]

[bibr23-0022034520916161] Policy on early childhood caries: classifications, consequences, and preventive strategies. 2016. Chicago (IL): American Academy of Pediatric Dentistry; [accessed 2019 July 6]. https://www.aapd.org/globalassets/media/policies_guidelines/p_eccclassifications.pdf. [PubMed] [Google Scholar]

[bibr24-0022034520916161] Pourat N, Martinez AE, Crall JJ. 2015. Better together: co-location of dental and primary care provides opportunities to improve oral health. Los Angeles (CA): UCLA Center for Health Policy Research; [accessed 2019 July 6]. http://healthpolicy.ucla.edu/publications/Documents/PDF/2015/Dental-brief-sep2015.pdf [PubMed] [Google Scholar]

[bibr25-0022034520916161] Quinonez RB, Kranz AM, Lewis CW, Barone L, Boulter S, O’Connor KG, Keels MA. 2014. Oral health opinions and practices of pediatricians: updated results from a national survey. Acad Pediatr. 14(6):616–623. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr26-0022034520916161] Recommendations for preventive pediatric health care. 2019. Itasca (IL): Bright Futures / American Academy of Pediatrics; [accessed 2019 July 6]. https://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf. [Google Scholar]

[bibr27-0022034520916161] Sengupta N, Nanavati S, Cericola M, Simon L. 2017. Oral health integration into a pediatric practice and coordination of referrals to a colocated dental home at a federally qualified health center. Am J Public Health. 107(10):1627–1629. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr28-0022034520916161] Silk H, Sachs Leicher E, Alvarado V, Cote E, Cote S. 2018. A multi-state initiative to implement pediatric oral health in primary care practice and clinical education. J Public Health Dent. 78(1):25–31. [DOI] [PubMed] [Google Scholar]

[bibr29-0022034520916161] Stearns SC, Rozier RG, Kranz AM, Pahel BT, Quinonez RB. 2012. Cost-effectiveness of preventive oral health care in medical offices for young Medicaid enrollees. Arch Pediatr Adolesc Med. 166(10):945–951. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bibr30-0022034520916161] Wasserstein RL, Lazar NA. 2016. The ASA’s statement on P-values: context, process, and purpose. Am Stat. 70(2):129–133. [Google Scholar]

[bibr31-0022034520916161] Watt RG, Daly B, Allison P, Macpherson LM, Venturelli R, Listl S, Weyant RJ, Mathur MR, Guarnizo-Herreño CC, Celeste RK, et al. 2019. Ending the neglect of global oral health: time for radical action. Lancet. 394(10194):261–272. [DOI] [PubMed] [Google Scholar]

[bibr32-0022034520916161] Zhu Y, Close K, Zeldin L, White B, Rozier RG. 2018. Implementation of oral health screening and referral guidelines in primary health care. JDR Clin Trans Res. 4(2):167–177. [DOI] [PubMed] [Google Scholar]

PERMALINK

Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits?

AM Kranz

RG Rozier

BD Stein

AW Dick

Abstract

Introduction