The Einstein Series
A Conversation With Burton L. Edelstein, DDS, MPH
The founder of the Children's Dental Health Project talks candidly about the what progress has been made in improving access to care for underserved children.
INSIDE DENTISTRY (ID): Dr. Edelstein, your contributions are extensive, but none as large as the Children's Dental Health Project (CDHP), which you founded in 1997. What led you to develop that public policy group?
BURTON L. EDELSTEIN (BE): During my 15-month fellowship as a health Legislative Aide to the US Senate Minority Leader, I gained a hands-on perspective of how Congress and federal agencies do their work. I realized the tremendous potential to improve children's oral health and dental care through the lever of public policy. I also observed how little oral health was understood as essential to children's health and welfare. For example, during my fellowship, Congress determined that dental care for children was an "optional" service in CHIP (the Children's Health Insurance Program). Working with colleagues from across dentistry, medicine, and child advocacy, I founded CDHP to represent the oral health interests of children and families in federal and state actions. We have succeeded beyond all expectations—among our signature successes are our leadership roles in making pediatric dental care now mandatory in CHIP and in Healthcare Reform to provide dental insurance to over 10 million previously uninsured children.
ID: Has the situation measurably changed? Do we need a CDHP as much today as when you founded it?
BE: Yes, much has changed for the better. CDHP, in collaboration with a wide variety of partners, has firmly established pediatric oral health as an important issue for federal and state policymakers. In addition to securing private and public dental coverage for millions of children, CDHP was instrumental in initiating a federal grant program for states to improve dental access; securing authority for expanded evidence-based caries management studies; expanding federal support for dental training; and promoting the dental home concept from early in life. We also work closely with federal agencies on Medicaid and CHIP policy.
CDHP also manages programs that assist professional associations, advocacy groups, trade associations, and state officials. We are the federally designated National Maternal and Child Oral Health Policy Center, the technical assistance agency for state dental directors, and the managers of national programs targeting perinatal and adolescent populations. Now that policymakers "get it" about children's oral health, CDHP's role is even more important as an independent, reliable, and research-based organization than when it was founded 14 years ago.
ID: CDHP advocates for a risk-based approach to childhood dental caries prevention. Can you describe what is involved in that approach and any case studies that show its worthiness?
BE: Although decades-old caries science is well understood by dental professionals, it's little known to parents who make day-to-day decisions that directly impact their children's oral health. Children vary considerably in their risk for getting cavities—from virtually no risk at all to extreme risk. Yet our prevention programs typically treat all children alike—for example with six month "recalls." As dentists, we hope that our brief reminders to brush with fluoride and cut down on sugars will do the trick. When they don't, we become frustrated, blame the parent, and get back to filling more cavities. The idea of "risk-based disease management" borrows heavily from medicine, health education, social work, and nutrition to shift gears toward a more intensive behavioral and pharmacologic approach. It involves careful and detailed risk assessment; engendering meaningful behavioral change through techniques like motivational interviewing and peer counseling; and close follow-up with high-risk families, most effectively by lay health workers.
Let's consider an analogy: diabetes is not managed by physicians simply telling patients to watch out for sugar and use their insulin as prescribed. Rather, Certified Diabetes Educators and other medical personnel work intensely with families to figure out how to maintain physiological balance. Children with the highest caries activity need the same kind of tailored disease management that translates sound science into good practice. Great examples include Caries Management by Risk Assessment (CAMBRA), the American Academy of Pediatric Dentistry's new care paths, and the DentaQuest Early Childhood Caries Initiative. The DentaQuest program at Children's Hospital Boston has shown that risk-based disease management can arrest caries, reduce the occurrence of childhood dental pain, cut down on operating room use, and limit cavity recurrence.
ID: Don't most children in general have better oral health today than in the past? Why is CDHP calling for such a strong focus on disease management when the problem appears to be going away on its own?
BE: Their oral health has indeed improved, but too many children—nearly half—still have cavities before starting kindergarten. Low-income children—such as the 40% in Medicaid and the growing populations of minority children—are at far greater risk, yet they have far less access to dental care. Our profession has focused exquisitely on dental repair, but that alone isn't working for too many children. For example, more than half of young children treated in the operating room for early childhood caries develop new cavities within 2 years. CDHP has successfully advocated for evidence-based caries management, early care, expanded roles for physicians and health educators, and prevention that is tailored to risk. We work to put the dollars, training, and incentives in place to help dentistry keep moving closer to adopting risk-based disease management.
ID: Does risk-based care change the venue where care is delivered or who delivers it?
BE: It certainly could. Disease management efforts have been successfully implemented in early childhood venues including Head Start and WIC nutrition programs. Using learning technologies that assure fidelity to cariology science, dental and non-dental personnel could work intimately with individual families—inside or outside of dental offices— to change behaviors appropriate to risk. NIH currently supports the development of such technologies at Columbia University to allow caries management to take place in medical offices, safety net clinics, community-based early childhood programs, and homes as well as in dental offices.
ID: In February 2007, Deamonte Driver died of a brain abscess caused by an infected tooth, putting a face to childhood caries. What data do we have to better understand the prevalence of this disease?
BE: The most valuable data come from a national survey that includes detailed visual dental examinations by dentists, the CDC's National Health and Nutrition Examination Survey (NHANES). For methodological reasons and because radiographs are not taken, the findings tend to be understated. Nonetheless, this survey finds that 11% of 2-year-olds, 21% of 3-year-olds, 34% of 4-year-olds, and 44% of 5-year-olds have visible cavities, and the percentages keep climbing with age. Three quarters of early childhood decay hasn't been treated. Low-income and minority children have the highest rates of disease and lowest access to dental care, even by pediatric dental specialists. Nationally, the ADA reports that about 6% of general dentists' patients and 18% of pediatric dentists' patients are insured by Medicaid and CHIP, although 40% of all children are in these programs. Only one in 10 practicing dentists has a patient following that is 30% Medicaid or more. These data confirm the disparities that leave millions of children with dental problems that could be almost completely avoided.
ID: In a 2009 JADA article, you wrote that "the true impact of a disease lies outside the realm of direct medical care delivery."1 Can you comment on the non-biological factors of ECC and the work being done to understand them?
BE: Dental caries is a classic chronic disease with social as well as biological determinants. Its social correlates include low income, minority status, and low parental education. Landmark studies on social determinants by Thomson and others have shown that declines or improvements in social standing are tightly linked with caries risk and incidence. The JADA article demonstrated that childhood dental caries is truly consequential to the lives of many children and that these consequences ripple throughout families and communities.
ID: School performance is often cited as a consequence of childhood caries. What do we know about this problem?
BE: Most typically, the effect is subtle. Teachers report that children who experience intermittent dental symptoms are distracted from learning. But it can also be quite overt. Children with acute dental pain and infection often have diminished capacity for the basic functions of eating, sleeping, speaking, and certainly attending to learning. Educational sociologist Jonathan Kozol, in his landmark study of children in poverty, notably observed that: "Children get used to feeling constant pain. They go to sleep with it. They go to school with it… Children live for months with pain that grown ups would find unendurable. The gradual attrition of accepted pain erodes their energy and aspiration."2
ID: Another sequela of ECC is the increased use of the hospital emergency room as a treatment of last resort. How prevalent is this practice and what's the cost to the medical system?
BE: Most importantly, it is far too prevalent given two key facts. First, tooth decay is overwhelmingly preventable and shouldn't ever progress to the point where a child heads to the ER. Second, hospital ERs have almost nothing definitive to offer children who suffer from ECC. All they can typically advise is taking prescription medications for pain and infection and finding a dentist to provide definitive care. Finding a dentist for a young child with severe caries, particularly if that child is on public insurance, is often the hardest of the recommendations to follow.
A 2010 study of hospital ER visits for dental caries reports conservatively (compared to prior studies) that 25,000 children under 18 years of age in 2006 presented to the nation's ERs at a cost of nearly $15 million—all for essentially palliative care.3 Demonstrating how severe the need can be, in 2009 an emergency medicine training program in Maine was featured in the press for training medical residents to provide dental extractions.4
ID: Also, patients seen in the ER simply get returned to the delivery system that failed them in the first place. What solutions are you advocating to help improve this?
BE: The ultimate solution is to prevent the problem in the first place through early parental education. That's why CDHP secured a provision in the CHIP law that now requires payers of birth services to provide information—at the time of birth—to poor and low-income parents about ECC prevention and the need for early care. The next key solution is to identify those children at greatest risk and to manage that risk so that they don't develop cavities that will need repair. That's why CDHP worked to secure additional provisions in health reform that authorize grants for "research-based dental caries disease management;" establish a national 5-year public oral health education campaign with an ECC focus; and promote more attention to caries management in dental training programs. Finally, the supply of dental care available to families with public insurance needs to be markedly improved through payment, training, workforce, and delivery fixes. CDHP has successfully obtained federal support for each of these approaches as well—in the Clinton-era CHIP program, the Bush-era Safety Net Improvement Act, and the Obama-era health reform.
ID: The Great Recession of the last few years must have exacerbated the lack of access to dental care, with families struggling to make ends meet and high unemployment rates. What affect have you seen on children's dental health that you can attribute to the economic plight of the country?
BE: It is hard to tell with any precision, because data won't be available until well after the fact. But here's what we do know. Medicaid and CHIP are "countercyclical" programs—they expand dramatically because of unemployment when the economy is down. Yet these expansions occur just as states are struggling with their budgets because tax revenues are also down. So we have a perfect storm of more people on public insurance just when government has the least funds available. In these times, optional programs—including adult dental care in Medicaid—get cut. But states can't cut dental care for children in Medicaid. Some observers have suggested that during these stressed economic times, more dentists are accepting children with public insurance to help fill chair time that is opened up by higher income families who are deferring dental care while riding out the recession.
ID: What has been your organization's advocacy for improving funding streams for dentist Medicaid reimbursement?
BE: CDHP prides itself on being research-based, non-partisan, and as objective as we can be in pursuing our vision of achieving oral health for all children to ensure that they reach their full potential. So when it comes to Medicaid payments, we started at the beginning, by closely studying the relationship between Medicaid fees and children's use of dental care. Without question, adequate payments that reflect the market are essential—and legally required—to ensure equitable access. Higher payments relate to more dentists participating and more children being served. But what is curious about dentistry—and different than pediatric and family medicine—is how few practitioners participate and how few children get served even after meaningful fee fixes. This suggests that fee fixes are an essential but not sufficient condition to improve access. So CDHP's position has been strongly in support of payments that reflect the market while also addressing the many other barriers that keep kids from care—barriers on both the dentists' and parents' side of the equation.
ID: What is your perspective on the dental provisions in the healthcare reform package and how will those affect the lack of access to dental care?
BE: Together with dental groups and family advocates, CDHP ensured that dental provisions are included throughout the Affordable Care Act (ACA). (The 22 dental provisions are summarized on our website at www.cdhp.org under CDHP's Healthcare Reform Center box.)
ACA is most centrally a coverage bill, and coverage is often the first step to gaining access. We are thrilled that children's dental services are covered in ACA's "essential benefit package." As a result, almost every American child will now have access to either private or public dental insurance. When CDHP began, there were over 25 million children without dental coverage. Now, 14 years later, access is markedly improved. The great disappointment is that Congress did not include at least emergency relief of dental pain and infection for adults.
ID: Many would ask how we are going to pay for all this expanded care and programming, as states are cutting back on services across the board?
BE: Indeed, the recession is causing states to cut back wherever they can. Because children's dental coverage in Medicaid and CHIP is required of states, they will not be cut. The concern is that adult dental services in Medicaid—because they are optional—will erode or disappear entirely.
ACA does help some families who were already eligible for Medicaid and CHIP to enroll, but we expect relatively few new children to join public programs because of ACA. Rather, private coverage that will be purchased by families through the new State Insurance Exchanges will have to include dental coverage for children. Payment will be made by the families for this coverage, not by government (although some federal subsidies will be available to families at the edge of low-income).
ID: Have you been surprised over the public reaction to the implementation of the health bill? What do you make of the debate to repeal portions of the bill?
BE: In all fairness, ACA is of necessity multifaceted—because healthcare in the United States is multifaceted. And the public, rightfully, has little tolerance for details. To make matters worse, I don't think the reform has been well explained by the Administration or by Congress. The simple message that this bill keeps people insured, staves off medical bankruptcy, and improves the delivery of care hasn't been well stated. So, no, I'm not surprised that politicians have made inappropriate election-time controversy out of it nor that the public is confused and upset. I don't expect to see repeal but do anticipate a great deal of heated debate and some serious efforts to limit or stop funding for a variety of programs created by the law.
ID: What are you seeing on the horizon in terms of opportunities or challenges for the profession?
BE: Technology—both clinical and communications—will either integrate or marginalize dentistry from the larger healthcare environment. The future is clearly "virtual," and "systems of care" will rely upon computers and telecommunication as much as bricks and mortar. The Federal HITECH law that incentivizes healthcare providers (including dentists) to adopt advanced health information records and exchanges is likely to pass dentistry by, leaving it outside of organized systems of healthcare just when dentists are more aware of medical–dental interactions. While medicine is preparing to adopt technological changes, dentistry has yet to develop a single certified software system.
Workforce—both traditional and novel—will likely develop along with technology. The advent of telemedicine combined with sophisticated mobile dental equipment raises a number of possibilities for effective delegation and distribution of services. Advanced dental disease management—the kind that effectively assesses risk and individualizes disease suppression in addition to traditional repair—will gradually move dentistry into an increasingly medical rather than surgical mode. This transition is underway and has been very slow in coming, but will gain a boost from payers of services who have the most to gain from appreciating that better health at a lower cost is possible.
I anticipate a resurgence of group practices, stimulated this time not by philosophy or business–think (as was the case in the 1960s and 1970s), but by a changing generational demographic of new dentists, many of whom see their careers far differently than we did in the past. Increasing numbers of women and men who want to balance family and work; continually rising student debt; desire to share responsibility and reduce business roles; and a generational interest in multiple careers over a lifetime may all instigate more rapid growth of large groups managed by business experts. What I don't see, unless many people continue to work hard at it, is greater equity in dental care. None of these changes will inherently move the profession toward focusing its capacities on those with the greatest oral health needs.
ID: If you could change one thing about dentistry in the United States, what would it be?
BE: Equitable distribution of dental services.
ID: You spent time in Senator Daschle's office during your Robert Wood Johnson Fellowship working on health policy. What was that experience like and what was the most important thing you learned?
BE: The experience was intensive, fascinating, dynamic, and challenging. What I learned is that the overwhelming majority of members of Congress and their staffs work extraordinarily hard; that government does respond to the public; and that meaningful positive change is always hard won.
ID: Can you tell us about that key challenge or turning point for you?
BE: There have been plenty in personal life but let's stick to policy. A critical bruise that taught me much about policymaking occurred during an early visit to Congress representing the American Academy of Pediatric Dentistry. During my visit, a senior and powerful member of Congress told me simply, "I understand your problem. What do you want me to do about it?" Having no worthy answer, I headed home chastened and aware that real change would require real work.
ID: You spent time in Senator Daschle's office during your Robert Wood Johnson Fellowship working on health policy. What was that experience like and what was the most important thing you learned?
BE: The experience was intensive, fascinating, dynamic, and challenging. What I learned is that the overwhelming majority of members of Congress and their staffs work extraordinarily hard; that government does respond to the public; and that meaningful positive change is always hard won.
ID: What's the best piece of advice you ever got?
BE: "Be honest and persistent and let the chips fall as they may."
References
1. Casamassimo PS, Thikkurissy S, Edelstein BL, Maiorini E. Beyond the dmft. The human and economic cost of early childhood caries. J Am Dent Assoc. 2009;140(6):650-657.
2. Kozol J. Savage Inequalities. New York: Harper Perennial; 1992:20-21.
3. Nalliah RP, Allareddy V, Elangovan S, et al. Hospital based emergency department visits attributed to dental caries in the United States in 2006. J Evid Based Dent Pract. 2010;10(4):212-222.
4. Zezima K. Short of dentists, Maine adds teeth to doctors' training. New York Times. March 3, 2009:A12.
About the Interviewee
Burton L. Edelstein, DDS, MPH, is a Professor of Dentistry in the College of Dental Medicine and Health Policy & Management in the Mailman School of Public Health, Columbia University. A board-certified pediatric dentist, he is Chairman of Social and Behavioral Sciences in the dental school. Dr. Edelstein is also the president of the Children's Dental Health Project, a DC-based policy organization that promotes federal and state legislation and programs to improve children's oral health. After 22 years of private practice, his career switched to health policy as a Robert Wood Johnson Foundation Health Policy Fellow in the US Senate. From 1998 to 2001, he worked with the US Department of Health and Human Services on its oral health initiatives, chaired the US Surgeon General's Workshop on Children and Oral Health, and authored the child section of the US Surgeon General's Report on Oral Health in America. Dr. Edelstein currently serves as the designated dental expert on the Congressional Medicaid and CHIP Payment and Access Commission (MACPAC), which advises Congress on public insurance policy.
