This issue's policy forum focuses on initiatives that promote oral health and on challenges the state currently faces. Commentaries discuss new practice models and trends in dental practice, dentist workforce numbers, the East Carolina University School of Dental Medicine education model, and insurance innovation in dental coverage. Several articles focus on access to oral health care in specific populations including children, adult Medicaid recipients, and people with special needs. Original articles examine reasons for tanning bed use among community college students and evaluate the effectiveness of mailed interventions to increase colon cancer screening.
Access to Dental Health Care for Children in North Carolina
Oral health is an essential part of overall health and commonly affects nutrition and overall quality of life. In general, the oral health of most Americans and utilization of dental services for the general population has improved over past decades, yet considerable disparities in access to dental care services remain [1,2].
Despite this promising trend, a significant number of children experience dental caries and have low dental care utilization rates. Children from low-income families experience higher rates of dental disease, have a higher percentage of unmet dental needs, and have significantly lower utilization of dental services than children not living in poverty . Inadequate access to dental care is common among populations living in poverty and has been documented by numerous national and state reports including the US Government Accountability Office  and the Surgeon General .
In addition to lower socioeconomic status, minority race has also consistently been identified as an independent risk factor for children to not visit the dentist . Identifying and reaching out to low-income populations and other at-risk populations to address oral health problems early is important for both ensuring overall health and controlling the cost associated with treating severe dental disease.
Since the early 1990s, low-income parents and racial and ethnic minorities have identified access to oral health services as their number one child health concern . This concern is substantiated by research. In the late 1980s, a national study found that 66% of children living in poverty between the ages of 2 and 4 had not had a dental visit during the preceding year . Results from the 2003-2004 National Survey of Children’s Health indicated that only 4.8% of white children aged 0-17 did not have a preventive dental visit in the previous year compared to 11.8% of Latino children and 11.3% of African American children .
The major barrier low-income parents face in obtaining needed dental care for their children is lack of financial resources . Other barriers include low numbers of dentists accepting Medicaid patients, long waiting periods for appointments, extensive travel time to appointments in rural areas, and lack of awareness about dental care needs [6, 9].
Factors found to significantly affect dental utilization for children 5-18 years of age include race of the child, household income, parental education, parental employment, insurance sta¬tus of the parents, preventive behaviors of the parents, and access to dental care for the parents . Edelstein and colleagues  analyzed data from the 1996 federal Medical Expenditures Panel Survey to determine the percentage of children that obtained a dental visit and the number of visits children experienced by age, sex, ethnic/racial background, family income, and parental education. They concluded that, overall, just 43% of all children ages 0-18 years obtained at least 1 dental visit in 1996. Among the children who saw a dentist, the average number of visits was 2.7. Low income, low education, and minority status were all associated with lower numbers of visits per child.
Addressing Access to Care Barriers in North Carolina
Access to dental care in North Carolina is largely dependent on workforce availability, insurance coverage, and socioeconomic factors. Therefore, dental education, proper distribution of the dental workforce, expansion of insurance coverage, and outreach are critical to ensuring access to care for North Carolina citizens.
The Medicaid Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program recommends screening and referral for oral health care for all eligible children by age 3. Regrettably, the EPSDT program has fallen short of this goal. Nationwide, less than one one-third of eligible children under age 5 received dental services in fiscal year 2007 . While oral health care services are a required service for most Medicaid-eligible children as a required component of the EPSDT guidelines, it is an optional service for the adult population.
Despite falling short of this goal, North Carolina has made great progress toward improving dental coverage for underserved populations through improved Medicaid reimbursement. Medicaid reimbursement rates for dental services steadily increased about 31% per unit of dental service between 2002 and 2005 . During this same timeframe, dentist participation in the Medicaid program has also increased. Educating families about how to enroll in and access the Medicaid system, streamlining Medicaid administrative procedures, and adjusting provider reimbursement could facilitate broader access to dental care.
As noted by Fraher and colleagues in this issue of the NCMJ, North Carolina’s dentist to population ratio is 4.4 dentists per 10,000 population compared to the national average of 6.0 dentists per 10,000 population, and 4 counties currently report no dentist practicing within their borders . The University of North Carolina at Chapel Hill trains an estimated 75-80 students per year with plans to increase the class size to 100. For years, North Carolina had just 1 dental school; however, in 2012, the East Carolina University School of Dental Medicine opened its doors, welcoming an inaugural class of 50 dental students. This collective effort to train more dentists in North Carolina has the potential to nearly double the number of dentists trained yearly within the borders of the state.
With water fluoridation and increased use of sealants, the overall dental health of North Carolina’s population has improved significantly, but several barriers to access to care remain. Although North Carolina has made clear strides in addressing issues that hinder access to care, there is still significant room for improvement. Dental service utilization for the Medicaid population still lags behind some national averages for higher income populations. While it is encouraging that North Carolina continues to educate and train more dentists, and in fact, is enhancing these efforts, steps must be taken to retain and adequately distribute dentists in order to ensure improved access for North Carolina’s youngest citizens.
Potential conflicts of interest. J.Y.L. has no relevant conflicts of interest.
1. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Washington, DC: US Department of Health and Human Services; 2000.
2. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/nchs/nhanes.htm. Accessed May 15, 2011.
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4. US General Accounting Office. Children’s Dental Services under the Medicaid Program. Washington, DC: United States Government Printing Office; 2000.
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6. Jones CM, Tinanoff N, Edelstein BL, et al. Creating partnerships for improving oral health of low-income children. J Public Health Dent. 2000;60(3):193-196.
7. National Center for Education in Maternal and Child Health. Oral Disease: A Crisis Among Children in Poverty. Washington, DC: US Department of Health and Human Services; 1998.
8. Flores G, Tomany-Korman SC. Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children. Pediatrics. 2008;121(2):e286–e298.
9. Edelstein BL, Douglass CW. Dispelling the myth that 50 percent of U.S. schoolchildren have never had a cavity. Public Health Rep. 1995;110(5):522-530.
10. Hayward RA, Meetz HK, Shapiro MF, et al. Utilization of dental services: 1986 patterns and trends. J Public Health Dent. 1989;49(3):147-152.
11. Centers for Medicare & Medicaid Services. 2008 National Dental Summary. Washington, DC: US Department of Health and Human Services; 2008. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Downloads/2008-National-Dental-Sum-Report.pdf. Accessed May 15, 2011.
12. North Carolina Institute of Medicine. 2005 North Carolina Oral Health Summit: Access to Dental Care. Summit Proceedings and Action Plan. Durham, NC: North Carolina Institute of Medicine; 2005. http://www.nciom.org/wp-content/uploads/NCIOM/projects/dental/2005dentalupdate.pdf. Accessed April 8, 2012.
13. Fraher E, McGee V, Hom J, Lyons J, Gaul K. We’re Not Keeping Up with the Joneses: North Carolina Has Fewer Dentists per Capita Than Neighboring (and Most Other) States. N C Med J. 2011;73(2):XXX-XXX (in this issue).
Jessica Y. Lee DDS, MPH, PhD associate professor, Department of Pediatric Dentistry, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina.
Address correspondence to Dr. Jessica Y. Lee, 228 Brauer Hall, CB# 7450, Department of Pediatric Dentistry, University of North Carolina-Chapel Hill, Chapel Hill, NC 27599 (firstname.lastname@example.org).