A 2011 study from the University of Michigan’s Department of Orthodontics reflects on the problem of caries in children undergoing orthodontic treatment: “This widespread problem…is an alarming challenge and warrants significant attention from both patients and providers that should result in greatly increased emphasis on effective caries prevention.” In 2013, leading authorities from Baylor University commented that “Orthodontists need to be mindful of [caries] risk factors when making treatment decisions.” Unanswered is specifically how orthodontists might act on these recommendations—particularly in an era when demography in the United States is shifting toward increasing proportions of low-income and minority children who are enrolled in Medicaid and the Children’s Health Insurance Program that cover orthodontic treatment.
The federal Medicaid authority reports that 43.7 million children—about half of all children and adolescents in the United States—were covered by public insurance in 2014, with the vast majority covered by Medicaid. The American Dental Association’s Health Policy Institute credits expansions in such public coverage with increasing dental utilization by America’s youth, even as dental visits by adults are declining. Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment benefit requires that all medically necessary care be provided to beneficiaries from birth to age 21 years in sufficient “amount, duration, and scope” to meet individual needs. Through this unique benefit, “medically necessary” orthodontic services are mandated. But regulations require states—in consultation with recognized health authorities—to determine the definition of medical necessity and thereby the criteria used to establish eligibility for a given level of malocclusion. As a result, there is tremendous—and biologically implausible—interstate variability in the criteria used to qualify patients for orthodontic care. The federal government also grants states substantial latitude in determining administrative policies including prior authorization processes, payment levels, payment mechanisms, contracting arrangements, and reporting. As a result, there is also tremendous—and economically implausible—variability in payment rates and submission procedures.
The U.S. Centers for Disease Control and Prevention reports that African American and Latino children experience higher caries rates than do white children. Because more African American and Latino children are enrolled in public insurance, America’s orthodontists can expect to see more Medicaid children and youth who have both orthodontic and caries challenges enrolled in the Children’s Health Insurance Program.
Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment program benefit is broad enough to ensure management of both malocclusions and caries. How, then, might Medicaid’s orthodontic services be enhanced to meet beneficiaries’ needs, improve their treatment experiences, create better outcomes, and even lower reparative dental costs as suggested by the “triple aim” that envisions improved health outcomes at reduced cost with improved patient experience?
Needed now is a policy across the United States that ensures enhanced dental prevention benefits for publicly insured children undergoing orthodontic care. Increasing the frequency of dental prevention visits by primary care dentists, allowing frequent placement of fluoride varnish by orthodontists, and ensuring that these children receive sealants hold real promise to reduce orthodontic-affiliated caries risks and experiences. Many states have already applied similar approaches to combat early childhood caries by empowering medical and dental providers to deliver frequent fluoride varnish treatments. States can now model an orthodontic benefit on this experience.
We recommend the following specific actions to improve the oral health and orthodontic care of Medicaid beneficiaries under the age of 21 years.
Once orthodontic care starts, the orthodontist should coordinate caries management strategies with the primary care dentist to ensure that an individualized caries suppression program is in place that reflects each patient’s level of caries risk and experience and aggressively manages early carious lesions.
State-level orthodontic societies should work closely with their state Medicaid authorities and Medicaid vendors to modify their state’s Early and Periodic Screening, Diagnostic, and Treatment periodicity guidelines so that more frequent caries-management visits by primary care dentists and frequent placement of fluoride varnish by orthodontists are routinely covered benefits paid at reasonable rates.
Orthodontic authorization for patients who do not achieve a satisfactory level of caries risk reduction should be withheld until the risk reduction is demonstrated so that orthodontic treatment does not further exacerbate the caries risk.
Determination of orthodontic visit frequency should incorporate consideration of caries risk so that children with higher risks are seen more frequently whether or not more visits are required for orthodontic considerations alone.
As caries risk-assessment tools become better refined, the state-level approval process for determining Medicaid coverage for orthodontic treatment should incorporate a caries risk-assessment component. Children with high and medium caries risks should have their risks addressed before bonding according to the “care paths” and protocols of the American Academy of Pediatric Dentistry’s Guideline on Caries Risk Assessment and Management for Infants, Children, and Adolescents.
Successful pursuit of these recommendations holds meaningful promise for improving oral health while enhancing the quality of orthodontic treatment so that poor and low-income youth can enjoy all the benefits of orthodontic care.