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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Public Health Dent. Author manuscript; available in PMC Dec 9, 2008.
Published in final edited form as:
PMCID: PMC2597804
NIHMSID: NIHMS29311

PROVIDING A DENTAL HOME FOR PREGNANT WOMEN: A COMMUNITY PROGRAM TO ADDRESS DENTAL CARE ACCESS

Abstract

Objective

This paper describes a community-based intervention to provide a dental home for women covered by Medicaid in Klamath County, Oregon. In 2001, 8.8% of pregnant women served by Medicaid in Oregon received care.

Methods

Pregnant women received home/WIC visits and were assigned a dental home under a dental managed care program (DCO). All initial care was provided at the Oregon Institute of Technology Dental Hygiene Clinic under the contract with the DCO. Emergency, preventive and restorative care was provided.

Result

Between February 2004 and January 2006, 503 pregnant women were identified: 421 women were contactable. Of these, 339 received home visits (339/421, 80.5%) and 235 received care (235/339, 69.3%). Overall, 55.8% of eligible women received care (235/421). Most who did not have a visit either moved or were not the caretaker of the baby. The missed appointment rate was 9%.

Conclusion

A community health partnership led to a successful and sustainable model extending care to pregnant women.

Keywords: Dental care/utilization, prenatal care/utilization, health maintenance organizations

INTRODUCTION

Healthy People 2010 established objectives to reduce disparities among preschool children (1). However, programs aimed at reducing disparities focusing solely on children may fail to identify solutions that enhance access. An alternative is to focus on the association between mother and child. When low-income pregnant women and mothers with infants have regular dental visits, both mother and child should experience benefits (2).

A model of dental prevention and cure is needed that conceptualizes dental caries as an infectious process. From this perspective, dental care would focus on the reduction of pathogens as well as promoting hygiene and diet protective against disease. To do so means adopting a primary focus on the mother-child dyad, rather than the child alone; and intervening before the child is born. This concept is not new, as evidence for mother to child transmission has been known since the 1970s. Nevertheless, there are no reports in the U.S. literature describing programs to promote the use of dental care during pregnancy (3). New York State recently issued a set of comprehensive guidelines (4). Massachusetts extended Medicaid dental benefits to mothers from pregnancy to three years after the baby is born. This kind of change is an example of the models that are badly needed. A focus on the new mother is also developmentally appropriate, especially for the woman having her first child (5).

This paper describes the initial evaluation of a community-based intervention to provide dental services for low-income pregnant women. The goal is to stimulate discussion about how to best meet the needs of this population. The proportion of low-income Oregon pregnant women on Medicaid who saw a dentist in 2001 was 8.8%.

METHODS

Setting

The setting is Klamath County in rural southeast Oregon. The population in 2003 was 64,769 and growth 2000 to 2003 was 1.6%. The county in 2000 was 87% white, 7.8% Hispanic, 4.2% American Indian or Alaska Native, 0.8% Asian, 0.6% black, and 0.1% Pacific Islander (6). Per capita income in 2000 was $16,719 (16). There is no artificial fluoridation and little naturally occurring fluoride.

Over half (435, 52.0%) of the 836 births in Klamath County in 2003 were covered by the Oregon Health Plan (OHP), the Medicaid program (7). Pregnant low-income women were eligible for the OHP Plus package and paid no premium. The women were covered for the duration of their pregnancy, the month they delivered, and two months afterwards.

Program Description

The goal of the intervention program was to shift the focus of dental professionals and their clients from the existing paradigm of dental services to a model in which the mother was treated in order to prevent infection and disease in the child. The program consisted of outreach and anticipatory guidance to pregnant women served by Medicaid and placement with a dentist. Follow-up was included to be sure that the newborns were seen by age 1.

Program administration was in the Klamath County Health Department and the outreach coordinator (OHSC) was a health department employee. The salary of the outreach coordinator was initially covered by a foundation grant but is sustained locally. To aid in recruitment and coordinate services, the department developed a community health partnership including the Oregon Institute of Technology (OIT), the Women, Infant and Children (WIC) program, Klamath Tribal Health Services, local safety net medical providers, the DCOs and local dentists, and other community agencies working with Medicaid families. The University of Washington Northwest/Alaska Center to Reduce Oral Health Disparities provided technical assistance.

The second trimester was chosen initially as a starting point for care mainly to avoid concerns in the dental community about treatment when the fetus was most vulnerable. Often also women in low-income families either do not know they are pregnant or do not seek prenatal care early in the pregnancy. The eligible pregnant women were identified by the OHP and referrals made from WIC or other partners. Visits with the OHSC were scheduled at WIC. Oral Health Toolkits were provided. The kits were adapted from the Community Health Partners’ Teeth Under Construction program in Washington State (for information on the program, contact Ms. Smolen). Educational material was available in Spanish and English.

Initial contact focused on participation. The focus of subsequent home/WIC visits was on providing information on the mother seeing the dentist and preventing caries transmission. A major goal was to reduce barriers to care. To provide dental coverage, OHP contracted with Dental Care Organizations (DCO). The DCOs serving Klamath County are Northwest Dental Services (NWDS) and Capitol Dental. In 2004 there were 28 active dentists, most in NWDS. The DCOs contracted with the dental hygiene program at OIT. The program provided diagnostic and preventive services: assessment, radiographs, prophylaxis, topical fluoride and chlorhexidine mouth rinse. The hygienist communicated with the treating physician. The two DCOs negotiated a flat fee of $38 with the dental hygiene program. Faculty members or volunteer hygiene students provided care when school was not in session. Once initial care was completed, a staff member picked up the client’s chart and delivered it to the assigned dental office.

Case management focused on reducing no-shows. Follow-up contact with the mother was designed to deliver the additional toolkits (Figure 1). The DCOs’ central staff reviewed many of the treatment plans to provide care appropriate to the program goals. Care included restorative, periodontal and oral surgical services. The focus was on eliminating reservoirs of disease with the extraction of hopeless teeth and filling of open cavities. After delivery, mothers were dispensed xylitol chewing gum at WIC for six months. Fluoridated toothpaste was provided in each of the oral health toolkits. The cost of the preventive agents, not normally covered in a typical Medicaid program, was underwritten by the DCO.

Figure 1
Oral Health Toolkits

Continuing Education

Because a shift in practice patterns cannot occur without confronting the changing scientific evidence, a continuing education program was offered. Sixteen dentists and nine dental hygienists attended. The students received instruction averaging three hours a term as part of a public health program. A major concern was that the medical community was unaware of the need for treatment during pregnancy and that dental care was safe. Continuing medical education, offered as Grand Rounds at the local hospital, identified the goals of treatment and prevention and specified the drugs and procedures such as x-rays used by dentists and their safety.

RESULTS

Between February 2004 and January 2006, 503 pregnant women were identified: 421 women were contacted. Of these, 339 women received home visits (339/421, 80.5%), 235 received care at either OIT or the dentist (235/339, 69.3%), and 220 received care from both (220/339, 64.9%). Overall, 55.8% of eligible women received care (235/421). Most who did not have a visit either moved or were not the caretaker of the baby. The missed appointment rate was 9%.

The typical pregnant woman had eight decayed, missing or filled teeth (range 0-24). Ninety percent had one or more untreated cavities with an average of six (range 0-19). Overall periodontal health was fair. The majority had gingivitis with generalized 1 to 4 mm pockets and bleeding. Fifteen percent had ≥1 teeth with pocket depths > 5 mm. About 4% had moderate or severe disease.

DISCUSSION

The program is on going and the children of the participants in this study are being seen and oral health data is being collected. Ameliorating the high rate of early childhood caries in the children from low-income families is vexing and seemingly impossible without changing the paradigm or treatment model that underlies the approach. The predominant approach in the United States, embodied in the EPSDT program, is to focus on the child alone. Benefits for mothers are much more limited, and practically speaking; dental care is inaccessible because of the concerns of dentists about liability and the low fees in Medicaid adult programs. Work by Kohler and colleagues in Sweden demonstrated several decades ago that treating the mother was an effective ECC prevention strategy (8-11). Similarly, recent data from the North Carolina Medicaid program confirmed that children who receive preventive dental care early in life have lower overall treatment costs (12). In the face of these findings relatively simple treatment of the pregnant woman or new mother plus home visits and intensive preventive treatment of the child may result in improved health. If so, in comparison the typical state Medicaid program is using its resources poorly.

This is a preliminary descriptive report of the program in Klamath County Oregon. The initial two years of this new program were successful in addressing the philosophical change needed to eventually bring about more effective control of caries in children of low-income families and increased access for pregnant low-income women. It is too soon to know if the program has been successful in reducing child disease rates. Nevertheless, the utilization rate for the mothers exceeded the prevailing rate for Medicaid mothers throughout the state by five-to-six fold and it even exceeded the 48% rate for all pregnant women regardless of income. The program demonstrates collaboration between the public (both public health and dental education) and private sector care providers (13). A community health partnership is in place to serve as the champion of this change. Dentists, dental hygienists, and physicians were trained. An outreach and case management system was put in place that identified and served pregnant women. All of the women were assigned a dentist.

The community health partnership identified sustainability as an important issue to be addressed during the early part of the grant support. Major progress has been made in that support for the outreach position is likely to be assumed by the DCOs. Also WIC staff, already also part of the Health Department, can assume greater responsibility for some aspects of outreach. As long as the adult benefits in the OHP are maintained, provision of care for the pregnant women can be sustained. However, the participants are vigilant because the adult dental coverage is often viewed as elective by state legislators. Thus, if current benefits hold this program should be sustainable.

Acknowledgments

Supported, in part, by a grant from the Robert Wood Johnson Foundation to the State of Oregon and Grant No. U54 DE 014254 from the NIDCR/NIH.

Footnotes

Reprints requests to: Dr. Milgrom

References

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