Dental disorders

Costs and Benefits of Early Dental Visits

CHALANDA JONES, MD

Dr Jones is a pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Charles A. Pohl, MD––Series Editor:Dr Pohl is professor of pediatrics and senior associate dean of student affairs and career counseling at Jefferson Medical College in Philadelphia, Pennsylvania.

 

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A new analysis finds that more preventive pediatric dental visits do not shrink overall health costs, but that early preventive services do improve children’s oral health and reduce the need for nonpreventive care later.

The American Dental Association, the Academy of General Dentistry, and the American Academy of Pediatric Dentistry are united in encouraging parents to establish a dental home for their child by his or her first birthday.1 Early preventive dental visits have been shown not only to reduce dental disease,2 but also to reduce health care expenditures. For example, a highly regarded and widely cited 2004 study by Savage and colleagues3 showed that dental costs for Medicaid-eligible children who began dental visits between the ages of 1 and 2 years were approximately 60% of the cost for children who began seeing a dentist between the ages of 4 and 5 years.3

However, Sen and colleagues4 reported in May 2013 that reanalysis of Savage’s study data actually may show that children who received preventive visits before the age of 1 year had no statistical difference in subsequent dental outcomes compared with the rest of the sample. Sen et al also reported that children who received their first preventive visit either between 1 and 2 years of age or between 2 and 3 years of age had significantly higher use of restorative and emergency dental services compared with children who had their first preventive visit at 3 years of age or later.

Sen and colleagues investigated whether children’s who received preventive dental care had reduced need for nonpreventive dental services compared with children who received no preventive dental care. The authors say their article is the first in the pediatric preventive dental care literature that uses established econometric techniques to control for unmeasured differences among children that underlie the selection problem inherent in previous studies.

STUDY METHODS

The study population was derived from enrollees in ALL Kids, which is Alabama’s Children’s Health Insurance Program (CHIP). ALL Kids requires no copayments for preventive and diagnostic dental care and provides coverage for Alabamians younger than 19 years of age with family incomes from 101% to 300% of the federal poverty level.

Data were collected over a 2-year period, with a minimum requirement of 3 years of continuous enrollment in ALL Kids and no gaps in coverage greater than 1 month. A further inclusion criterion was the absence of any dental claims beyond preventive care in the first year of continuous enrollment.

Data were analyzed using what is referred to in econometrics as the individual fixed effect (FE) specification model. In this method, each child essentially is used as his or her own control, allowing researchers to test whether a given child has different levels of nonpreventive dental visits or expenditures after the years in which he or she had more preventive dental visits compared with the years in which that child had fewer visits or none at all. Models were estimated separately for children younger than 8 years of age (n=14,972, representing 34,491 pooled child-year observations) and children 8 or older (n=21,833, representing 76,716 pooled child-year observations).

RESULTS

The results obtained using the FE model showed that having 1 or more preventive dental visits in the past year (compared with no visits) was associated with fewer nonpreventive visits for children in the younger and older groups alike, and having more preventive visits was associated with lower subsequent nonpreventive expenditures in both age groups. These results differed from those obtained when the authors analyzed the same data using what they termed the “naive” model, which did not control for unmeasured differences among children. The authors proposed that the contrasting results indicated the presence of time-invariant, child-specific confounders, affirming that estimates from the naive model were biased and yielded little useful information about the effectiveness of preventive dental visits.

The substantial differences in estimates from the FE model versus the naive specifications emphasize the limitations of previous studies (including that of Savage et al3), which failed to control for unobserved child-specific factors (including characteristics of the child’s parents) that could have caused some children to “select” into making more visits for preventive and nonpreventive dental care.

Based on analysis of data about ALL Kids enrollees in Alabama, preventive dental visits in a given year reduced a child’s subsequent nonpreventive dental visits and expenditures compared with years in which the same child had no preventive visits. Restorative services obtained during preventive visits further reduced subsequent nonpreventive dental visits and expenditures, results that are similar to the findings of other researchers.4 These findings hold true for younger and older children alike.

However, the researchers found no evidence that preventive dental visits generated net savings for the program, at least during the study’s 2-year follow-up period. Although nonpreventive dental expenditures were lower when children had more preventive visits, overall dental expenditures and medical costs inclusive of dental expenditures were higher with more preventive visits.

The authors acknowledge important limitations of their study, including that while using the FE method, they could not estimate outcomes associated with obtaining preventive dental care at a specific age versus later; that the findings cannot inform about any possible long-term health benefits or savings from preventive dental visits; and that the study lacks information on such variables as the quality of dental care during preventive visits (for example, whether children received cavity-preventing fluoride varnishes) and variation in dentists’ decisions about restorative care.

CONCLUSIONS

The results of this study indicate that children require fewer nonpreventive dental visits when they have more preventive visits, suggesting that preventive services do improve children’s oral health. Although the study did not find preventive dental visits to result in overall cost savings to the ALL Kids program, these preventive visits may have societal benefits, considering the potentially improved quality of life of the enrolled children as a result of their having fewer oral health problems. The researchers call for continued research into the effectiveness of pediatric preventive dental care.

REFERENCES:

1. American Academy of Pediatric Dentistry Council on Clinical Affairs. Policy on the dental home. In: AAPD Reference Manual. Chicago, IL: American Academy of Pediatric Dentistry; 2013:24-25.

2. Hagan JF Jr, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

3. Savage MF, Lee JY, Kotch JB, Vann WF Jr. Early preventive dental visits: effects on subsequent utilization and costs. Pediatrics. 2004;114(4):e418-e423.

4. Beil H, Rozier RG, Preisser JS, Stearns SC, Lee JY. Effect of early preventive dental visits on subsequent dental treatment and expenditures. Med Care. 2012;50(9):749-756.