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At the Intersection of Health, Health Care and Policy

Cite this article as:

Dianne Riter, Russell Maier and David C. Grossman
Delivering Preventive Oral Health Services In Pediatric Primary Care: A Case Study
Health Affairs, 27, no.6 (2008):1728-1732
doi: 10.1377/hlthaff.27.6.1728

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G r a n t Wat c h

G r a n t Watc h R e p o r t
Delivering Preventive Oral Health Services In
Pediatric Primary Care: A Case Study
The Washington Dental Service Foundations investment has been
paying off.
by Dianne Riter, Russell Maier, and David C. Grossman
ABSTRACT: Dental disease, the most prevalent chronic disease of childhood, affects childrens overall health and ability to succeed. Integrating oral health into routine well-child
checkups is an innovative and practical way to prevent dental disease. The Washington
Dental Service Foundation is partnering with Group Health Cooperative, a large integrated
delivery system, and other providers in Washington State to change the standard of care by
incorporating preventive oral health services into primary care for very young children. This
paper describes systemic and policy changes for engaging primary care providers in oral
health, including provider training, expanding access to dental care, and reimbursement.
[Health Affairs 27, no. 6 (2008): 17281732; 10.1377/hlthaff.27.6.1728]

e n ta l d i s e a s e is the most prevalent chronic disease of childhood.

Dental decay is so widespread and the
health effects so substantial that in 2000, the
U.S. surgeon general classified dental disease
as a silent epidemic.1 A child with untreated
dental disease has difficulty eating and sleeping properly because of pain, may experience
a delayed ability to speak, and is at risk for
further health problems.2
Although dental disease rates had been declining over the past four decades for most
Americans, the latest national survey indicates
that the prevalence of dental decay in childrens primary teeth is increasing. Among U.S.
children ages 25, the prevalence of dental disease increased from 24 percent during 1988

1994 to 28 percent during 19992004.3

In Washington State in 2005, 45 percent of
low-income preschoolers had dental decay,
based on a survey involving oral screenings.4
The rate of dental decay increased over the
19942005 period: 38.3 percent of low-income
preschoolers had dental decay in 1994, compared with 45 percent in 2005.5 Treating severe cases of dental disease in a hospital operating room can cost $5,000$7,000 per child.6
In 2007 Washington States Medicaid program
spent more than $40 million treating children
for dental disease.7 Much of this cost could
have been avoided if prevention had been a
higher priority.

Dianne Riter ( is a senior program officer at the Washington Dental Service
Foundation (WDSF), in Seattle. Russell Maier is a family practice physician and residency director at Central
Washington Family Medicine in Yakima and is a WDSF board member. David Grossman is medical director for
preventive care and a senior investigator in the Center for Health Studies at Group Health Cooperative, in Seattle.
He is also a professor of health services and an adjunct professor of pediatrics at the University of Washington, in


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G r a n t Wat c h

Innovative Approaches In
Washington State
Childrens dental disease is a national problem, but innovative solutions are often best initiated by states and communities. In Washington State there has been a concerted effort to
develop new ways to improve oral health for
young children.
The states Medicaid program was one of
the first to reimburse primary care providers
for applying fluoride varnish on childrens
teeth. The Access to Baby and Child Dentistry
(ABCD) program, a collaborative effort of public and private entities at the state and local
levels, is increasing the number of Medicaideligible children under age six who are receiving dental care.8
Early preventive and intervention services
can yield positive benefits and lead to an increased likelihood of future preventive services and decreased dental-related costs.9
Some professional organizations now recommend that children have their first dental
screening by age one. However, traditionally,
few children have had access to preventive
dental care at that age, because many family
dentists are not trained, or confident enough,
to see infants and toddlers. Because primary
care providers see young children eight times
or more for well-child visits before age three,
they are well positioned to deliver basic preventive oral health services.
In 2000 the WDSF, a 501(c)(4) nonprofit
organization, began evaluating options for preventing dental disease among infants and toddlers. To achieve oral health impact at the population level, the WDSF advocates for
strategic systemic changes. Starting in 2001,
the WDSF funded three pilot projects in
Washington State that addressed oral health
during well-child checks: (1) Seattle Childrens
Hospitals Healthy Smiles Project; (2) ABCDExpanded, developed by Spokane Regional
Health District; and (3) Kids Get Care, operated by Public HealthSeattle and King
County. These initial efforts identified early
adopters willing to champion oral health and
led to the development of new materials for

physicians to use, including a risk assessment

tool and pocket guide to help identify decay.
The pilots also showed that there were major
barriers to overcome before preventive oral
care could be routinely delivered in primary
care offices.

Engaging Physicians Support

Physician focus groups were convened to
determine how oral health could be addressed
during well-child checks. The physicians identified three needs: training on how to deliver
the services; availability of follow-up dental
care, especially for Medicaid-insured patients;
and reimbursement for providers delivering
the services.
Gaining the support of the medical community was essential to convincing a broader audience that oral health is an important health
issue. As one physician said, Its time we
stopped looking right past the teeth to check
the tonsils. Several oral health champions
were identified in each professional medical
group. In 2002 the Washington Academy of
Family Physicians and the Washington State
Medical Association adopted resolutions urging physicians to address the oral health of
mothers and their young children.
n Oral health training and support. Physicians can learn to identify children at risk for
dental disease who need to be referred to a
dentist for follow-up care.10 Drawing on the
best practices developed in the pilot projects,
the WDSF developed a continuing education
curriculum on oral health for physicians and
staff. To establish credibility and to respond to
clinically oriented questions, dentists or physicians under contract with the WDSF conduct the training. It includes a presentation on
the importance of oral health, the roles for primary care providers in preventing dental disease, useful tips for delivering oral health services during well-child checks, and when to
make dental referrals.
The ninety-minute didactic session features
a hands-on demonstration of oral screenings,
risk assessments, and fluoride varnish applications. Brochures and bookmarks are disseminated to deliver consistent health messages to

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families. These materials, along with posters,

help keep oral health visually prominent in
medical offices. The training also includes information on billing Medicaid and Washington Dental Service and ordering supplies.
WDSF staff and consultants provide ongoing
technical assistance.
To ensure that new physicians are trained
to include oral health in their practices, the
WDSF sponsored an elective course on oral
health for first- and second-year medical students at the University of Washington, beginning in 2005. The foundation, together with
the Oral Health Foundation (located in
Boston, Massachusetts), Connecticut Health
Foundation, and other philanthropies, also
sponsored the development of the Society of
Teachers of Family Medicines oral health curriculum for family medicine residents, Smiles
for Life, which has been used nationwide.11
n Ensuring availability of follow-up dental care. Physicians identified lack of access
to dental care as one barrier to addressing
their patients oral health. Physicians were
concerned that if they identified dental problems, they would not have a place to refer patients for follow-up dental care, especially
those covered by Medicaid. The collaborative
ABCD program helped address this issue by
working to expand access to dental care for
Medicaid-enrolled children under age six. The
program operates in more than 75 percent of
Washington counties, where 93 percent of the
states Medicaid-enrolled children under age
six reside.12 The University of Washington
trains dentists to provide preventive and restorative dental care for young children. Local
health departments identify and enroll eligible
children in ABCD and link them with trained
dentists. The state Medicaid program provides
enhanced reimbursements to such dentists,
and the WDSF provides three-year start-up
grants to local health departments to support
the launch of local ABCD programs. Data demonstrate that ABCD has contributed to an increase in dental access for young children. Between 1997 and 2007, the Medicaid dental
utilization rate for children under age six increased from 21.1 percent to 36.8 percent.13


n Reimbursing medical providers. Physicians identified reimbursement as a critical

factor in their providing preventive oral health
services. In 2004 Washington Dental Service,
the nonprofit funder of the WDSF and the
states leading dental benefits company, began
to reimburse physicians for delivering oral
screenings and applying fluoride varnish.
The Washington Medicaid program had
been reimbursing primary care providers for
fluoride varnish since 1998. Although that was
an important step, in 2000 only 145 Medicaidenrolled children under age six received this
service.14 To further promote prevention and
early intervention, the logical next step was to
pursue Medicaid reimbursement for primary
care providers who deliver oral screening and
oral health education (a service that Washington Medicaid reimburses through the ABCD
program). It was necessary to lay a foundation
for this policy change by increasing public
awareness of oral healths importance and convincing key audiences such as legislators and
state agencies that oral health is both a personal and a community responsibility.

Building Political Will

To gain the approval of the legislature and
governor, the WDSF designed a campaign including radio, television, and print advertising
explaining that childrens oral health matters. Other credible organizations, such as
medical associations and hospitals, partnered
with the WDSF on its campaign to promote
the importance of childrens oral health. The
foundation worked to generate media interest
and helped place several opinion pieces in
newspapers statewide. To build public awareness about the importance of preventing dental disease, materials were distributed to parents through pharmacies and state and local
health agencies.
Instead of developing a stand-alone bill, the
WDSF and other child advocates made a strategic decision to include the proposal to
broaden the types of oral health services reimbursed by Medicaid as part of broader legislation to increase health care coverage for children. The WDSF spent considerable time

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building support among key legislators and

actively engaging stakeholders including physician groups, hospitals, and dental and childrens advocacy groups.
In 2007, thanks to the work of a broadbased coalition, the legislature and the governor approved the legislation to ensure that all
children in Washington State get comprehensive health care coverage, regardless of income
or citizenship. This legislation also specified
that Medicaid reimburse trained primary care
providers for oral screening and oral health education. Reimbursement for applying fluoride
varnish was set at $13.66; for family oral health
education, $27.58; and for a periodic oral evaluation, $29.46, for a total of $70.70.15

Demonstrating Best Practices

In 2007 a demonstration project was
launched to develop best practices for including oral health in well-child visits in a large
medical system. The WDSF partnered with
Group Health Cooperative, a consumergoverned, nonprofit health care system that
serves more than 568,000 members in Washington State and Idaho, to implement a threeyear demonstration project in six of its primary care medical centers in Washington.
Nationally, this is the first comprehensive project that pairs a large health care delivery system with public and private dental payers. If
the project proves successful, the ultimate goal
is to expand it to all Group Health primary
care centers statewide.
The goal of this collaboration is to develop a
clinical, business, and operating model for providing oral health care as part of standard
medical care for infants and young children.
The project provides real-world experience;
feedback from physicians, staff, and parents;
and information about best practices for creating this new standard of care.
Washington Dental Service covers the
costs of the preventive services for its eligible
subscribers who are also Group Health members. Medicaid covers the costs of these services for its enrollees. To remove any financial
barriers related to patient fees, during the
demonstration project the WDSF is paying for

preventive services to be delivered to all other

Group Health members, even those not in a
Washington Dental Service plan.
In the projects first sixteen months, 1,403
children (out of a total of 3,160 with well-child
checks) received oral screening, fluoride varnish, and oral health education, representing
44 percent of all children with well-child visits. These early results indicate that oral health
services have been well accepted by participating primary care teams. Building support
among all members of the team led by a physician-champion is a critical predictor of successful adoption of this model. Developing efficient clinical workf lows and tools for
documentation and coding are also essential
for success. The demonstration project also
will include discussions with other private
dental insurance carriers to determine the feasibility of reimbursement. It is hoped that this
WDSF/Group Health collaboration can serve
as a national model for early childhood caries
prevention in primary care.

Results: Changing The Standard Of

Since 2001 the WDSF has invested $1.6 million to engage primary care providers in oral
health. Largely because of the WDSFs overall
engagement with program partners and primary care providers since 2001 and the combination of efforts noted in this paper, the number of fluoride varnish applications in medical
settings in Washington delivered to Medicaidenrolled children under age six increased from
145 in 2000 to 9,098 in 2007.16 The new legislation will likely increase this number.
Although the WDSF ultimately aims to
reach all primary care providers in Washington State, more than 775 pediatricians and
family physicians have been trained through
the foundations initiatives to address oral
health. This represents 24 percent of the states
nearly 3,300 family physicians and pediatricians.17 At least 270 institutions nationwide
use the Smiles for Life curriculum, and twenty
medical schools use it in their core curricula.18
Lessons learned from these efforts, plus lessons from other programs, such as North

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Carolinas Into the Mouths of Babes, will help

reach the goal of delivering preventive oral
health services during well-child visitsand
may eventually lead to changing the standard
of care throughout the United States.19

a s e d o n t h e o utcomes of the
WDSFs initiatives to engage primary
care providers, it is clear that such providers are interested in oral health. A physician-champion is critical to gaining support
from other clinicians and staff. With efficient
office processes and procedures, appropriate
educational materials and training, and adequate reimbursements, providers can and
will include oral health in well-child checkups. Another key factor is that primary care
providers need to be able to easily refer patientsespecially those in Medicaidfor
follow-up dental care.
Integrating oral health into well-child visits
is both logical and practical, although evidence
of its impact is still needed. It is an opportunity to provide prevention services that can result in a lifetime of improved oral health. The
bottom line is that dental disease can and
should be prevented for every child at every
opportunityincluding at the medical office.
Highlights of the Group Health Cooperative
demonstration project were presented at the American
Academy of Pediatrics Peds 21 Conference, 10 October
2008, in Boston, Massachusetts. The Washington
Dental Service Foundation provides financial support
to Group Health Cooperative for implementing the
demonstration project described in this paper. The
authors acknowledge the organizations and individuals
that have contributed to the initiatives in Washington
State that are mentioned in this paper.











(accessed 11 August 2008).

Washington State Department of Health, Washington State Smile Survey 2005 (Olympia: DOH, Office of Maternal and Child Health, 2006).
Ibid, 37.
Joel Berg, director of dentistry, Childrens Hospital and Regional Medical Center, Seattle, Washington, personal communication, June 2008.
Washington State Health and Recovery Services
Administration, Dental Services Utilization
Data, Fiscal Years 19972007 (Olympia: Washington State HRSA, 2008).
G.J. Donahue et al., The ABCDs of Treating the
Most Prevalent Childhood Disease, American
Journal of Public Health 95, no. 8 (2005): 13221324.
M.F. Savage et al., Early Preventive Dental Visits:
Effects on Subsequent Utilization and Costs, Pediatrics 114, no. 4 (2004): e418e423.
K.M. Pierce, R.G. Rozier, and W.F. Vann Jr., Accuracy of Pediatric Primary Care Providers
Screening and Referral for Early Childhood Caries, Pediatrics 109, no. 5 (2002): e82e88.
A.B. Douglass et al., Smiles for Life: A National
Oral Health Curriculum for Family MedicineA
Model for Curriculum Development for STFM
Groups, Family Medicine 39, no. 2 (2007): 8890.
Washington State HRSA, Dental Services.
Washington State HRSA, Memorandum no. 0803, 21 February 2008,
dshs/maa/Download/Memos/2008Memos/0803%20Dental_PhysReimb.pdf (accessed 30 June
Center for Health Workforce Studies, WWAMI
Physician Workforce 2005 (Seattle: University of
Washington, School of Medicine, Department of
Family Medicine), 4.
Douglass et al., Smiles for Life.
G.G. dela Cruz, R.G. Rozier, and G. Slade, Dental Screening and Referral of Young Children by
Pediatric Primary Care Providers, Pediatrics 114,
no. 5 (2004): e642e652.


U.S. Department of Health and Human Services,

Oral Health in America: A Report of the Surgeon General
(Rockville, Md.: National Institute of Dental and
Craniofacial Research, May 2000), 17.
2. Ibid, 2.
3. B.A. Dye et al., Trends in Oral Health Status: United
States, 19881994 and 19992004, April 2007, http://


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