摘要：Objectives. Most state Medicaid programs reimburse nondental primary care providers (PCPs) for providing preventive oral health services to young children. We examined the association between who (PCP, dentist, or both) provides these services to Medicaid enrollees before age 3 years and oral health at age 5 years. Methods. We linked North Carolina Medicaid claims (1999–2006) to oral health surveillance data (2005–2006). Regression models estimated oral health status (number of decayed, missing, and filled primary teeth) and untreated disease (proportion of untreated decayed teeth), with adjustment for relevant characteristics and by using inverse-probability-of-treatment weights to address confounding. Results. We analyzed data for 5235 children with 2 or more oral health visits from a PCP, dentist, or both. Children with multiple PCP or dentist visits had a similar number of overall mean decayed, missing, and filled primary teeth in kindergarten, whereas children with only PCP visits had a higher proportion of untreated decayed teeth. Conclusions. The setting and provider type did not influence the effectiveness of preventive oral health services on children’s overall oral health. However, children having only PCP visits may encounter barriers to obtaining dental treatment. Guidelines from the American Dental Association, American Academy of Pediatric Dentistry, and the American Academy of Pediatrics recommend that children visit a dentist by their first birthday. 1–3 Early dentist visits provide an opportunity to establish and promote good oral health practices, evaluate caries risk factors, and deliver caries prevention strategies, such as application of topical fluoride. 2 Despite recommendations, few Medicaid-enrolled children visit dentists. During 2007, only 4 states (Iowa, North Carolina, Texas, and Washington) reported that 20% or more of its Medicaid-enrolled children younger than 3 years visited dentists. 4 Recognizing that primary care providers (PCPs) see young children frequently and can provide many of these services, most state Medicaid programs now reimburse PCPs for delivery of preventive oral health services in medical offices. 5 Since 2000, a North Carolina Medicaid program, known as Into the Mouths of Babes (IMB), has trained PCPs (e.g., physicians, physician assistants, nurse practitioners) to provide preventive oral health services to children younger than 3 years. Training is provided at the request of PCPs working in private offices and public health clinics. As described on the program’s Web site, 6 IMB visits include an oral evaluation and risk assessment, anticipatory guidance for parents, and application of fluoride varnish to prevent dental caries—services similar to those provided during preventive visits in a dental office. Children suspected to have caries or to be at elevated risk are referred to dentists when they are available in the community. This program and similar programs in other states have helped increase access to oral health services and reduce treatments for young children enrolled in Medicaid. 7–9 By 2006, nearly 30% of well-child medical visits for children younger than 3 years included IMB services. 9 Overall, the percentage of Medicaid children younger than 5 years obtaining oral health services in North Carolina increased from 17% in 2002 to 59% in 2011. 10 Although the benefits of IMB services are well-documented, 8,9 less is known about the oral health status of these children after their third birthday when they are no longer eligible to receive preventive oral health services from PCPs. The IMB services are intended to coincide with recommended well-child medical visits at 6, 9, 12, 15, 18, and 24 months of age and end at an age when well-child visits in the medical office become less frequent and more dentists are willing to accept them as patients. 11,12 Previous research indicates that children who had 4 or more IMB visits (compared with zero IMB visits) between 2000 and 2006 received fewer caries-related treatments after their IMB eligibility expired (ages 40 to 72 months). 8 Although this finding suggests that IMB visits may be associated with better oral health, the study did not control for preventive services received from dentists or examine the program’s effect on clinical disease, which provides a better measure of overall oral health and access to dental care. Some barriers to dental care for children may ease as they age because dentists are more willing to care for older children 12 ; however, workforce shortages and dentists’ low rate of participation in Medicaid remain as barriers to dental care as children age. 13,14 Widespread support exists for the integration of dentistry and medicine to promote young children’s oral health, 15–18 yet, to date, no study has directly compared the oral health outcomes of children receiving preventive oral health services from PCPs or dentists (with or without PCP visits). This comparison is important because more than 40 state Medicaid programs reimburse PCPs for application of fluoride varnish. 5 By using a unique combination of oral health surveillance data and Medicaid claims to help overcome limitations of dental claims data, we aimed to determine whether the provider of preventive oral health services is associated with (1) the number of decayed, missing, and filled primary teeth (dmft) per child, a measure of lifetime caries experience at 5 years of age; and (2) the proportion of dmft that is untreated, a measure of the extent to which a child’s treatment needs are being met. Because children who receive preventive oral health services before their third birthday during IMB or dentist visits are expected to benefit from early screenings, anticipatory guidance, and applications of fluoride varnish, 2,19 we hypothesized that these children will have a similar number of dmft in kindergarten. Furthermore, because IMB providers are trained to refer children suspected to have, or be at elevated risk for, caries to dentists when they are available in the community, we hypothesized that the IMB program will improve access to dental treatment and thus children with IMB or dentist visits will have a similar proportion of dmft that is untreated in kindergarten.
