Preventive dental visits may not lower kids’ costs

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According to the American Academy of Pediatric Dentistry, it is recommended that children see a pediatric dentist as soon as their first tooth appears to prevent dental problems. But earlier research actually does not show that these visits lead to less costly dental issues in kids, according to lead author Bisakha Sen, PhD, an associate professor in the department of healthcare organization and policy at the University of Alabama at Birmingham.

“It was shocking to us to find that previous data was misinterpreted, and there was actually more expensive restorative procedures among kids with more preventive dental visits, because this is counterintuitive,” Sen explained in a university news release. “The problem is that these prior studies were limited by selection bias because children are not randomly taken to get preventive dental services. It may be overly cautious or concerned parents, or children with a family history of dental problems who get these visits, then also use more restorative care.”

To investigate further without bias, Sen’s team used data collected from 1998 to 2010 by Alabama’s Children’s Health Insurance Program (CHIP), ALL Kids, a low-cost, comprehensive healthcare coverage program for children younger than age 19; benefits of ALL Kids include regular dental care.

Children who were continuously enrolled in CHIP for at least three years were included. Children who used nonpreventive dental services the first year were not included, because there was no information about their prior preventive dental service use. A total of 14,972 kids younger than age 8 and 21,833 age 8 and older were included.

Using a technique called individual fixed effects, the team was able to use each child as their own control, and then compare what happens to child X in a year when they do not get preventive visits, to a year when they do get preventive visits.

“Simpler techniques gave us the same findings of earlier work, but this more advanced technique we used was an effective, though not foolproof, way of controlling for the selection problem of past literature,” Sen said.

What they found was that more preventive visits were associated with fewer subsequent restorative services for the same child for both age groups, even though the cost savings for CHIP do not appear to sufficiently cover the cost of the preventive services.

For example, the researchers found that when children had one preventive visit, their subsequent nonpreventive costs went down by an average of $25.67. However, this savings of $25.67 was not enough to offset what CHIP paid for the preventive visit. So when the costs of preventive visits and nonpreventive visits were added together, overall CHIP spending was actually $90.94 more.

Despite the figures, the researchers caution against interpreting findings only with dollar figures in mind.

 

 

        

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According to Paul Casamassimo, DDS, MS, the director of the AAPD Pediatric Oral Health Research and Policy Center, it is important to put the authors’ findings into context in recognition of the inherent limitations of this study.

 

Although the authors correctly indicate that children covered by Medicaid tend to be at higher risk for dental caries, the report does not recognize that these children may not have access to care or enjoy appropriate preventive services. The higher risk of dental caries, along with this lack of early preventive care, may result in the first visit being sought in response to existing decay that causes pain. Often, this necessitates restorative treatment at their first visit. In addition, children with higher risk of caries need an increased number of preventive services, so cost would likely be maximized. Finally, a body of literature speaks to the residual continued disease occurrence in children afflicted early in life with dental caries.

 

Inherent problems with extrapolating from Medicaid data include episodic care seeking, enrollment variations, no differentiation of levels of dental caries risk, lumping diagnostic and preventive services together, and the vast unknown of what is not reported or discernible from the data. Additionally, restorative expenditures, as compared with diagnostic and preventive costs, will be very high.

 

“Unfortunately, current data collection limitations and the dearth of studies on these consequences of dental caries do not allow a full picture of what preventive services may be doing for children,” said Warren Brill, DDS, AAPD president. “Our policies and guidelines encourage early preventive care not only to reduce cost, but also to improve the quality of life for children.”

Consideration of costs must take into account prevention’s effects on the reduction of emergency department visits for tooth pain and also the need for general anesthesia care to treat dental caries. Reports cited by the Pediatrics study authors include these "hidden costs," which can be sizable but are usually found in medical claims data, not dental data. Also, the Pediatrics study does not take into account costs such as emergency room visits and services that must be provided under general anesthesia.

 

Readers should also be aware of the hidden human costs of dental caries, which include the morbidities of chronic pain, impaired learning, lower self-esteem, and compromised nutrition.

 

 

        

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