May 2019 Volume LIV Number 3


New Technical Brief from the AAPD Pediatric Oral Health Research and Policy Center The Use of Case Management to Improve Dental Health in High Risk Populations

September 2013 Volume XLIX Number 5

Untreated tooth decay affects more children than any other chronic infectious disease in the United States, leading to pain and suffering, and even death1, despite being a largely preventable disease. Minority and socioeconomically disadvantaged children are especially hard-hit; they have higher rates of tooth decay and greater difficulty accessing dental care. The ravages of pediatric dental disease are especially disconcerting since there are resources available to prevent and treat dental diseases in this at-risk population. Informing caregivers of the existence of dental health resources is the crux of this public health crisis while dental care case management, and establishment of a dental home, are the answers.
Dental care is readily available from dentists who accept Medicaid and CHIP; unfortunately low-income parents facing a pediatric dental crisis may be hobbled by health illiteracy, as well as limited funds for dental care and few personal resources to access care when it is available. Thus, only 38 percent of Medicaid eligible children received a dental service in 2008, well below the Healthy People 2010 goal.2 Although over 70 percent of AAPD members accept public insurance3, only 5.4 percent of general practitioners accept public insurance.4 Dentists who desire to provide care to publically insured patients are discouraged by low reimbursement rates and administrative burdens. The combination of patient and provider barriers leads to low utilization of dental care options by publically insured pediatric patients, higher dental disease rates and treatment costs. Only by overcoming barriers to care will these children receive cost-effective preventive as well as therapeutic care.
Barriers to care can be breached by case management, which is a collaborative process of assessment, planning, facilitation, care coordination, valuation and advocacy for options5, that has been shown to be a cost-effective tool to increase dental health in the publically insured population. Motivational interviewing (MI), a key component of case management, has proved to be effective in improving not only dental outcomes, but health outcomes in any population; when used in conjunction with other services (fluoride, Xylitol, and/or treatment of disease) MI has been found to reduce cavity prevalence by 62 percent.6 The potential for such a radical reduction in cavity prevalence could result in substantial cost savings.
Individualized case management services allow for differences in physical, psychological and cultural makeup and addresses community-specific barriers to care. Case management is not only the customization of available resources to specific patient and provider needs, but the communication of, explanation and support for good oral health practices. Comprehensive case management has been found to increase publically insured beneficiaries' use of services and improve oral health literacy and treatment compliance. Ideally, use of case management leads to the patient adoption of a dental home. A dental home is a primary dental care provider that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. 7
In sum, case management may be a cost-effective service that has the potential to reduce costs and improve oral health. The full report is available at
1 Centers for Disease Control and Prevention. Health disparities experienced by racial/ethnic minority populations. MMWR 2004;53:755. 2 National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012. 3 American Academy of Pediatric Dentistry. Member Needs Assessment, Winter, 2009. 4 American Dental Association. 2012 Survey of Dental Practice Pediatric Dentists in Private Practice Characteristics Report. 2012 5 Case Management Society of America. Standards of practice for case management, revised 2010. 6 Hirsch, G, Edelstein, B, Frosh, M, and Anselmo, T. A Simulation Model for Designing Effective Interventions in Early Childhood Caries. CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0219.