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Letters: Sealant utilizations

April 01, 2013

I am an ADA member and dental director for the North Carolina Department of Health and Human Services/Division of Medical Assistance. Our agency administers the North Carolina Medicaid and Health Choice (CHIP) dental programs. I would like to comment on the editorial, "Tennessee Sealant Experience at Variance with Pew Report" (March 4 ADA News), sent by my colleague Dr. James Gillcrist, dental director of the Tennessee's State Medicaid (TennCare) program. I agree with Dr. Gillcrist's analysis of the Pew Children's Dental Campaign's report, "Falling Short: Most States Lag on Dental Sealants," released in January 2013. I would like to elaborate on an important point that Dr. Gillcrist made about the lack of a benchmark measuring the utilization of sealants by Medicaid and CHIP children.

The introduction of the Pew report clearly states the objective of their analysis:

"In both 2010 and 2011, the Pew Children's Dental Campaign released reports grading all 50 states and the District of Columbia on children's dental health, relying on eight evidence-based policies that cover prevention, financing and workforce issues. However, this year, Pew's 50-state report focuses on prevention, examining states' efforts to improve access to sealants for low-income kids."

The study purports to examine the barriers to low-income children receiving one of the most cost-effective preventive techniques available to dental professionals who provide pediatric oral health services. As Dr. Gillcrist properly asserted, utilization data is currently available at both the individual state level and through the Centers for Medicare & Medicaid Services Annual Early and Periodic Screening, Diagnostic and Treatment Participation Report otherwise known as the CMS-416 Report. Dr. Gillcrist is also correct when he states that this was not one of the four benchmarks that Pew chose to use when examining states' performance in improving sealant utilization for low-income children. If the Pew study targets improvement in the delivery of services to low-income children, it would make sense that the reader should expect that all of the states that received high grades ("As" and "Bs") from Pew would also be among the leaders in terms of high utilization of sealant services for Medicaid children in the 6-9 age group as reported on the CMS-416. This measure is an important one because the CMS National Oral Health Initiative has called for states to improve the utilization rates for sealants on 6-9-year-old Medicaid and CHIP children by 10 percentage points over a five-year time frame.

After examining the most current data available from the CMS-416 for Federal Fiscal Year 2011, I have concluded that there is little correlation to scoring well on Pew's self-determined benchmarks and having high utilization rates for sealant services delivered to Medicaid children. My home state, North Carolina, received an "F" on the Pew Report. I discovered that four of the 13 states that received an "A" or "B" had sealant utilization rates below North Carolina's—ranging from two to five percentage points below our state's 17 percent utilization rate for 6-9-year-old beneficiaries. The average for all 50 states for this age group on the FFY 2011 CMS-416 Report is 17 percent. It is clear that having met all or nearly all of Pew's benchmarks has not necessarily translated into successful outcomes for low-income children in the Medicaid beneficiary population in several states that received high grades from Pew.

I would like to further support Dr. Gillcrist's argument by stating that I believe that it is imperative that any scientific analysis measuring whether low-income children are receiving sealant services in appropriate proportions must have at least one benchmark that reports utilization data from the Medicaid and CHIP pediatric beneficiary population. It seems to me that Pew focused more attention on benchmarks that attempted to determine whether the process of how states deliver sealants to children met with their approval rather than on outcome measures that report actual utilization and prevalence of sealants in the states. I firmly believe that if more scientifically sound outcome benchmarks had been included in the Pew report, that it would be far more meaningful and would also have presented readers with a better idea of current success or failure of states in the delivery of sealants to low-income children. To portray some states as leaders and some as laggards without fully examining the data is simply wrong. As Dr. Gillcrist indicated, the Pew report is a disservice to the many dedicated dental professionals who are state employees that have spent their careers implementing policies and programs to improve the oral health of disadvantaged children.

Mark W. Casey, D.D.S., M.P.H.
Dental Director
North Carolina Department of Health and Human Services
Division of Medical Assistance
Raleigh, N.C.