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Dental guidelines for Title XIX programs
Dental guidelines for Title XIX programs
Council on Dental Health
A long-standing need in dental consultation with state Title XIX programs was a national state ment of guidelines for dental aspects of the pro gram. This need was filled when the House of Delegates, in its 1968 annual session, approved the Guidelines f o r D ental Programs under T itle X IX .
The dental profession is well aware of the im plications of Title XIX programs for the financing of dental services for the needy and medically indigent now and in the future. Currently, ap proximately 35 state programs include some den tal services provided through private practice. By 1975, all state programs under Title XIX must include dental services. Potentially, as many as 35 million persons in the present population could be eligible for Title XIX coverage, and at present nearly half of the federal government’s total annual expenditure for dental matters goes to Title XIX. The confusion that has accompanied the im plementation of Title XIX in many states under lines the need for guidelines for dental society leaders concerned with public programs and for nondental administrators responsible for Title XIX programs. At the request of the Medical Services Admin istration, Department of Health, Education, and Welfare, an ad hoc committee of dentists met in Pittsburgh in J anuary 1968 to draft guidelines for the dental aspects of Title XIX. The resulting draft was submitted to the Council on Dental
Health for revision and editing. Finally, the guide lines were adopted by the House of Delegates in Miami Beach in October 1968. Since one of the objectives of the guide lines was the information and guidance of non dental administrators, the document begins with background on the nature of dental problems and their possible solutions. Special attention is given to the importance of preventive measures. Regarding the design of the program, the guidelines recommend that the Title XIX admin istering agency in each state establish a dental advisory committee in conjunction with the state dental association. If priorities for dental care programs are necessary because of financial limi tations, the guidelines recommend that highest priority go to comprehensive care for children. This would provide a mechanism for funding care for children in accordance with the Association’s Dental Health Program for Children. Further recommendations of the guidelines in clude prioritiesfor dental procedures in care for adults, special attention to care of population groups such as the handicapped or institution alized, the use of the usual and customary fee mechanism, and administration by a fiscal inter mediary such as a dental service corporation. The guidelines also recommend that provisions be made for periodic evaluation of quantity and types of dental services provided and for peer review— the professional review of treatment provided. It is obvious that the dental societies have an important role to play in assuring the effective implementation of dental care programs under Title XIX. The following guidelines will provide assistance in fulfilling this responsibility: 133
Guidelines for Dental Programs Under Title XIX The nature of the dental problem ■ Prevalence o f Dental Disease:
Dental disease is the most common health problem. Dental de cay is nearly universal, beginning at a very early age and continuing throughout life. By age two, 50% of children have decayed teeth. Surveys show an average incidence of one new cavity per year in children aged 6 to 11 years, and one and onehalf cavities a year in children aged 12 to 15 years. Periodontal disease, the next most common dental problem, affects three fourths of adults by age 50. This disease begins early in life and, if uncontrolled, will eventually result in loss of teeth. The accumulated effects of dental disease are demonstrated by the fact that 1% of persons be tween ages 18 and 24 have lost all their teeth while almost 50% of persons aged 65 to 74 have lost all their teeth. It is well known by the dental profession that many people who require den tures could have saved their natural teeth with regular care and preventive measures initiated at an early age. ■ Utilization o f Dentists’ Services:
Dental prob lems are created and compounded by the low lev el of utilization of dentists’ services. About one half of all children in the United States under age 15 have never been to a dentist. For children in rural areas, the percentage is even higher. The seeking of dentists’ services is related to the educational and income level of the family, the availability of dental service, and the effec tiveness and organization of dental programs. The relationship of family income to dental care is indicated by the finding that 66% of children in families with incomes under $4,000 have never been to a dentist, compared to 40% of children from families with incomes of $4,000 or more. Utilization of dentists’ services can be increased by removing or reducing financial barriers as demonstrated by the experience of dental pre payment programs. Utilization was increased to 70% in a program for children which included a periodic recall system. An effective program of dental health education can also increase utiliza tion. 134 ■ JADA, Vol. 7 8 , January 19 69
■ The Importance o f Prevention: The dental profession has long urged the use of proven pre ventive procedures which can significantly re duce the incidence of dental disease and the total dimensions of the dental problem. The following preventive measures should be fully employed:
■ Full Use of Fluorides: Fluoridation of the communal water supply can reduce the incidence of dental decay approximately 60% . Every state and community should provide the benefits of water fluoridation to its citizens to the maximum degree possible. It has been demonstrated that the cost of dental care programs for children in nonfluoridated communities is more than double the cost for children in fluoridated communities. In areas without a community water supply, con sideration should be given to fluoridation of school water supplies. Where fluoridation of the public water supply is not feasible, provision should be made for the topical application of fluorides or for the use, when indicated, of dietary fluoride supplements. ■ Anticariogenic Dentifrices: The use of ef fective anticariogenic dentifrices should be en couraged. ■ Control of the Consumption of Sweets: Edu cational campaigns should be conducted to re duce the frequency of consumption of sweets. Special attention should be given to the elimina tion of the sale of sweets in schools. ■ Toothbrushing Instruction: Toothbrushing instruction and regular oral prophylaxis should be encouraged, starting at an early age. ■ Malocclusion: To prevent malocclusion, de cayed teeth should be restored, spaces resulting from the early loss of primary teeth should be maintained where indicated, and deleterious oral habits should be corrected. Determinations of need for orthodontic treatment can be assisted by the available index for the assessment of handi capping malocclusion. ■ Dental Health Education: Comprehensive and continuing dental health education for the individual patient and the public should be an essential component of all treatment programs.
The design of the dental program ■ Advisory Committee:
In accordance with the Handbook o f Public Assistance Administration, D-7220 and D-7520, state plans are required to have at least the part-time services of a dentist in cluded in the medical assistance unit in the state agency office. It is recommended, in view of Sec. 1902(a)-30, that the state administrative agency establish an additional dental advisory committee in conjunc tion with the state dental association. This com mittee should consist of at least five dentists. It could be financially supported under Sec. 1903(a). The guidance of a dental advisory committee would be most valuable in designing and admin istering the dental program. ■ Priority o f Care to be Provided: The goal of dental care programs should be to provide com prehensive dental care for all eligible segments of the population. When necessary because of financial or other limitations, a system for priority of care should be established. Experience has demonstrated that a comprehensive program for one segment of the eligible population can be a better approach to the goal than a fragmented care program for all. Relief of pain and infection and necessary diag nostic procedures should be provided to all eligi ble recipients. The highest priority for compre hensive care should be given to a program for children. Other segments of the population should be added as the program expands so that all eligi ble recipients will have dental care during or be fore 1974 as required in the law. It is recommended that a care program for chil dren be initiated for a specified age group and be expanded on a systematic basis to include initial care for additional age groups and maintenance care for all children in the program. ■ Services for Children: The program should provide all indicated treatment necessary to re store and maintain the dental and total health of the child. All programs should be designed to include: Complete examination and diagnosis includ ing radiographs when indicated. Elimination of pain and infection. Treatment of injuries. Elimination of diseases of bone and soft tissue. Treatment of anomalies.
Restoration of decayed or fractured teeth. Maintenance or recovery of space between teeth when this service will affect occlusion. Replacement of missing permanent teeth. Treatment of malocclusion with priority for interceptive treatment and disfiguring and handi capping malocclusion. Periodic recall for preventive and treatment services. ■ Services fo r Adults:
A state may choose to implement a dental program for a segment of the population in addition to children. A program for adults should provide all indicated treatment ser vices necessary to restore and maintain the dental and total health of the patient. Programs should be designed to include the following services in accordance with the need of the specific program: Complete examination and diagnosis including radiographs as indicated. Elimination of pain and infection. Treatment of injuries. Elimination of diseases of bone and soft tissue. Treatment of anomalies. Restoration of decayed or fractured teeth. Maintenance or recovery of space between teeth when this service will affect occlusion. Replacement of missing teeth. Early detection of oral manifestations of sys temic diseases and treatment of oral lesions. If financial limitations will not allow a compre hensive program for adults, the following se quence of treatment is recommended: Treatment of acute conditions and elimination of pain and infection. Complete examination and radiographs when indicated. Treatment of diseases of bone and soft tissue with restoration of decayed teeth. Replacement of missing teeth with full or partial prosthesis.
■ Treatment fo r Special Population Groups:
It is recommended that specific arrangements be made for the provision of dental care for handi capped persons who are homebound or residing in institutions or nursing homes. These special population groups have often been neglected in organized dental programs of state and local gov ernments. Services provided should include exam inations at regular, periodic intervals and pre ventive maintenance care. The dental profession should be involved in the planning, operation REPORTS OF C O U N C ILS A N D B U REA U S ■ 135
and evaluation of programs for these special groups. ■ Fiscal Administration: The state administra tive agency should establish the usual, customary, and prevailing fee mechanism to assure quality care and broad participation by the profession. The use of a fiscal intermediary, such as a state dental service corporation or other qualified agency, is encouraged. ■ Method o f Providing Services:
The program should utilize to the fullest extent existing dental facilities and resources, especially those of pri vate practice. The provision of dental treatment through private practice should be the preferred method in order to restore the eligible recipients to the mainstream of society. Freedom of choice should be preserved for both patient and practi tioner. Increased manpower recruitment should be encouraged in areas where there is a shortage of health manpower. ■ Program Evaluation: Provision should be made for periodic evaluation of quantity and types of dental care provided to provide informa tion for improving or extending the dental pro gram. The administering agency should use uni form methods for accounting, tabulations, and identification of services to provide data on costs, utilization, and services rendered. Evaluation should be extended to the systems of delivery of care to assure that all eligible re cipients have access to quality care. ■ Review o f Care Provided:
Programs should utilize mechanisms developed by the dental ad
visory group for peer review— the professional re view of treatment provided. Review committees should be established at the local level in cooper ation with local dental societies. The mechanisms for quality evaluation should be reviewed to as sure objectivity and effectiveness.
Conclusion In planning dental care programs under Title XIX, it is recommended that care be provided accord ing to the following priorities: ■ Emergency care for all recipients. ■ Establishment of care programs for children. ■ Comprehensive care for additional age groups as funds become available. ■ Comprehensive care for adults. The requirements of the program should not in any way impair the professional judgment of the dental profession in providing treatment, or cause the treatment provided under the program to be inferior to that provided in the private sec tor of dental practice.
American Dental Association. Dental health program for children. Transactions 1966, p 175. US Department of Health, Education, and Welfare, Na tional Center for Health Statistics. Dental visits: time in terval since last visit. Series 10, no. 29. Washington, DC, Government Printing Office, 1966. US Department of Health, Education, and Welfare, Na tional Center for Health Statistics. Selected dental findings in adults by age, race and sex. Series 11, no. 7. Washing ton, DC, Government Printing Office, 1965.
Supplement to the List of Certified Dental Materials Council on Dental Materials and Devices
Since publication of the most recent List of Cer tified Dental Materials revised to January 1, 1968; published in the February 1968 issue of t h e j o u r n a l (JADA 76:367) the following changes have been made in the List.
6 for Dental Mercury and are being added to the List as new certifications. CERTIFIED DENTAL MERCURIES ADA Specification No. 6
Simmons Mercury Simmons Refining Company
Addition— The following materials conform to American Dental Association Specification No. 136 ■ JADA, Vol. 7 8 , January 19 6 9
Tamco Dental Mercury Texas American Mercury Company
Council on Dental Health
A long-standing need in dental consultation with state Title XIX programs was a national state ment of guidelines for dental aspects of the pro gram. This need was filled when the House of Delegates, in its 1968 annual session, approved the Guidelines f o r D ental Programs under T itle X IX .
The dental profession is well aware of the im plications of Title XIX programs for the financing of dental services for the needy and medically indigent now and in the future. Currently, ap proximately 35 state programs include some den tal services provided through private practice. By 1975, all state programs under Title XIX must include dental services. Potentially, as many as 35 million persons in the present population could be eligible for Title XIX coverage, and at present nearly half of the federal government’s total annual expenditure for dental matters goes to Title XIX. The confusion that has accompanied the im plementation of Title XIX in many states under lines the need for guidelines for dental society leaders concerned with public programs and for nondental administrators responsible for Title XIX programs. At the request of the Medical Services Admin istration, Department of Health, Education, and Welfare, an ad hoc committee of dentists met in Pittsburgh in J anuary 1968 to draft guidelines for the dental aspects of Title XIX. The resulting draft was submitted to the Council on Dental
Health for revision and editing. Finally, the guide lines were adopted by the House of Delegates in Miami Beach in October 1968. Since one of the objectives of the guide lines was the information and guidance of non dental administrators, the document begins with background on the nature of dental problems and their possible solutions. Special attention is given to the importance of preventive measures. Regarding the design of the program, the guidelines recommend that the Title XIX admin istering agency in each state establish a dental advisory committee in conjunction with the state dental association. If priorities for dental care programs are necessary because of financial limi tations, the guidelines recommend that highest priority go to comprehensive care for children. This would provide a mechanism for funding care for children in accordance with the Association’s Dental Health Program for Children. Further recommendations of the guidelines in clude prioritiesfor dental procedures in care for adults, special attention to care of population groups such as the handicapped or institution alized, the use of the usual and customary fee mechanism, and administration by a fiscal inter mediary such as a dental service corporation. The guidelines also recommend that provisions be made for periodic evaluation of quantity and types of dental services provided and for peer review— the professional review of treatment provided. It is obvious that the dental societies have an important role to play in assuring the effective implementation of dental care programs under Title XIX. The following guidelines will provide assistance in fulfilling this responsibility: 133
Guidelines for Dental Programs Under Title XIX The nature of the dental problem ■ Prevalence o f Dental Disease:
Dental disease is the most common health problem. Dental de cay is nearly universal, beginning at a very early age and continuing throughout life. By age two, 50% of children have decayed teeth. Surveys show an average incidence of one new cavity per year in children aged 6 to 11 years, and one and onehalf cavities a year in children aged 12 to 15 years. Periodontal disease, the next most common dental problem, affects three fourths of adults by age 50. This disease begins early in life and, if uncontrolled, will eventually result in loss of teeth. The accumulated effects of dental disease are demonstrated by the fact that 1% of persons be tween ages 18 and 24 have lost all their teeth while almost 50% of persons aged 65 to 74 have lost all their teeth. It is well known by the dental profession that many people who require den tures could have saved their natural teeth with regular care and preventive measures initiated at an early age. ■ Utilization o f Dentists’ Services:
Dental prob lems are created and compounded by the low lev el of utilization of dentists’ services. About one half of all children in the United States under age 15 have never been to a dentist. For children in rural areas, the percentage is even higher. The seeking of dentists’ services is related to the educational and income level of the family, the availability of dental service, and the effec tiveness and organization of dental programs. The relationship of family income to dental care is indicated by the finding that 66% of children in families with incomes under $4,000 have never been to a dentist, compared to 40% of children from families with incomes of $4,000 or more. Utilization of dentists’ services can be increased by removing or reducing financial barriers as demonstrated by the experience of dental pre payment programs. Utilization was increased to 70% in a program for children which included a periodic recall system. An effective program of dental health education can also increase utiliza tion. 134 ■ JADA, Vol. 7 8 , January 19 69
■ The Importance o f Prevention: The dental profession has long urged the use of proven pre ventive procedures which can significantly re duce the incidence of dental disease and the total dimensions of the dental problem. The following preventive measures should be fully employed:
■ Full Use of Fluorides: Fluoridation of the communal water supply can reduce the incidence of dental decay approximately 60% . Every state and community should provide the benefits of water fluoridation to its citizens to the maximum degree possible. It has been demonstrated that the cost of dental care programs for children in nonfluoridated communities is more than double the cost for children in fluoridated communities. In areas without a community water supply, con sideration should be given to fluoridation of school water supplies. Where fluoridation of the public water supply is not feasible, provision should be made for the topical application of fluorides or for the use, when indicated, of dietary fluoride supplements. ■ Anticariogenic Dentifrices: The use of ef fective anticariogenic dentifrices should be en couraged. ■ Control of the Consumption of Sweets: Edu cational campaigns should be conducted to re duce the frequency of consumption of sweets. Special attention should be given to the elimina tion of the sale of sweets in schools. ■ Toothbrushing Instruction: Toothbrushing instruction and regular oral prophylaxis should be encouraged, starting at an early age. ■ Malocclusion: To prevent malocclusion, de cayed teeth should be restored, spaces resulting from the early loss of primary teeth should be maintained where indicated, and deleterious oral habits should be corrected. Determinations of need for orthodontic treatment can be assisted by the available index for the assessment of handi capping malocclusion. ■ Dental Health Education: Comprehensive and continuing dental health education for the individual patient and the public should be an essential component of all treatment programs.
The design of the dental program ■ Advisory Committee:
In accordance with the Handbook o f Public Assistance Administration, D-7220 and D-7520, state plans are required to have at least the part-time services of a dentist in cluded in the medical assistance unit in the state agency office. It is recommended, in view of Sec. 1902(a)-30, that the state administrative agency establish an additional dental advisory committee in conjunc tion with the state dental association. This com mittee should consist of at least five dentists. It could be financially supported under Sec. 1903(a). The guidance of a dental advisory committee would be most valuable in designing and admin istering the dental program. ■ Priority o f Care to be Provided: The goal of dental care programs should be to provide com prehensive dental care for all eligible segments of the population. When necessary because of financial or other limitations, a system for priority of care should be established. Experience has demonstrated that a comprehensive program for one segment of the eligible population can be a better approach to the goal than a fragmented care program for all. Relief of pain and infection and necessary diag nostic procedures should be provided to all eligi ble recipients. The highest priority for compre hensive care should be given to a program for children. Other segments of the population should be added as the program expands so that all eligi ble recipients will have dental care during or be fore 1974 as required in the law. It is recommended that a care program for chil dren be initiated for a specified age group and be expanded on a systematic basis to include initial care for additional age groups and maintenance care for all children in the program. ■ Services for Children: The program should provide all indicated treatment necessary to re store and maintain the dental and total health of the child. All programs should be designed to include: Complete examination and diagnosis includ ing radiographs when indicated. Elimination of pain and infection. Treatment of injuries. Elimination of diseases of bone and soft tissue. Treatment of anomalies.
Restoration of decayed or fractured teeth. Maintenance or recovery of space between teeth when this service will affect occlusion. Replacement of missing permanent teeth. Treatment of malocclusion with priority for interceptive treatment and disfiguring and handi capping malocclusion. Periodic recall for preventive and treatment services. ■ Services fo r Adults:
A state may choose to implement a dental program for a segment of the population in addition to children. A program for adults should provide all indicated treatment ser vices necessary to restore and maintain the dental and total health of the patient. Programs should be designed to include the following services in accordance with the need of the specific program: Complete examination and diagnosis including radiographs as indicated. Elimination of pain and infection. Treatment of injuries. Elimination of diseases of bone and soft tissue. Treatment of anomalies. Restoration of decayed or fractured teeth. Maintenance or recovery of space between teeth when this service will affect occlusion. Replacement of missing teeth. Early detection of oral manifestations of sys temic diseases and treatment of oral lesions. If financial limitations will not allow a compre hensive program for adults, the following se quence of treatment is recommended: Treatment of acute conditions and elimination of pain and infection. Complete examination and radiographs when indicated. Treatment of diseases of bone and soft tissue with restoration of decayed teeth. Replacement of missing teeth with full or partial prosthesis.
■ Treatment fo r Special Population Groups:
It is recommended that specific arrangements be made for the provision of dental care for handi capped persons who are homebound or residing in institutions or nursing homes. These special population groups have often been neglected in organized dental programs of state and local gov ernments. Services provided should include exam inations at regular, periodic intervals and pre ventive maintenance care. The dental profession should be involved in the planning, operation REPORTS OF C O U N C ILS A N D B U REA U S ■ 135
and evaluation of programs for these special groups. ■ Fiscal Administration: The state administra tive agency should establish the usual, customary, and prevailing fee mechanism to assure quality care and broad participation by the profession. The use of a fiscal intermediary, such as a state dental service corporation or other qualified agency, is encouraged. ■ Method o f Providing Services:
The program should utilize to the fullest extent existing dental facilities and resources, especially those of pri vate practice. The provision of dental treatment through private practice should be the preferred method in order to restore the eligible recipients to the mainstream of society. Freedom of choice should be preserved for both patient and practi tioner. Increased manpower recruitment should be encouraged in areas where there is a shortage of health manpower. ■ Program Evaluation: Provision should be made for periodic evaluation of quantity and types of dental care provided to provide informa tion for improving or extending the dental pro gram. The administering agency should use uni form methods for accounting, tabulations, and identification of services to provide data on costs, utilization, and services rendered. Evaluation should be extended to the systems of delivery of care to assure that all eligible re cipients have access to quality care. ■ Review o f Care Provided:
Programs should utilize mechanisms developed by the dental ad
visory group for peer review— the professional re view of treatment provided. Review committees should be established at the local level in cooper ation with local dental societies. The mechanisms for quality evaluation should be reviewed to as sure objectivity and effectiveness.
Conclusion In planning dental care programs under Title XIX, it is recommended that care be provided accord ing to the following priorities: ■ Emergency care for all recipients. ■ Establishment of care programs for children. ■ Comprehensive care for additional age groups as funds become available. ■ Comprehensive care for adults. The requirements of the program should not in any way impair the professional judgment of the dental profession in providing treatment, or cause the treatment provided under the program to be inferior to that provided in the private sec tor of dental practice.
American Dental Association. Dental health program for children. Transactions 1966, p 175. US Department of Health, Education, and Welfare, Na tional Center for Health Statistics. Dental visits: time in terval since last visit. Series 10, no. 29. Washington, DC, Government Printing Office, 1966. US Department of Health, Education, and Welfare, Na tional Center for Health Statistics. Selected dental findings in adults by age, race and sex. Series 11, no. 7. Washing ton, DC, Government Printing Office, 1965.
Supplement to the List of Certified Dental Materials Council on Dental Materials and Devices
Since publication of the most recent List of Cer tified Dental Materials revised to January 1, 1968; published in the February 1968 issue of t h e j o u r n a l (JADA 76:367) the following changes have been made in the List.
6 for Dental Mercury and are being added to the List as new certifications. CERTIFIED DENTAL MERCURIES ADA Specification No. 6
Simmons Mercury Simmons Refining Company
Addition— The following materials conform to American Dental Association Specification No. 136 ■ JADA, Vol. 7 8 , January 19 6 9
Tamco Dental Mercury Texas American Mercury Company