Survey of Medicaid EPSDT guidelines yields mixed results

A survey of state Medicaid early and periodic screening, diagnosis, and treatment (EPSDT) guidelines shows there is a reasonable level of adherence across the U.S. to the American Academy of Pediatric Dentistry (AAPD) recommendations for infant and toddler oral health practices (Journal of the American Dental Association, March 2013, Vol. 144:3, pp. 297-305)

However, the information on some of the states' EPSDT guidelines can be hard to find and is sometimes contradictory, the investigators found.

"This underlines the need for more clear and consistent messaging, for Medicaid administrators, clinicians, parents, and children," said Jessica Y. Lee, DDS, MPH, PhD, one of the co-investigators and a distinguished professor of pediatric dentistry and of health policy and management at the University of North Carolina at Chapel Hill. "When there are contradictions between different sources of information, there can be confusion."

Multiple EPSDT periodicity schedules

The survey was conducted in 2011 and paid for by the AAPD. The researchers found 32 states and the District of Columbia had separate dental EPSDT periodicity schedules. Under federal law, schedules specifying the content and periodicity of dental services under EPSDT must be established by each state after consultation with recognized dental organizations involved in child healthcare.

Dr. Lee and Jacqueline Hom, DMD, a pediatric dentistry resident at the University of North Carolina Chapel Hill, along with their co-investigators, found that none of the other 18 states had adopted the AAPD's guidelines. However, they all adhered to at least some of the AAPD's recommendations -- particularly those surrounding clinical oral examination, which call for a thorough first exam at the time of the eruption of the first tooth and no later than 1 year of age.

Two of these states, Maryland and Tennessee, followed the AAPD recommendations in every respect except timing of first referral to a dentist; Maryland's guidelines stipulate this should occur by age 2 and Tennessee by age 3.

Among the 32 states that did have separate EPSDT periodicity schedules, the vast majority followed all the AAPD recommendations. Ten states adhere to the criteria for timing and content of every aspect of the AAPD guidelines, including clinical oral examination, caries risk assessment, prophylaxis and topical fluoride, fluoride supplementation, anticipatory guidance/counseling, oral hygiene counseling, and first referral to a dentist. These were California, Georgia, Idaho, Iowa, Massachusetts, Pennsylvania, Rhode Island, Texas, Utah, and Vermont.

Another 14 states and the District of Columbia adhered to all the AAPD recommendations except timing of first referral to a dentist. Only 11 of the 32 states follow the AAPD's recommendation for first referral to a dentist by age 1, according to the survey findings.

Contradictory information

DrBicuspid.com attempted to obtain a comment about lack of adherence to AAPD recommendations from several state Medicaid departments. Only one, MaineCare, responded. John Martins, the director of public and employee communications for the Maine Department of Health and Human Services, said they fully adhere to the AAPD guidelines, including first oral exam no later than 1 year of age, and that "the regulations have been in place for at least three years and perhaps much longer."

This apparent contradiction -- between Martins' assertion and the fact that Dr. Hom's team was told that Maine requires first referral to a dentist only by age 3 -- points to two of the main challenges the researchers faced when conducting the survey: the difficulty accessing some of the states' EPSDT guidelines and the sometimes contradictory information they received.

In the case of Maine, the Medicaid-CHIP State Dental Association (MDSA) told the researchers that MaineCare had adopted the AAPD dental periodicity recommendations, while in contrast the MaineCare Benefits Manual states that Maine follows the Bright Futures/American Academy of Pediatrics' Recommendations for Preventive Pediatric Care. The Bright Futures/AAP guidelines call for first dentist referral at age 3. Similar situations exist for Idaho and North Dakota.

Even when there are not contradictions between different sources, the information on states' Medicaid guidelines sometimes can be hard to find. The researchers had first tried to access the information via the Internet, and if this was not fruitful, they wrote to and visited the MDSA headquarters.

The researchers were particularly puzzled by many states either not providing a recommendation for the age of first referral to a dentist or recommending this be done by age 2 or 3.

"Referral by age 3 is outdated -- it was a very common belief years ago before early childhood caries started to escalate. It could still be a carryover from there," Dr. Hom said. "But I think that we'll find things will definitely continue to improve, that states will continue to adhere more and more closely to evidence-based oral health practices for the pediatric population."