RESEARCH

IN ACTION

Agency for Healthcare Research and Quality • www.ahrq.gov

The oral health of Americans has improved in recent years,

yet considerable gaps in the provision of dental care

remain, according to a recent report by the Surgeon

General.1

This Research in Action highlights dental care research

sponsored by the Agency for Healthcare Research and

Quality (AHRQ). Studies look at the impact of factors such

as reimbursement, race, income, and age on access to and

use of care. Research suggests that educating families about

how to enroll in and access the Medicaid system,

streamlining Medicaid administrative procedures, and

adjusting provider reimbursement could facilitate broader

access to dental care. Studies show that specific treatments

such as dental sealants for children may have a positive

impact on both health outcomes and costs. The quality of

dental care can be further improved by developing and

using performance measures for specific treatments.

Finally, the production of evidence reports evaluating

research on various aspects of care helps to advance

evidence-based dental practice and thereby improve the

quality of care. 

Background

The Surgeon General’s recent report states that oral health

is essential to the general health and well-being of all

Americans.1 Although oral health extends beyond dental

health, the report clearly stresses the importance of the two

leading types of dental disease: tooth decay (dental caries)

and periodontal disease. 

Dental care can be either preventive or restorative.

Preventive care, such as tooth cleaning and dental sealants,

is aimed at avoiding dental problems. Restorative care

Dental Care: Improving Access and Quality

Making a Difference

Poor children receive fewer preventive health care visits

than those with higher incomes...Page 3

Dental sealants can reduce the number of cavities and

decrease the cost of care in the Medicaid program...

Page 4

Minority elderly receive less dental care because of

financial barriers to care...Page 5

Unexplained variations in dentists’ clinical decisions are

widespread...Page 6

Relative cost-effectiveness of dental crowns and their

alternatives has not been established...Page 7

Use of performance measures by dental plans could

improve quality of care...Page 8

Evidence-based practice is advanced by evidence reports

evaluating various interventions....Page 9

Issue #13 July 2003

Author: Mark W. Stanton, M.A.

Managing Editor: Margaret K. Rutherford

Design and Production: Joel Boches

Suggested Citation: Stanton MW, Rutherford MK. Dental care: improving access and quality. Rockville (MD): Agency for Healthcare Research and Quality; 2003.

Research in Action Issue #13. AHRQ Pub No. 03-0040.
repairs problems such as those caused by tooth decay and

periodontal disease. 

Oral health improves overall but gaps exist 

Over the past several decades, oral health in the United

States has improved.a Among most age groups, the average

number of teeth per person affected by dental caries has

decreased. Also, the average number of teeth per person

that show no signs of infection, as well as the proportion of

the population that is caries free, has increased. In addition,

a lower proportion of U.S. adults have lost all their natural

teeth (a process associated with both tooth decay and

periodontal disease) now than was the case two decades

ago. This improvement is most pronounced at older ages. 

Despite the overall improvement in oral health status, gaps

in the provision of care remain. Over the 20-year period

1977-96, the gap in the use of services between low-income

people (those with incomes under 200 percent of the

Federal poverty level) and higher income people (those

with incomes over 400 percent of the Federal poverty level)

increased.2 The number of preventive visits is below

recommended levels, and access to dental care remains

problematic for minorities, the elderly, children on

Medicaid, and other low-income children. For example: 

• More than one third (36.8 percent) of poor children ages

2 to 9 have one or more untreated decayed primary

teeth, compared to 17.3 percent of nonpoor children. 

• Uninsured children are half as likely as insured children

to receive dental care.3

• Untreated dental decay afflicts one-fourth of children

entering kindergarten in the United States. 

• Low-income and minority children have more dental

cavities than other children. 

• Poor Mexican-American children ages 2 to 9 have the

highest proportion of untreated decayed teeth (70.5

percent), followed by poor non-Hispanic black children

(67.4 percent). 

• Poor Mexican-American and non-Hispanic black

children see the dentist less often than other children. 

• Less than one of every five poor children enrolled in

Medicaid receives preventive dental services in a given

year, even though Medicaid provides dental coverage for

enrolled children.

In addition to the considerable access problems faced by

poor and Medicaid-eligible children, poor elderly people

and minorities have their own problems with access. 

• In the 50-69 age group, non-Hispanic blacks (31.2

percent) are more likely than Mexican Americans (28.2

percent) or non-Hispanic whites (16.9 percent) to have

at least one tooth site with periodontal disease. 

• In the age category 70 years and over, the percentages

rise to 47.1 percent, 32.0 percent, and 24.1 percent for

the three groups. 

With more elderly people having discretionary income and

retaining their natural teeth, demand for dental services

among the elderly has grown. But this demand can be

substantially influenced by financial barriers and other

health concerns. Studies show that the elderly typically

underuse needed dental services. 

The underuse of cost-effective preventive services such as

dental sealants, plastic coating applied to protect the

chewing surface of teeth, also illustrates that dental care in

the United States has room for improvement. 

Performance measurement is in its early stages

Beyond the issues of access and underuse, there is the

question of how to measure the quality of care that is

delivered. The ability to measure the quality of dental care

is a key to improving it, but most plans do not collect data

to produce standardized measures. Once the process of

performance measurement is underway, it will be possible

to identify specific treatment areas where improvements

can be made. For example, some research has shown that

the treatment of dental patients with previous restorations

(different repairs to teeth, such as fillings, crowns, and

bridges, that restore original function) has a relatively high

degree of variability, which may or may not be related to

patient-specific factors. Further research may be able to

show which type of restoration is most effective.

Measuring performance becomes more feasible when

evidence reports are available that systematically evaluate

the efficacy of techniques for the diagnosis, prevention, and

treatment of dental caries and other dental diseases. 

2 www.ahrq.gov

a

Unless otherwise referenced, the information in this section comes from

the Surgeon General’s report.
Access to adequate care 

AHRQ-funded studies have identified disparities in the

dental care used by poor children and elderly blacks. These

studies have shown that, despite Federal requirements,

children who are enrolled in the Medicaid program or are

among the near-poor receive less dental care than is

recommended for their age group. For example, they are

less likely to receive regular preventive visits than those in

higher income groups. Also, they are less likely to have

their teeth treated with dental sealants (plastic coating on

the chewing surfaces of teeth), a treatment shown to

improve outcomes and lower overall treatment costs. Poor

elderly minority people also may not receive needed dental

care. The reasons for these disparities are varied, but they

include financial barriers to care, unavailability of dentists

in poor neighborhoods, administrative complexities in

qualifying for Medicaid eligibility and treatment approval,

and insufficient participation by dentists in the Medicaid

program. 

Low-income children have unmet dental needs 

An AHRQ-supported study analyzing data from the 1996

Medical Expenditure Panel Survey (MEPS)b on use of

preventive dental care by 6,595 children and adolescents

found that poor children have significantly fewer preventive

dental visits than those with higher incomes.4 Poor and

near-poor children age 18 and under were only about half

as likely to have had preventive dental visits as children in

middle or high income brackets across racial/ethnic groups

(Figure 1).c For example, 16 percent of poor black children

and 12 percent of near-poor black children had preventive

visits, compared with 26 percent of those with middle or

high income. 

The same study also analyzed Maryland-specific data from

the Centers for Medicare & Medicaid Services and found

that only 31 percent of Medicaid-insured children had

received preventive care during 1996. This proportion was

unexpectedly low, given that States are required by Federal

law to provide dental care to all Medicaid-eligible children

from birth to 21 years of age. The required coverage

includes annual dental exams, prophylaxis and fluoride

treatments, and other emergency, preventive, and restorative

services, such as fillings and oral surgery.4

www.ahrq.gov 3

b

MEPS is the third in a series of medical expenditure surveys conducted

by AHRQ. It is a nationally representative survey that collects detailed

information on the health status, access to care, health care use and

expenses, and health insurance coverage of the civilian

noninstitutionalized population of the United States. 

c

In 1996, the Federal poverty line was approximately $16,500 for a

family of four. The near-poor are those between 101 and 200 percent of

the Federal poverty line.

42.9

46.0

26.1

32.6

20.1

25.4

11.8

14.6

20.0

25.4

15.7 17.6

Total Non-Hispanic white Non-Hispanic black Hispanic

0

10

20

30

40

50 Near-poor

Middle or high income

Poor

Percent

Figure 1. Percent of children 18 and under with a preventive dental visit, by poverty status and race/ethnicity:

United States, 1996

Source: Watson MR, Manski RJ, Macek D. The impact of income on children’s and adolescents’ preventive dental visits. J Am Dental Assoc 2001;132:1580-7.
The situation for Medicaid children in Georgia and

Alabama is comparable to the situation in Maryland,

according to a study by the Children’s Health Insurance

Research Initiative (CHIRITM),d funded by AHRQ, The

David and Lucile Packard Foundation, and the Health

Resources and Services Administration.5 Less than a third

of Georgia Medicaid children (30 percent) received dental

care in 1997, and less than a quarter of Alabama Medicaid

children (18 percent) received dental care in 1999. Almost

all of the children who had any dental care received

preventive care, with approximately half receiving acute

dental services such as emergency or restorative care. 

Another AHRQ-funded study reported that half of 1,297

Medicaid-enrolled schoolchildren in North Carolina never

used dental services. Among children who got care, 45

percent needed restorations in primary teeth and 25 percent

needed restorations in permanent teeth. Among these

children, 29 percent had all their dental needs met, 28

percent had their needs partially met, and 43 percent had no

dental needs met.6

Dental sealants for Medicaid children are underused

Even when poor and near-poor children have access to a

dentist, they may not receive generally accepted

recommended care such as dental sealants. Dental sealants

prevent tooth decay, save money, and are an important

preventive measure, complementing the use of fluorides.

They work by preventing decay from developing in the pits

and fissures of teeth, channels that are often inaccessible to

brushing and where fluoride may be less effective. All

States now include sealants as a dental benefit for children

enrolled in their Medicaid dental programs; however, dental

sealants are underused.

An AHRQ-funded study that examined the dental

experiences of 15,438 children enrolled in the North

Carolina Medicaid program from 1985 to 1992 found that

sealants were effective in preventing tooth decay in the

chewing (occlusal) surfaces of the bicuspid and molar

teeth.7 This reduced the need for CRSOs (caries-related

services involving the occlusal surfaces of these teeth). The

most effective use of sealants was among children who had

more dental services for cavities before sealant placement.

Furthermore, researchers found that restoration rates (cavity

fillings) for high-risk children peaked at 8 years for

unsealed teeth and at 9 years for sealed teeth (18 vs. 8

percent). The effects of sealants are greatest when the child

is roughly 8 years old; after that age, sealant effectiveness

declines. 

The Medicaid program saved money by using sealants for

children prone to cavities. The greatest difference between

expenses for sealed and unsealed teeth ($15.21 per molar)

4 www.ahrq.gov

d

The CHIRITM study is based on claims data from Alabama (1999) and

Georgia (1997); therefore, its findings cannot be directly compared to the

earlier study based on 1996-97 survey data from MEPS. 

AHRQ-Funded Research on Dental Care

Research Programs Discussed in This Report

Clinical Performance Measures for Dental Plans. University of North Carolina School of Dentistry. The project developed

measures of performance for dental care plans. The dimensions of performance for which measures were developed include

the effectiveness of the care provided by the plan (the extent to which appropriate evaluation and treatment is provided and

new disease is prevented), use of services (the rates and/or ratios at which selected services are provided), and access (the

availability of plan benefits to enrollees).

Strategies for Management of Dental Caries in Children. University of North Carolina School of Dentistry. This project used

North Carolina Medicaid data to explore factors associated with providers’ use of sealants in this population, including the

initiation of a reimbursement benefit for dental sealants.

The Effect of Medicaid Policy on Dentist Participation. Sheps Center for Health Services Research, University of North

Carolina. This project studied how changes in Medicaid policy, in particular fee increases and the size of the Medicaid

population, affect providers’ participation in the North Carolina Medicaid program. In addition, the study explored the

relationship between Medicaid price increases and charges to non-Medicaid dental patients.
www.ahrq.gov 5

occurred among the high-risk patients at age 9. These

savings were realized within a 2-year period following

sealant application among children with two or more prior

CRSOs.

However, AHRQ research has documented that, in spite of

the savings realized from their use, these treatments are

underused in the Medicaid program.6 For example, among

219 North Carolina children enrolled in Medicaid who

needed sealants for 615 teeth, only 21 teeth (3 percent)

were sealed, 195 (32 percent) received fillings, 23 (4

percent) were extracted, and 376 (61 percent) received no

treatment within a 2-year followup period. 

Poor elderly African Americans may lack access

The Surgeon General’s report found that people 55 to 74

years of age have higher rates of periodontal disease and

also have an increasing amount of tooth decay compared to

younger adults. The elderly’s use of dental care can be

substantially influenced by financial barriers and other

nondental health concerns. AHRQ-supported researchers

analyzed dental and medical claims data from 1983 to 1992

for 3,458 individuals age 62 years and over who visited two

urban health care facilities and participated in a special

Medicare-waiver program that reimbursed for dental

services (not usually covered by Medicare).8 They

compared age, race, medical use, and pharmaceutical use

among people who used both medical and dental services

(dental users) and those who used only medical services

(nondental medical users).

Researchers found that among poor, elderly city residents,

blacks were twice as likely as whites to use dental services

that are reimbursed by a Medicare waiver program.

Eliminating financial barriers among less affluent and less

educated minority elderly people has a definite effect on

their use of oral health care services. 

In addition, nondental medical users had twice as many

medical visits each month and more than twice the monthly

medical charges in the program as dental users had (.99

visit vs. .56 visit per month and $43 vs. $21 in charges per

month). Dental users were more likely to be younger (born

after 1910) and black (63 percent vs. 36 percent white) than

nondental users, with twice as many blacks as whites

participating in the dental waiver program. 

The decrease in oral health care services associated with

increased use of medical services seems to indicate that as

health declines, people are less inclined or able to seek

dental care. This could indicate a decrease in the priority

given to oral health care, decreased ability to access oral

health care services, or both. The researchers suggested that

African Americans in the study were more likely to use

dental services because their access to services improved.

The absence of private-sector dentists in their own

communities was mitigated by the availability of a city-run

facility providing dental services under a special Medicarewaiver program that reimbursed for dental services.8

Access to Medicaid dental care may be improved

AHRQ-supported researchers have offered their own

suggestions about how to improve access to Medicaid

dental care. Their suggestions focused on two areas:

education and administrative simplification. For example,

the research team that studied the impact of income on the

use of preventive care suggested that poor and near-poor

families may not know how to use available resources

effectively. They concluded that educating families eligible

for Medicaid and State Children’s Health Insurance

Program (SCHIP) programs about how to enroll and access

the system may be essential for the success of these

programs.4

Another group of researchers who studied schoolchildren

and Medicaid suggested that streamlining Medicaid

administrative procedures (e.g., Medicaid eligibility,

treatment approval) could also contribute to better care. For

example, instituting a mechanism for prior approval of care

once a child appears for his or her first dental visit would

help to ensure that all needed care could be completed

quickly and without the need for further approvals.6

One factor contributing to insufficient dental care may be

that dentist participation rates in Medicaid remain low. The

CHIRITM study5 found that children were more likely to

receive restorative dental care if they lived in counties

where there was a greater than average number of

Medicaid-participating dentists per enrollee. 

The dentist participation rates are themselves partly a

function of the reimbursement levels provided under the

Medicaid program. One AHRQ-funded study examined

what happened to participation when reimbursement rates

were increased.9 The study found that increasing provider

reimbursement by 23 percent, even when accompanied by a

doubling of enrollment for individuals under age 21, had
6 www.ahrq.gov

only marginal effects on increasing access to dental

services for the Medicaid population. From 1985 to 1991,

Medicaid enrollment doubled in North Carolina; during the

final 4 years of the study (1988-91) there was a 23-percent

increase in Medicaid reimbursement to dentists. However,

following the implementation of these two measures, the

percentage of dentists seeing 5 or more Medicaid-insured

children per quarter remained fairly constant and the

percentage seeing 10 or more such children per quarter

increased only slightly.

Among providers seeing at least 10 Medicaid children per

quarter, an increase in real Medicaid reimbursement from

$13 to $14 yielded an expected 3 percent (.83 person)

increase in the number of Medicaid children seen per

quarter. Pediatric dentists were significantly more likely to

participate in Medicaid than general dentists (probability of

.58 vs. .20). Pediatric dentists also saw more than 2.5 times

as many Medicaid children per quarter as general dentists

did. Dentists in solo versus group practices were more

likely to participate in Medicaid, and dentists with more

years of experience were less likely to participate. 

The researchers who conducted the North Carolina study

did not conclude that increased reimbursement had little or

no effect on dentist participation. Instead, they concluded

that greater participation may require much larger increases

in reimbursement.9

Measuring the quality of dental care 

An important focus of performance measurement to

improve quality of care is the study of variations in the use

of dental procedures. These variations (by geographic area,

practice type, etc.) suggest the possibilities of overuse and

underuse. Similar concerns are found in medical care. For

example, health services research has examined variations

in the provision of medical care for patients with similar

medical conditions living in different geographic areas. It

has also studied patterns of possible overuse and underuse

of medical procedures.10-12 These studies in turn have raised

questions about the extent to which patient-specific factors,

provider preferences, and practice styles influence treatment

decisions.

Unexplained variations in clinical decisions are

widespread

Are documented variations in the provision of dental

treatments simply reflections of the art of dentistry or are

they caused by uncertainty or disagreement about which

treatment is the most effective? Because quality-of-care

measures for evaluating the performance of oral health

insurance plans have not been available, these questions

have not yet been answered and the quality of care

furnished cannot be systematically evaluated. 

In a comprehensive review of the literature regarding

variation in dentists’ clinical treatment decisions, AHRQfunded researchers found substantial variation in areas such

as the rate of provision of specific procedures, the cost and

number of procedures recommended for specific patients,

diagnoses, intervention decisions, and treatment selection

for individual teeth.13 For example, in one study that

compared six capitated practices with five fee-for-service

practices, average rates of restorative services were higher

in the fee-for-service practices: three times as high for

adults and four times as high for children. In another study,

the proposed treatment costs for two patients examined by

15 North Carolina dentists ranged from $180 to $1,340 for

one patient and $420 to $2,400 for the other.13

From their review of the literature, the researchers

concluded that even when differences in patients are

accounted for, variations in dentists’ clinical decisions are

widespread. Such variations, which raise questions about

possible overuse and underuse of care, definitely need to be

better understood.13 The studies discussed below have

begun to lay the foundations of evidence-based

performance measurement for dental care.

Cost-effectiveness of different restorative treatments

is unknown

Further studies examine restorative treatment

recommendations and the effects of the choice of treatment

on the cost of care. One study examined the extent to which

dentists agreed about the treatment of 1,187 teeth in 43

patients.14 Each patient was examined by an average of 6.6

dentists, with a total of 51 participating dentists. Overall,

agreement among the participating dentists in

recommending individual teeth for treatment was 62

percent. Among all teeth receiving at least one

recommendation for treatment, only 22 percent received a

unanimous recommendation. However, over half of all

instances of lack of agreement occurred when one dentist’s

recommendation differed from those of all the other

dentists examining the tooth. The results suggested that

much of the variation stemmed from basic differences in

recommended treatment for individual teeth with specific
www.ahrq.gov 7

conditions. In cases where a tooth had been previously

restored, differences in treatment recommendations tended

to be greater. The researchers conclude that their study

shows the need to develop objective criteria for treatment of

teeth with previous restorations.14

Another study by the same researchers explored the effects

of variation in both dentists’ decisions to treat and choices

of restorative treatment on the cost of care.15 The patients

selected for the study needed decisions about a variety of

single-tooth restorations and had no substantial periodontal

complications. Three types of restorations–amalgam

fillings, composite fillings, and crowns–varying widely in

cost were considered.e Thirty-seven patients were

examined individually by several practicing dentists. For

each dentist’s recommended treatment for each patient, the

total cost of restorative treatment was calculated first by

using the least expensive treatment possible for each tooth

designated as needing treatment and second by using the

treatment selected by the dentist. The average cost per

patient of the treatment selected ($893) was three times

larger than the cost per patient of basic treatment ($269).

Most dentists did not consistently recommend either higher

or lower cost treatment plans. 

The findings suggest that inconsistencies in both dentists’

decisions to perform restorations and their selection of

treatment have a profound effect on costs. However, the

researchers caution that since there is a relative lack of

information about the cost-effectiveness of low- and highcost treatment alternatives, appropriate treatment planning

and rational cost containment are very difficult. The

researchers suggest that comprehensive efforts to improve

consistency across the profession would be more productive

than focusing on “outlier” dentists who choose more highcost treatments.15

Use of dental crowns and alternatives varies

Another AHRQ-funded study looked at the use of dental

crowns and their alternatives.16 It found that the use of

crowns among patients with substantially compromised

posterior teeth varies significantly by age and region and

that these differences, in turn, are related to substantial

differences in costs. The study found that older patients are

significantly more likely to receive crowns than young

patients. Patients 50 and over had an average cost per tooth

of $269, compared to an average cost per tooth of $181 for

patients ages 18-34. Also, regional variation in the

provision of crowns appears to contribute to a 31-percent

difference in the average per-tooth treatment cost between

the highest and lowest cost regions. The most notable

geographic difference in average cost per tooth was

between the Northeast ($173) and the West ($251). Based

on the sample included in the study, the average cost of

restoring a tooth requiring either a crown or its alternative

was $225. Since crowns can cost up to six times as much

as the alternative, seemingly small differences in the use of

crowns can have major effects on overall costs.16 

In addition, the ratio of crowns to their alternatives varies

more than the amount that can be accounted for by the

patient and practice factors that were measurable through

the claims data used in this study, raising questions about

the consistency of dentists’ treatment recommendations.17

For example, 43 percent of practices provided crowns at

either 50 percent below or 150 percent above the expected

rate. This variation found at the practice level also raises

concerns about the appropriateness of care. However, as the

researchers note, “... a determination of appropriateness

depends upon comparison with a known standard of

treatment effectiveness, which is currently unavailable.”15

Other reasons for disagreement about treatment

recommendations could include differences in the

thoroughness of the examination, application of diagnostic

criteria used to define a condition, assessment of risk,

interpretation of nonclinical patient factors, and

interpersonal interaction between the dentist and patient. 

The researchers concluded that if a substantial portion of

the variation noted in this study indeed stems from dentists’

idiosyncratic use of crowns, the profession has a clear

indication of the need to improve knowledge of treatment

outcomes among practitioners. Since there is substantial

disagreement about the relative life expectancies of crowns

vs. their alternatives, the researchers conclude that more

outcomes effectiveness research is needed, given the wide

difference in the costs of alternative treatments. 

In fact, one of the researchers points out that the dental

profession lacks basic evidence that many of the dental

treatments provided are even effective.17 He also suggests

e

Amalgam fillings are made from a silver/mercury mixture. Composite

fillings contain a mixture of filler particles such as silica, aluminum,

zinc, tin, copper, and iron in a liquid resin. A crown is full coverage for a

tooth (used when the tooth cannot be restored by a filling). Crowns are

much more expensive than either the amalgam or composite fillings.

Most dental schools teach that a crown is the preferred treatment for

substantially compromised posterior teeth with extensive caries,

fractures, or large defective restorations (fillings), as opposed to a direct

metal alloy (amalgam) or composite resin filling.
8 www.ahrq.gov

that soon payers and consumers will no longer accept

anecdotal stories about quality; they will want measurement

and quantification instead. He argues that dental schools

are the logical site for the development of valid, reliable,

and acceptable health services research methods and

databases. In addition, he describes the actual development

of an insurance claims database to demonstrate the types of

investigations possible with it. This database was used to

conduct the study described here on practice variations in

the use of crowns.16

Dental performance measures have been developed

Performance measures for dental care plans can improve

the ability to measure effectiveness of care and use of

services, but no standardized measures of the performance

of dental care plans exist. Currently most plans do not

collect sufficient administrative information to determine

the outcomes of care delivered by their providers. To fill the

gap left by the lack of standardized performance measures,

AHRQ-funded researchers developed seven effectivenessof-care measures and six use-of-services measures modeled

after the Health Plan Employer Data and Information Set

(HEDIS®) measures of medical care.18 (See the text box.)

The measures enable oral health plans to determine the

percentage of enrollees with various conditions and the

percentage receiving various services. Since basic

restorative and periodontal care accounts for one-half of all

dental expenditures and approximately 50 percent of the

population has some dental care coverage, these measures

cover care costing more than $10 billion.

All of the measures are expressed as proportions, i.e., the

proportion of all enrollees meeting certain criteria who have

experienced a certain clinical outcome or have received a

certain service. For example, the first effectiveness-of-care

measure, “current disease activity assessment,” reports the

percentage of all enrollees who have had a caries activity

assessment within 2 years of the end of the reporting year.

The proportions for children (ages 6-17) and adults (ages

18 and over) are reported separately. The second and third

measures address dental caries: a process measure assessing

receipt of appropriate preventive services such as fluoride

treatment or dental sealants, and an outcome measure

assessing caries experience among enrollees. This pattern is

repeated for periodontal disease. A final measure assesses

the extent of tooth loss from both diseases.

Of the six use-of-services measures, three are ratio

measures comparing the provision of services that could be

considered alternative therapies (e.g., endodontic treatment

vs. extraction). Two measures are concerned with wisdom

tooth (third molar) extractions. Another measure is a

traditional assessment of the proportion of enrollees

receiving prophylaxis.

The two groups of measures were pilot tested using

administrative data from two group model oral health plans

with approximately 205,000 eligible enrollees. The testing

provided partial evidence that the measures are reliable and

sensitive to differences among plans. However, the results

reported in the study are not to be taken as benchmarks for

comparison with other dental plans since they are the first

such performance data to be reported for any dental plan. 

The measures offer several advantages that can help

promote their implementation. They can be calculated

directly from a dental plan’s administrative data system

(assuming that the system included diagnostic codes),

thereby minimizing data collection costs and related

recording errors. They are standardized to facilitate

comparisons across plans. They include a means of risk

adjustment to account for differing oral disease status

among enrollees of different plans. However, the measures,

in their final form, cannot be widely implemented

Effectiveness-of-care measures

• Current disease activity assessment.

• Preventive treatment for caries-active children and

adults.

• New caries.

• Periodontal treatment for perio-present adults.

• Improvement in periodontal status.

• Deterioration in periodontal status.

• Tooth loss. 

Use-of-services measures

• Receipt of prophylaxis.

• Preventive treatment: restorative treatment ratio.

• Casting (e.g., crown, inlay): large direct fillings ratio.

• Endodontic treatment: extraction ratio.

• Receipt of third molar (wisdom tooth) extractions.

• Mean number of third molars extracted. 

Source: Bader JD, Shugars DA, White A, et al. Development of effectiveness of care and

use of services measures for dental care plans. J Public Health Dent 1999; 59(3):142-9.
immediately because diagnostic codes are not routinely

used in dentistry and a universally accepted set of codes is

not available at present. The researchers also reported a set

of interim measures that can be applied using audit-based

data until carriers do include diagnostic codes in their

administrative data systems.19

Scientific evidence for tooth decay treatment

strategies is limited

Measuring the quality of care presupposes the ability to

systematically evaluate the validity and effectiveness of

diagnostic, preventive, and surgical interventions. AHRQ,

in a collaborative effort with the National Institute of

Dental and Craniofacial Research (NIDCR), sponsored an

evidence report systematically evaluating research on the

diagnosis, prevention, and nonsurgical treatment of dental

caries.20 The Evidence-based Practice Center (EPC)

performing the analysis looked at 39 studies describing the

performance of diagnostic methods.f The analysis included

separate evaluations for different types of tooth decay (e.g.,

cavitated lesions, lesions involving dentin, enamel lesions)

and also for different surfaces and tooth types. The EPC

report found that that the strength of the evidence on the

performance of almost all diagnostic methods is poor.

Several factors were responsible: an insufficient number of

studies, variation among reported results, and the quality of

the available studies. The evidence did not support the

superiority of either visual or visual/tactile diagnostic

methods since the number of available assessments was

small and there was substantial variation among the reports

for each method. The evidence suggests, but is not

conclusive, that some digital radiographic methods offer

small gains in sensitivity compared to conventional film xrays. The evidence also suggests that electrical

conductance methods may offer heightened sensitivity on

occlusal surfaces, but at the expense of specificity. Again,

the evidence was not conclusive.

The EPC also reviewed nine methods of managing cariesactive individuals: fluoride varnishes, fluoride topical

solutions, fluoride rinses, chlorhexidine varnishes,

chlorhexidine topicals, chlorhexidine rinses, combined

chlorhexidine-fluoride applications, sealants, and other

approaches. In its analysis of 35 studies, the evidence for

the efficacy of fluoride varnishes was rated as fair and the

evidence for all other methods was incomplete.g

Once again, the number of available studies for any specific

method proved to be a serious limitation. Among studies

addressing a method, the variety of experimental protocols,

comparison groups, and other community and individual

preventive dentistry exposures further restricted the

opportunity to draw conclusions about the efficacy of

specific methods. Also, generalization from the studies to

the broader U.S. population is problematic, as nearly all

studies included only children and evaluated changes only

in the permanent teeth. 

Finally, the EPC report evaluated the the efficacy of

preventive methods among individuals who have

experienced, or are expected to experience, an elevated

incidence of noncavitated tooth decay. Here the evidence

was rated as incomplete, since the team found only five

studies addressing the topic. No conclusions were drawn. 

More AHRQ-funded evidence reports on dental care

are available

Cardiovascular Effects of Epinephrine in Hypertensive

Dental Patients. AHRQ and NIDCR sponsored and issued

an evidence report on the cardiovascular effects of

epinephrine in hypertensive dental patients.21 Epinephrine

is widely used as an additive in local anesthetics to improve

the depth and duration of the anesthesia, as well as to

reduce bleeding. The added risks attributed to the use of

epinephrine in hypertensive patients include the increased

probability of acute hypertensive crisis (dangerously high

blood pressure), angina pectoris, myocardial infarction, and

cardiac arrhythmias. 

The EPC looked at five studies on the outcomes of the use

of epinephrine-containing anesthetic solutions in

hypertensive patients. The report rated the evidence on this

issue as poor because the outcomes considered in the five

studies did not represent a reasonably complete assessment

of risk indicators. Also, transient effects in blood pressure

and heart rate, the principal outcomes reported, might have

remained undetected in three of five studies. 

The EPC recommended that a long-term research study be

initiated in one or more large dental clinics in order to

www.ahrq.gov 9

f

Evidence reports are based on rigorous, comprehensive reviews of

relevant scientific literature performed under contract by Evidence-based

Practice Centers. The reports’ emphasis is on explicit and detailed

documentation of methods, rationale, and assumptions. The goal of these

reports is to provide the scientific foundation that public and private

organizations can use to develop their own clinical practice guidelines,

quality measures, review criteria, and other tools to improve the quality

and delivery of health care services.

g

The conclusions of the EPC report apply to research published between

1966 and 1999. The earlier discussion of sealant effectiveness was based

on research published in 2001.
10 www.ahrq.gov

quantify the magnitude of additional risk represented by the

use of epinephrine in hypertensive dental patients. 

Management of Dental Patients Who Are HIV Positive.

Another evidence report cosponsored by AHRQ and

NIDCR focused on several aspects of the dental

management of a special population subgroup—the

estimated 900,000 people in the United States with

HIV/AIDS.22 These aspects include:

• Complications associated with invasive dental

treatments. 

• Dental conditions as markers or indicators of change in

HIV serostatus and immunosuppression. 

• The efficacy or effectiveness of available antifungal

drugs to prevent or treat oral candidiasis.

The EPC found that there is limited evidence on the risks of

oral procedures among people with HIV/AIDS. Very few

studies have been reported, and only two types of

procedures—root canal therapy and extractions—have been

investigated. From this limited base, there is little evidence

of unusual rates or severity of complications for these

procedures among people with HIV/AIDS.

Evidence for the utility of selected oral lesions as markers

for seroconversion is limited to a single study of a single

oral condition—candidiasis. The review does not suggest

the use of oral conditions as markers for seroconversion. 

The evidence with respect to the efficacy of fluconazole to

prevent oropharyngeal candidiasis is good, but for other

antifungal agents there is no evidence. The situation is

different with respect to the effectiveness of antifungals as

treatments for oropharyngeal candidiasis. With the

exception of amphotericin B, the evidence is good that all

tested antifungals are effective, although all are not equally

effective.

Ongoing research and programs

U. S. Preventive Services Task Force (USPSTF)

Recommendations on Dental Care. In fall 2003, the

USPSTF will issue recommendations to cover primary

prevention in pre-school-aged children. These

recommendations will update the previous USPSTF

recommendations, which were issued in 1996. 

The Effect of Public Insurance on Oral Health

Outcomes. University of North Carolina. R03 HS11514.

This project represents an indepth comparison of the use of

dental services, effectiveness of established pediatric oral

health performance measures, and oral health status for

children enrolled in either the North Carolina Medicaid

program or the North Carolina Health Choice for Children

program (North Carolina’s SCHIP program). This study

provides an opportunity to determine the benefits of public

dental insurance for low-income children when it is

structured similarly to private insurance.

Effects of WIC on Child Medicaid Dental Use and

Costs. University of North Carolina. R03 HS11607. The

purpose of this research project is to examine the

relationship of the Women, Infants and Children’s

Supplemental Food Program (WIC) on the oral health use

patterns and cost to the Medicaid program of children

under age 5. The current low level of oral health service use

in Medicaid had presented a major public policy challenge,

as evidenced by reports from the Office of Technology

Assessment, the General Accounting Office, and the Office

of the Surgeon General. This investigation will examine the

role of a partnership between Medicaid and WIC, and its

effects on Medicaid use and expenses.

Conclusion

Despite a falling general rate of tooth decay among

children, widespread disparities exist in the provision of

care to poor and minority populations because of a cluster

of access and financial issues. Availability of coverage and

provider reimbursement rates seem to make a difference in

access to care and in quality of care. 

Measuring the quality of dental care provided through

dental care plans is a difficult task, but one that has

parallels in performance measures already in use for health

care. The quality of dental care provided by oral health

plans could benefit if performance measures developed for

dental services by AHRQ-funded research were put into

broader use. AHRQ’s evidence reports, such as the one on

validity and efficacy of diagnostic, treatment, and

preventive strategies for carious lesions, are designed to

evaluate the strengths and weaknesses of existing research

on a broad array of health care subjects. Where gaps in the

research are shown to exist, AHRQ-funded research, such

as evaluation of the effectiveness of dental sealants, can

help to address the need for more evidence-based practice.

In addition, the relatively recent growth in alternative

treatments available for both diagnosis and management of

dental caries has yet to be fully assimilated by dental
practice. Thorough reviews of methods for diagnosis and

management of dental caries should assist in that

assimilation process.

AHRQ’s research has continued to point out the disparities

in the provision of care that need to be addressed, the

possibility of systematic measurement of dental plan

performance leading to improvements in the quality of

care, and the paths that dental research should take in

pursuing the goal of evidence-based practice. 

References

1. Department of Health and Human Services [U.S.]. Oral

health in America: a report of the Surgeon General.

Rockville (MD): National Institute of Dental and

Craniofacial Research, National Institutes of Health;

2000.

*2. Manski RJ, Moeller JF, Maas WR. Dental services: an

analysis of utilization over 20 years. J Am Dental Assoc

2001;132:655-64. 

*3. Manski RJ, Edelstein BL, Moeller JF. The impact of

insurance coverage on children’s dental visits and

expenditures, 1996. J Am Dental Assoc 2001;132:

1137-45.

*4. Watson MR, Manski RJ, Macek D. The impact of

income on children’s and adolescents’ preventive dental

visits. J Am Dental Assoc 2001;132:1580-7.

*5. VanLandeghem K, Bronstein J, Brach C. Children’s

dental care access in Medicaid: the role of medical care

use and dentist participation, CHIRITM Issue Brief No. 2.

Rockville (MD): Agency for Healthcare Research and

Quality; 2003.

*6. Robison VA, Rozier RG, Weintraub JA. A longitudinal

study of schoolchildren’s experience in the North

Carolina Dental Medicaid Program, 1984-1992. Am J

Public Health 1998;88(11):1669-73.

*7. Weintraub JA, Stearns SC, Rozier G, et al. Treatment

outcomes and costs of dental sealants among children

enrolled in Medicaid. Am J Public Health 2001;

91(11):1877-81.

*8. Strayer MS, Kuthy RA, Caswell RJ, et al. Predictors of

dental use for low-income, urban elderly people upon

removal of financial barriers. Gerontologist 1997;

37(1):110-16.

*9. Mayer ML, Stearns SC, Norton EC, et al. The effects of

Medicaid expansions and reimbursement increases on

dentists’ participation. Inquiry 2000;37:33-44.

10. Wennberg J, Gittelsohn A. Small area variations in health

care delivery. Science 1973;142:1102-8.

11. Eisenberg J. Doctors’ decisions and the cost of medical

care: the reasons for doctors’ practice patterns and the

ways to change them. Ann Arbor (MI): Health

Administration Press; 1986.

12 Chassin M, Kosecoff J, Park R, et al. Does inappropriate

use explain geographic variations in the use of health

care services? A study of three procedures. JAMA 1987;

258:2533-7.

*13. Bader JD, Shugars DA. Variations in dentists’ clinical

decisions. J Public Health Dent 1995;55(3):181-8.

*14. Bader JD, Shugars DA. Agreement among dentists’

recommendations for restorative treatment. J Dent Res

1993;72(5):891-6.

*15. Shugars DA, Bader JD. Cost implications of differences

in dentists’ treatment decisions. J Public Health Dent

1996;56(4):219-22.

*16. Shugars DA, Hayden WJ, Crall JJ, et al. Variation in the

use of crowns and their alternatives. J Dent Educ

1997;61(1):22-8.

*17. Hayden WJ. Dental health services research utilizing

comprehensive clinical databases and information

technology. J Dent Educ 1997;61(1):47-55.

*18. Bader JD, Shugars DA, White A, et al. Development of

effectiveness of care and use of services measures for

dental care plans. J Public Health Dent 1999;59(3):142-9.

*19. Bader J, Shugars D, White A, et al. Evaluation of auditbased performance measures for dental care plans. J

Public Health Dent 1999;59(3):150-8.

*20. Diagnosis and management of dental caries. Summary.

Evidence Report/Technology Assessment Number 36.

AHRQ Pub. No. 01-E055, February 2001. Agency for

Healthcare Research and Quality, Rockville (MD).

AHRQ Web site: <http://www.ahrq.gov/clinic/

epcsums/dentsumm.htm>.

*21. Cardiovascular effects of epinephrine in hypertensive

dental patients. Summary. Evidence Report/Technology

Assessment Number 48. AHRQ Pub. No. 02-E005,

March 2002. Agency for Healthcare Research and

Quality, Rockville (MD). AHRQ Web site:

<http://www.ahrq.gov/clinic/epcsums/ephypsum.htm>.

*22. Management of dental patients who are HIV positive.

Summary. Evidence Report/Technology Assessment

Number 37. AHRQ Pub. No. 01-E041, March 2001.

Agency for Healthcare Research and Quality, Rockville

(MD). AHRQ Web site: <http://www.ahrq.gov/clinic/

epcsums/denthivsum.htm>.

*AHRQ-funded/sponsored research

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Issue Title Publication Number

12 Advance Care Planning: Preferences for Care at the End of Life AHRQ 03-0018

11 AHRQ Tools for Managed Care AHRQ 03-0016

10 AHRQ Tools and Resources for Better Health Care AHRQ 03-0008

9 Reducing Costs in the Health Care System: Learning From AHRQ 02-0046

What Has Been Done

8 Prescription Drug Therapies: Reducing Costs and Improving Outcomes AHRQ 02-0045

7 Improving Treatment Decisions for Patients with Community- AHRQ 02-0033

Acquired Pneumonia

6 Medical Informatics for Better and Safer Health Care AHRQ 02-0031

5 Expanding Patient-Centered Care to Empower Patients and Assist Providers AHRQ 02-0024

4 Managing Osteoarthritis: Helping the Elderly Maintain Function and Mobility AHRQ 02-0023

3 Preventing Disability in the Elderly With Chronic Disease AHRQ 02-0018

2 Improving Care for Diabetes Patients Through Intensive Therapy AHRQ 02-0005

and a Team Approach

1 Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs AHRQ 01-0020