4 Not surprisingly, Connecticut dentists are unwilling to accept new Medicaid children into their practices mainly because of the low reimbursements rates for children [25]. In North Carolina, the case is not much diﬀerent than other states. It has been documented that only 16% of dentists in NC participate in the Medicaid policy [25]. 5. Access and Utilization of Dental Preventive Services The fourth section of this paper presents the access and the utilization of PDC among Medicaid-eligible children. People are confused and cannot diﬀerentiate between access and utilization of dental care. Measuring access and utilization is not an easy task. In fact, within access and utilization of dental care, there are many subvariables that are critical when measured. The deﬁnition of access to dental care is “the abil- ity to gain available, appropriate services as determined by personal, economic, cultural, geographic, and other factors” [26]. On the other hand, utilization of dental care is related to patients’ or families’ familiarity and their uses of available dental resources eﬀectively [27]. Having an accessible dental care does not necessarily mean utilizing it; however, utilizing dental care means accessibility is approached. Many researchers have addressed the issue of access and utilization of PDC among Medicaid-enrolled children. A longitudinal retrospective cohort study found that 23% of 15,438 Medicaid-enrolled children receive at least a single dental caries prevention [15]. Other study did not ﬁnd the percentage of 31% children enrolled in Medicaid who received dental services convincing, leaving about 69% without any kind of dental services in Maryland [27]. A North Carolinian 5-year cohort study found that pre- school-aged children enrolled in Medicaid who have a his- tory of at least one preventive dental visit (PDV) are more likely they utilize PDC in the future and lower dental-related costs [5]. Researchers found that the utilization of PDC is positively correlated with the number of available dentists and previous PDV but negatively correlated with restorative dental visits if PDC was received before the age of one year. They also included that minority of Medicaid-enrolled children are less likely to utilize dental services in general [5]. Many studies from diﬀerent states such as Connecticut [28], Michigan [29], Alabama, and Georgia [30] share North Carolina the same result that Medicaid-enrolled children who utilize PDC receive less dental treatments, caries restora- tions, and comprehensive dental care than non-Medicaid children [31]. Furthermore, Washington State found that the majority of dental procedures performed on Medicaid- enrolled children among 3,244 diﬀerent dental procedures are preventive and diagnostic procedures [32]. The type of dental provider also aﬀects the utilization of PDC. Medicaid-enrolled children in New Hampshire are more likely to receive comprehensive PDC when they are seen by pediatric dentists than those who receive PDC from general dentists [33]. Pediatricians and general physicians are major players in referring Medicaid-eligible children to dentists for PDC. It has been suggested that it is diﬃcult International Journal of Dentistry for pediatricians to comply with EPSDT if each and every single community does not have enough dentists who accept Medicaid beneﬁciaries [34]. Children identiﬁed as children with special health care need (CSHCN) who are Medicaid-enrolled children are also eligible for full dental coverage. This special group of child- ren, aged 1–17 years, do not receive PDC as much as CSHCS who are not enrolled in Medicaid because of the low reim- bursements of Medicaid dental procedures [35]. Another comparative preventive dental utilization study was made in Iowa by Chi and colleagues [36]. Investigators from Iowa compared intellectual and/or development disability (IDD) Medicaid-enrolled children with peers without IDD to study their utilization of PDC. They concluded that regardless of the barriers that may face IDD children, both Medicaid- enrolled IDD children and those without IDD utilize PDC just as the same level [36]. According to the Oﬃce of Inspector General, there are fewer Medicaid-eligible children who receive PDC. Only one ﬁfth of Medicaid-eligible children utilized PDC [7]. The oﬃce presented lists of reasons that led to the low propor- tion of PDC among Medicaid-eligible children. The reasons include Medicaid low imbursements, low number of dentists who participate in Medicaid, diﬃculty in obtaining PDC, unreasonable rejections of payments, slow payments, preap- proval requirements for dental services, and dentists not willing to treat young children. Medicaid families are also blamed for their under utilization of PDC because they do not see PDC as a high priority practice, plus they like to receive an immediate treatment than waiting for dental ap- pointment or make transportation arrangements [7]. 6. Contributing Factors Contributing factors of preventive dental utilization at micro, meso, and macro levels are brieﬂy discussed below. 6.1. Micro Level (Individuals and Families). The lack of den- tal coverage is the ﬁrst inﬂuencing factor of accessing, utilizing, and receiving PDC among Medicaid-eligible ben- eﬁciaries [32]. Dentists’ skills, attitudes, and behaviors have huge impacts on accessing PDC. Some dentists are not will- ing to treat very young children or participate in Medicaid due mainly to low reimbursements and payments issues which would negatively aﬀect their income [7]. The relation- ship between Medicaid families and dental care providers may lead to underutilizing PDC. Some Medicaid families experienced disrespectful treatments from dental staﬀ, dis- crimination, and long waiting time [19]. Knowledge of Medicaid families, attitudes, and behaviors largely aﬀect the utilization of PDC. Families may not place having regular PDC as high priority, and they may lack the knowledge of how important is PDC [7]. Due to the little awareness of the necessity of PDC and as long as the child does not require any immediate pain relief, Medicaid families may not like to book or wait for a PDV and may think that it is worthless to make a traveling eﬀort for only PDV [7]. In addition, family demographic factors such as ability to speak English can aﬀect PDC utilization [37].