A community-based randomized trial of postcard mailings to increase dental utilization among low-income children.

Children who qualify for Medicaid are entitled to comprehensive oral health coverage through the federally mandated Early Periodic Screening, Diagnostic, and Treatment program. According to an analysis by the Kaiser Commission on Medicaid and the Uninsured, 43% of low-income children on Medicaid or Children’s Health Insurance Program (CHIP) have had a dental visit within the past year vs 34% of those uninsured and 40% with insurance.1 Nevertheless, disparities in oral health remain among poor, middle, and higher-income familes2 and dental health among preschoolers is worsening.3 The focus of much effort is now on the youngest children, whose utilization of preventive care is especially low.4 To address the underutilization of Medicaid dental services by the very young, the Washington State Access to Baby and Child Dentistry (ABCD) program was developed in 1995.5 The program has been deemed successful and has expanded to 37 of the 39 counties in Washington State. This program consists of 4 components: (1) outreach to parents and families; (2) training and certification of dentists; (3) enhanced dental benefits; and (4) enhanced dental fees. Initial evaluation of the Spokane, Wash., ABCD program found that only 54% of children visiting the dentist received a fluoride treatment.6 One reason for underutilization of fluoride treatment for children is attributable to the lack of parental knowledge about this benefit. A focus group study indicated that many caregivers were not aware of their coverage.7 An American Dental Association-sponsored symposium also recently highlighted parent education as important.8 In medicine, lack of parental knowledge about immunization schedules has been found to contribute to mothers not taking their children for immunization.9 In June 1999, Yakima County, Wash., began its own version of the ABCD program, entitled “Mom and Me.” 10 The Yakima version of the program differs from prior versions in that primary responsibility for the outreach component of the program rests with the local dental society rather than with the local health department. An outreach manager accepts referrals from various organizations in the community and visits homes to provide family oral health instruction and acts as a liaison between the family and the dentist. In 2001, 51% of the 4,705 0-to 6-year-olds who were enrolled in the Mom and Me program had had at least 1 dental visit.10 In 2009, Yakima County’s dental Medicaid utilization rate for children 5 years of age and younger was the highest in the state at 58%.11 Even so, 42% of this population was still not receiving any dental care that year. A recent review of parent reminder and patient recall systems showed that reminders increased vaccination rates among children by 1.45 to 2.87 times.12 All types of reminders, including postcards, letters, telephone, and auto dialer, were effective. Moreover, postcards with a health message have been found to be more effective in promoting the use of prevention compared to a neutrally worded postcard reminder.12,13 Patient-directed postcards in conjunction with physician reminders are more effective than physician reminders alone.14 Postcard reminders are often used in dental practices for 6-month recalls, and their positive effect on attendance behavior has been documented.15,16 This study evaluated the effect of postcards with information about the dental society-run program in Yakima on utilization of dental care by young children enrolled in Medicaid.