A Cross-Sectional Analysis of Community Water Fluoridation and Prevalence of Pediatric Dental Surgery Among Medicaid Enrollees

Abstract

IMPORTANCE Dental surgery under general anesthesia (DGA) is an ineffective, costly treatment for caries. Interventions to reduce the need for DGA are challenging because children's parents may not seek care until surgery is required. Community water fluoridation (CWF) effectively prevents early childhood caries, but its effectiveness in reducing severe early childhood caries is unknown. OBJECTIVE To determine whether access to CWF is associated with the prevalence of DGA. DESIGN, SETTING, AND PARTICIPANTS This is a cross-sectional analysis of Medicaid claims data from 2011 to 2012. Deidentified data were derived from Medicaid claims and enrollee files for Massachusetts, Texas, Connecticut, Illinois, and Florida for children aged 9 years and younger enrolled in either a fee-for-service or managed care plan through their state's Medicaid program. Linear regression models tested for associations between CWF and covariates. Multivariable linear regression models tested for associations between CWF and outcomes. Regression models included clustered SEs at the county level. Data analysis was performed from December 2018 to March 2020. EXPOSURES Access to CWF was determined by estimating the proportion of a county's total population that had access to a fluoridated public water system. MAIN OUTCOMES AND MEASURES The main outcome was county-level DGA prevalence. Other outcomes were caries-related visit prevalence and patient quality indicators (asthma and diabetes). Covariates included county-level demographic, socioeconomic, and dental practitioner variables. RESULTS A total of 436 counties within 5 states per year (872 county-year observations), were included in the analysis. Adjusted analysis revealed that a 10% increase in the proportion of county's population access to CWF was associated with lower caries-related visit prevalence (−0.45 percentage points; 95% CI, −0.59 to −0.31 percentage points; P < .001). Increasing CWF access in 10% increments was associated with decreased DGA prevalence in unadjusted analysis (−0.39 percentage points; 95% CI, −0.67 to −0.12 percentage points; P = .006) but not in adjusted analysis (−0.23 percentage points; 95% CI, −0.49 to 0.02 percentage points; P = .07). Increasing the proportion of county's access to CWF by 10% was not associated with the prevalence of asthmarelated exacerbations (−0.02 percentage points; 95% CI, −0.10 to 0.05 percentage points; P = .53) or diabetes-related exacerbations (−0.0003 percentage points; 95% CI, −0.0014 to 0.0009 percentage points; P = .66). CONCLUSIONS AND RELEVANCE This study extends our understanding of CWF's benefits for children's oral health. Specifically, these findings suggest that increasing a population's access to CWF's is associated with decreased caries-related visits and may also be associated with use of dental surgical services within high-risk populations.

Socio‐demographic and familial factors associated with hospital admissions and repeat admission for dental caries in early childhood: A population‐based study

“…Our findings present policy makers with clear opportunities for multi-pronged approaches within the health system to reduce preventable hospitalizations related to dental caries. Child oral health, like other complex public health problems, is modified by social, 28 environmental 29 and commercial determinants 30 with multiple causes and no universal solution, 12 and therefore requires broad public health approaches to counteract environmental, 29 social and commercial determinants for health. 30 The inequalities identified also puts forward the case for proportional universalism 26 where further scale and intensity can be provided to those identified as being most in need.…”

Childhood caries and dental surgery under general anesthesia: an overview of a global disease and its impact on anesthesiology

“…However, though fluoridated water is considered a significant public health intervention to reduce global disease, it does not eliminate disease for high-risk populations. In the United States, access to community water fluoridation was not associated with decreased use of pediatric DGA services 45…”

“…In the United States, access to community water fluoridation was not associated with decreased use of pediatric DGA services. 45 Despite increased Medicaid expenditures on dental care, access to DGA services remains variable and unpredictable, with wait times for a surgical date reported up to 60 weeks. The variability in DGA utilization has not been shown to correlate with provider (dental or anesthesia) reimbursements 39 or population disease burden, possibly reflecting differences in costs, demand, statelevel budgeting, or capacity of systems and facilities to provide anesthesiology services for DGA.…”

Mothers’ Sources of Child Fluoride Information and Misinformation From Social Connections

“…7 , 9 , 10 Whether administered topically or systemically, fluoride can be an effective addition to comprehensive caries prevention or management intervention at individual and community levels. 2 , 7 , 8 , 9 , 10 , 11 , 12 , 13 Guidelines support the application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. 14 Fluoride’s mechanisms of action for caries prevention and management include its ability to decrease demineralization of enamel, increase remineralization of early carious lesions, and inhibit bacterial activity in dental plaque.…”

“… 11 There is extensive literature documenting that appropriate fluoride use is both safe and effective for preventing and managing dental caries. 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 …”