Oral Health Quality Improvement Resources

Tooth decay, or dental caries, is a common yet preventable chronic disease among children in the United States. Recognizing the importance of oral health, Medicaid programs are required to cover comprehensive oral health care for all beneficiaries under age 21 as part of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services. Children and adolescents from low-income families, including those covered by Medicaid and the Children’s Health Insurance Program (CHIP), are roughly twice as likely to have untreated tooth decay as their higher-income peers. Other gaps exist as well. For example, roughly 33% of Mexican American and 28% of non-Hispanic Black children ages 2 to 5 have had cavities in their primary teeth, compared with 18% of non-Hispanic White children¹.

To address gaps in children’s oral health, the Centers for Medicare & Medicaid Services (CMS) provides quality improvement (QI) technical assistance to support states in enhancing oral health care for children enrolled in Medicaid and CHIP, improving access to preventive services and ongoing dental care. From 2020-2023, a CMS learning collaborative focused on advancing oral health preventive services in primary care. While the technical assistance was focused on this intervention, the underlying QI principles are broadly applicable. The materials below may be useful to states seeking to implement oral health-focused QI efforts on a range of topics.

The technical assistance has two components:

1. QI resources to help state Medicaid and CHIP staff and their QI partners get started.
2. Advancing Oral Health Prevention in Primary Care materials, including state examples of successful QI practices developed as part of CMS’s Advancing Oral Health Prevention in Primary Care learning collaborative.

For more information on these materials and other QI technical assistance, please email MedicaidCHIPQI@cms.hhs.gov.

Getting Started with QI

Here are some technical assistance tools to help interested states develop their own oral health-focused QI projects:

• Advancing Oral Health Prevention in Primary Care: Getting Started on Quality Improvement. This video provides an overview of how Medicaid and CHIP agencies can start a QI project to advance oral health prevention in primary care. The Model for Improvement begins with small tests of change, enabling state teams to “learn their way” toward strong programs and policies.
• Advancing Oral Health Prevention in Primary Care Driver Diagram and Change Idea Table. A driver diagram is a visual display of what “drives” or contributes to improvements in children’s oral health. This example driver diagram shows the relationship between the primary drivers (the high-level elements, processes, structures, or norms in the system that must change to improve oral health outcomes) and the secondary drivers (the places, steps in a process, time-bound moments, or norms in which changes are made to spur improvement). The document also includes change idea tables, which contain examples of evidence-based or evidence-informed QI interventions to advance oral health prevention in primary care. The change ideas were tailored for Medicaid and CHIP.
• Advancing Oral Health Prevention in Primary Care Measurement Strategy. This measurement strategy provides examples of measures that can be used to monitor QI projects focused on advancing oral health prevention in primary care.

For more information on these materials and other QI technical assistance, please contact MedicaidCHIPQI@cms.hhs.gov.

Advancing Oral Health Prevention in Primary Care

Young children under 5 are more likely to see a primary care provider (PCP) than a dental provider. PCPs are uniquely positioned to provide oral health preventive services as part of primary care visits and connect beneficiaries to dental care. In 2020, CMS launched the Advancing Oral Health Prevention in Primary Care learning collaborative (previously known as the Advancing Prevention and Reducing Childhood Caries in Medicaid and CHIP) to support state Medicaid and CHIP programs’ efforts in improving children’s oral health. The learning collaborative included an affinity group and webinar series and that supported state Medicaid and CHIP programs’ QI efforts. The webinars described approaches that states can use to improve children’s oral health outcomes.

State Stories

State Highlights Brief from the Advancing Oral Health Prevention in Primary Care Affinity Group

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Fourteen states participated in the action-oriented affinity group where teams designed and implemented a QI project focused on advancing oral health prevention in primary care. Learnings and success stories from participating states can be found in the state highlights brief.

Figure: States participating in the Advancing Oral Health Prevention in Primary Care Affinity Group

Video | Transcript: State Story—Increasing Oral Health Services in Pediatric Primary Care Offices in Connecticut

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This brief video gives an overview of Connecticut’s utilization and revenue report, which identified primary care practices providing oral health assessments and fluoride varnish. Practices not submitting claims were also identified, along with a calculation of the “missed revenue” from not providing these services. The report enabled Connecticut to quantify and address missed opportunities to address children's oral health in primary care.

Webinar Series

• State Spotlights: Advancing Oral Health Prevention in Primary Care (video, transcript). From February 2021 through March 2023, CMS worked with fourteen states participating in the Advancing Oral Health Prevention in Primary Care affinity group. CMS provided state Medicaid and CHIP programs and their QI partners with information, tools, and expert support to advance oral health prevention in primary care efforts for their Medicaid and CHIP beneficiaries. This June 2023 webinar featured several state QI projects from the affinity group, highlighting their strategies, partnerships, and lessons learned.
• Pathways to Improving Children’s Oral Health Using Silver Diamine Fluoride (audio, transcript). This May 2020 webinar introduced successful approaches for using silver diamine fluoride (SDF) to arrest dental decay and improve the oral health of children enrolled in Medicaid and CHIP. Scott Tomar, DMD, MPH, DrPH, Associate Dean for Prevention and Public Health Sciences, University of Illinois at Chicago College of Dentistry, shared an overview of the science and strategies for incorporating SDF into Medicaid oral health delivery models. Bruce Austin, DMD, former Statewide Dental Director, Oregon Health Authority, Kellie Skenandore, Dental Program Manager, Oregon Health Authority, and Zachary Hairston, DDS, Smiles for Children Dental Consultant, Virginia Department of Medical Assistance Services, shared how they designed and assessed policies and reimbursement strategies to promote the delivery of SDF in their state Medicaid programs.
• Improving Children’s Oral Health Using Fluoride Varnish in Non-Dental Settings (audio, transcript). This September 2020 webinar featured successful state approaches for advancing fluoride varnish use in non-dental settings to improve the oral health of children enrolled in Medicaid and CHIP. Amy Belisle, MD, MBA, Chief Child Health Officer, Maine Department of Health and Human Services, and Cassie Grantham, MA, director, Child Health Programs, MaineHealth, shared how Maine engaged in a quality improvement initiative to increase the uptake of fluoride varnish in primary care practices. Rhonda Stephens, DDS, MPH, public health dentist supervisor, North Carolina Department of Health and Human Services, and Mark Casey, DDS, MPH, dental officer, North Carolina Medicaid, shared updates from North Carolina’s long-standing, evidence-based initiative, Into the Mouths of Babes, that trained medical providers to deliver preventive oral health services, including fluoride varnish application, to young children enrolled in Medicaid. Speakers from both states discussed how to leverage fluoride varnish programs as a pathway to connect Medicaid and CHIP beneficiaries to a system of care that addresses their oral health needs.
• Oral Health Care Coordination and Effectuated Referrals (audio, transcript). This October 2020 webinar featured state initiatives that successfully advanced care coordination between medical and dental providers for Medicaid and CHIP-enrolled children. Bonnie Stanley, DDS, Dental Director, NJ FamilyCare, discussed working with managed care organizations and the state American Academy of Pediatrics chapter to engage pediatric primary care providers in fluoride varnish delivery and coordinated referrals to dental providers. Patty Braun, MD, MPH, FAAP, Professor of Pediatrics, University of Colorado Anschutz School of Medicine, provided an overview of her state’s model of integrated care coordination, which includes an embedded oral health care provider in primary care settings.
• Introduction to the Advancing Prevention and Reducing Childhood Caries in Medicaid and CHIP Affinity Group (audio, transcript). This October 2020 information session introduced the “Advancing Prevention and Reducing Childhood Caries in Medicaid and CHIP” affinity group. Natalia Chalmers DDS, MHSc, PhD, Dental Officer, CMCS, provided an overview of national Medicaid trends in childhood caries, access to dental services, and the use of fluoride varnish. Mathematica, CMS’s technical assistance provider outlined the structure for the affinity group. During this session, states had the opportunity to raise questions and hear answers about the affinity group. An Affinity Group Fact Sheet is also available.

[1]Centers for Disease Control and Prevention. Health Disparities in Oral Health. Available here.