Leveraging Technology to Reach At-Risk Families: Preventing and Managing Early Childhood Tooth Decay in New York City

Legal and policy approaches can be important tools for achieving healthier communities. A new report—The Role of Law and Policy in Increasing the Use of the Oral Health Care System and Services—provides evidence-based information and identifies priority areas that can help communities achieve Healthy People objectives.

This Bright Spot describes how a multidisciplinary group of professionals from Columbia University created the MySmileBuddy program to stop the progression of tooth decay in children who are high risk.

Challenge: Helping families develop positive oral health behaviors to prevent harmful tooth decay in young children

Tooth decay in children under age 6 (also called early childhood caries) is a common chronic health condition in the United States¹—and one that disproportionately affects minority children and children from low-income households.² Children with untreated cavities often have pain and infections that can cause problems with eating, speaking, playing, and learning. As a result, children with poor oral health often miss more school and get lower grades than children with good oral health.³ Children who have tooth decay (or cavities) early on are also more likely to have lifelong oral health problems.

Tooth decay is typically treated with clinical interventions like fillings and other types of repair. Dentists also typically provide generic behavioral advice about tooth brushing and diet. But these interventions don’t identify or address the specific behavioral risk factors a child may have, and so recurrence rates after treatment are high.⁴

Behavioral interventions are an effective alternative that can prevent tooth decay or stop it after it starts, but they need sustained, individualized, and family-centered support to be effective—and dentists aren’t typically reimbursed by payers like Medicaid for these types of services. Additionally, most dentists aren’t trained to educate families about disease prevention.

In 2014, the American Academy of Pediatric Dentistry—which sets clinical policy around children’s dentistry—released updated guidelines on caries risk assessment and management, highlighting the need for effective behavioral risk assessment tools and interventions to address tooth decay in children.

To address the need for sustained behavior change interventions, a multidisciplinary group of professionals from Columbia University—including experts from public health, pediatric medicine, social work, health education, nursing, and pediatric dentistry—secured funding from the National Institutes of Health to develop and test the MySmileBuddy program. This technology-assisted, family-centered program aims to stop tooth decay progression in young children who are high risk.⁵

Strategy: Use tablet-based technology to reach at-risk families

MySmileBuddy seeks to address tooth decay in the context of social determinants of health in high-risk, economically-stressed families in New York City. The program was initially developed and tested with Latinx families, and it’s now been tailored for children from South Asian families as well.

The MySmileBuddy platform—which includes an app, widgets, videos, and more—identifies targeted behaviors (like swapping sugary snacks with something healthy) as goals. Community health workers (CHWs) use the platform to help families generate an action plan and remove barriers to taking action. CHWs also use the platform to facilitate dialogue with families and offer support, and then follow up to assist families in meeting their goals.

According to Dr. Christie Lumsden, associate research scientist at the Columbia University College of Dental Medicine, many of these families face a variety of social and environmental barriers to good oral health, including low incomes, limited access to healthy foods, and transportation challenges.⁶ And while many families using the MySmileBuddy program qualify for programs like Medicaid or CHIP, many have trouble accessing these benefits and face other barriers to care.

Lumsden points out that helping families overcome these barriers is an important part of preventing tooth decay in kids. “It’s about helping families understand how to make and sustain these changes, and how to make these behaviors possible in the context of complicated lives,” she says.

Existing laws and policies address many of these barriers—for example, states are responsible for making sure that Medicaid recipients have access to transportation to their appointments. But these programs aren’t always implemented consistently, and many families don’t know the best way to access them.

MySmileBuddy helps to fill the gap by supporting families as they navigate these challenges and connecting them to their oral health providers. The program itself serves as a “navigator” that allows families to take an active role in their child’s care, helping them overcome health literacy and language barriers, communicate with their providers, plan transportation to appointments, and more—ultimately increasing their access to oral health care services.

Impact: Families find it easier to manage their kids’ oral health care

In an effectiveness trial funded by the Centers for Medicare & Medicaid Services (CMS), the MySmileBuddy team found that the program reduced the progression of caries and had high acceptability among families and CHWs:

• Before taking part in the multi-week MySmileBuddy program, 51% of parents reported “poor or fair” oral health for their kids—after being in the MySmileBuddy program, only 2% reported “poor or fair” oral health
• 41% of children in the program had early childhood caries that didn’t get worse—a much higher rate than most children with caries, which typically get worse even after dental repair
• 87.3% of parents reported that the platform helped them reach their goal

The team has also received a lot of positive feedback from families and CHWs in the program, and from providers as well.

Lumsden says that ultimately MySmileBuddy has helped reduce barriers to oral health care for vulnerable populations, including many families with Medicaid. Many of these families haven’t previously had easy access to oral health care, and needed to overcome barriers to good oral health—like having a safe and stable home, access to resources like toothbrushes, and not feeling empowered to seek care. “Before you can address the health behaviors, you need to address the greater social and environmental barriers that stand in the way,” she says.

Looking Ahead: Shaping policy by prioritizing health outcomes

Tooth decay isn’t typically treated as a chronic disease that requires significant behavioral management, according to Dr. Burton Edelstein, professor of dental medicine and health policy at Columbia University—but future laws and policies could facilitate this approach by treating tooth decay as a chronic disease. Medicaid and other insurance programs don’t typically reimburse providers for the services MySmileBuddy provides. Since medical and dental insurance are usually separate, oral conditions like tooth decay are often treated as cosmetic or inconsequential rather than as health conditions.

Going forward, laws and policies that improve dental provider education can help address this. Dental professionals need more support to use their medical understanding of tooth decay to communicate clearly with patients and their families. Future policies can also support behavior change by encouraging dental professionals to engage with community health workers and other health professionals who can help families adopt healthy behaviors.

Edelstein predicts that Medicaid will be the true driver of change, as Medicaid enacts reforms that focus on paying health care providers for patients’ health outcomes rather than the services they provide.⁷ This means that if dental interventions like MySmileBuddy are shown to improve oral health, this could lead to a host of policies, programs, and procedures that will support this program and others like it. This is also important because the percentage of kids with the highest disease burden for tooth decay are also Medicaid beneficiaries.

“When dentists are paid for health outcomes, there will be a demand for behavioral interventions that have been shown to be effective,” Edelstein says.

About the Law and Health Policy Project

The goal of the Healthy People Law and Health Policy project was to highlight how evidence-based legal and policy interventions and strategies can facilitate progress toward Healthy People 2020 targets by improving community health and well-being. In addition to reports and webinars, the project included "Bright Spots," or success stories, that highlighted successful policy interventions that led to improved health outcomes. The project was a collaboration between the HHS Office of Disease Prevention and Health Promotion (ODPHP), the Centers for Disease Control and Prevention (CDC), the CDC Foundation, and the Robert Wood Johnson Foundation.