Let’s face it: A visit to the dentist doesn’t exactly make kids smile. But avoiding the dentist’s chair is not only costing kids their health, it’s costing their parents and the American taxpayer tons of money.

A study from the July issue of Health Affairs found that one in four children under age 11 in California has never seen a dentist. Nationally, the numbers aren’t much better. A February report from the Pew Center on the States found that one out of every five children under the age of 18 goes without dental care every year.

In 2009, the total dental expense for children in the U.S. was approximately $30.6 billion, one-third of all spending on dental care. Dental costs are roughly 20 percent of a child’s total health care expenses, and these costs are growing quickly. According to the Pew report, total annual spending for dental care is expected to increase 58 percent – from $101.9 billion to $161.4 billion – between 2009 and 2018.

When parents don’t take their children for routine checkups and diagnostic tests, the risks of tooth decay and hospitalization rise. “The use of ambulatory surgery for dental problems is among the top five reasons for [same-day] surgery in kids under five,” says Dr. James J. Crall, child advocate at the American Academy of Pediatric Dentistry, who recommends that children have their first visit by age one. “The best way is to find the kids early on who are demonstrating signs that they are high risk, and getting ahead of it rather than trying to fix mouths full of cavities in two- or three-year-old kids, which many times requires either the use of sedation or taking the kid to the hospital. So the cost of dental conditions is actually higher than what’s recorded under dental services; there are those other aspects of health care that get rolled into it.”

A 2004 study from the American Academy of Pediatrics looked at Medicaid costs – both dental and medical dental costs-in preschool-age children in North Carolina. “When they incorporated those costs, they found that the younger the child’s age when they first got their checkup and dental visit, the lower the overall cost over the entire preschool year,” says Dr. Crall.

Both costs and tooth decay are rising for children under five. According to a 2007 Centers for Disease Control and Prevention (CDC) study, in the past decade, the number of cavities in children between the ages of two and five has increased 15 percent. For children with families living under the poverty line, it’s even worse: They’re twice as likely to have untreated tooth decay. “It sort of gives us pause to think about what the future might be,” says Dr. Crall. “Tooth decay in primary teeth is one of the better predictors as to whether kids are going to have tooth decay in permanent teeth.”

In This Economy, Fewer Patients
The recession has exacerbated the problem. Dr. Lindsay Robinson, a pediatric dentist in Grass Valley, Calif., says her patient roster has dropped off significantly in the past two years. “Due to the economy, I’ve seen a decrease in demand. That’s not to say that children don’t need the care, but in general, people are being extremely conservative right now as far as any kind of out-of-pocket, or perceived out-of-pocket.” One of her recent patients, a five-year-old boy, was diagnosed with a small cavity but didn’t return to have the problem addressed until a year and a half had passed. He was in so much pain that Dr. Robinson had to extract the tooth. “We had to put in a space maintainer, which is about triple the cost,” she says. “It’s this whole idea of preventing the need for costly care down the road.”

Income is a strong determinant of dental visits. In 2004 (the earliest data available), 62 percent of children from high-income families saw the dentist at least once, compared to 34 percent of children from low-income families. Dr. Crall says that about 75 to 80 percent of dental disease in the country is in 20 to 25 percent of the children, and those children tend to be low income and covered by public programs.

In 2004, 26 percent of children had public coverage under Medicaid or the Children’s Health Insurance Program (CHIP), which launched in 1997, and 20 percent had no coverage, whereas 54 percent of children had private coverage. About twice as many children lack dental coverage as those that lack medical insurance.

As the California study found, children with public insurance are much less likely than those with private insurance to see the dentist. The authors suggest the shortage of pediatric dentists who accept Medicaid is a factor. Only 5 percent of California dentists in private practice are pediatric dentists, and only 42 percent of all dentists in California participate in Medicaid. “These findings raise concerns about Medicaid’s ability to address disparities in dental care access and, more broadly, in health care,” the authors write in the study.

The Medicaid Conundrum
Ironically, dental care is much less expensive under Medicaid, due to below-market prices negotiated by the state. But lower payments mean fewer dentists are willing to treat Medicaid patients. Dr. Robinson says that when she started her practice in 1996, she saw primarily Medicaid patients, but as costs have risen and Medicaid fees remain constant she’s had to adjust. Only 10 percent of her patients are now on Medicaid. “It’s becoming unsustainable for a private practice to have primarily Medicaid patients,” she says. “The payer mix had to adjust with the economy.”

In addition, many states – the most recent being California – have dropped their coverage for parents, which is a factor in their child’s dental visits. “Parental use of dental services, and what their experiences have been in the past, could very well be at work here,” says Dr. Crall. “If you have a child on Medicaid, odds are that his or her parents aren’t covered for dental services, because adult dental services are considered optional by the states. And I can tell you, over the past 10 years they’ve been dropping adult dental coverage like a hot potato, given the fiscal situation.”

Under President Obama’s health care reform bill, Medicaid will be expanded, allowing more children to be covered for dental services. Starting in 2014, health plans purchased through the state-run Health Benefit Exchange must also include pediatric oral care for dependents under 21.

“The cost to the state is going to be enormous,” says Dr. Robinson of California. “Currently, we can barely afford the matching dollars to pull the federal dollars down for the Medicaid program. And when we add more people to the rolls, it’s going to be increasingly difficult for the state to pay their portion.”