A 4-year-old child climbs up in my dental chair and grins, showing his only 2 teeth, which appear sharp and pointed. He looks at me and says, “I want teeth.” And it strikes me that a smile is so fundamental to people that even this 4-year-old child grasps its importance.

That we can put smiles on the faces of our patients—both figuratively and literally—is one of the most rewarding aspects of being a dentist. Helping people have good health and a good self-image goes a long way toward making smiles. Without question, some of the most rewarding moments in my dental career have been providing an esthetic and functional dentition to people with developmental dental and orofacial defects. Providing that first set of teeth to a 4-year-old child with only 2 conical-shaped incisors and seeing that first dentate smile is truly priceless. Not infrequently, I also get to witness parents’ teary eyes as they watch their child’s smile transform. We dentists are privileged to engage in these deeply gratifying, sharing, and giving moments with a variety of patients throughout our patients’ lifetimes.

Barriers to SmilesBut many children and their parents cannot take a smile for granted. Four of 100 children in the United States are born with congenital anomalies that include oral, facial clefts, vision defects, hearing loss from microtia, and other malformations.1The prevalence of selected major birth defects in the United States. Therapies to manage these conditions can be complex and require ongoing habilitation throughout a person’s life.

People with craniofacial anomalies are less likely to receive oral health care than the general population. Barriers to care include financial, lack of access to care, and limited number of experts with the specialization necessary to care for these complex cases. Overcoming these barriers presents significant societal challenges and will require commitment. Is habilitating people with these conditions considered by payers to be medically necessary? How can this (often costly) care be financed?

About 95% of children in the United States have medical insurance. Dental insurance for US children through private or Medicaid or Children’s Health Insurance Program provides oral health benefits for a little more than 90% of children.2American Dental Association, Health Policy Institute
Dental benefits coverage in the U.S. 2020. This leaves about 10% of children in the United States with no dental coverage. Despite a majority of children having insurance, there are both medical and dental expenses not covered to habilitate congenital defects. Congenital defects should be funded through medical insurance as most dental coverage is for preventive care with limitations and restrictions for costly and complex restorative and surgical care. For adults, the outlook is much bleaker with nearly 30% having no dental insurance, and most dental insurance is focused on examinations and preventive care with limited resources for costly restorative and surgical care.2American Dental Association, Health Policy Institute
Dental benefits coverage in the U.S. 2020.Medical NecessityUnfortunately, many of the congenital orofacial anomalies are lifetime disabilities requiring repeated specialized oral health care. Take, for example, the case of a young woman with highly sensitive and brown-discolored teeth due to amelogenesis imperfecta that required full-coverage crowns in the primary dentition. Owing to her age and dental sensitivity, the crowns were placed in the operating room with the aid of general anesthesia—an expensive start to her oral health care. Transitional dental treatment provided a pain-free and reasonably esthetic dentition. She is now in her early second decade of life with a full permanent dentition and wants to be free of pain when eating and chewing and wants to have a pretty smile, requiring full-mouth rehabilitation of her dentition. The 4-year-old with severe hypodontia will likely benefit from implant-supported prostheses as a young adult. I have sent more than a few letters on my patients’ behalf to try and get insurance to cover the extensive care on the grounds of medical necessity with varying levels of success. Sometimes my letters are effective; sometimes medical insurance rejects the request because, they explain, they do not cover dental care. These insurance denials are frequently associated with the categorization of certain treatments or body parts as being cosmetic and not medically necessary.

Many of the congenital orofacial anomalies are lifetime disabilities requiring repeated specialized oral health care.

So, what is the definition of medical necessity? It depends on whom you ask. Many insurance carriers have their own definitions and exclusions, which makes it challenging to know a priori whether treatments are covered by any given program. The HealthCare.gov website defines medically necessary as “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.”3HealthCare.gov
Medically necessary. Some insurance carriers will claim that “medically necessary” refers to health care services a physician deems prudent. To address this issue and provide support for people lacking insurance coverage for crucial health-related treatment needs, the Ensuring Lasting Smiles Act (ELSA) was written and, as of this writing, is on Capitol Hill.ELSA was developed (originally introduced August 23, 2018) to help address the financial barrier created by medical insurers. This bill was reintroduced to the US Congress on March 16, 2021, with strong bipartisan support. If passed, this legislation would require all private group and individual health plans to cover medically necessary items and services that are needed to repair congenital anomalies, including any missing or abnormal body part that is medically necessary for body function and appearance (includes dental, orthodontic, and prosthodontic care). Furthermore, this bill proposes to ensure coverage for ongoing or subsequent treatment required to maintain function or approximate a normal appearance.4Ensuring Lasting Smiles Act
HR 1916, 117th Cong (2020-2021).Conclusion

The ELSA legislation has broad support from professional and patient organizations, including that of the American Dental Association among many other dental organizations. ELSA will provide support for those with congenital ear, eye, and other craniofacial conditions. Being able to create smiles and change the lives of people is truly an amazing part of being a dentist. I urge you to let your congressional leaders know you want them to support ELSA. When I put a smile on my face it costs nothing, but it speaks volumes to those who see me. Putting smiles where they could not fully be present may cost a lot, but to me it says we are putting resources where they will enrich us all. Smiles are priceless!

References

The prevalence of selected major birth defects in the United States.

Semin Perinatol. 41: 338-344American Dental Association, Health Policy Institute

Dental benefits coverage in the U.S. 2020.

()

Medically necessary.

()Ensuring Lasting Smiles Act

HR 1916, 117th Cong (2020-2021).

()Biography

Dr. Wright is the Bawden Distinguished Professor, Division of Pediatric Dentistry and Public Health, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, and the Editor, The Journal of the American Dental Association.

Article InfoFootnotes

Editorials represent the opinions of the authors and not necessarily those of the American Dental Association.

Identification

DOI: https://doi.org/10.1016/j.adaj.2021.05.002

Copyright

© 2021 American Dental Association. All rights reserved.

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