The Centers for Disease Control and Prevention (CDC) ranks Missouri 47th in access to oral health care. The Pew Charitable Trusts gives Missouri a “C” for children’s oral health and a "D" for use of dental sealants. Sixty-three percent of Missouri Medicaid-enrolled children receive no dental care, and Missouri is one of four states without a dental sealants program for students in high-risk schools. Forty-four percent of skilled nursing facility residents were assessed as having untreated decay. A 2012 MSN Health article noted the City of St. Louis as having the worst oral health of any American city. Kansas City was ranked the 9th worst city. A recent USA Today article focused attention on the increased use of expensive Emergency Rooms to address dental pain when regular dental care is not available.