A Model Dental Public Health Program :

Alameda County California

Jared I. Fine, DDS, MPH

Percent of Children with Dental Decay at WIC ** compared to Healthy People 2010 Objective

20%

70%

11%

0%

10%

20%

30%

40%

50%

60%

70%

<9mos 9-15mos 16mos-5yrs 2-4 yrsHP2010 Goal

*Includes white spot lesions ** 7/2009-3/2010

*

Children from low income families suffer more untreated dental disease.

23

31

46

18

28

44

05

101520253035404550

<25% 25-49% >=50%

Per

cent

age

% Students Free or Reduced Price Meals

KindergartenersThird Graders

Percentage of School Children with Untreated Decay by School Poverty Status, Alameda County, 2002-2004

Impact of Poor Oral Health 1.6 million missed

school days Difficulty with

learning Failure to thrive High cost of dental

care Lost self esteem

52% of California women reported dental problems

during pregnancy

Percentage of women delivering in California who received no dental care

during pregnancy, by income: MIHA 2002-2007

80%73%

62%

52%

41% 39%

49%58%

68%73%

0%

20%

40%

60%

80%

100%

0-100% FPL 101-200%FPL

201-300%FPL

301-400%FPL

401%+ FPL

All women (n=21,732) Women w/dental problem (n=11,346)

Main reason for not receiving dental care during pregnancy among women with dental problems, MIHA 2004-2007

(n=8,558)

28%

21%21%

19%

11%Financial barriers

Attitudinalbarriers

No perceivedneed

Patient thoughtcare unsafe

Provider advisedagainst care

US Surgeon General’s Report on Oral Health 2000

“In spite of the safe and effective means of maintaining oral health that have benefited the majority of Americans over the past half century, many among us still experience needless pain and suffering, complications that devastate overall health and well-being, and financial and social costs that diminish the quality of life and burden American society”

Mission of Public Health:

The fulfillment of society’s interest in assuring the conditions in which people can be

healthy.

Core functions:–Assessment–Policy Development–Assurance

Essential Services of Public Health Monitor health

status Diagnose and

investigate Inform, educate

and empower Mobilize

community partnerships

Develop policies and plans

Enforce and laws and regulations

Link people to needed service/assure care

Assure a competent workforce

Evaluate health services

Research

Legal Basis Federal Law EPSDT(CHDP) defined by the

Social Security Act specifies that dental services are :

1) to be provided at intervals that meet standards…in consultation with recognized dental organizations;

2)provided at medically necessary intervals; 3) at minimum include relief of pain and

infection, restoration of teeth and maintenance of dental health.

What do the professions say?

“..every child should begin to receive oral health risk assessments by 6 months…”– American Academy of Pediatrics

“…children should be seen by a dentist following eruption of 1st tooth but no later than 12 months of age..”

– American Academy of Pediatric Dentistry

Maternal and Child Health Oral Health Performance Objective for the nation:

By 2020- increase by 28% the number of 6-9 yr olds have had at least one dental sealant on a permanent first molar

What’s the ideal?Capacity to : Conduct surveillance

and assessment Conduct individual

and group health education;

Mobilize community and organizational partnerships

Community Water Fluoridation

Client Support Outreach

Case management

Insurance assistance

Clinical Preventive Services

Dental screening

Fluoride varnish application

Dental sealants

Restorative Dental Treatment

Primary Dental Care

Specialty Care: e g Pediatric Dentistry

or Oral Surgery

Sedation Hospital based services

Assessment–Professionally and client defined

health needs

– Causal factors

– Manpower, facilities, services, programs and financing to address those needs

Dental disease is nearly 100% preventable yet…

By kindergarten > 32% of all children have untreated tooth decay; in low income schools that proportion is 46%

By 3rd grade 69% of all students have had tooth decay

8% of kindergarteners and 9% of 3rd graders had toothaches or dental abscesses at the time of examination

Children experience pain, difficulty chewing, learning, smiling, even failure to thrive.

Recent Oral Health and Systemic Disease Studies

Cardiovascular disease Diabetes mellitus Obesity Osteoporosis Respiratory diseases Adverse pregnancy outcomes Malnutrition and Iron Deficiency

Reduced Cost by Providing Dental Preventive Services

Aetna- Columbia University 144,000 insured

Cigna, and Blue Cross Blue Shield of MichiganWashington Dental Service,Costco,MetLife Inc.Kellog Co.,Ford Motor Co.

History of DiabetesCoronary Artery Disease Cerebrovascular Disease

Reduced Medical Cost 9% 16% 11%

What causes early childhood caries?

Assurance

– Provision of or guarantee of access to state of the art resources, services that are acceptable, accessible, of high quality, comprehensive and continuous; and

– information with which people can make individual, family or community decisions.

WIC/Oral Health Collaborative

To strengthen partnerships that enables WIC to be the “entry point” for dental care :

To increase the number of at risk one year olds who :

have access care; receive preventive dental

services;

have a dental home.

WIC Oral Health Program Internal promotion: flagging clients,

signups, appointments, reminder calls, bookmarks;

Nutrition assistant conducted group oral health education;

Dental hygienist oral assessment, toothbrush cleaning, fluoride varnish, anticipatory guidance, goal setting;

Case manager insurance assistance and dental appointment making.

Services at WICJuly1,2008-December 31. 2012

# of children served(73% on Medi-Cal)

5098(3726)

# prophylaxis/fluoride varnish treatments

4411

children 9-15 months 56%

children 16-months-5yrs

44%

Impact of WIC Dental DaysWIC dental days participants

have 42% less restorative dental care needs compared to other Medi-Cal enrollees

Cost savings was estimated to be 54% of those who had not benefitted from WIC services

Comprehensive School Oral Health Program

School Based School Linked

Examinations Case management

Education for Dental Care

Dental sealants for Insurance

Fluoride treatments other services

Parent notificationPreventive &Restorative Care

Pave way to tx

Educate to self care

Limit lost school hours

Build partnerships

Minimize barriers eg geography, language.

Positive dental experience

Financial Sustainability Dental hygienist: FFS Medi-Cal and

private grant Dental assistant: City grant and MCH

federal/local (FFP) Dentist: FQHC clinic partners Case manager: CHDP federal/local

(FFP) and local general funds; Administrative staff: MCH

federal/local (FFP) Project manager: MCH federal/local

(FFP)

Know Where the Money Is, “Go Where the Money Is!” eg.

Federal Financial Participation (FFP)Title XIX Medicaid funding for MCH,CHDP

Federally Qualified Health Centers (FQHC)

Tobacco Tax Settlement funds Private and Public Foundations State, City and County General Funds In kind support – volunteers and staff First 5

Federal Financial Participation Skilled licensed professional personnel

including dentists, dental hygienists can . . .

For example: Coordinate a sealant program Plan a needs assessment Establish an early childhood caries

prevention program at WIC

Matching Sources: Local General, State General, Philanthropic or Private Funds donated to the County.

Policy Development

–Means to create policies and programs via a participatory process that addresses the identified needs.

ACCESS New paradigm -Federally Qualified

Health Centers collaborating as the school based dental delivery system.

La Clinica de la Raza, Asian Health Services and Lifelong Medical

Oakland Unified School District

EDUCATION Study of the impact of Sugar

Sweetened Beverages on the economy and on health of Alameda County Residents i.e– Dental caries – Obesity– Diabetes– Heart disease– Stroke

Coordination and Oversight Institutionalized Public Health

Commission Dental Subcommittee

Provide Advocacy

Coordination

Aid in resource development

KNOWLEDGE

PREVENTION

KNOWLEDGE

STRATEGIES

PREVENTION

POLITICAL W

ILL

KNOWLEDGE

STRATEGIES

PREVENTION

Office of Dental Health Resources

1 Dental Director, Dental Hygienist Program Manager, Program Financial Specialist, Administrative Assistant.

4 Community Health Outreach/Case managers

1 Registered Dental Hygienist, 1 Registered Dental Assistant

5 workgroups – School Based Implementation, Public Health Commission Dental Subcommittee, Sustainability, Perinatal Dental Care, Evaluation.

Building Capacity for Sustainability

Create Credible Need

Develop a Constituency of Advocates

Establish Broad Goals and Tangible Objectives

Create Credible Need Establish, package and promote Define it, prepare it for specific

audiences Deliver it in language they

understand Make it relevant to them and their

values

Build and Nurture Partnerships

Learn who your partners are and cultivate them

Policy Makers, universities, dental, medical, and nursing providers, school nurses, school advocates, child health, MCH, EPSDT, etc.

Internal and external, natural and unanticipated – e.g. insurance/finance

Build consensus on mutual goals Develop memorandums of

understanding

Establish Broad Goals and Tangible Objectives

Clarify shared values, perceived needs

Normative goals/vision Short term achievable objectives

“Advocacy without recommendations is no advocacy at all”

Be a Win3 Opportunist Network of schools, providers Prevalence of dental problems = a contact opportunity

for well child visits, immunizations, and insurance enrollment (Medicaid/SCHIP)

New research – periodontal disease and birth outcomes

New paradigms – S. mutans transmissible infection

“It’s never ‘self serving’ if you are serving”

Success Requires: Credibility Accountability Responsiveness Follow through Helping others look good Maintaining your sense of humor!