ORAL HEALTH IN NEW YORK STATEDECEMBER 11, 2012

Jayanth Kumar, DDS, MPHBureau of Dental Health

Learning Objectives

Understand the functions, infrastructure and capacity of a state oral health program

Discuss the strategies used for promoting interventions

Describe the evaluation efforts related to the fluoridation program

Vision & Mission

The Bureau of Dental Health will provide an environment to encourage all New Yorkers to develop an awareness of the importance of oral health, and to assure it’s inclusion in public health programs targeted toward the building of healthier communities.

Our mission is to improve the oral health of all New Yorkers.

IMPACT

• Reduction in : Caries, Periodontal disease, Oral cancer

• Reduced Disparities in Oral Health Outcomes

• Reduced transmission of infection

• Enhanced Quality of life

• State Health Department

• State Partners

• CDC technical assistance and funding

• Other resources

• CDC • HRSA

ASSESS

DEVELOP POLICY

ASSURE

OUTCOMESIncreased Program

-Quality

-Magnitude

-Sustainability

-Cultivation

Burden document

Conduct surveillance

Maintain a state oral health plan

Support statewide coalition & partnerships

Develop leadership

Promote systems & policy change

Promote & Manage programs

Institutionalize strong evaluation

Resources-Activities-Outcome-Impact

Technical Support

BUREAU OF DENTAL HEALTH

Indian Health

Migrant Health

School Health

Community Health Centers Dental Care for

persons with HIV

Investigation of disease transmission

Local Health

Medicaid

Child Health Plus

Office of Children and Families

Rural Health

Managed care

Primary Care

Chronic disease programs

Public Health Action

Surveillance & Epidemiology Children, Adults & Elderly

Community based interventions Fluoridation School-based interventions

Health system interventions Guidelines and Training Programs Infection Control Practice

Community clinical linkages Care Coordination, School Certificate Program

Prevalence Trends, Third Grade SurveyUpstate New York

All children

High inco

me

Low inco

me

All children

High inco

me

Low inco

me0

10

20

30

40

50

60

70

53.848.6

65.8

29.6

23

41.845.4

31.1

62.3

24

14.3

35.2

42

20

2002-04 2009-11 SOHP

Caries Prevalence Untreated Caries

Prevalence of Sealants, Third Grade Survey, Upstate New York

All children

High inco

me

Low inco

me0

10

20

30

40

50

60

38.142.5

28.9

4244.9

38.4

502002-04 2009-11 SOHP

Perecent of Medicaid enrollees (ages 2-20 years) who had at least one dental visit within the last year.NYS Medicaid Data, 2005-2010

02 Y

ears

04 Y

ears

06 Y

ears

08 Y

ears

10 Y

ears

12 Y

ears

14 Y

ears

16 Y

ears

18 Y

ears

20 Y

ears

0.0

10.0

20.0

30.0

40.0

50.0

60.0

2005 2010

All ages ( 2-20 years)

2010 - 42.3%

2005 – 35.3%

Target – 56% HP2010

<12 years12 years

>12 yearsMale Female

< 25K >= 25KWhite, N-H

Others

TOTAL Education SEX INCOME RACE

0

10

20

30

40

50

60

70

80

90

100

37.61

15.5

25

44.4

34.839.3

21.3

42 40.8

28.5

Perc

ent w

ith 9

5% C

onfid

ence

Inte

rval

Percent of persons (aged 45 to 64) who have never had a permanent tooth extracted due to dental caries or periodontal disease. New York State BRFSS, 2010.

Trends in tooth loss. Percent of persons (ages 65 and older) who have lost all natural permanent teeth. New York State BRFSS, 1999 to 2010.

1999 2002 2004 2006 2008 20100

5

10

15

20

25

%

Oral cancer cases diagnosed at early stage by gender, race and year. New York State Cancer Registry, 1976-2008.

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

0

10

20

30

40

50

60

Male Blacks Female Blacks Male_Whites Female_Whites

Percent of people who visited a dentist or a dental clinic within the past year. BRFSS, 2010.

18-4445-64 >65 <12 years12 years

>12 yearsMaleFemale

<15K>=15K WhiteOthersTOTAL AGE Education SEX INCOME RACE

0

10

20

30

40

50

60

70

80

90

100

Perc

ent w

ith 9

5% C

onfid

ence

Inte

rval

Dental visit during pregnancy by race, age, years of education, marital status and participation in Medicaid. PRAMS 2008.

TOTAL AGE (years) EDUCATION (years) RACE MARITAL STATUS

MEDICAID STATUS

0

10

20

30

40

50

60

70

80

90

100

Perc

ent W

ith 9

5% C

onfid

ence

Inte

rval

Framework for ComprehensiveState Oral Health Plan

Knowledge forEvidence-BasedDecision Making

What should be done?Setting Optimal National

and State Objectives:(data-driven)

What can be done?Planning Feasible Strategies

(capacity-driven)

What is achieved?Implementing

Effective Strategies(outcome-driven)

What could be done?Determining

Possible Strategies(science-driven)

Data: societal influences,current capacity,

environmental analysis

SurveillanceData: unmet

needs, serviceand data gaps

Data: provenprevention andbest processes

Data: process,outcome, impact

evaluationsData: diseaseburden, target

populations, andimplementation

barriers

Example: A blueprint for action

Counseling pregnant women and parents; Health education and social marketing campaigns;Training

Promote dental sealant, fluoride varnish & annual dental visits, and practice guidelines

School-based dental sealant & fluoride rinse programs;

Fluoridation; Require dental examinations; Healthy school lunch; Prohibit vending machines and soda pouring rights in schools;

Address oral health literacy

Public Health Action Framework

Key prevention strategies:

Community water fluoridation School-based sealant program Preventive dental visits by age one Engaging primary care providers to provide

Risk assessment and early disease detection Fluoride varnish Anticipatory guidance

Engaging prenatal care providers and perinatal networks to promote oral health

Increasing the capacity to treat disease

Fluoridation

Strategies to promote fluoridation

Build support - Internal & External Engage partners and stakeholders

State Oral Health Coalition Rural Water Association Local Health Departments State Dental Association

Develop resources Provide training Explore financing options

Mean claim per recipient for caries related procedures was correlated with county fluoridation status

Spearman Correlation Coefficient -0.53 (p < 0.01).Each bubble denotes the size of the Medicaid population.

1.66 1.33 1.23

Fluoridation status of the county was not correlated with other non-caries related procedures

Spearman Correlation Coefficient was -0.12 (p =0.36). Each bubble denotes the size of the Medicaid population.

Parameter Standard P-valueVariable estimate error

Intercept 1.881 0.328 <0.0001

Fluoridation coverage (percent)a -0.060 0.002 0.003

Children on free or reduced school lunch program (percent) -0.007 0.006 0.271

Population non-white (percent) 0.012 0.009 0.190

Urban population (percent) -0.003 0.004 0.355

Number of providers per 100,000 eligible Medicaid enrollees 0.001 0.001 0.303

Table 3. Regression analysis of claims for restorative, extraction, and endodontic procedures per child, New York State Medicaid Claims Data, 2006a

Medicaid Redesign Team Recommendations

13) Medicaid Coverage of Water Fluoridation: To address disparities in access to dental services the Workgroup recommends that Medicaid funding be made available to support costs of fluoridation equipment, supplies and staff time for public water systems in population centers (population over 50,000) where the majority of Medicaid eligible children reside.

Is there a link between severe fluorosis and caries?

“Severe enamel fluorosis compromises thathealth-protective function by causing structural damage to the tooth… Moreover, the plausible hypothesis concerning elevated frequency of caries in persons with severe enamel fluorosis has been accepted by some authorities, and the available evidence is mixed but generally supportive.”

- NRC Report 2006 (Page 3)

DOES FLUORIDE IN DRINKING WATER DELAY TOOTH ERUPTION I. Adeyemi Jolaoso et al. Bureau of Dental Health, NYSDOH

Number of erupted permanent teeth (weighted) and number of erupted permanent first molars by Age and Water Fluoride Level

Adjusted mean number of Erupted First Permanent Teeth among 7 year old children

Water Fluoride Level(F mg/L)

Mean Number of Erupted First Molars

<0.3 3.82 (0.06)

0.3 -<0.7 3.67 (0.09)*

0.7 -1.2 3.92 (0.06)*

Other variables included in the model were age, gender, race, metropolitan status and school region.

Adjusted Caries Attack Rate among 5-17 year old children

Water Fluoride Level Attack Rate in First Molars DMFS Per 1000 Surfaces

<0.3 92.8

0.3-<0.7 81.2

0.7 – 1.2 77.7

Other variables included in the model were age, gender, race, metropolitan status and school region.

Resources

New York State Department of Health (NYSDOH) website CDC and ADA

Technical Assistance Center in Rochester ILikeMyTeeth.org - NewYork.ILikeMyTeeth.org Fluoride Science.org

Rural Water Association Local Health Department

Water Fluoridation Manual

Features:

Topic summaries

Critical appraisals

Videos featuring fluoride researchers

Planning School Dental Programs in New York State

Treatment

School-based Dental Sealant

Dental Certificate (Screening & referral)

Dental Home

Fluoride rinseFluoridation

Policy InterventionDental health certificate, School curriculum, Health education, Mouth guards in contact sports, Injury protocol, Healthy nutrition – school lunch, vending machines and soda pouring rights.

TARGET (IDEAL)Number of Schools

NYC Rest NYS

50 100

200 500

1048 418

0 100

1542 3127

36

Oral health in young children

Prevalence in 2-5 year old is 27.9%

Mean dfs =2.4 Among children under 4 years old

enrolled in the EPSDT, less than 16% received any preventive dental visit.

In New York, approximately 4800 children (<6 years) treated in an OR for dental caries.

Oral health care during pregnancy

Guidelines Ask questions and assess Incorporate education into prenatal care Facilitate referral

Consultation form List of dentists

Identified champions to promote interventions Included dental health deliverables in Perinatal

Network contracts Dental measures in perinatal standards

Diabetes and Oral Health

New York State Medicaid Program

NY US19.2 m Population 307.9 m

Medicaid Enrollment as a % of Total Pop5.2 m (27% in NY) vs 62.7 m (20% Nation)Essential dental benefits are covered Effective July 1, all beneficiaries are enrolled in a Managed Care Program

Medicaid Caseloads of New York Dentists

“New York has 79 dentists per 100,000 population, which is well above the national rate of 55 dentists per 100,000 population.”

Dental Licenses Issued during Past Eight Calendar Years

Workforce

Dental practice maps Dental health professional shortage areas Recruitment

Fairs and meetings My Health Career® Website HealthMatch Program New York State Primary Care Service Corps School Dental Certificate Program

Workforce flexibility

Questions?