improving children's oral health in new york

Improving Improving Children’s Oral Children’s Oral Health in NYHealth in NY

Dr Tim CookeDr Tim CookeBureau of Dental HealthBureau of Dental Health

New York State Department of HealthNew York State Department of HealthAlbany, NY.Albany, NY.

ChallengeChallengess

Convincing the public that oral health is an important part of their overall health

Improving the utilization of effective preventive measures

Improving the distribution, diversity and flexibility of the dental workforce

Limited data

Policy development

Statewide Statewide StrategiesStrategies

CDC grant funded NY Oral Health Initiative:

Develop State Oral Health PlanDevelop an Statewide Oral Health CoalitionNew York Oral Health Surveillance System- Burden document

MCH block grant funded projects:

Preventive dentistry grantsInnovative services grantsTechnical assistance center

State Oral Health State Oral Health PlanPlan

State Plans are part of CDC’s chronic disease strategy

Steering committee convened representing key organizations

Stakeholders invited to paricipate, ~80 in 5 workgroups (Access, Prevention, Surveillance and Research, Workforce, Policy)

About two years of work

State Oral Health State Oral Health PlanPlan

Key Messages:

• Oral health is much more than healthy teeth

• Oral health is integral to general health

• Safe, effective, easy to adopt disease prevention measures exist

• General health risk factors also affect oral and craniofacial health

Goal 1: Develop and promote policies supporting improved oral health

Goal 2: Promote oral health as a valued and integral part of general health across the life

cycle

Goal 3: Improve access to oral health services and eliminate disparities

Goal 4: Enhance the oral health information and knowledge- sharing infrastructure

Goal 5: Address risk factors for oral diseases

Specific GoalsSpecific Goals

Goal 6: Increase capacity, diversity, and flexibility of

the workforce

Goal 7: Promote educational opportunities and experiences of the oral health workforce

Goal 8: Encourage oral health professionals to be competent in public health principles and

practice.

Goal 9: Develop a research agenda

Goal 10: Maintain and enhance the existing surveillance system

Specific Goals Specific Goals (Contd...)(Contd...)

1.Explore opportunities to form regional oral health networks

2.Formalize a statewide coalition to promote oral health

3. Encourage stakeholders to examine and make recommendations on:

a. Laws and regulationsb. Financing of dental educationc. Effective approaches to address disparitiesd. Strengthening the dental health workforcee. Ways to involve retired dentists and dental hygienists

StrategiesStrategies (Priorities for action) (Priorities for action)

4.Assess gaps in dental health educational materials and explore ways to integrate oral health into health literacy programs.

5.Develop and widely disseminate guidelines, recommendations and best practices

6. Strengthen the oral health surveillance system

StrategiesStrategies (Priorities for (Priorities for action):action):(Contd...)(Contd...)

Key Strategies from the Oral Key Strategies from the Oral Health PlanHealth Plan

Integrate oral health into health literacy programs. Develop and disseminate educational materials focusing attention on topics such as caries in young children, maternal oral health, oral cancer, fluoride, dental sealants and the importance of good dietary habits.

Disseminate existing guidelines, recommendations and best practices to the dental health work force, physicians, nurse practitioners, counselors and other appropriate health care workers regarding childhood caries, maternal oral health, tobacco and alcohol use.

Work with primary health care training programs to integrate inspection of the oral tissues as part of routine physical examination curricula.


Integrate oral health into primary health care by scheduling medical and dental visits together where possible, and facilitating the development of effective referral networks. Potential link between poor periodontal health and pre-term/ low birth weight

Work with professional groups to increase referrals among oral health care providers and other health specialists. Work with professional organizations of health care professionals to target physician’s offices for integrating oral health screening as part of routine physical examinations, and providing anticipatory guidance to families on proper oral health care.


Improve oral care in primary care medical practice settings by including dental conditions on pre-printed primary care records.

Explore incentives for dentists who significantly increase their service to Medicaid clients.

Identify factors that affect the participation of the dental workforce in public health programs, location of practice in dental health professional shortage areas and provision of services to underserved populations.


Identify the existing data collection systems regarding diabetes, the elderly and pregnant women and explore opportunities to include oral health indicators.

Expand the Pregnancy Risk Assessment and Monitoring System (PRAMS) to ascertain dental need.


Explore models from other states that allow dental hygienists to bill for services provided in schools, nursing homes, and such other public health settings

Actively promote fluoridation in large communities (population size greater than 10,000) and in counties with low fluoridation penetration rates. Educate the public regarding the benefits of fluoride by incorporating effective messages in health campaigns.

Encourage Article 28 facilities to establish school based dental health centers in schools and Head-Start Centers to promote preventive dental services in high need areas.


Collaborate with early childhood programs to conduct surveys and focus groups regarding the availability of dental care.

Collect more comprehensive data on needed care for children (in addition to EPSDT visit assessment.)

Collaborate with new partners such as Head Start Centers and WIC to collect data regarding oral health status and unmet treatment needs.

PrioritiesPriorities

Establish oral health networksIncrease the number of school-based and school-linked programsDevelop and disseminate guidelines for oral health care of pregnant women and young childrenCollect data using the re-registration process for assessing underserved areasDevelop educational materialsEliminate administrative barriers

Issues in Pregnant Womenand Young Children

• Prevalence of dental caries in 2-5 year old is 27.9%• Of children aged 1-5 years old enrolled in EPSDT (Medicaid), only 16% received any preventive service

•In New York, over 2900 children (<6 years) are admitted to a hospital for the treatment of dental caries (~$1m)

Infants and ToddlersInfants and Toddlers

Early Childhood Caries (ECC)Early Childhood Caries (ECC)

Any dental caries in a child under 6 years of age

Severe ECC affects <5% children but many more in certain groups who usually don’t access the oral health care system, e.g.:

Low income Minorities Migrants

Very limited state data on disease in young children

Caries PatternsCaries Patterns

ECC

Caries PatternsCaries Patterns

Specific Perinatal Specific Perinatal IssuesIssues

NY has a strong history of providing school based care BUT many children have oral health problems by the time they reach school age

Children with dental caries at a young age are more likely to continue to have cariesPrimary care givers with oral health problems can pass these on to childrenAccess to care is often a problem for both pregnant women and children (especially age 1-3)

Dental visit (%) during pregnancy By race and participation in Medicaid

48.4

51.4

22.7

33.8

54.5

Perc

ent (

95%

CI)

Source: PRAMS, 2002

Total Race Medicaid Status

White Black Yes No

Use of dental services in Medicaid Children: Annual Dental Visit in 2003

25%

45%

Children ages <21 Continuously Enrolled Children ages 4-21

Source:

Evidence Based Evidence Based SolutionSolution

Primary care giver’s (usually mother) oral health impacts child’s oral health

Risk factors for oral disease can be assessed at a young age

Certain parenting practices increase risk

Disease can be prevented if detected early but the window of opportunity is short

Intervention in pregnancy and early childhood can be effective!

Other FactorsOther Factors

Pregnancy may be the only time a woman has dental insurance

There is an association between poor oral health an birth outcomes

There MAY be a causal link between poor oral health an birth outcomes, but the evidence is not yet conclusive

Key Points from Dr Key Points from Dr IidaIida

Dental caries is the most common chronic disease of children (5x as common as asthma)

Most dental disease is concentrated in a small number of children

Early Childhood Caries:- Caries in young children- Often progresses fast- Mostly in low income groups- Expensive to repair- High rate of relapse

Key Points from Dr Key Points from Dr IidaIida

Many factors involved that predict disease:- Parental behavior- Parental attitude- Bacteria from primary care giver

Pregnancy is a good time to promote oral health- Receptive patient- Multiple healthcare visits- Insurance

“Interventions aimed at child health that ignore the welfare of the mother are likely to be less successful than those that also address the mothers' needs.”

Key Points from Dr Key Points from Dr IidoIido

Guidelines: “Oral Health Care During Pregnancy and Early Childhood”- Improve awareness of the importance of oral health care among professionals and the public- Correct misconceptions among professionals and patients- Facilitate coordinated and appropriate dental care during pregnancy and early childhood- Establish oral health care as a key component of prenatal care

IOM: When Guidelines are NeededIOM: When Guidelines are Needed

Problem is common or expensive

Great variation exists in practice patterns

Enough scientific evidence to determine appropriate/optimal practice

Guidelines Address Key IssuesGuidelines Address Key Issues

Few low income and minority women receive any dental visit during pregnancy

Dentists are unwilling to provide needed treatment and preventive interventions in pregnancy

Advice for dentists is not consistent

Oral health is not addressed in pre-natal visits

Potential link between poor periodontal health and pre-term/ low birth weight

Oral Health GuidelinesOral Health Guidelines

Outlines responsibilities of prenatal, dental and pediatric providers

Encourages referral of pregnant women to oral health care providers

Emphasizes that:•most dental care is safe and effective during pregnancy•all necessary care should be carried out

Outlines key role of pediatric providers in children’s oral health and oral development

Guidelines are Written… What Guidelines are Written… What Now?Now?

Inform providersProvide information in a medium that providers will useIncrease awareness of the importance of oral health careEducate everyone involved in perinatal and infant care about what oral health care women and children should receiveEducate patients and raise expectations“Standards of care”

Local Issues

15,037 6,167 4,753 2,669 308549591

1276.2 1311.1

2038.7

3052.6

2142.5

850.2

1402.1

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

State Total New York C ity Downstate-Metro

Upstate-Metro Rural-Urban-Suburban

Rural-Urban Rural

REGION

NU

MB

ER

OF

DE

NT

IST

S

0.0

500.0

1000.0

1500.0

2000.0

2500.0

3000.0

3500.0

PO

PU

LA

TIO

N / D

EN

TIS

T

Number

Population/Dentist

Number Of Dentists And Population Per Dentist By Region In New York State:

State Education Dept Licence Data, 2004

1.83

4.29

2.28

0.96 0.96 0.660.66

0.0

1.0

2.0

3.0

4.0

5.0

All State New York

City

Downstate-

Metro

Upstate-

Metro

Rural-

Urban-

Suburban

Rural-Urban Rural

Region

Ra

tioRatio of Dentists to Dental Hygienists in New York State:

Source:

Fluoridation

Grant FundingGrant Funding

Bureau of Dental Health distributes MCH block grant money in two grant programs:

• Preventive Dental Services Grants

• Innovative Oral Health Initiative

Preventive Dental Services Preventive Dental Services GrantsGrants

2000-2006: Funded 25 programs with $900,000 annually- most focused on school aged children- two targeted the prenatal and perinatal population

New grants will soon be announced- more programs focus on pregnancy/ early childhood- almost all programs address these issues even if they focus on school children

Innovative Oral Health Innovative Oral Health InitiativeInitiative

2003-2006: Funded 7 programs with $1,350,000 annually- programs could design innovative models to meet local needs- Funded a “Technical Assistance Center” (www.oralhealthtac.org) to provided help statewide in developing oral health projects and overcoming barriers

New grant RFA will be released in 2007- Will be targeted at integrating oral health into existing networks (perinatal, rural health)

Web LinksWeb Links

Guidelines (link for now):http://cdhp.org/Projects/PPMCHResources.asp

Oral Health Plan:http://www.health.state.ny.us/prevention/dental/

oral_health_plan.htm

Oral Health Coalition (under development):http://www.nyspha.org/~nysphaor/nysohp/index.shtml

National Maternal and Child Health Oral Health Resource Center):http://www.mchoralhealth.org/

Dr Tim Cooke

[email protected]

(518) 474-1961

improving children's oral health in new york

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