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State of the State North Carolina Oral Health Section Division of Public Health NC DHHS

State of the State North Carolina Oral Health Section Division of Public Health NC DHHS. Rebecca S King, DDS, MPH Chief, Oral Health Section. UCSF DPH-175 Seminar November 13, 2012. Objectives. Identify the origin of state DPH program Infrastructure Describe program components

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State of the State North Carolina Oral Health Section Division of Public Health NC DHHS

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  1. State of the State North CarolinaOral Health SectionDivision of Public HealthNC DHHS Rebecca S King, DDS, MPH Chief, Oral Health Section UCSF DPH-175 Seminar November 13, 2012

  2. Objectives • Identify the origin of state DPH program • Infrastructure • Describe program components • Status of fluoridation in NC • Pre-school preventive activities • School-based preventive services

  3. Turn of the Last Century • 1910 -- Dr. RM Squires: The true function of both medicine and dentistry is to prevent the ills they are called upon to cure. • 1918 – NC Dental Society gets legislative funding • Reduce pain and infection • Educate on importance of oral health

  4. Oral Health Section, 2012 Focus: To promote conditions in which all North Carolinians can achieve oral health as part of overall health. To work towards eliminating disparities in oral health by using best practices. Motto: North Carolina children – cavity-free forever

  5. Oral Health Section Staff • 4 Public health dentists • 41 Public health dental hygienists • 2 Health education staff • 2 Equipment technicians • Support staff

  6. Oral Health Section Regions and Staff Assignments Central Region 7 State Hygienist positions 15 Counties Western Region 16 State Hygienist positions 1 Local Hygienist 39 Counties CAM- DEN ALLE- GHANY CURRITUCK GATES NORTH- AMPTON ASHE WARREN SURRY HERT- FORD STOKES ROCKING- HAM CASWELL VANCE PER- QUIMANS PERSON PASQUO- TANK GRAN- VILLE HALIFAX WATAUGA WILKES CHO- WAN YADKIN ORANGE BERTIE FORSYTH MITCHELL FRANKLIN GUILFORD AVERY YAN- CEY NASH ALEX- ANDER CALDWELL ALA- MANCE DURHAM EDGE- COMBE DAVIE MADISON WASH- INGTON IREDELL DAVID- SON DARE MARTIN TYRRELL WAKE BURKE WILSON BUN- COMBE CHATHAM RANDOLPH HAY- WOOD CATAWBA MCDOWELL BEAU- FORT PITT ROWAN SWAIN HYDE JOHNSTON LINCOLN GREENE RUTHER- FORD LEE GRAHAM HENDER- SON CABARRUS JACK- SON WAYNE HARNETT CLEVE- LAND MONT- GOMERY TRAN- SYLVANIA GASTON MOORE LENOIR STANLY POLK MACON CHEROKEE CRAVEN MECKLEN- BURG PAM- LICO CLAY CUMBER- LAND JONES SAMPSON RICH- MOND HOKE DUPLIN UNION ANSON SCOT- LAND CARTERET ONSLOW ROBESON BLADEN 34 State Hygienists 3 State Supervisors 5 Vacant RDH Positions 10 Local Preventive Dental Programs 1 Local Hygienists Under State Supervision 11 Counties With No Preventive Dental Program PENDER NEW HANOVER COLUMBUS BRUNSWICK Eastern Region 16 State Hygienist positions 46 Counties Revised 10/01/2012

  7. Budget Total ~ $5.38 M • Mostly state appropriations • ~25% Federal match (Medicaid “Federal Financial Participation” - FFP) • Salaries/fringes ~ $4.33 M • Non-salary ~ $1.12 M • $806,000 operating • Other federal grants ~ $309,500

  8. Program Components • Dental disease prevention • Oral health assessment • Dental health education and promotion • Access to dental care • Dental public health residency

  9. 1 Dental Disease Prevention • Water fluoridation • Pre-school & school-based dental preventive programs • Dental sealants • Fluoride mouthrinse

  10. Community Water Fluoridation Healthy People 2020 goal– 79.6% on community water systems NC surpassed - 87%

  11. Pre-school Dental Prevention Programs in North Carolina

  12. Motivating Assumptions • ECC is a serious public health problem • Its burden can be reduced through prevention targeted to very young, high risk children • Virtually all infants & toddlers obtain care at medical offices and it is a logical place to provide services

  13. Into The Mouths of Babes Statewide Medicaid Dental Prevention Program for Young Children

  14. Goals Enlist our Medical colleagues to help: • Increase access to preventive dental care for low-income children • Reduce the prevalence of ECC in low-income children • Reduce the burden of treatment needs on a dental care system already stretched beyond its capacity to serve young children

  15. Dental Prevention Service Package Medicaid children from tooth eruption to age 3 1/2 • Oral evaluation and risk assessment • Referral for dental care • Caregiver education • Fluoride • supplements • toothpaste • fluoride varnish

  16. Into the Mouths of Babes • >450 physician practices, residency programs, local heath departments trained and supported • OHS position for trainer • Originally funded by a series of federal grants (MCH, HRSA, CDC)

  17. # Annual IMB Preventive Dental Visits in NC Medical Offices

  18. Percent of Health Check Screenings Receiving IMB Services * *For years 2000-2006 includes 1-2 yr olds only, for 2007 on includes 1-3 year olds.

  19. Rates

  20. IMB Program Contributed to: • Increase in access to preventive dental services • Reduction in treatment services, particularly in early life • Increase in dental use through referral, which attenuated treatment reductions observed in dental claims because of disease treatment • Reduction in hospitalization • 50% chance of breakeven for costs

  21. Early Head Start • Surveys and focus groups to find needs • Teachers • Parents • Developing and piloting training materials • Expand the concept that baby teeth are important • Urge parents to seek early preventive care

  22. Carolina Dental Home • HRSA Access to Dental Care Grant • ~$115,000/year for three years • Brought providers together to pilot test how to best get more dental referrals for very young high-risk children, develop risk assessment tool • Collaborators: Local dentists and Pediatric Dentist, Family Physicians, Pediatricians, Medicaid, NC Dental Society, Oral Health Section, UNC Schools of Dentistry and Public Health, community leaders, others

  23. PORRT • Targeted State Maternal and Child Oral Health Service System Grant • $160,000/year for 4 years • Evidenced-based review of risk factors • Priority Oral Risk Assessment and Referral Tool • Expand pilot statewide and evaluate tool • Latest modification: develop curriculum for CHIPRA QI staff to train using video

  24. ZOE • Zero Out Early Childhood Tooth decay • Children in Early Head Start (EHS), birth – age three • UNC School of PH, OHS, Head Start • 5 year NIDCR, NIH grant • Improve access to improve prevention – improve oral health • Evaluate effectiveness of interventions

  25. ZOE Components • Train EHS staff • preventive services in the classroom • parent education • how to encourage parents to care for children's teeth at home (Motivational Interviewing) • Link EHS children with IMB medical providers • Incentivize parents whose children get ZOE age 3 dental exam

  26. School-based Dental Prevention Programs in North Carolina

  27. Dental Sealants • Statewide goal is 50% - a top OHS priority • OHS target population • K-3 high-risk children • 5,700 sealants placed per year • Fifth graders with sealants increased from 28% (1996) to 44% (2010)

  28. Fluoride Mouthrinse • School-based program from mid-1970s to 2002 • Increasingly targeted in early 1990s • Discontinued due to budget cuts and lack of recent data

  29. Effect of Fluoride Mouthrinse* FRL Fluoride Mean Mouthrinse dfs No No 3.09 Yes 1.38 Yes No 5.36 Yes 3.55 P<.001 *2004-2007 NC OHS Statewide Dental Survey

  30. Fluoride Mouthrinse Resurgence • Survey data showed decreased disparities • Obtained expansion budget funding in 2006 • Targeting schools with highest decay rates who promise compliance, grades 1 – 5. • Began in January 2007 • Increase in budget 2008 • Serving ~ 52,000 children

  31. Effectiveness School-Based FMR* • Each ‘FMR year’ associated with weak overall caries-preventive effect • Trend towards higher caries prevention in high-risk schools • Children in high-risk schools who participated for 3+ years demonstrated a sizable ‘FMR Effect’ • Children in high risk schools can experience substantial caries-preventive benefits from long term FMR participation, reducing disparities * Divaris et al, http://jdr.sagepub.com/content/early/2011/12/21/0022034511433505

  32. 2 Oral HealthAssessment • Statewide dental surveys • Oral health surveillance

  33. Statewide Dental Surveys Provide evidence base for program: • Early 1960s • 1976-1977 • 1986-1987 • 2003-2004

  34. 2003-2004 Statewide Dental Survey • Sample: 8000 children K-12 • Study how well NC decay prevention programs are reducing decay • Measure • Disparities • Parents’ knowledge and opinions • How dental health affects quality of life • Results used for Section strategic planning

  35. Trends in Tooth Decay (DMFT) in 12-17-Year-Old Children* Mean DMFT 7.6 3.1 1.4 *NC OHS Statewide Dental Survey Data

  36. Trends in Untreated Decay in Permanent Teeth* Percent Year *NC OHS Statewide Dental Survey Data

  37. % Permanent Teeth with Untreated Decay, by Race Percent White Black Other *2003-2004 NC OHS Statewide Dental Survey

  38. Percent of Children with Dental Insurance by Type and Race* Percent White Black Hisp White Black Hisp White Black Other Private Public None *2003-2004 NC OHS Statewide Dental Survey

  39. Percent of Children with Any Decay (>0 DMFS)* Percent 1986-87 2003-04 *NC OHS Statewide Dental Surveys

  40. Percent of Children With Caries Experience* Primary Permanent *2003-2004 NC OHS Statewide Dental Survey

  41. Trends in Mean dfs(primary teeth) by Education Level* dfs <HS WHITES • Increases in all races • Increases in all educational levels • Particularly severe in those families with low education HS >HS 86-87 03-04 dfs OTHER RACES <HS Key: Less than High School Ed. High School Ed. Greater than High School Ed. HS >HS 86-87 03-04 *2003-2004 NC OHS Statewide Dental Survey

  42. Trends in Untreated Cavities by Education Level* %d/dfs WHITES • Increased treatment in lower income families • Middle and upper income families show little change <HS HS >HS 86-87 03-04 %d/dfs OTHER RACES <HS HS Key: Less than High School Ed. High School Ed. Greater than High School Ed. >HS 86-87 03-04 *2003-2004 NC OHS Statewide Dental Survey

  43. Trends in Dental SealantsChildren with >1 Sealant* Percent 6-11 yrs 12-17 yrs *NC OHS Statewide Dental Surveys

  44. Prevalence of Non-Cavitated and Cavitated Lesions in Permanent Teeth Cavitated only Non-Cavitated only Non-Cavitated & Cavitated 10% 24% 65% Children *2003-2004 NC OHS Statewide Dental Survey

  45. Value Placed on Oral Health* Baby teeth do not need to be filled because they are going to fall out anyway! “% of parents who agree” Percent White Black Hispanic *2003-2004 NC OHS Statewide Dental Survey

  46. Oral Health Surveillance Calibrated dental assessments 2011-2012 • By PH RDHs • Grades K and 5 • School oral health status data • Referral for treatment needs

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