A Model Dental Public Health Program : Alameda County California

1. A Model Dental Public Health Program :Alameda County California Jared I. Fine, DDS, MPH

2. Percent of Children with Dental Decay at WIC ** compared to Healthy People 2010 Objective * *Includes white spot lesions ** 7/2009-3/2010

3. Children from low income families suffer more untreated dental disease. Percentage of School Children with Untreated Decay by School Poverty Status, Alameda County, 2002-2004

4. 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

5. 52% of California women reported dental problems during pregnancy

6. Percentage of women delivering in California who received no dental care during pregnancy, by income: MIHA 2002-2007

7. Main reason for not receiving dental care during pregnancy among women with dental problems, MIHA 2004-2007 (n=8,558)

8. 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”

9. 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

10. 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

11. 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.

12. 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

13. 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

14. What’s the ideal? Capacity to : • Conduct surveillance and assessment • Conduct individual and group health education; • Mobilize community and organizational partnerships

15. Community Water Fluoridation

16. Client Support • Outreach • Case management • Insurance assistance

17. Clinical Preventive Services • Dental screening • Fluoride varnish application • Dental sealants

18. Restorative Dental Treatment • Primary Dental Care • Specialty Care: e g Pediatric Dentistry or Oral Surgery • Sedation Hospital based services

19. Assessment • Professionally and client defined health needs • Causal factors • Manpower, facilities, services, programs and financing to address those needs

20. 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.

21. Recent Oral Health and Systemic Disease Studies • Cardiovascular disease • Diabetes mellitus • Obesity • Osteoporosis • Respiratory diseases • Adverse pregnancy outcomes • Malnutrition and Iron Deficiency

22. Reduced Cost by Providing Dental Preventive Services Aetna- Columbia University 144,000 insured Cigna, and Blue Cross Blue Shield of Michigan Washington Dental Service,Costco,MetLife Inc. Kellog Co.,Ford Motor Co. Reduced Medical Cost 9% 16% 11% History of Diabetes Coronary Artery Disease Cerebrovascular Disease

23. What causes early childhood caries?

24. 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.

25. 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.

26. 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.

27. Services at WICJuly1,2008-December 31. 2012

28. Impact of WIC Dental Days • WIC 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

29. Pave way to tx Educate to self care Limit lost school hours Build partnerships Minimize barriers eg geography, language. Positive dental experience Comprehensive School Oral Health Program School BasedSchool Linked Examinations Case management Education for Dental Care Dental sealants for Insurance Fluoride treatments other services Parent notification Preventive & Restorative Care

30. 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)

31. 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

32. 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.

33. Policy Development • Means to create policies and programs via a participatory process that addresses the identified needs.

37. 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

38. 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

39. Coordination and Oversight • Institutionalized Public Health Commission Dental Subcommittee • Provide Advocacy • Coordination • Aid in resource development

40. PREVENTION KNOWLEDGE

41. PREVENTION KNOWLEDGE STRATEGIES

42. PREVENTION KNOWLEDGE STRATEGIES POLITICAL WILL

43. 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.

44. Building Capacity for Sustainability • Create Credible Need • Develop a Constituency of Advocates • Establish Broad Goals and Tangible Objectives

45. 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

46. 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

47. 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”

48. 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”

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