Improving Children’s Oral Health in NY

1. Improving Children’s Oral Health in NY Dr Tim Cooke Bureau of Dental Health New York State Department of Health Albany, NY.

2. Challenges • 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

3. Statewide Strategies • CDC grant funded NY Oral Health Initiative: • Develop State Oral Health Plan • Develop an Statewide Oral Health Coalition • New York Oral Health Surveillance System • Burden document • MCH block grant funded projects: • Preventive dentistry grants • Innovative services grants • Technical assistance center

4. State Oral Health Plan • 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

5. State Oral Health Plan • 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

6. Specific Goals 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

7. Specific Goals (Contd...) 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

8. Strategies (Priorities for action) • Explore opportunities to form regional oral health networks • Formalize a statewide coalition to promote oral health • Encourage stakeholders to examine and • make recommendations on: • a. Laws and regulations • b. Financing of dental education • c. Effective approaches to address disparities • d. Strengthening the dental health workforce • e. Ways to involve retired dentists and dental hygienists

9. Strategies (Priorities for action):(Contd...) • Assess gaps in dental health educational materials and explore ways to integrate • oral health into health literacy programs. • Develop and widely disseminate guidelines, recommendations and best practices • Strengthen the oral health surveillance system

10. Key Strategies from the Oral Health 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.

11. Key Strategies from the Oral Health Plan • 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.

12. Key Strategies from the Oral Health Plan • 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.

13. Key Strategies from the Oral Health Plan • 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.

14. Key Strategies from the Oral Health Plan • 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.

15. Key Strategies from the Oral Health Plan • 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.

16. Priorities • Establish oral health networks • Increase the number of school-based and school-linked programs • Develop and disseminate guidelines for oral health care of pregnant women and young children • Collect data using the re-registration process for assessing underserved areas • Develop educational materials • Eliminate administrative barriers

17. Issues in Pregnant Women and Young Children

18. Infants and Toddlers • 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)

19. 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

20. Caries Patterns ECC

21. Caries Patterns

22. Specific Perinatal Issues • 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 caries • Primary care givers with oral health problems can pass these on to children • Access to care is often a problem for both pregnant women and children (especially age 1-3)

23. Dental visit (%) during pregnancy By race and participation in Medicaid White Black Yes No Total Race Medicaid Status Source: PRAMS, 2002

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

25. Evidence Based Solution • 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!

26. Other 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

27. Key Points from Dr Iida • 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

28. Key Points from Dr Iida • 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.”

29. Key Points from Dr Iido • 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

30. IOM: When Guidelines are Needed • Problem is common or expensive • Great variation exists in practice patterns • Enough scientific evidence to determine appropriate/optimal practice

31. Guidelines 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

32. Oral 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

33. Guidelines are Written… What Now? • Inform providers • Provide information in a medium that providers will use • Increase awareness of the importance of oral health care • Educate everyone involved in perinatal and infant care about what oral health care women and children should receive • Educate patients and raise expectations • “Standards of care”

34. Local Issues

35. Number Of Dentists And Population Per Dentist By Region In New York State: State Education Dept Licence Data, 2004

36. Ratio of Dentists to Dental Hygienists in New York State: Source:

37. Fluoridation

38. Grant Funding • Bureau of Dental Health distributes MCH block grant money in two grant programs: • Preventive Dental Services Grants • Innovative Oral Health Initiative

39. Preventive Dental Services Grants • 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

40. Innovative Oral Health Initiative • 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)

41. Web 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/

42. Dr Tim Cooke tlc06@health.state.ny.us (518) 474-1961