Oral Health Surveillance in Texas

David P. Cappelli, DMD, MPH, PhDAssociate Professor

Department of Community DentistryUniversity of Texas Health Science Center at San Antonio

Texas Oral Health Summit: Advocacy, Equity & AccessAustin, Texas

September 9-10, 2004

Components of a State Oral Health Surveillance

SystemClear purpose and objectivesCore set of measuresAnalyze trendsCommunicate data and information to decision-makers and to the public

CDC, Division of Oral Health, May, 2003

CDC Surveillance DataNational Oral Health Surveillance System (NOHSS)Behavioral Risk Factor Surveillance System (BRFSS)Water Fluoridation Reporting System (WFRS)Pregnancy Risk Assessment Monitoring System (PRAMS)Youth Risk Behavior Survey (YRBS)Surveillance, Epidemiology & End Result (SEER)Basic Screening Survey (BSS)National Health and Nutrition Survey (NHANES)National Health Interview Survey (NHIS)

National Oral Health Surveillance System

Capture data from four questions listed on BRFSS and WFRS

Last dental visit within the past yearTeeth cleaned by a dentist/dental hygienist in the past yearPopulation over the age of 65 years who have lost all of their teethPopulation on public water systems receiving fluoridated water

Last Dental Visit within the Past Year

010203040506070

1995 1996 1997 1999 2002

Yes No

CDC, BRFSS

64.160

Teeth Cleaned within Past Year

010203040506070

1999 2002

Yes No

CDC, BRFSS

Lost 6+ Teeth Due to Tooth Decay or Gum Disease

0102030405060708090

1995 1996 1997 1999 2002

Yes No

CDC, BRFSS

19.114.2

Water Fluoridation Reporting System (WFRS)

Fluoridated Nonfluoridated

34%66%

CDC, Oral Health Resources, 2003

SMART BRFSS DataDallas and Houston Metropolitan AreasContains data on 7 health indicators

None directly relate to oral healthSmoking statusDiabetesObesity

National Data Collection Opportunities

PRAMS: Four questions that could be asked directly related to oral health

SEER: Forty-one states + DC analyze for state-specific data on oral cancer

YRBS: Oral health related questions could be included

Statewide Data Collection Opportunities

Texas State Board of Dental ExaminersCollects annual data on workforce of dentists and dental hygienists

Age and practice locationNumber of auxiliaries utilized

Obtains information on location of practice and practice activity (hours/weeks worked)Medicaid/Insurance ProviderAccessibility for persons with disabilities

Statewide and Regional Data Collection Opportunities

‘Statewideness’ Assessment of Oral Health

Data by county available on:Number of Medicaid eligible children age one year and olderNumber of Medicaid eligible children who received at least one dental serviceNumber of Medicaid eligible providers who provided at least one dental service

Statewide and Regional Efforts

Multiple statewide and regional projects and groups that obtain data on:

Prevalence of oral diseaseUntreated dental cariesUrgent dental care needsSealant prevalence

Statewide and Regional Efforts

Texas Dental Health Survey, “Make Your Smile Count”, 1998

TDH in cooperation with UTHSCSA, Community DentistryState survey of Preschool, 2nd and 8th grade students

Parental Questionnaire and Direct Screening16 elementary/16 adjacent middle schools110 Preschoolers/1124 2nd graders/802 8th graders

Statewide and Regional Efforts

Texas Dental Health Survey, “Make Your Smile Count” Findings:

66% (2nd)/53% (8th) had a dental caries experience44% (2nd)/22% (8th) had untreated tooth decay16% (2nd)/24% (8th) received dental sealantsMedicaid Enrollment was associated with:

Positive parental perception of good oral healthGreater likelihood of dental visit in past yearLower likelihood of never having a dental visitGreater likelihood of having a dental home

Statewide and Regional Efforts - El Paso

El Paso Oral Health Care Community Plan, 2000

Statewide evaluation of the oral health status of children (6-8 years)Students on free and reduced lunch program (4,012 Medicaid/10,104 Non-Medicaid)

Findings:Non-Medicaid children had more active caries and received fewer preventive servicesNon-Medicaid children had more urgent care needs

Statewide and Regional Efforts - El Paso

TEXAS EL PASO REGION

Medicaid (%)

Non-Medicaid (%)

Medicaid (%)

Non-Medicaid (%)

Caries History 58.7 58 65.9 65.4Active Caries 36.0 46.2 46.6 48.3

Sealants Present 21.8 13.8 12.9 14.1Urgent Care

Needed9.7 14.3 38.8 40.7

Routine Referral Needed

29.3 35.5 9.7 10.8

Sealants Needed 38.2 32.9 34.8 34.4No Treatment

Needed22.8 17.3 16.7 14.0

Statewide and Regional Efforts -El Paso

Dr. Michael NajeraHow to best provide needed dental health education message to low-income childrenAdministered 80-question oral health survey to 400 mothers enrolled in WIC clinics in El Paso, TXFindings:

Oral health knowledge was less in mothers born in Mexico, with less than HS education, and low ability to read EnglishOral health of the child was significantly adversely affected by having a younger mother (under age 25), mother born in Mexico, Spanish is principal language and low English literacyOral health of the mother and dental practices of both mother and child were affected by low English literacy

Statewide and Regional Efforts Lower Rio Grande

ValleyLower Rio Grande Valley: Dr. Ramon Baez, UTHSCSA

Conducted between 1990-19953,450 individuals were examinedFindings:

85% of the population was in need of dental careNeed for emergency dental care increased with age (69% of persons over age 55 needed care)

Statewide and Regional Efforts

Lower Rio Grande ValleySouth Texas Health Status Assessment, Community Health Development Program, 2003

Household survey of adults and children living five South Texas counties (Cameron, Hidalgo, Starr, Webb, Willacy) to look at oral health services for colonia residentsSupported by funds from RWJ Foundation for the Integrated Health Outreach Services Project (IHOS) and HRSA

Statewide and Regional Efforts

Lower Rio Grande ValleySouth Texas Health Status Assessment, Community Health Development Program, 2003Findings:

Dentists per 100,000 Population: 9.6-16.2 (Texas: 36.4)Over 65% of all respondents stated that cost was a consideration in seeking dental care, even if insured55% of adults traveled to Mexico for dental/medical careOver 25% of adults never had a dental exam (14% of children)Over 30% of adults (25% of children) had tooth or gum problems at the time of the survey

Statewide and Regional Efforts - Houston

Innovative Method to Improve the Impact of the Texas Oral Health Program

Collaboration between UT-Houston Dental Branch and Dental Health Task Force of Greater HoustonFunded by TDH-Innovations Grant

Goals and ObjectivesDevelop and test a cost-effective method to generate data for development of evidence-driven oral health policiesUtilize data to develop a strategy to improve the oral health of Texas children

Statewide and Regional Efforts - Houston

Used direct screeningdft/DMFTUntreated cariesSealant prevalence

Questionnaire to collect dataPerceptions of healthOral health promoting practicesExposure to sugar-containing foodsHistory of dental experiences

Statewide and Regional Efforts - Houston

Selected 7 counties in TDH region 6 (total of 13 counties) based on SES variables2,781 children in Pre-K, Grades 2, 7 and 10 were includedConclusions:

Prevalence of untreated decay 13.5%-54.3%Sealant prevalence 27.8%-51%Based on findings, provided strategic recommendations for both individual and community measures

Statewide and Regional Efforts - San Antonio

Behavioral Risk Factor Survey of Bexar County, Texas, 2002

Collaboration with Bexar County Community Health Collaborative and UTHSCSA, Community DentistryComponent of a community health assessment to guide efforts toward prevention and health improvementTelephone survey of 1,010 adults

Findings:66% of adults had a dental visit in the past yearPersons at greater risk or lower SES were less likely to have had a dental examination in the past year78% of children had a dental visit in the past year

Statewide and Regional Efforts - Dallas

Children’s Oral Health Coalition, 2002Screened 5,000 children in 13 Fort Worth ISD elementary schoolsFindings:

16% require urgent care18% have dental caries

Survey to 612 dentists, 16 school district nurse administrators, 421 families who received care at low-income clinicsAssess perceptions of the extent of oral health problems and availability of dental services for children

Statewide and Regional Efforts - Dallas

Children’s Oral Health Coalition, 2002 Findings:

53% of nurse administrators reported that dental problems presented to schools daily/weekly85% reported that services are inadequate and 77% noted that the service were not easily accessible58% of families were enrolled in Medicaid, and 44% did not have a dentist20% of families had a child with dental pain that was not being treated16% of dentists responding were Medicaid providers

Of those accepting Medicaid, only half of those were accepting new patients

Statewide and Regional Efforts - Dallas

Dental Health Arlington: Sealant Program, “SMILES”

Non-profit, full service dental clinic, serving low income residents of Tarrant CountySMILES: School-based sealant program in operation for 9 yearsCollect data for the nine years of the programs existence

Inputs Activities Intermediate Outcomes

Long-term (Distal) Outcomes

•Improved Oral Health

•Ongoing monitoring of trends in oral health indicators

•Increase in evidence-based interventions, planning, and evaluation

•Increase in programs for populations most in need

•Staff (contract and in-kind) for: Epidemiological support Data management Information Technology (IT) Oral health policy leadership Data collection

•Data Sources: National data sources State data sources Community data sources

•Equipment: IT hardware/software

•Other: Funding Community Support Support for Partners

•Develop a surveillance plan •Establish surveillance objectives•Select and develop case definitions and indicators using standard health indicators whenever possible•Link existing data sources•Identify gaps in data•Obtain community IRB approval•Collect data to obtain community-level indicators and meet other needs•Analyze data and interpret findings•Develop and write surveillance report•Disseminate surveillance results•Ensure data security and confidentiality•Develop strategies for sustaining surveillance system•Evaluate state surveillance system

LOGIC MODEL SURVEILLANCE

CDC, Division of Oral Health, May, 2003

Recommendations for Future Action

Develop a coalition of statewide partners to establish objectives and identify core measuresCreate a statewide plan for continued surveillance of oral healthLeverage funds to participate in national surveillance programs

Make surveillance a priority in the state oral health program

Recommendations for Future Action

Coordinate regional efforts at a statewide level to standardize information and to serve as a repository for findings

Recommend standardized system for all surveillance efforts (i.e., ASTDD Basic Screening Survey or BRFSS)

Support existing regional surveillance at the statewide level by providing technical assistance on design, collection, and analysis

Thank You