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

1

State of the State North Carolina

Oral Health SectionDivision of Public Health

NC DHHSRebecca S King, DDS, MPHChief, Oral Health Section

UCSF DPH-175 SeminarNovember 13, 2012

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Objectives• Identify the origin of state DPH

program• Infrastructure• Describe program components

o Status of fluoridation in NCo Pre-school preventive activitieso School-based preventive services

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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 fundingReduce pain and infectionEducate on importance of oral

health

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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

Oral Health Section, 2012

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Oral Health Section Staff

• 4 Public health dentists• 41 Public health dental hygienists• 2 Health education staff• 2 Equipment technicians• Support staff

GASTONCHEROKEE

SWAIN

MACON

GRAHAM

CLAY

JACK-SON

HAY-WOOD

HENDER-SONTRAN-

SYLVANIA POLK

RUTHER-FORD

BUN-COMBE

YAN-CEYMADISON

MITCHELLAVERY

CLEVE-LAND

LINCOLN

CATAWBABURKE

MECKLEN-BURG

UNION

CABARRUS

ROWAN

IREDELL

STANLY

DAVID-SON

MONT-GOMERY

RANDOLPH

MOORE

ANSONRICH-MOND

HOKE

CHATHAM

LEEHARNETT

CUMBER-LAND

ROBESON

SCOT-LAND

BLADEN

SAMPSON

COLUMBUS

BRUNSWICK

NEWHANOVER

PENDER

ALA-MANCE

ORANGE

DURHAM

CASWELLPERSON GRAN-VILLE

VANCEWARREN

FRANKLIN

WAKE

NASH

JOHNSTONWAYNE

DUPLIN

GREENE

PITT

JONES

ONSLOW CARTERET

PAM-LICO

BEAU-FORT

CRAVEN

HYDE

DARETYRRELLWASH-INGTON

BERTIE

MARTIN

HERT-FORD PASQUO-

TANKCHO-WAN

CAM-DEN

PER-QUIMANS

CURRITUCKNORTH-AMPTON

GATES

HALIFAX

EDGE-COMBE

ROCKING-HAM

STOKESSURRY

FORSYTH GUILFORDYADKIN

DAVIE

ASHE

WATAUGA WILKES

ALLE-GHANY

CALDWELL ALEX-ANDER

MCDOWELLWILSON

Central Region 7 State Hygienist positions

15 Counties

Western Region 16 State Hygienist positions

1 Local Hygienist 39 Counties

Oral Health Section Regions and Staff Assignments

Eastern Region 16 State Hygienist

positions 46 Counties

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

Revised 10/01/2012

LENOIR

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BudgetTotal ~ $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 operatingOther federal grants ~ $309,500

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Program Components• Dental disease prevention • Oral health assessment• Dental health education and

promotion• Access to dental care• Dental public health residency

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Dental Disease Prevention

Water fluoridation Pre-school & school-

based dental preventive programs

Dental sealants Fluoride mouthrinse

1

Community Water Fluoridation

Healthy People 2020 goal – 79.6% on community water systems

NC surpassed - 87%

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Pre-school Dental Prevention Programs in

North Carolina

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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

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Into The Mouths of Babes

Statewide Medicaid Dental Prevention Program for Young Children

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GoalsEnlist 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

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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 toothpastefluoride varnish

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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)

# Annual IMB Preventive Dental Visits in NC Medical

Offices

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000 Chart Title

Percent of Health Check Screenings Receiving IMB

Services *

Q1 200

0

Q3 200

0

Q1 200

1

Q3 200

1

Q1 200

2

Q3 200

2

Q1 200

3

Q3 200

3

Q1 200

4

Q3 200

4

Q1 200

5

Q3 200

5

Q1 200

6

Q3 200

6

Q1 200

7

Q3 200

7

Q1 200

8

Q3 200

8

Q2 200

9

Q4 200

9

Q2 201

0

Q4 201

0

Q2 201

1

Q4 201

1

Q2 201

20%5%

10%15%20%25%30%35%40%45%50%

* For years 2000-2006 includes 1-2 yr olds only, for 2007 on includes 1-3 year olds.

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RatesCDT 2007 Code

Description Reimburse-ment Rate

DO145Oral evaluation for patient < age 3 and counseling with primary caregiver.Once every 60 days.Six times before age 3 1/2.

$35.62

D1206Topical fluoride varnish, therapeutic application for moderate to high risk patients. Once every 60 days.Six times before age 3 1/2.

$15.72

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IMB ProgramContributed 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

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Early Head Start• Surveys and focus groups to find

needsTeachersParents

• Developing and piloting training materialsExpand the concept that baby teeth are

importantUrge parents to seek early preventive care

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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

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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

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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

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ZOE Components• Train EHS staff

o preventive services in the classroomo parent education o 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

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School-based Dental Prevention Programs in

North Carolina

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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)

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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

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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

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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

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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

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Oral Health Assessment

Statewide dental surveys

Oral health surveillance

2

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Statewide Dental Surveys

Provide evidence base for program:• Early 1960s• 1976-1977• 1986-1987• 2003-2004

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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

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Trends in Tooth Decay (DMFT)

in 12-17-Year-Old Children*

1960-62 1976-77 1986-87 2003-040

1

2

3

4

5

6

7

8

5.4

4.7

2.9

1.9

Blacks

Whites

5.9

Mean DMFT

7.6

3.1

1.4

*NC OHS Statewide Dental Survey Data

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Trends in Untreated Decay in Permanent Teeth*

1960-62 1976-77 1986-87 2003-040

102030405060708090

100 92

77

35

30

60

34

1519

BlacksWhites

Percent

Year*NC OHS Statewide Dental Survey Data

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% Permanent Teeth with Untreated Decay, by

Race

Series1

Percent

White Black Other*2003-2004 NC OHS Statewide Dental Survey

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Percent of Children with Dental Insurance by Type and

Race*

Series1

Percent

Private Public None

White Black OtherWhite Black Hisp White Black Hisp

*2003-2004 NC OHS Statewide Dental Survey

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5 6 7 8 9 10 11 12 13 14 15 16 170

102030405060708090

100

Age

Percent

Percent of Children with Any Decay (>0 DMFS)*

1986-87

2003-04

*NC OHS Statewide Dental Surveys

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Percent of Children With Caries Experience*

5 6 7 8 9 10 11 12 13 14 15 16 170

102030405060708090

100

Perc

ent

Age

Primary Permanent

*2003-2004 NC OHS Statewide Dental Survey

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Trends in Mean dfs (primary teeth)

by Education Level* Increases in all races Increases in all

educational levels Particularly severe in

those families with low education

Series11

2

3

4

5

Series11

2

3

4

5

86-87 03-04

86-87 03-04

WHITES

OTHER RACES

<HS

>HS HS

>HS HS<HS

dfs

dfs

*2003-2004 NC OHS Statewide Dental Survey

Key:

Less than High School Ed.

High School Ed.

Greater than High School Ed.

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Trends in Untreated Cavities

by Education Level* Increased treatment

in lower income families

Middle and upper income families show little change

Series1102030405060

Series1102030405060

86-87 03-04

86-87 03-04

WHITES

OTHER RACES

<HS

>HS HS

>HS

HS<HS

%d/dfs

%d/dfs

*2003-2004 NC OHS Statewide Dental Survey

Key:

Less than High School Ed.

High School Ed.

Greater than High School Ed.

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Trends in Dental Sealants

Children with >1 Sealant*

Series10

10

20

30

40

50

601986-872003-04

Percent

6-11 yrs 12-17 yrs

*NC OHS Statewide Dental Surveys

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Prevalence of Non-Cavitated and Cavitated Lesions in Permanent

Teeth

Non-Cavitated only Cavitated only

65%

10%24%

Non-Cavitated & Cavitated

Children*2003-2004 NC OHS Statewide Dental Survey

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Value Placed on Oral Health*

Series1

Perc

ent

White Black Hispanic

Baby teeth do not need to be filled because they are going to fall out anyway! “% of parents who agree”

*2003-2004 NC OHS Statewide Dental Survey

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Oral Health Surveillance

Calibrated dental assessments 2011-2012

• By PH RDHs• Grades K and 5• School oral health

status data• Referral for treatment

needs

51

52

Kindergarten Children (primary teeth, to 2010-2011)*

1996

-97

1998

-99

2000

-2001

2002

-2003

2004

-2005

2006

-2007

2008

-2009

010203040506070

Caries-freeUntreated caries

Year

Perc

enta

ge o

f chi

ldre

n

*NC OHS annual assessment data

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1996

-97

1997

-98

1998

-99

1999

-00

2000

-01

2001

-02

2002

-03

2003

-04

2004

-05

2005

-06

2006

-07

2007

-08

2008

-09

2009

-2010

0

0.5

1

1.5

2

dmftdtfmt

Year

Prim

ary

teet

h

*NC OHS annual assessment data

Kindergarten Children

(primary teeth, to 2010-2011)*

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Fifth Grade Children: Avg. # Decayed (permanent teeth to 2009-

2010) *

1996

-97

1997

-98

1998

-99

1999

-00

2000

-01

2001

-02

2002

-03

2003

-04

2004

-05

2005

-06

2006

-07

2007

-08

2008

-09

2009

-2010

0

0.02

0.04

0.06

0.08

0.1

0.12

DT

Year

Perm

anen

t Tee

th

*NC OHS annual assessment data

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Fifth Grade Children(permanent teeth, to 2009-2010)

1996

-97

1997

-98

1998

-99

1999

-00

2000

-01

2001

-02

2002

-03

2003

-04

2004

-05

2005

-06

2006

-07

2007

-08

2008

-09

2009

-2010

00.10.20.30.40.50.60.7

DMFTFMTDT

Year

Perm

anen

t Tee

th

*NC OHS annual assessment data

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Fifth Grade Children with Sealants(permanent teeth, to 2009-2010)*

1996

-97

1997

-98

1998

-99

1999

-00

2000

-01

2001

-02

2002

-03

2003

-04

2004

-05

2005

-06

2006

-07

2007

-08

2008

-09

2009

-2010

0

20

40

60

80

100

28 30 31 34 37 37 41 43 44 42 45 44 44Sealants

Year

Perc

enta

ge o

f Chi

ldre

n

*NC OHS annual assessment data

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New Data• Worked with state department of

public instruction• Download directory data by class into

our screening rostero Nameso Race/ethnicityo Sexo DOBo Contact information for parent/guardian

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Race/EthnicityKindergarten 2009-2010

fmt dt dmft0

0.5

1

1.5

2

2.5

3

American IndianAsianBlackHispanicMuli-racialWhite

Teet

h

59

Race/EthnicityKindergarten 2009-2010

fmt dt0

0.20.40.60.8

11.21.41.61.8

2

American IndianAsianBlackHispanicMulti-racialWhite

Teet

h

Race/EthnicityFifth Grade 2009-2010

Sealants0

10

20

30

40

50

60

American IndianAsianBlackHispanicMulti-racialWhite

Perc

ent

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Dental Health Education

School-based education Community outreach Professional education Educational materials

3

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School-based Education

• 118,000 children in classrooms

• 11,000 adultsparent education teacher supporthealth

professionals

63

Exhibit PromotionsAging, consumerism,

diabetes, careers, sealants, early childhood caries, fluorides, oral hygiene, nutrition, tobacco, injury prevention, OHS program

64

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Access to Dental Care

Referral/follow-up for care Improved access for low-

income families “Under direction” activities

4

66

Oral Health Surveillance

2011-2012: • 105,000 screened in K,5

o for sealants o special activities (Give Kids a

Smile!) and o at request of school nurses

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Give Kids a Smile! • NC Dental Society initiative to provide

education, preventive and restorative care to children who do not have access to care

• To date since 2003, more than:o 123,000 children servedo $10.5 M free careo 14,700 dental volunteers

• OHS PH Dental Hygienists screen and coordinate

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Local Dental Safety Net Clinics

• OHS provides TA for new clinics

• Number increased dramatically from the early 1990s to 132 fixed, mobile and “free” clinics

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Dental Care Safety Net Facilities Prior to 1996

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Dental Care Safety Net Facilities

Now

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Dental Public Health Residency

Training for dental public health specialists Growth for the Division

5

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Rebecca S King, DDS, MPHChief, Oral Health Section

[email protected]

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Questions?