1. Mean DMFT/S Among School Attending 12-year-olds Residing in Puerto Rico: Academic Years 1997-1998 and 2010-2011 K. Ramirez 1, S. Rivas-Tumanyan 2, W.J. Psoter 3, E. Santiago 2, A. Elias 2 ( 1 ) University of Costa Rica, San Jose, CR ( 2 ) University of Puerto Rico School of Dental Medicine, San Juan, PR ( 3 ) New York University College of Dentistry, New York, USA

2. Specific Aims  Assess mean DMFT/S among school attending 12-year-olds residing in Puerto Rico during academic year 2010-2011  Compare the mean DMFT/S among school attending 12-year-olds residing in Puerto Rico during academic year 2010-2011 with mean DMFT/S reported in the academic year 1997- 1998

3. Timetable of Health Reform Implementation and Data Collection 1993 1997-1998 2000 2010-2011 Health Reform Implemented Health Reform Implemented School Survey Data Collection Health Reform Completed Health Reform Completed School Survey Data Collection

4. Puerto Rico Health Reform*  Contracted private insurance companies  Increased provider’s service network  Access to medical and dental services to medically indigent population (approximately 40% of PR**)  Establishes basic minimal coverage for dental services *Law #72 of September 7, 1993, Government of Puerto Rico **Puerto Rico Community Surveys, 2009

5. Health Reform Dental Coverage: Levels of Prevention PrimarySecondaryTertiary Health Disease (miSalud, 2012; Harris et al., 2009)

6. Study1997-19982010-2011 Design Cross-sectional Diagnostic criteria Oral Health Surveys of the National Institute of Dental Research Diagnostic Criteria and Procedures Sample - Probabilistic - Stratified by clusters  11 regions  types of schools  grade profile  socioeconomic status (school poverty levels and tuition cost)  urban or rural - n=74 schools - 12-year-old-school attendants (n=1,435); (N=71,358) - Probabilistic - Stratified by clusters  11 regions  types of schools  gender  socioeconomic status (school poverty levels and tuition cost) - n=133 schools - 12-year-old-school attendants (n=1,550); (N=53,198) Selection of schools Probability: proportional to size Selection of participants  Approximately 25 children in each school  Quota sample balance by gender  Approximately 20 children in each school (10 boys and 10 girls)  Randomized selection from student lists Comparison of Methodologies

7. 1997-19982010-2011 ExaminerIntraInterExaminerIntraInter 1.91.96 3.97.96 2.984.89 Intra and Inter Weighted Kappa Statistic for DMFS 1997-1998 and 2010-2011

8. Schools Selected by Health Reform Regions

9. Results

10. Mean DMFT Index Among School Attending 12-year-olds Residing in Puerto Rico

11. Mean DMFT Index and 95% Confidence Interval by School Type* and Puerto Rico *Proxy for SES

12. Mean DMFS Index Among School Attending 12-year-olds Residing in Puerto Rico

13. Comparison: DMFS Puerto Rico 6.5 4.2 (3.8-4.5) Filled 1997-1998 2010-2011 64% 50% (48%-52%) D M F DMFS 42% (41%-43%) 8% (7.96%-8.04%) 3% 32% Δ%Δ% CI 95% 35% 24% 63% 28% CI 95% (29%-35%) (5.8-7.2) (1.1%-2.2%) (61%-67%) Missing Decayed Missing Filled

14. Mean DMFS Index and 95% Confidence Interval by School Type* and Puerto Rico *Proxy for SES Public Private PR Public Private PR 1997-19982010-2011 PublicPrivatePRPublicPrivatePR Upper7.95.27.24.72.94.5 Mean7.24.76.54.32.44.2 Lower6.44.25.83.92.03.8

15. DISCUSSION: PR-USA Mean DMFT/S PopulationAgeYearDMFT/S Fluoride Program PR 12 years old 1997-1998 (1) 2010-2011 3.8/6.5 2.7/4.2 None USA 12 to 15 years old 1988-1994 (2) 1999-2000 (2) 2.1/3.3 1.8/2.8 Water (64.3%) (3) ( 1) Elias 2003; (2) CDC 2005, (3) CDC 2008

16. Conclusions  Mean DMFT/S Indices decreased in Puerto Rico from 1997 to 2011  Mean DMFT/S Indices are higher in Puerto Rico than USA  A health disparity between public and private school attending children persists

17. Recommendation  Additional analysis are needed taking in consideration secular changes, in order to measure the impact of the health reform

18. Acknowledgements  Dr. Ottón Fernández, Director Graduate Programs School of Dentistry, University of Costa Rica  Dr. Estela Estapé, Post-Doctoral Master of Science in Clinical Research Program, University of Puerto Rico  Partially funded by NIH S21MD001830 and,  Colgate-Palmolive Company

19. Comparison of PR and other Racial Groups in the USA PopulationAgeRace/EthnicityYearDMFS/T PR 12 years old Hispanic1997-1998 (1) 2010-2011 6.5/3.8 4.2/2.7 USA (2) 6 to 19 years old Mexican American Black Non-Hispanic White Non-Hispanic 1999-2000 3.1/1.8 2.6/1.4 2.6/1.6 ( 1) Elias 2003; (2) CDC 2005