1. PANEL DISCUSSION MAKING THE CONNECTION: Why We Care About Oral Health
Dr. Leila Alter, DDS – Moderator
Dr. James Miller, DDS, MSD, PhD - State Oral Health Director, Indiana State Department of Health
Dr. Luis E. Garabis, DDS - School Smiles On Site Dental Care
Dr. Isaac Zeckel, DDS - Chief Dental Officer, HealthLinc Community Health Centers

2. The Status of Children’s Oral Health in Indiana and Ways To Make Improvements
James R. Miller, DDS, MSD, PhD
State Oral Health Director
Oral Health Program

3. Ways To Make Improvements
Oral health of children in Indiana
Above the national average
Specific groups of children
Some have poor oral health
Improvement
Desirable and achievable

4. Strategies for Improvement
IMPROVEMENT through CHANGE
Policies
Programs

5. Strategies for Improvement
Assume improvement
Improvement is not automatic
Did policy cause improvement
Did program cause improvement
MEASURE to EVALUATE

6. Policies / Programs State County One size does not fit all
Large vs. Small
Wealthy vs. Poor
City vs. Rural

7. Bartholomew County Policy > Resources for Oral Health >
Bartholomew County Health Dept. (BCHD) >
Program Full-time Licensed Dental Hygienist
Coordinate federal, state and county resources
Engage community and organizations
Engage schools and school nurses
Engage local dentists and hygienists

8. Bartholomew County BCHD Licensed Dental Hygienist
SCREEN > Almost ALL children in 2nd & 5th grades in county
ORAL HEALTH EDUCATION > Almost ALL children in selected grades
FOLLOW-UP CARE > Coordinate care with health care professionals

9. Bartholomew County
Screening the oral health status of children each year allows:
Evaluation of the PREVALENCE (Burden) of oral disease each year
Evaluation of the CHANGE in PREVALENCE from year to year
Evaluation of the EFFECTIVENESS of program at reducing oral disease

10. Comments
Bartholomew County is an example of what can be done with limited resources
The oral health metrics measured by the BCHD allow it to evaluate the prevalence (burden) of oral disease in Bartholomew County and see changes in this prevalence over time
To compare data across counties, or to the state averages, one would need to measure STANDARD oral health metrics

11. The Status of Children’s Oral Health in Indiana
Oral Health Metrics
Indiana State Department of Health * Data Brief * December 2013
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Indiana State Department of Health * Report * January 2018
The Use of Oral Health Metrics in Promoting
Oral Health

12. Data Brief & Report (available online)
ISDH Data Brief December 2013.
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population.
Retrieved on April 3, 2018, from
ISDH Report January 2018.
The Use of Oral Health Metrics in Promoting Oral Health.
Retrieved on April 3, 2018, from

13. The Status of Children’s Oral Health in Indiana
Indiana State Department of Health * Data Brief * December 2013
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population

14. The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Design
Clinical screening of third graders in Indiana from a sample of public elementary schools
Screening available to all third graders in the participating schools, but only to those with written permission

15. Used Basic Screening Survey (BSS) protocol
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Used Basic Screening Survey (BSS) protocol
Association of State and Territorial Dental Directors (ASTDD)
Screening allowed determination of the PREVALENCE of various oral health metrics

16. Decay Experience Prevalence (Burden) of Disease
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Oral Health Metrics (These are STANDARD metrics used by ISDH)
Decay Experience Prevalence (Burden) of Disease
Dental Fillings
Untreated Decay
Dental Sealants Prevalence of Preventive Intervention
Presence of dental sealant on one or more permanent first molar

17. These data were collected at “one point in time”
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
These data were collected at “one point in time”
These data represent the proportion of the people screened with fillings, untreated decay, and/or dental sealants
Thus, these data are PREVALENCE data and are expressed as a percent

18. DECAY EXPERIENCE 51% 58% ** DENTAL SEALANTS 34% 33%
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
IN US
Dental Fillings 34% 29%
Untreated Decay 17% 29% **
DECAY EXPERIENCE 51% 58% **
DENTAL SEALANTS 34% 33%
** Large and statistically significant difference between IN and U.S.

19. The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
The proportion of 3rd graders in Indiana with Dental Fillings was about the same as the national average
The proportion of 3rd graders in Indiana with Untreated Decay was better (less Untreated Decay) than the national average
Thus, the proportion of 3rd graders in Indiana with DECAY EXPERIENCE was better (less Decay Experience) than the national average

20. The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
The proportion of 3rd graders in Indiana with a dental sealant on at least one permanent molar was about the same as the national average.

21. Values all are percent (%)
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Values all are percent (%)
Fillings Decay EXPERIENCE Sealants
ALL U.S. 3rd Grade
* ALL INDIANA 3rd Grade (v. U.S) (v. U.S) *
Race/Ethnicity (IN)
White
African-American (v. IN)
Hispanic (v. IN) (v. IN) (v. IN)
Economic Level (IN)
Moderate to High (v. IN) (v. IN) (v. IN)
Low (v. IN)

22. Demographic Variables
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Demographic Variables
Race/ethnicity related to oral disease
Economic Status related to oral disease

23. Demographic Variables
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Demographic Variables
Age was kept constant in this survey (3rd graders)
Thus, could not determine if age was related to oral disease
Other studies have shown age is related to oral disease
Gender was not related to oral disease in this survey

24. The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Comments
Many oral diseases are influenced by demographic variables (age, race/ethnicity, gender, SES)
It is important to measure demographic variables, along with oral health metrics
One can then account for the influence of the demographic variables on oral health metrics

25. Challenges with this survey
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Challenges with this survey
Project provided good information, but …
Expensive ~ 80K
Participation of schools from the original sample of schools was less than optimal
Participation of children from participating schools was considerably less than optimal
Validity can be compromised by lack of participation

26. The Status of Children’s Oral Health in Indiana
Indiana State Department of Health * Report * January 2018
The Use of Oral Health Metrics in Promoting
Oral Health

27. The Use of Oral Health Metrics in Promoting Oral Health
Compilation of other Oral Health Metrics
Effort to find more affordable metrics than those used in the 2013 Indiana Oral Health Survey

28. The Use of Oral Health Metrics in Promoting Oral Health
Methods for measuring these other oral health metrics included:
Phone interviews
Clinical records
Registries
Licensing boards

29. The Use of Oral Health Metrics in Promoting Oral Health
Considerations in selecting other oral health metrics:
Affordable
Valid
Pertinent
Periodic, sustainable

30. The Use of Oral Health Metrics in Promoting Oral Health
School-Age Children
Note: Age groups

31. The Use of Oral Health Metrics in Promoting Oral Health
School-Age Children
Dental visits for all children/adolescents (1-17) is measured every four years by NSCH and for year 2016 was 81.4%
Dental visits for children/adolescents (0-20) enrolled in Medicaid is measured every year by CMS and for year 2016 was 46.1%
Dental sealant, at least one sealant on a molar, for children aged 6-9 years is measured every year by CMS and for 2016 was 18.7%

32. The Use of Oral Health Metrics in Promoting Oral Health
School-Age Children
Although these data are expressed as “percent,” they are not prevalence data
These data are CUMULATIVE INCIDENCE data
They are measurements of the first-time occurrences of dental visits, dental services, and dental sealants among a representative sample of the indicated population (1-17, 0-20, 6-9) during a particular year

33. The Use of Oral Health Metrics in Promoting Oral Health
School-Age Children
Notes
Cumulative incidence is a specific type of incidence and is considered a measurement of risk, but often is referred to as a rate
Cumulative incidence is typically reported as a decimal
Example: 19% in this table actually means 19/100/year, which could be reported as the decimal 0.19

34. IMPORTANT POINTS Oral Health Metrics
There are different types of data
(i.e. prevalence and incidence)
Interpretation of data can be difficult
Need to compare “apples to apples”
When in doubt, ask for assistance

35. The Use of Oral Health Metrics in Promoting Oral Health
For your consideration
The Oral Health of Indiana’s Third Grade Children Compared to the General U.S. Third Grade Population
Dec 2013
DENTAL SEALANTS (Children aged 8-9 years) %
The Use of Oral Health Metrics in Promoting Oral Health
Why are the two values for dental sealants NOT comparable?
Different populations (All children versus children enrolled in Medicaid)
Different age groups ( 8-9 versus 6-9 )
Different year ( 2013 versus 2014): In this case, just one year difference in cohorts might not matter that much
Different measurements (Prevalence versus Cumulative Incidence)

36. TAKE HOME ORAL HEALTH PROGRAM IN YOUR REGION
Find a local champion
Use limited resources
Let government be your partner
Use oral health metrics
STANDARD metrics would be best
Evaluate prevalence periodically
Evaluate effectiveness of program

37. Contact Information
James R. Miller, DDS, MSD, PhD
State Oral Health Director
Oral Health Program

38. CHILDREN’S ACCESS TO DENTAL CARE
Dr. Luis Garabis, DDS—Dental Director

39. Why are we here today?
1. Make you aware of the dental issues that affect your kids
2. Give you information of dental programs available
3. Get you involved

40. What are the Issues 1. Dental Provider Shortage Areas
2. Dental problems affecting our children
3. Lack of participation from parents
4. Understanding how to become a part of the solution

41. Accessing Dental Care Limitations: 1. Finances 2. Travel
3. Provider Shortage Areas
4. Lack of Information
5. Fear of Dentist
6. Language Barrier

43. This is what we are missing!

45. How can you help? Get Involved!!!!!!!
1. Get informed about programs available and what type of services they provide and how they provide them;
Private Practice Preventive/Restorative
Portable Dentistry Preventive only
Mobile Dentistry
Get Involved!!!!!!!

46. How can we help? 1. Provide On Site Portable Dentistry
2. Provide full administrative support for the enrollment process
3. Establish relationships with school administration and medical staff
4. Manage the dental care and re-care of kids in need that do not have a dentist

47. School Smiles Foundation, Inc.
Formed in late 2014.
Grant funding currently available in certain geographic regions.
Continuously applying for grant funding.
Grants will be to provide funding for children who are uninsured and do not qualify for state assistance (Medicaid) or do not have the ability to pay out of pocket for services.
Nominations for children to receive grant funding made by school (nurse, principal, guidance counselor, teacher, etc.)
Applicants will be screened through home office.

48. Progression of Tooth Decay in School Aged Children

49. Adult Teeth – Second Chance
Preschool
Adult Teeth – Second Chance
Elementary School
Kindergarten

50. 16 y Male Patient Middle School High School Every tooth has a cavity
4 back teeth are too decayed to be fixed and must be removed
Multiple appointments to repair damage
How does this happen?
Lack of access – slows progression of dx
Lack routine of self care
Did not know how much sugar was in athletic beverages
High School

51. What Can Be Done?
In the U.S., limited literacy skills are a stronger predictor of an individual’s health status than age, income, employment status, education level, and racial or ethnic group.1
Health literacy is the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.
Websites for further information:
1Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004.

52. DISCUSSION / Q & A