Chapter Outline Chapter outline Background

Healthiest Wisconsin 2020 Baseline and Health Disparities Report Oral Health

Chapter Outline Chapter outline Background
Overview of Healthiest Wisconsin 2020 Baseline and Health Disparities Report Healthiest Wisconsin 2020 objectives and indicators Rationale Key points Data Tooth removal and dental care among adults Dental care utilization Access Prevention Dental health needs among children References Links to additional reports and resources Contacts Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Overview Report overview
This chapter is part of a larger report created by the Wisconsin Department of Health Services to track progress on the objectives of Healthiest Wisconsin 2020 (HW2020) and identify health disparities in the state. The full report is available at: The report is designed to address the Health Focus Areas in HW2020. Where direct measures exist, data are presented; where direct measures are not available, related information may be included. Information about populations experiencing health disparities is provided in the Health Focus Area chapters and is summarized in separate chapters devoted to specific populations. Technical notes are available at: Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Format Full Report Chapters Format: PDF
Report overview Report Format Sample annotated slide Full Report Format: PDF Intended use: reference document Chapters Format: Annotated PowerPoint slide set Intended uses: presentations to Decision-makers Service providers Community leaders The public The report is available in two formats. The first, intended to serve as a reference document, is a PDF of annotated slides, as shown in this slide. The second is a series of slide sets, each of which is a chapter in the report. The purpose for providing slide sets is to foster sharing of the data in presentations to decision-makers, service providers, community leaders, and the public. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Outline Executive Summary Section 1: Introduction
Report overview Report Outline Executive Summary Section 1: Introduction Section 2: Demographic overview Section 3: Health focus areas Section 4: Infrastructure focus areas Section 5: Data summaries by population Section 6: Technical notes Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Outline: Detail
Report overview Report Outline: Detail Section 3: Health focus areas Alcohol and other drug use Chronic disease prevention and management Communicable diseases Environmental and occupational health Healthy growth and development Injury and violence Mental health Nutrition and healthy foods Oral health Physical activity Reproductive and sexual health Tobacco use and exposure Section 4: Infrastructure focus areas Access to health care Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Report Outline: Detail
Report overview Report Outline: Detail Section 5: Data summaries by population Racial/ethnic minority populations American Indians Asians Blacks Hispanics People of lower socioeconomic status People with disabilities Lesbian, gay, bisexual, and transgender populations Geography Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Data notes Report overview
Please refer to the Technical Notes chapter for a more detailed description of limitations and methods: The 95% confidence intervals are denoted by error bars. Where confidence intervals do not overlap, as shown in the example on the right, differences are statistically significant. Larger confidence intervals may indicate less reliable estimates that should be interpreted with caution. Population estimates that are considered unreliable are excluded. Misclassification of racial/ethnic groups may affect the accuracy of rates. Unless otherwise indicated, the Hispanic population may include people of various races; Whites, Blacks, Asians, and American Indians are non-Hispanic. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Factors that influence health
Report overview Factors that influence health Social determinants of health drive at least 50% of morbidity and mortality rates.1 Social determinants of health include socioeconomic status (SES), usually measured by income, employment, education, or housing. Groups with lower SES typically have significantly shorter life expectancy, higher rates of infant mortality, higher rates of chronic disease, and significantly lower self-rated health status.2 Health inequities are costly. The Joint Center for Political and Economic Studies estimates that the combined costs of health inequalities and premature death in the United States during were $1.24 trillion.3 Further, addressing social determinants of health is an essential component of several key principles of the Public Health Code of Ethics which frame the ethical practice of public health.4 Healthiest Wisconsin 2020, the State Health Plan, lists two crosscutting focus areas: 1) Health Disparities, and 2) Social, Economic and Educational Factors that Influence Health.5 These broad focus areas have the potential to affect both the health focus area and public health infrastructure components of the plan and help set priorities in order to achieve large, equitable changes in health outcomes while saving health care dollars in Wisconsin. Social determinants of health Source: University of Wisconsin Population Health Institute. County Health Rankings 2013, Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Healthiest Wisconsin 2020 objectives and indicators
HW2020 objectives Healthiest Wisconsin 2020 objectives and indicators Objective 1 By 2020, assure access to ongoing oral health education and comprehensive prevention, screening and early intervention, and treatment of dental disease in order to promote healthy behaviors and improve and maintain oral health. Objective 1 Indicators Percent of third-graders with dental sealants and untreated decay. Percent of Head Start children with untreated decay. Percent of adults with self-reported oral health problems. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Oral Health Focus Area Profile. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Healthiest Wisconsin 2020 objectives and indicators
HW2020 objectives Healthiest Wisconsin 2020 objectives and indicators Objective 2 By 2020, assure appropriate access to effective and adequate oral health delivery systems, utilizing a diverse and adequate workforce, for populations of differing races, ethnicities, sexual identities and orientations, gender identities, and educational or economic status and those with disabilities. Objective 2 Indicators Proportion of BadgerCare+ enrollees with at least one dental claim in a year. Number of oral health related emergency room visits by population group. Percent of schools with school-based dental screening/sealant programs. Number of dental providers by type of provider by demographics and location. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Oral Health Focus Area Profile. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Rationale Rationale Good oral health means being free of mouth pain, tooth decay, tooth loss, oral and throat cancer, gum (periodontal) disease, and other diseases that affect the mouth and surrounding structures. Oral health is integral to general health throughout the life span and can be achieved by everyone. Many systemic diseases may initially start with and be identified through oral symptoms. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Oral Health Focus Area Profile Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Key points Key points Adults Only one-quarter of Medicaid/Badgercare+ enrollees had a dental service in the past year. The number of emergency department visits for non-traumatic dental complaints increased by 20% from 2006 to 2010. Four out of ten adults had at least one permanent tooth removed due to tooth decay or gum disease, while three out of ten did not visit a dentist within the past year. In 2010, nearly 90% of the population on public water systems had access to fluoridated water in Wisconsin, exceeding the national target of 80%. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Key points Key points Adults Compared to Whites and Asians, Black, Hispanic, and American Indian adults were significantly more likely to have permanent teeth removed due to tooth decay or gum disease, and not to have visited a dentist, dental hygienist, or dental clinic in the past year. Permanent tooth removal and lack of dental visits are significantly more common among people earning lower incomes. More than half of adults with a disability had at least one permanent tooth removed due to tooth decay or gum disease, while more than one-third did not have a dental visit in the past year. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Key points Key points Youth The percentage of third-grade children with untreated tooth decay decreased by 35% from the school year to the school year. School-based dental sealant programs have expanded rapidly since the school year. Twenty-six percent of children in Head Start (aged 3-5) had untreated decay. Schools with a higher proportion of students from low income households were considerably more likely to have children with untreated tooth decay than schools with a higher SES population. One in three Asian, Black, or Hispanic third-grade children had untreated tooth decay, compared to one in six White children. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Tooth removal and dental care among adults
Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Rates of tooth removal and dental visits in the past year among Wisconsin adults, by sex, The Wisconsin Behavioral Risk Factor Survey (BRFS) is an annual telephone survey of state residents ages 18 and older carried out by the Wisconsin Department of Health Services in conjunction with the Centers for Disease Control and Prevention (CDC). Estimates for the total adult population and by sex and age use a combined landline and cellphone sampling design from years Estimates by race/ethnicity, income, education, geography, disability status, and sexual orientation are from the landline-only sample population from years For more information, refer to the Technical Notes chapter. Routine dental visits are recommended at least once a year for preventive care.6 The BRFS asks respondents whether they have visited a dentist, dental hygienist, or dental clinic in the past year as well as how many permanent teeth have been removed due to tooth decay or gum disease. In Wisconsin, 41% of adults had at least one permanent tooth removed due to tooth decay or gum disease, while 31% did not visit a dentist within the past year. Rates by sex did not vary significantly. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-cellphone combined dataset. Note: Tooth removal question asked in 2010 and Dentist visit question asked in 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Rates of tooth removal and dental visits in the past year among Wisconsin adults, by age, Older adults are at increased risk for dental decay.7 Despite the increased risk for dental decay, nearly one-third of adults ages 65+ did not visit a dentist, dental hygienist, or dental clinic in the past year. Adults ages had the highest percentage with no dental care in the past year, significantly higher than adults ages 45+. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-cellphone combined dataset. Note: Tooth removal question asked in 2010 and Dentist visit question asked in 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Age-adjusted rates of tooth removal and dental visits in the past year among Wisconsin adults, by race/ethnicity, More than half of Black and American Indian adults had permanent teeth removed due to tooth decay or gum disease, a significantly higher proportion than for any other racial/ethnic group. Blacks, Hispanics, and American Indians were significantly more likely not to have visited a dentist, dental hygienist, or dental clinic in the past year compared to Whites and Asians. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Note: Tooth removal question asked in 2008, 2010, and Dentist visit question asked in 2008 and 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Age-adjusted rates of tooth removal and dental visits in the past year among Wisconsin adults, by household income level, More than half of low-income adults had permanent teeth removed due to tooth decay or gum disease, a significantly higher proportion than for middle- or high-income adults. Similarly, low-income adults were about three times as likely not to have seen a dentist within the past year when compared with people in the high-income group. Adults with less than high school education were more likely than those with a college education to have at least one permanent tooth removal and no dental visits (data not shown). Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Note: Tooth removal question asked in 2008, 2010, and Dentist visit question asked in 2008 and 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Age-adjusted rates of tooth removal and dental visits in the past year among Wisconsin adults, by level of urbanization, The county of residence for each BRFS respondent was characterized by one of three levels of urbanization: large metropolitan, which in Wisconsin consists only of Milwaukee County; smaller metropolitan, which consists of 24 fringe metropolitan areas or counties with smaller cities; and 47 non-metropolitan counties, which are found in predominantly rural regions. Compared to residents of other metropolitan areas, a significantly higher percentage of residents of Milwaukee County and non-metropolitan counties had permanent teeth removed and did not visit a dentist within the past year. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Note: Tooth removal question asked in 2008, 2010 and Dentist visit question asked in 2008 and 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Rates of tooth removal and dental visits in the past year, by disability status, Wisconsin adults ages 18-64, In the BRFS, living with a disability is defined by responding affirmatively to at least one of two questions: Are you limited in any way in any activities because of physical, mental, or emotional problems? Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? (Includes occasional use or use in certain circumstances.) About half of Wisconsin adults ages with disabilities had permanent teeth removed, a significantly larger percentage than adults without disabilities. Adults with disabilities also had a higher rate of not having visited a dentist in the past year than adults without a disability. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Note: Tooth removal question asked in 2008, 2010, and Dentist visit question asked in 2008 and 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Rates of tooth removal and dental visits in the past year among Wisconsin adults, by sexual orientation, There was no significant difference by sexual orientation in the percentage of adults who have had permanent teeth removed; however, LGB adults were significantly more likely not to have visited a dentist within the past year compared to heterosexual adults. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Note: Tooth removal question asked in 2008, 2010, and Dentist visit question asked in 2008 and 2010. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Dental care utilization

Percentage of Medicaid/BadgerCare+ enrollees who received a dental service in the past year, Wisconsin, 2009 One in four Wisconsin Medicaid and BadgerCare+ enrollees had at least one dental service in the past year, a rate that has been relatively consistent from 2004 to Dental services may include dental sealants through a school-based program and do not necessarily mean that the patient was in a dental office or received all services needed. Children and pregnant women enrolled in Wisconsin Medicaid/BadgerCare+ were enrolled in comprehensive dental coverage. However, enrollees may have had a difficult time finding a Medicaid-certified dentist taking new patients. Thus, coverage does not necessarily translate to access to available services.8 A review of 2008 National Health Interview Survey data revealed that adults with Medicaid were nearly five times as likely to have poor oral health as adults with private health insurance.9 Among people who reported having an oral health problem nationally, cost and lack of dental coverage were identified as the primary reasons they did not seek medical attention.9 Source: Wisconsin Department of Health Services, 2010 — Burden of Oral Disease in Wisconsin. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Emergency department visits for non-traumatic dental complaints, Wisconsin, Many people who are unable to obtain dental services seek care in emergency departments. From 2006 to 2010, the number of emergency department visits for non-traumatic dental complaints increased by nearly 20%. In 2008, 39% of these emergency department visits listed Medicaid as the primary payer and 33% had self-pay listed as the primary payer (data not shown). Self-pay typically refers to the uninsured and the underinsured, or those with out-of-network insurance policies.8 Source: Wisconsin Department of Health Services, Office of Health Informatics, Wisconsin Emergency Department Data unpublished data. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Emergency department visits for non-traumatic dental complaints by age group, rate per 100,000, Wisconsin, 2010 More than 75% of emergency department visits for non-traumatic dental complaints occurred among adults 18 to 44 years of age. Source: Wisconsin Department of Health Services, Office of Health Informatics, Wisconsin Emergency Department Data (unpublished). Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Access to dental care Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Access to dental care Lack of routine preventive medical and dental care and unmet medical and dental needs among children, by poverty status, Wisconsin, In , about half of Wisconsin children living in households below the federal poverty level (FPL) did not see a health care provider for preventive medical and dental care during the past 12 months. This percentage was significantly higher than among children living in households with incomes at least twice the FPL. Children living in households with incomes below the FPL were also significantly more likely to have unmet medical and dental needs than were children living in households with incomes over 200% of the FPL. Children living in households where the highest education level of adults was high school graduate were significantly more likely to lack preventive medical and dental care than were children living in households where the highest level of adult education was more than high school (data not shown). Source: National Survey of Children's Health. Note: Estimates were not available for all groups. FPL is the Federal Poverty Level, based on household size and income. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Access to dental care Number of dentists per 100,000 people by county urbanization characteristics, Wisconsin, 2010 Non-metropolitan counties had a significantly lower rate of dentists per 100,000 people. Smaller metropolitan counties had significantly more dentists in relation to the population. In 2007, the national rate of dentists per 100,000 was 60.10 Source: Wisconsin Department of Safety and Professional Services licensure lists; population estimates from Wisconsin Department of Health Services, Office of Health Informatics. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Access to dental care Number of full-time-equivalent (FTE) dentists needed to reduce significant shortages for Medicaid members, 2009 This map shows the number of full-time-equivalent (FTE) dentists needed to eliminate a significant dentist shortage for populations enrolled in Medicaid and eligible for dentist services for calendar year Removing a “significant shortage” means having a ratio of 3,000 Medicaid-enrolled members to 1.0 FTE dentist or lower, as defined by the federal Office of Shortage Designation; this is not an optimal ratio.11 In 2009, there were four Wisconsin counties in which there were zero dentist FTEs providing dental services to Medicaid patients: Calumet, Florence, Lincoln, and Pepin. Milwaukee County needed the highest number of FTE dentists to eliminate significant shortages for the Medicaid-enrolled population. Data were not available to describe the total state dental workforce in detail or to describe dental access for the total state or uninsured populations. State workforce data needed to meet federal criteria to designate dentist shortages for the entire population are not available. For additional information about data limitations, see: Source: Wisconsin Department of Health Services, Primary Care Office, Shortage Designation Program. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Prevention of tooth decay

Percentage of population on public water systems receiving fluoridated water, by state, 2010 U.S. rate: 73.9% Community water fluoridation is a safe and effective way to prevent tooth decay. Community water fluoridation and school-based dental sealant programs are recognized as the leading evidence-based practices to prevent tooth decay.12 In 2010, nearly 90% of Wisconsin’s population on public water systems were receiving fluoridated water. This percentage exceeded the national rate (73.9%) as well as the target (79.6%) established by the federal health plan, Healthy People Source: Centers for Disease Control and Prevention, 2010 Water Fluoridation Statistics Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Percentage of schools with school-based dental sealant programs, Wisconsin, Since the school year, the Wisconsin Department of Health Services, in collaboration with the Children’s Health Alliance of Wisconsin, has administered the Seal-A-Smile school-based dental sealant program. Seal-A-Smile has experienced continual growth, with increased state General Purpose Revenue funding, federal Health Resources and Services Administration (HRSA) funding, and private foundation funding from Delta Dental of Wisconsin. Since the school year, the number of Wisconsin schools with a school-based dental sealant program has increased from 17% to 40%. Note: These percentages represent the total number of schools that have a dental sealant program in Wisconsin out of the total number of public schools with any students enrolled in the target grades of 1 through 8. Sources: Wisconsin Department of Health Services dental sealant program data; Wisconsin Department of Public Instruction public school enrollment data. Note: Public schools grades 1 through 8 Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Dental health needs among children

Percentage of children with untreated tooth decay, Wisconsin, selected years Tooth decay among young children can result in difficulty speaking, chewing, and swallowing; needless pain; lost school days; and low self-esteem. While the percentage of third-grade children with tooth decay has significantly declined, tooth decay among Head Start children (aged 3-5) has remained unchanged. More than one in four Head Start children in Wisconsin has untreated tooth decay. In recent years, partnerships have expanded among primary care providers, local health departments, large clinics, and private practices to advocate for the accessibility of preventive oral health services and the implementation and maintenance of fluoride varnish programs. These factors contributed to the decline in untreated tooth decay among third-grade students in Wisconsin.13 Head Start children with untreated decay Third-grade children with untreated decay Sources: Wisconsin Department of Health Services, Make Your Smile Count Survey and Healthy Smiles for Healthy Head Start Survey. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Percentage of third-grade students with untreated decay and dental sealants by race/ethnicity, Wisconsin, school year During the school year, one in three Black, Hispanic, and Asian third-graders had untreated tooth decay, more than twice the proportion in White children. Over half of White third-graders had dental sealants, while Black third-graders were significantly less likely to have this preventive measure for tooth decay. During the school year, 51% of third-grade students had dental sealants (data not shown above). Source: Wisconsin Department of Health Services, Make Your Smile Count Survey. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Percentage of third-grade students with untreated decay and no dental sealants by school percentage of students eligible for the free/reduced price lunch (FRL) program, Wisconsin, This graph displays oral health data based on each school’s percentage of students eligible for the free/reduced price lunch (FRL) program. Eligibility for FRL is used as a proxy for household income among children in school; schools with a higher percentage of students enrolled in the FRL program indicate a lower SES population. These data are grouped at the school level and not the student level. Children in schools with the highest proportion of students eligible for free/reduced price lunches are more than three times as likely to have untreated tooth decay and are also much more likely to lack the benefit of dental sealants, compared to children in schools with the lowest proportion of students eligible for free/reduced price lunches. Sources: Wisconsin Department of Health Services, Make Your Smile Count survey. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Percentage of children with oral health needs by disability status, Wisconsin, The federal Maternal and Child Health Bureau defines children with special health care needs (CSHCN) as “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”14 The National Survey of Children’s Health (NSCH) is a telephone survey conducted by the National Center for Health Statistics at the CDC under the direction and sponsorship of the federal Maternal and Child Health Bureau. A higher proportion of Wisconsin children with special health care needs had teeth in fair/poor condition and had one or more oral health problems within the past year than children with no special health care needs; however, the differences were not statistically significant. (The NSCH defines oral health problems as having had a toothache, decayed teeth, or unfilled cavities in the past 12 months.) Source: National Survey of Children's Health. Healthiest Wisconsin 2020 Baseline and Health Disparities Report

References References
University of Wisconsin Population Health Institute. County Health Rankings, Center for Urban Population Health. Milwaukee Health Report, LaVeist TA, Gaskin DA, Richard P (2009). The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. Thomas JC, Sage M, Dillenberg J, Guillory VJ (2002). A Code of Ethics for Public Health. Am Journal of Public Health. 92(7):1057– Wisconsin Department of Health Services (DHS). Healthiest Wisconsin American Dental Association. American Dental Association Statement on Regular Dental Visits. Centers for Disease Control and Prevention (CDC). Oral Health for Older Americans. Wisconsin Department of Health Services. Burden of Oral Disease in Wisconsin, 2010: Healthiest Wisconsin 2020 Baseline and Health Disparities Report

References National Center for Health Statistics: Oral Health Status and Access to Oral Health Care for U.S. Adults Aged 18-64: National Health Interview Survey, The Henry Kaiser Foundation. State Health Facts. Wisconsin Department of Health Services, Wisconsin Primary Care Office. Number of Dentists Needed to Reduce Significant Shortages for Medicaid Members. CDC. Community Water Fluoridation. CDC. Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancers At A Glance Data Resource Center for Child and Adolescent Health. Who Are Children with Special Health Care Needs? Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Links to additional reports and resources
Burden of Oral Disease in Wisconsin, 2010: Make Your Smile Count, 2008: Healthy Smiles for a Healthy Head Start, 2009: County Oral Health Wisconsin Surveillance System (COWSS): Centers for Disease Control and Prevention (CDC). Division of Oral Health: Healthiest Wisconsin 2020 Baseline and Health Disparities Report

Contact Melissa Olson, MS Epidemiologist Wisconsin Oral Health Program
Contacts Contact Melissa Olson, MS Epidemiologist Wisconsin Oral Health Program Bureau of Community Health Promotion Division of Public Health Wisconsin Department of Health Services Healthiest Wisconsin 2020 Baseline and Health Disparities Report

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