1. ORAL HEALTH IN NEW YORK STATE DECEMBER 11, 2012 Jayanth Kumar, DDS, MPH Bureau of Dental Health

2. Learning Objectives  Understand the functions, infrastructure and capacity of a state oral health program  Discuss the strategies used for promoting interventions  Describe the evaluation efforts related to the fluoridation program

3. Vision & Mission  The Bureau of Dental Health will provide an environment to encourage all New Yorkers to develop an awareness of the importance of oral health, and to assure it’s inclusion in public health programs targeted toward the building of healthier communities.  Our mission is to improve the oral health of all New Yorkers.

4. IMPACT Reduction in : Caries, Periodontal disease, Oral cancer Reduced Disparities in Oral Health Outcomes Reduced transmission of infection Enhanced Quality of life State Health Department State Partners CDC technical assistance and funding Other resources CDC HRSA ASSESSASSESS DEVELOP POLICYDEVELOP POLICY ASSUREASSURE OUTCOMES Increased Program -Quality -Magnitude -Sustainability -Cultivation Burden document Conduct surveillance Maintain a state oral health plan Support statewide coalition & partnerships Develop leadership Promote systems & policy change Promote & Manage programs Institutionalize strong evaluation Resources-Activities-Outcome-Impact

5. Technical Support BUREAU OF DENTAL HEALTH Indian Health Migrant Health School Health Community Health Centers Dental Care for persons with HIV Investigation of disease transmission Local Health Medicaid Child Health Plus Office of Children and Families Rural Health Managed care Primary Care Chronic disease programs

6. Public Health Action  Surveillance & Epidemiology  Children, Adults & Elderly  Community based interventions  Fluoridation  School-based interventions  Health system interventions  Guidelines and Training Programs  Infection Control Practice  Community clinical linkages  Care Coordination, School Certificate Program

7. Prevalence Trends, Third Grade Survey Upstate New York Caries Prevalence Untreated Caries

8. Prevalence of Sealants, Third Grade Survey, Upstate New York

9. Perecent of Medicaid enrollees (ages 2-20 years) who had at least one dental visit within the last year. NYS Medicaid Data, 2005-2010 All ages ( 2-20 years) 2010 - 42.3% 2005 – 35.3% Target – 56% HP2010

10. Percent of persons (aged 45 to 64) who have never had a permanent tooth extracted due to dental caries or periodontal disease. New York State BRFSS, 2010.

11. Trends in tooth loss. Percent of persons (ages 65 and older) who have lost all natural permanent teeth. New York State BRFSS, 1999 to 2010.

12. Oral cancer cases diagnosed at early stage by gender, race and year. New York State Cancer Registry, 1976- 2008.

13. Percent of people who visited a dentist or a dental clinic within the past year. BRFSS, 2010.

14. Dental visit during pregnancy by race, age, years of education, marital status and participation in Medicaid. PRAMS 2008.

15. Framework for Comprehensive State Oral Health Plan Knowledge for Evidence-Based Decision Making What should be done? Setting Optimal National and State Objectives: (data-driven) What can be done? Planning Feasible Strategies (capacity-driven) What is achieved? Implementing Effective Strategies (outcome-driven) What could be done? Determining Possible Strategies (science-driven) Data: societal influences, current capacity, environmental analysis Surveillance Data: unmet needs, service and data gaps Data: proven prevention and best processes Data: process, outcome, impact evaluations Data: disease burden, target populations, and implementation barriers

16. Example: A blueprint for action

17. Counseling pregnant women and parents; Health education and social marketing campaigns; Training Promote dental sealant, fluoride varnish & annual dental visits, and practice guidelines School-based dental sealant & fluoride rinse programs; Fluoridation; Require dental examinations; Healthy school lunch; Prohibit vending machines and soda pouring rights in schools; Address oral health literacy Public Health Action Framework

18. Key prevention strategies:  Community water fluoridation  School-based sealant program  Preventive dental visits by age one  Engaging primary care providers to provide  Risk assessment and early disease detection  Fluoride varnish  Anticipatory guidance  Engaging prenatal care providers and perinatal networks to promote oral health  Increasing the capacity to treat disease

19. Fluoridation

20. Strategies to promote fluoridation  Build support - Internal & External  Engage partners and stakeholders  State Oral Health Coalition  Rural Water Association  Local Health Departments  State Dental Association  Develop resources  Provide training  Explore financing options

22. Mean claim per recipient for caries related procedures was correlated with county fluoridation status Spearman Correlation Coefficient -0.53 (p < 0.01). Each bubble denotes the size of the Medicaid population. 1.66 1.33 1.23

23. Fluoridation status of the county was not correlated with other non-caries related procedures Spearman Correlation Coefficient was -0.12 (p =0.36). Each bubble denotes the size of the Medicaid population.

24. ParameterStandard P-value Variableestimateerror Intercept1.8810.328 <0.0001 Fluoridation coverage (percent) a -0.0600.002 0.003 Children on free or reduced school lunch program (percent)-0.0070.006 0.271 Population non-white (percent)0.0120.009 0.190 Urban population (percent)-0.0030.004 0.355 Number of providers per 100,000 eligible Medicaid enrollees0.001 0.303 Table 3. Regression analysis of claims for restorative, extraction, and endodontic procedures per child, New York State Medicaid Claims Data, 2006 a

25. Medicaid Redesign Team Recommendations 13) Medicaid Coverage of Water Fluoridation: To address disparities in access to dental services the Workgroup recommends that Medicaid funding be made available to support costs of fluoridation equipment, supplies and staff time for public water systems in population centers (population over 50,000) where the majority of Medicaid eligible children reside.

26. Is there a link between severe fluorosis and caries?

27. “Severe enamel fluorosis compromises that health-protective function by causing structural damage to the tooth… Moreover, the plausible hypothesis concerning elevated frequency of caries in persons with severe enamel fluorosis has been accepted by some authorities, and the available evidence is mixed but generally supportive.” - NRC Report 2006 (Page 3)

30. DOES FLUORIDE IN DRINKING WATER DELAY TOOTH ERUPTION I. Adeyemi Jolaoso et al. Bureau of Dental Health, NYSDOH Number of erupted permanent teeth (weighted) and number of erupted permanent first molars by Age and Water Fluoride Level

31. Adjusted mean number of Erupted First Permanent Teeth among 7 year old children Water Fluoride Level (F mg/L) Mean Number of Erupted First Molars <0.33.82 (0.06) 0.3 -<0.73.67 (0.09)* 0.7 -1.23.92 (0.06)* Other variables included in the model were age, gender, race, metropolitan status and school region.

32. Adjusted Caries Attack Rate among 5-17 year old children Water Fluoride LevelAttack Rate in First Molars DMFS Per 1000 Surfaces <0.392.8 0.3-<0.781.2 0.7 – 1.277.7 Other variables included in the model were age, gender, race, metropolitan status and school region.

33. Resources  New York State Department of Health (NYSDOH) website  CDC and ADA  Technical Assistance Center in Rochester  ILikeMyTeeth.org - NewYork.ILikeMyTeeth.org  Fluoride Science.org  Rural Water Association  Local Health Department  Water Fluoridation Manual

34. Features:  Topic summaries  Critical appraisals  Videos featuring fluoride researchers

35. Planning School Dental Programs in New York State Treatment School-based Dental Sealant Dental Certificate (Screening & referral) Dental Home Fluoride rinse Fluoridation Policy Intervention Dental health certificate, School curriculum, Health education, Mouth guards in contact sports, Injury protocol, Healthy nutrition – school lunch, vending machines and soda pouring rights. TARGET (IDEAL) Number of Schools NYC Rest NYS 50100 200500 1048 418 0100 15423127 TARGET (IDEAL) Number of Schools NYC Rest NYS 50100 200500 1048 418 0100 15423127

36. 36 Oral health in young children  Prevalence in 2-5 year old is 27.9%  Mean dfs =2.4  Among children under 4 years old enrolled in the EPSDT, less than 16% received any preventive dental visit.  In New York, approximately 4800 children (<6 years) treated in an OR for dental caries.

37. Oral health care during pregnancy  Guidelines  Ask questions and assess  Incorporate education into prenatal care  Facilitate referral Consultation form List of dentists  Identified champions to promote interventions  Included dental health deliverables in Perinatal Network contracts  Dental measures in perinatal standards

38. Diabetes and Oral Health

40. New York State Medicaid Program NYUS 19.2 m Population307.9 m Medicaid Enrollment as a % of Total Pop 5.2 m (27% in NY) vs62.7 m (20% Nation) Essential dental benefits are covered Effective July 1, all beneficiaries are enrolled in a Managed Care Program

41. Medicaid Caseloads of New York Dentists

42. “New York has 79 dentists per 100,000 population, which is well above the national rate of 55 dentists per 100,000 population.”

43. Dental Licenses Issued during Past Eight Calendar Years

45. Workforce  Dental practice maps  Dental health professional shortage areas  Recruitment  Fairs and meetings  My Health Career® Website  HealthMatch Program  New York State Primary Care Service Corps  School Dental Certificate Program  Workforce flexibility

47. Questions?