2020 Oral Health Objectives:2020 Oral Health Objectives:Much progress but More to be Much progress but More to be

DoneDone

Rebecca S King, DDS, MPHRebecca S King, DDS, MPH

Section Chief, NC Oral Health Section Chief, NC Oral Health SectionSection

IntroductionIntroduction

• BackgroundBackground

• 2010 Healthy Carolinian Objectives2010 Healthy Carolinian Objectives

• 2020 Healthy Carolinian Objectives2020 Healthy Carolinian Objectives

We’ve come a long way We’ve come a long way baby!!baby!!

But we still have a ways to go!! Why?

Major FactorsMajor Factors

• SociodemographicSociodemographic

• Dental workforceDental workforce

• Need for prevention and Need for prevention and educationeducation

Social and Demographic Social and Demographic TrendsTrends “New Majority”“New Majority”

• … … South is the only region… where low South is the only region… where low income children = majority of public income children = majority of public school students – 54%.school students – 54%.

• % low income children in schools doubled % low income children in schools doubled since 1989since 1989

• 2000-07: pop. <5 year olds grew by 20%2000-07: pop. <5 year olds grew by 20%

• 2001-05: Hispanics = 50% of growth in 2001-05: Hispanics = 50% of growth in public schoolspublic schools

Southern Educational Association, 2007

Poverty, poor education, and inequality lead to poor Poverty, poor education, and inequality lead to poor dental health!dental health!

Dentist Workforce Dentist Workforce TrendsTrends•4 counties have no dentist

•10 counties have 1 or fewer dentists/ 10,000 population

•NC Supply lags behind US supplySlight increase over the last 10 years

•Future: expanding dental school graduates

GAO Report 2008GAO Report 2008

• Millions of poor American children have untreated Millions of poor American children have untreated tooth decaytooth decay

• 6.5 million children enrolled in Medicaid had 6.5 million children enrolled in Medicaid had untreated tooth decay (2005)untreated tooth decay (2005)– some could not find a dentist willing to treat them some could not find a dentist willing to treat them – only 1 in 3 received any dental care in a year only 1 in 3 received any dental care in a year

• Report was ordered after young boy died in 2007Report was ordered after young boy died in 2007

http://www.cnn.com/2008/US/09/23/dentalcare.medicaid/ind

Early Treatment is Early Treatment is EssentialEssential

Dental Care Safety Net Clinics Dental Care Safety Net Clinics Prior to 1996*Prior to 1996*

Note: Symbols indicate the base county of a facility and not necessarilyits specific geographic location or counties served.

Fixed Mobile

Local Health Department

Community Health Center

Other Non-Profit Facility

* NC Oral Health Section

Note: Symbols indicate the base county of a facility and not necessarilyits specific geographic location or counties served.

Fixed Mobile

Local Health Department

Community Health Center

Other Non-Profit Facility

Dental Care Safety Net Clinics Dental Care Safety Net Clinics March 2010*March 2010*

* NC Oral Health Section

Need for Prevention and Need for Prevention and EducationEducation

We’ve never cured a disease We’ve never cured a disease through a treatment program.through a treatment program.

Tooth Decay: Most Common Tooth Decay: Most Common Chronic Childhood DiseaseChronic Childhood Disease

• Mortality: can be fatal, usually notMortality: can be fatal, usually not

• Morbidity: quality of lifeMorbidity: quality of life– 6X more common than asthma6X more common than asthma– Advocacy groups rate highAdvocacy groups rate high

• Largely preventableLargely preventable

• Once diseased, have to repairOnce diseased, have to repair

• Able to track because it leaves a Able to track because it leaves a recordrecord

0 10 20 30 40

White

Black

Hispanic

Pain

Difficulty Eating

Percent

Quality of Life*Quality of Life*

Missed School

Financial Difficulties

††Occasionally, often or very often in lifetimeOccasionally, often or very often in lifetime

ImpactsImpacts† on Child and Family by Race, on Child and Family by Race, Grades K-3Grades K-3

*2003-2004 NC OHS Statewide Dental Survey

5.44.7

2.91.9

0

1

2

3

4

5

6

7

8

1960-62 1976-77 1986-87 2003-04

Blacks

Whites

5.9

Disparities in DiseaseDisparities in Disease

Mean DMFT

7.6

3.1

1.4

*NC OHS Statewide Dental Survey Data

Trends in Tooth Decay in 12-17-Year-Old Trends in Tooth Decay in 12-17-Year-Old

ChildrenChildren**

0

5

10

15

20

25

30

35

40

Disparities in AccessDisparities in Access

Percent

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

% Permanent Teeth with Untreated Decay, by % Permanent Teeth with Untreated Decay, by Race*Race*

Percent

Private Public None

White Black HispWhite Black Hisp White Black Hisp

*2003-2004 NC OHS Statewide Dental Survey

% Children with Dental Insurance by Type and % Children with Dental Insurance by Type and

Race*Race* **

Disparities in AccessDisparities in Access

Costs of Dental TreatmentCosts of Dental Treatment

2006 MEPS data2006 MEPS data

• Expenditures 7.4% of total health Expenditures 7.4% of total health carecare

• Mean/person $607Mean/person $607

• 42% had an expenditure42% had an expenditure– 43% paid by private insurance43% paid by private insurance– 49% out of pocket49% out of pocket

http://www.meps.ahrq.gov/data_files/publications/st263/stat263.pdf

Cost-Effective Preventive Cost-Effective Preventive MeasuresMeasures

• CDC recommends as most beneficial CDC recommends as most beneficial preventive measurespreventive measures– Water FluoridationWater Fluoridation

•Benefits children and adultsBenefits children and adults

•50 cents - $1/person/year50 cents - $1/person/year

•Lifetime costs less than cost of one fillingLifetime costs less than cost of one filling

– Dental SealantsDental Sealants

• Fluoride varnishFluoride varnish

Early Stage Decay and Early Stage Decay and Obvious Cavities in Permanent Obvious Cavities in Permanent Teeth*Teeth*

Early stage decay only Obvious cavities only

65%65%

10%10%

24%24%Both

Children

*2003-2004 NC OHS Statewide Dental Survey

Why Education?Why Education?

• ““You can’t be You can’t be healthy without healthy without good oral health”good oral health”– Dr. C. Everett KoopDr. C. Everett Koop

• Value placed on Value placed on oral healthoral health

0

10

20

30

40

50

60

70

Value Placed on Oral HealthValue Placed on Oral Health

Percent

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

Update on Healthy Update on Healthy Carolinians 2010 Oral Carolinians 2010 Oral

Health ObjectivesHealth Objectives

HC-2010 Oral Health HC-2010 Oral Health ObjectiveObjective1. Reduce tooth decay in preschool1. Reduce tooth decay in preschool

children. children.

Target: 1.3 average # decayed, missing Target: 1.3 average # decayed, missing and filled primary teeth (dmft).and filled primary teeth (dmft).

Baseline, 1999: 1.45 average # decayed, Baseline, 1999: 1.45 average # decayed, missing and filled primary teeth (dmft).missing and filled primary teeth (dmft).

Tooth Decay in Kindergarten Tooth Decay in Kindergarten Children Children (primary teeth)*(primary teeth)*

0

0.5

1

1.5

2

1996-97

1998-99

2000-01

2002-03

2004-05

2006-07

2008-09

HC 2010

Year

Pri

mar

y te

eth

dmftdtfmt

*NC OHS annual assessment data

Target 1.3Baseline 1.45

HC-2010 Oral Health HC-2010 Oral Health ObjectiveObjective

2. Increase the proportion of 5th 2. Increase the proportion of 5th graders whose permanent teeth graders whose permanent teeth are free of decay.are free of decay.

Target: 87%Target: 87%

Baseline, 1999: 79% fifth grade Baseline, 1999: 79% fifth grade children have never had a cavity in children have never had a cavity in a permanent tooth.a permanent tooth.

Fifth Grade Children with Fifth Grade Children with Permanent teeth Free from Permanent teeth Free from Decay*Decay*

65

70

75

80

85

90

Year

Per

cent

age

of C

hild

ren

Cavity free

Baseline 79% Target 87%

*NC OHS annual assessment data

?

Fifth Grade Children: Avg. # Fifth Grade Children: Avg. # Decayed Permanent Teeth*Decayed Permanent Teeth*

0

0.02

0.04

0.06

0.08

0.1

0.12

Year

Per

man

ent

Tee

th

DT

*NC OHS annual assessment data

HC-2010 Oral Health HC-2010 Oral Health ObjectiveObjective3. Increase the proportion of 3. Increase the proportion of

children < age 19 at or below children < age 19 at or below 200% Federal poverty level who 200% Federal poverty level who received any dental preventive received any dental preventive service during the last year.service during the last year.

Developmental Objective, baseline Developmental Objective, baseline data to be collected and analyzed data to be collected and analyzed by 2001.by 2001.

Access to Care for Medicaid Access to Care for Medicaid Children*Children*

25% 29% 33% 35% 37% 38% 40% 45%0

200000

400000

600000

800000

1000000

1200000

SFY 2001 - 2008

Nu

mb

er

of

Re

cip

ien

ts <

21

*NC Div. of Medical Assistance

Into The Mouths of BabesInto The Mouths of Babes

Statewide Medicaid Dental Statewide Medicaid Dental Prevention Program for Young Prevention Program for Young

ChildrenChildren

Dental Prevention Service Dental Prevention Service PackagePackage

Medicaid children from tooth eruption Medicaid children from tooth eruption to age 3 ½to age 3 ½

• Provided in a medical settingProvided in a medical setting

• Oral evaluation and risk assessmentOral evaluation and risk assessment

• Referral for dental careReferral for dental care

• Caregiver educationCaregiver education

• Fluoride varnishFluoride varnish

HC-2010 Oral Health HC-2010 Oral Health ObjectiveObjective4. Increase the proportion of adults4. Increase the proportion of adults

who visited a dentist within the who visited a dentist within the pastpast year. year.

Target: 73.9%Target: 73.9%

Baseline, 1999: 67.2% of adults 18 years Baseline, 1999: 67.2% of adults 18 years and older visited a dentist during the and older visited a dentist during the past year.past year.

How many visited dentist, How many visited dentist, clinic for any reason in last clinic for any reason in last year?*year?*

YearYear

Per

cent

Per

cent

*BRFSS

?67.2

69.4

67.6 67.5

65.2

67.2

73.9

60

62

64

66

68

70

72

74

1999 2001 2002 2004 2006 2008 2010

TargetBaseline

HC-2010 Oral Health HC-2010 Oral Health ObjectiveObjective5. Decrease the proportion of 5. Decrease the proportion of

adults,adults, ages 45 – 65 years, who lost 5+ ages 45 – 65 years, who lost 5+ teeth due to tooth decay or gum teeth due to tooth decay or gum disease. disease.

Target: 20%Target: 20%Baseline, 1999: 22.3% of adults, ages Baseline, 1999: 22.3% of adults, ages

45-64, had a tooth removed due to 45-64, had a tooth removed due to decay or gum disease. decay or gum disease.

Proportion of adults, ages 45-64, who lost Proportion of adults, ages 45-64, who lost 5+ teeth due to tooth decay or gum 5+ teeth due to tooth decay or gum disease*disease*

33.4 33.531.8

27.225.3

20

0

5

10

15

20

25

30

35

2001 2004 2008 *2010target

% P

eopl

e W

ho L

ost 6

+ T

eeth

*NC State Center for Health Statistics

??

YearYear

Target

Healthy Carolina 2020Healthy Carolina 2020

Draft Oral Health ObjectivesDraft Oral Health Objectives

HC-2020 Oral Health HC-2020 Oral Health Objective 1Objective 1

Increase the % of children enrolled Increase the % of children enrolled in Medicaid ages 1-5 who in Medicaid ages 1-5 who received any dental service received any dental service during the previous 12 months.during the previous 12 months.

• Target: 56.4%Target: 56.4%

• Baseline: 46.9% (2008)Baseline: 46.9% (2008)

• Method: 90Method: 90thth percentile for NC percentile for NC countiescounties

Draft

% Medicaid children receiving % Medicaid children receiving dental services, last 12 monthsdental services, last 12 months

3.4

22.2

31.133.8

46.9

56.4

0

10

20

30

40

50

60

2000 2004 2008 2012 2016 2020

Ages 1-5

Year

Target

Perc

en

tag

e

Baseline

HC-2020 Oral Health HC-2020 Oral Health Objective 2Objective 2Decrease the average number of Decrease the average number of

decayed, missing, or filled teeth decayed, missing, or filled teeth (dmft) among kindergartners.(dmft) among kindergartners.

Target: 1.06 average # decayed, missing Target: 1.06 average # decayed, missing and filled primary teeth (dmft).and filled primary teeth (dmft).

Baseline, 2008-09: 1.5 average # decayed, Baseline, 2008-09: 1.5 average # decayed, missing and filled primary teeth (dmft).missing and filled primary teeth (dmft).

Method: Best 10Method: Best 10thth percentile of NC counties. percentile of NC counties.

Draft

2. Tooth Decay in Kindergarten 2. Tooth Decay in Kindergarten Children Children (primary teeth)*(primary teeth)*

0

0.5

1

1.5

2

1996-97

2000-01

2004-05

2008-09

2012-13

2016-17

Year

Pri

mar

y te

eth

dmft

*NC OHS annual assessment data

Target 1.06Baseline 1.5

HC-2020 Oral Health HC-2020 Oral Health Objective 3Objective 3Decrease the percent of people (ages Decrease the percent of people (ages

18+) who have had permanent teeth 18+) who have had permanent teeth removed due to tooth decay or gum removed due to tooth decay or gum diseasedisease**

• # teeth removed due to tooth decay or gum disease? # teeth removed due to tooth decay or gum disease? Don’t include teeth lost for other reasons, such as Don’t include teeth lost for other reasons, such as injury or orthodontics.injury or orthodontics.

• Target: 35.8%Target: 35.8%

• Baseline: 54.3% (2001)Baseline: 54.3% (2001)

• Method: NC Pace applied out to 2020.Method: NC Pace applied out to 2020.

*BRFSS data

Draft

3. Percent of adults who had a permanent 3. Percent of adults who had a permanent tooth removed due to tooth decay or gum tooth removed due to tooth decay or gum disease*disease*

49.9 48.4 47.8

38.4

05

101520253035404550

2004 2006 2008 2010 2012 2014 2016 2018 2020

Per

cent

age

YearYear

Target

*BRFSS data

Questions LaterQuestions Later