1. Oral Health Surveillance in Texas David P. Cappelli, DMD, MPH, PhD Associate Professor Department of Community Dentistry University of Texas Health Science Center at San Antonio Texas Oral Health Summit: Advocacy, Equity & Access Austin, Texas September 9-10, 2004

2. Components of a State Oral Health Surveillance System Clear purpose and objectives Core set of measures Analyze trends Communicate data and information to decision-makers and to the public CDC, Division of Oral Health, May, 2003

3. CDC Surveillance Data National Oral Health Surveillance System (NOHSS) Behavioral Risk Factor Surveillance System (BRFSS) Water Fluoridation Reporting System (WFRS) Pregnancy Risk Assessment Monitoring System (PRAMS) Youth Risk Behavior Survey (YRBS) Surveillance, Epidemiology & End Result (SEER) Basic Screening Survey (BSS) National Health and Nutrition Survey (NHANES) National Health Interview Survey (NHIS)

4. National Oral Health Surveillance System Capture data from four questions listed on BRFSS and WFRS Last dental visit within the past year Teeth cleaned by a dentist/dental hygienist in the past year Population over the age of 65 years who have lost all of their teeth Population on public water systems receiving fluoridated water

5. Last Dental Visit within the Past Year CDC, BRFSS 64.1 60

6. Teeth Cleaned within Past Year CDC, BRFSS

7. Lost 6+ Teeth Due to Tooth Decay or Gum Disease CDC, BRFSS 19.1 14.2

8. Water Fluoridation Reporting System (WFRS) 34% 66% CDC, Oral Health Resources, 2003

9. SMART BRFSS Data Dallas and Houston Metropolitan Areas Contains data on 7 health indicators None directly relate to oral health Smoking status Diabetes Obesity

10. National Data Collection Opportunities PRAMS: Four questions that could be asked directly related to oral health SEER: Forty-one states + DC analyze for state-specific data on oral cancer YRBS: Oral health related questions could be included

11. Statewide Data Collection Opportunities Texas State Board of Dental Examiners Collects annual data on workforce of dentists and dental hygienists Age and practice location Number of auxiliaries utilized Obtains information on location of practice and practice activity (hours/weeks worked) Medicaid/Insurance Provider Accessibility for persons with disabilities

12. Statewide and Regional Data Collection Opportunities ‘Statewideness’ Assessment of Oral Health Data by county available on: Number of Medicaid eligible children age one year and older Number of Medicaid eligible children who received at least one dental service Number of Medicaid eligible providers who provided at least one dental service

13. Statewide and Regional Efforts Multiple statewide and regional projects and groups that obtain data on: Prevalence of oral disease Untreated dental caries Urgent dental care needs Sealant prevalence

14. Statewide and Regional Efforts Texas Dental Health Survey, “Make Your Smile Count”, 1998 TDH in cooperation with UTHSCSA, Community Dentistry State survey of Preschool, 2 nd and 8 th grade students Parental Questionnaire and Direct Screening 16 elementary/16 adjacent middle schools 110 Preschoolers/1124 2 nd graders/802 8 th graders

15. Statewide and Regional Efforts Texas Dental Health Survey, “Make Your Smile Count” Findings: 66% (2 nd )/53% (8 th ) had a dental caries experience 44% (2 nd )/22% (8 th ) had untreated tooth decay 16% (2 nd )/24% (8 th ) received dental sealants Medicaid Enrollment was associated with: Positive parental perception of good oral health Greater likelihood of dental visit in past year Lower likelihood of never having a dental visit Greater likelihood of having a dental home

16. Statewide and Regional Efforts - El Paso El Paso Oral Health Care Community Plan, 2000 Statewide evaluation of the oral health status of children (6-8 years) Students on free and reduced lunch program (4,012 Medicaid/10,104 Non-Medicaid) Findings: Non-Medicaid children had more active caries and received fewer preventive services Non-Medicaid children had more urgent care needs

17. Statewide and Regional Efforts - El Paso TEXASEL PASO REGION Medicaid (%) Non-Medicaid (%) Medicaid (%) Non-Medicaid (%) Caries History58.75865.965.4 Active Caries36.046.246.648.3 Sealants Present21.813.812.914.1 Urgent Care Needed 9.714.338.840.7 Routine Referral Needed 29.335.59.710.8 Sealants Needed38.232.934.834.4 No Treatment Needed 22.817.316.714.0

18. Statewide and Regional Efforts -El Paso Dr. Michael Najera How to best provide needed dental health education message to low-income children Administered 80-question oral health survey to 400 mothers enrolled in WIC clinics in El Paso, TX Findings: Oral health knowledge was less in mothers born in Mexico, with less than HS education, and low ability to read English Oral health of the child was significantly adversely affected by having a younger mother (under age 25), mother born in Mexico, Spanish is principal language and low English literacy Oral health of the mother and dental practices of both mother and child were affected by low English literacy

19. Statewide and Regional Efforts Lower Rio Grande Valley Lower Rio Grande Valley: Dr. Ramon Baez, UTHSCSA Conducted between 1990-1995 3,450 individuals were examined Findings: 85% of the population was in need of dental care Need for emergency dental care increased with age (69% of persons over age 55 needed care)

20. Statewide and Regional Efforts Lower Rio Grande Valley South Texas Health Status Assessment, Community Health Development Program, 2003 Household survey of adults and children living five South Texas counties (Cameron, Hidalgo, Starr, Webb, Willacy) to look at oral health services for colonia residents Supported by funds from RWJ Foundation for the Integrated Health Outreach Services Project (IHOS) and HRSA

21. Statewide and Regional Efforts Lower Rio Grande Valley South Texas Health Status Assessment, Community Health Development Program, 2003 Findings: Dentists per 100,000 Population: 9.6-16.2 (Texas: 36.4) Over 65% of all respondents stated that cost was a consideration in seeking dental care, even if insured 55% of adults traveled to Mexico for dental/medical care Over 25% of adults never had a dental exam (14% of children) Over 30% of adults (25% of children) had tooth or gum problems at the time of the survey

22. Statewide and Regional Efforts - Houston Innovative Method to Improve the Impact of the Texas Oral Health Program Collaboration between UT-Houston Dental Branch and Dental Health Task Force of Greater Houston Funded by TDH-Innovations Grant Goals and Objectives Develop and test a cost-effective method to generate data for development of evidence-driven oral health policies Utilize data to develop a strategy to improve the oral health of Texas children

23. Statewide and Regional Efforts - Houston Used direct screening dft/DMFT Untreated caries Sealant prevalence Questionnaire to collect data Perceptions of health Oral health promoting practices Exposure to sugar-containing foods History of dental experiences

24. Statewide and Regional Efforts - Houston Selected 7 counties in TDH region 6 (total of 13 counties) based on SES variables 2,781 children in Pre-K, Grades 2, 7 and 10 were included Conclusions: Prevalence of untreated decay 13.5%-54.3% Sealant prevalence 27.8%-51% Based on findings, provided strategic recommendations for both individual and community measures

25. Statewide and Regional Efforts - San Antonio Behavioral Risk Factor Survey of Bexar County, Texas, 2002 Collaboration with Bexar County Community Health Collaborative and UTHSCSA, Community Dentistry Component of a community health assessment to guide efforts toward prevention and health improvement Telephone survey of 1,010 adults Findings: 66% of adults had a dental visit in the past year Persons at greater risk or lower SES were less likely to have had a dental examination in the past year 78% of children had a dental visit in the past year

26. Statewide and Regional Efforts - Dallas Children’s Oral Health Coalition, 2002 Screened 5,000 children in 13 Fort Worth ISD elementary schools Findings: 16% require urgent care 18% have dental caries Survey to 612 dentists, 16 school district nurse administrators, 421 families who received care at low- income clinics Assess perceptions of the extent of oral health problems and availability of dental services for children

27. Statewide and Regional Efforts - Dallas Children’s Oral Health Coalition, 2002 Findings: 53% of nurse administrators reported that dental problems presented to schools daily/weekly 85% reported that services are inadequate and 77% noted that the service were not easily accessible 58% of families were enrolled in Medicaid, and 44% did not have a dentist 20% of families had a child with dental pain that was not being treated 16% of dentists responding were Medicaid providers Of those accepting Medicaid, only half of those were accepting new patients

28. Statewide and Regional Efforts - Dallas Dental Health Arlington: Sealant Program, “SMILES” Non-profit, full service dental clinic, serving low income residents of Tarrant County SMILES: School-based sealant program in operation for 9 years Collect data for the nine years of the programs existence

29. InputsActivities Intermediate Outcomes Long-term (Distal) Outcomes Improved Oral Health Ongoing monitoring of trends in oral health indicators Increase in evidence- based interventions, planning, and evaluation Increase in programs for populations most in need Staff (contract and in-kind) for: Epidemiological support Data management Information Technology (IT) Oral health policy leadership Data collection Data Sources: National data sources State data sources Community data sources Equipment: IT hardware/software Other: Funding Community Support Support for Partners Develop a surveillance plan Establish surveillance objectives Select and develop case definitions and indicators using standard health indicators whenever possible Link existing data sources Identify gaps in data Obtain community IRB approval Collect data to obtain community-level indicators and meet other needs Analyze data and interpret findings Develop and write surveillance report Disseminate surveillance results Ensure data security and confidentiality Develop strategies for sustaining surveillance system Evaluate state surveillance system LOGIC MODELSURVEILLANCE CDC, Division of Oral Health, May, 2003

30. Recommendations for Future Action Develop a coalition of statewide partners to establish objectives and identify core measures Create a statewide plan for continued surveillance of oral health Leverage funds to participate in national surveillance programs Make surveillance a priority in the state oral health program

31. Recommendations for Future Action Coordinate regional efforts at a statewide level to standardize information and to serve as a repository for findings Recommend standardized system for all surveillance efforts (i.e., ASTDD Basic Screening Survey or BRFSS) Support existing regional surveillance at the statewide level by providing technical assistance on design, collection, and analysis

32. Thank You