Oral Health, Health Disparities and Programs to Improve Access to Dental Care in the US and Washingt

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Oral Health, Health Disparities and Programs to
Improve Access to Dental Care in the US and
Washington State

• Peter Milgrom, DDS
• Professor of Dental Public Health Sciences
• Director, Northwest/Alaska Center to Reduce Oral
  Health Disparities

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Self Instruction Program

• Before beginning this program, please first
  review the required readings. Then, study the
  slides in this program.
• Complete the self-assessment. The assessment
  includes questions from the reading. There is a
  link to the self assessment in the last panel.
• You will not receive credit for completing the
  assignment without doing the self-assessment.

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Learning Objectives

• To recognize groups within the population that
  are most susceptible to dental disease.
• To understand the issue of access to care.
• Be able to discuss the importance of a workforce
  balance. Identify trends of dental supply,
  demand and need.
• To understand how sources of payment for dental
  treatment contribute to access to care.
• To be able to describe how effective the dental
  delivery system is in meeting the needs of all
  Americans.
• To recognize US goals for improving oral health.
• To be able to discuss oral health disparities in
  Washington State.

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Each child is an adventure into a better life -
an opportunity to change the old pattern and make
it new. Hubert H. Humphrey, Senator and Vice
President of the US
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Tooth Decay (dental caries) is the most common
disease condition among 5-17 year olds in the
United States
Includes decayed, filled and missing permanent
teeth
NHANES (NCHS) 1996
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Disparities in Dental Disease

• Learning Objective
• To recognize groups within the population that
  are most susceptible to dental disease.

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Early Childhood Caries (ECC) Is Tooth Decay in
Preschoolers
Disparities in Dental Disease

• Measured as decayed, missing or filled primary
  teeth (dmft) or surfaces (dmfs)
• Also called Baby Bottle tooth decay and nursing
  caries
• Severe ECC
• atypical or progressive or acute or rampant
  patterns of dental caries

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Percent of American Indian/Alaska Native
Preschool Children withSevere Early Childhood
Caries
Disparities in Dental Disease
National Rate for ECC is less than 5
IHS, 2002.
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Who are American Indian / Alaska Native
Preschool Children?
Disparities in Dental Disease

• Rural areas
• 34 live in poverty (below FPL)

FPL(Federal Poverty Level). For 2005 --
12,830/yr per couple for lower 48.
NCES 2005, 2000 Census
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Percent of Poor and Non-Poor Children (2-5 yrs)
with Untreated Decayed Teeth, by Ethnicity
Disparities in Dental Disease
Untreated Decayed Teeth d of dft
FPL(Federal Poverty Level). For 2006 --
13,200/yr per couple.
NHANES (NCHS) 2006
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Who are African American Mexican American
Preschool Children?
Disparities in Dental Disease

• African American Preschoolers
• Metropolitan areas
• 25 live in poverty (below FPL)

• Mexican American Preschoolers
• Rural, agricultural areas
• 29 live in poverty (below FPL)

FPL(Federal Poverty Level). For 2005 --
12,830/yr per couple for lower 48.
DeNavas-Walt, et al. 2005 2000 census
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Percent of Poor and Non-Poor Children (6-17 yrs)
with Untreated Decayed Teeth, by Ethnicity
Disparities in Dental Disease
Untreated Decayed Teeth D of DMFT
FPL(Federal Poverty Level). For 2006 --
13,200/yr per couple.
NHANES (NCHS) 2006
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Percent of Poor and Non-Poor Adults (18 years)
with Untreated Decayed Teeth, by Ethnicity
Disparities in Dental Disease
Untreated Decayed Teeth D of DMFT
FPL(Federal Poverty Level). For 2006 --
13,200/yr per couple.
NHANES (NCHS) 2006
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Percent of Persons with Advanced, Moderate, or
Mild Periodontitis by Age and Ethnicity
Disparities in Dental Disease
Periodontitis involves progressive loss of the
bone around teeth which may lead to loosening and
eventual loss of teeth if untreated.
Periodontitis is caused by bacteria that adhere
to and grow on tooth surfaces (microbial plaque
or biofilms), particularly in areas under the gum
line.
Albandar, et al. 1999. J Periodont. 70(1)13-29.
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Oral Pharyngeal Cancer Rates by Race and Sex
Disparities in Dental Disease
Oral Pharyngeal Cancer Cancer of the lip,
tongue, floor of the mouth, palate, gingiva and
alveolar mucosa, buccal mucosa, and oropharynx.
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Oral Cavity and Pharynx Cancer 5-Year Survival
Rates Race
Disparities in Dental Disease
Evans Kleinman, JADA 2000.
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Disparities in Access to Care

• Learning Objective
• To understand the issue of access to care.

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US Adults with at Least One Dental Visit
Disparities in Access to Care
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Percentage of Persons accessing Dental Care
within One Year by Income Status (2004)
Disparities in Access to Care
FPL Federal Poverty Level
FPL(Federal Poverty Level). For 2006 --
13,200/yr per couple.
NHANES (NCHS) 2006
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Percentage of Persons accessing Dental Care
within One Year by Ethnicity (2004)
Disparities in Access to Care
NHANES (NCHS) 2006
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Low Income Mothers Who Have a Regular Dentist
Disparities in Access to Care

• Contributing factors
• Dental insurance
• Greater education
• Income
• Length of residence
• Better mental health
• Increased supply of private dentists and safety
  net clinics
• Mother-to-child transmission of bacteria can
  cause childs tooth decay

Plt0.001
Grembowski D, Spiekerman C, Milgrom P. (2007)
Linking mother and child dental care reducing
oral health disparities by focusing on a regular
source of dental care among mothers of
medicaid-enrolled pre-school children.
Submitted, Journal of Health Care for the Poor
and Underserved.
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Meeting the Needs of the Population

• Learning Objective
• To be able to describe how effective the dental
  delivery system is in meeting the needs of all
  Americans.

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Percent of US School Children With Untreated
Tooth Decay Has Been Declining but the Newest
Survey Shows a Significant and Worrisome Increase
for Preschool Children
Meeting the Needs of the Population
NCHS, 2003 2007
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Unmet Treatment Need in Adults, by Race
Meeting the Needs of the Population
D/DMFT, Age 20-64
NCHS, 2007
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Delayed Dental Care in Adults, by Number of Risk
Factors
Meeting the Needs of the Population

• Access to care risk factors
• Race
• Ethnicity
• Income
• Insurance
• Regular source of care

Shi, et al. J Gen Intern Med 2005.
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Less than One-Half of Children Receive Preventive
Services in the U.S.
Meeting the Needs of the Population
Preventive Dental Services include general
exams/check-up, cleaning, polishing, x-rays,
bitewings, fluoride treatment, and sealants.
National Institute of Dental and Craniofacial
Research, 2002.
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Percent of Persons accessing Dental Care within
One Year, by Years of Education (1999-2004)
Meeting the Needs of the Population
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Percent of Persons accessing Dental Care within
One Year by Assessed Health Status (1989)
Meeting the Needs of the Population
Differences are correct absolute values inflated
in this survey
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Workforce Balance

• Learning Objectives
• Be able to discuss the importance of a workforce
  balance.
• Identify trends of dental supply, demand and need.

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Workforce Balance
Need
Demand
Productivity
Population Growth
Insurance
Safety Net
Supply
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Selected National Dentist Trends
Workforce Balance

• 12 decline in dentists per capita (1986-1996)
• Increase in percent female (more part-time)
• Leveling of female in dental school
• WA dentist graduating numbers flat
• 9 increase in dental hygienists
• 8.8 of dentists are minorities

Dental enrollment will increase by at least 10
during the next few years because of RIDE.
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Selected National Dentist Trends
Workforce Balance

• 12 decline in dentists per capita (1986-1996)
• Increase in percent female (more part-time)
• Leveling of female in dental school
• 9 increase in dental hygienists
• 11.5 of U.S. dentists are minorities
• (compared to 27.3 of the population)

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1986-1996 Change in Dental Workforce Graduates
per 100K Population
Workforce Balance
WA is 14th in dentists, 11th in hygienists, and
2nd in DAs per capita in the US.
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Washington Dentist Findings
Workforce Balance

• Work hours same as nationally
• Older than nationally
• Half reported retirement by 2013
• Relatively fewer dentists in rural places
• Volume limited by lack of hygienists

2001 Survey of Washington Dentists, Gary Hart
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Proportion of Rural Counties in the US without a
dentist in 1990
Workforce Balance

• Northeast 9.1
• Midwest 31.3
• South 46.3
• West 37.7

More than 1,000 counties in the US have been
defined as dentist shortage areas
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Rural Counties in the US without a Dentist (2000)
Workforce Balance
WWAMI Rural Health Research Center, 2003
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Financing

• Learning Objective
• To understand how sources of payment for dental
  treatment contribute to access to care.

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Adult Funding by Age and Source (2000)
Financing
Medical Expenditure Panel Survey
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Adult Funding by Income and Source (2000)
Financing
Medical Expenditure Panel Survey
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Adults with Dental Insurance by Ethnicity (1997)
Financing
1997 BRFSS (CDC)
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Adults with Dental Insurance, by Income (1997)
Financing
1997 BRFSS (CDC)
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Impact of Insurance on Access, by Income (1996)
Financing
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Oral Health Disparities in Washington State

• Learning Objectives
• To recognize and understand the discussed issues
  in regard to Washington State.

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The Smile Survey
Oral Health Disparities in Washington State

• Began in Washington State in 1996. Subsequent
  surveys were conducted in 2000 and 2005.
• Administered by counties.
• Provides oral health data for policy makers.
• Nationally known as the Basic Screening Survey
  for oral health
• Recommended by CDC and ASTDD to all states (33
  currently administer the Smile survey).
• Link to Washingtons 2005 Smile Survey Summary

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Percent of Washington Head Start Children with
Untreated Tooth Decay, by Race
Oral Health Disparities in Washington State
1995 2005 Washington Smile Surveys
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Treatment Needs among 3rd Grade Students (2005)
Oral Health Disparities in Washington State

• Percent with untreated decay 19
• Percent without sealants 50

Washington Smile Survey, 2005.
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Percent of Medicaid-Enrolled Children Who
Received Dental Services By County, 2000
Oral Health Disparities in Washington State
2000 Washington Smile Survey
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Percent of Adults accessing Dental Care within
One Year by Income Status (1999 2004)
Oral Health Disparities in Washington State
BRFSS
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Percent of Adults accessing Dental Care within
One Year by Race (1999 2004)
Oral Health Disparities in Washington State
BRFSS
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Percent of Adults accessing Dental Care within
One Year by Education (1999 2004)
Oral Health Disparities in Washington State
BRFSS
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Health Care Providers per 100K Population,Percent
Change 1990-2000
Oral Health Disparities in Washington State
WAMMI Rural Health Research Center
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Ethnicity of Dentists and General Population in
Washington State
Oral Health Disparities in Washington State
Tomar, 2004. Assessment of the Dental Public
Health Infrastructure in the United States.
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National Oral Health Goals

• Learning Objective
• To recognize US goals for improving oral health.

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Healthy People 2010
National Oral Health Goals

• National Health Objectives devised in order to
• Identify the most significant preventable threats
  to health
• Establish national goals to reduce these threats
• Oral Health Objectives
• Prevent and control oral and craniofacial
  diseases, conditions, and injuries and improve
  access to related services.
• What is Healthy People (HP) 2010?
• A public health document that is part strategic
  plan, part textbook on public health priorities
• A comprehensive set of national health objectives
  for the decade, designed to measure progress over
  time
• Who sets the HP 2010 goals?
• Developed by a collaborative process
• Coordinated by the Office of Disease Prevention
  and Health Promotion (U.S. Department of Health
  and Human Services)

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Healthy People 2010
National Oral Health Goals

• Required Reading HP 2010 Slideshow
  (http//www.healthypeople.gov/About/Slideshow_May_
  2001_files/v3_document.htm)
• Official Website www.healthypeople.gov

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Progress toward HP 2010 GoalsAdolescents Who
Ever Had Caries in Permanent Teeth
National Oral Health Goals
Percent
1988-94
1999-2000
2010 Target
Mexican American
Black
White
Total
Male
Female
Obj. 21-1c Reduce the proportion of adolescents
with dental caries experience in their permanent
teeth to 51.
NHANES (NCHS)
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Progress toward HP 2010 GoalsChildren Who Have
Ever Had Caries in Primary Teeth
National Oral Health Goals
Percent
1988-94
1999-2000
2010 Target
2-4 years old
Total
Black
Mexican American
White
Male
Female
Obj. 21-1a Reduce the proportion of young
children with dental caries experience in their
primary teeth to 11.
NHANES (NCHS)
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Annual Dental Visits for Personswith and without
Diabetes, 2002
National Oral Health Goals
Percent
Persons with diabetes
Persons without diabetes
2010 Target
Rural
Urban
Total
Black
Hispanic
White
100-199
gt200
lt100
Race/ethnicity
Urbanicity
Poverty level ()
Obj. 5-15 Increase the proportion of persons
with diabetes who have at least an annual dental
examination
Source National Health Interview Survey, NCHS,
CDC.
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Annual Dental Visits for Personswith and without
Diabetes 1997-2002
National Oral Health Goals
Percent
2010 Target
80
Persons without diabetes
60
Persons with diabetes
40
20
0
1997
1999
2000
2001
1998
2002
Obj. 5-15 Increase the proportion of persons
with diabetes who have at least an annual dental
examination
Source National Health Interview Survey, NCHS,
CDC.
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Link to the Self-Assessment

• To receive credit for this assignment, please
  complete the self-assessment. Paste the link to
  the assessment below in your web browser. Your
  record will automatically sent to the course
  director. Let us know if you encounter
  difficulty.
• URL https//catalysttools.washington.edu/survey/
  dfrc/41106