DSHS Grand Rounds Its Hard to Make As with a Toothache: Oral Health - - PowerPoint PPT Presentation

DSHS Grand Rounds

DSHS Grand Rounds It’s Hard to Make A’s with a Toothache: Oral Health Status of Texas Elementary Students

Rhonda Stokley, DDS State Public Health Dental Director DSHS

It’s Hard to Make A’s with a Toothache: Oral Health Status of Texas Elementary Students

Learning Objectives

• 1. Describe the impact of tooth decay on a child’s ability to learn.
• 2. Compare the oral health status of younger and older Texas

elementary school students.

• 3. Describe how the oral health status of Texas children compares

to Healthy People 2020 objectives and targets.

10/28/2019 3

It’s Hard to Make A’s with a Toothache: Oral Health Status of Texas Elementary Students

• Tooth Decay and its Impact on Learning
• Overview of Oral Health Improvement Program
• Kindergarten and Third Grade Oral Health Surveillance
• Healthy People 2020: Oral Health Targets
• Discussion
• Q&A

10/28/2019 4

What is tooth decay?

• Aka Dental Caries
• It is the destruction of tooth

enamel by acids produced by bacteria in your mouth

• Most common chronic

childhood disease¹

• Associated with diabetes,

heart disease, stroke and low birth weight babies²

1.Centers for Disease Control and Prevention (CDC). (2016, September 22). Hygiene-related Diseases: Dental Caries (Tooth Decay). Retrieved from https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html 2.Jackson, S. L., Vann, W. F., Kotch, J. B., Pahel, B. T., & Lee, J. Y. (2011). Impact of Poor Oral Health on Children’s School Attendance and

• Performance. American Journal of Public Health,101(10), 1900-1906. doi:10.2105/ajph.2010.200915

What causes tooth decay?

Carbohydrates Time Tooth Bacteria

CAVITY

What does tooth decay look like?

• Begins as white spots on

the enamel (reversible)

• Turns brown or black
• Can develop on the tongue

and cheek sides, chewing surfaces, and between teeth

• Dentists can detect early

decay before the patient feels them

Tooth Decay and Learning

• Children with poor oral health

are 1.4 times more likely to have poor school performance and 3 times more likely to miss school.1,2

• 12.6% of 8th and 11th graders

reported missing school, at least twice in the past year, because

• f a sore mouth or teeth 3
• 3.9% of 2nd graders missed

school at least twice for the same reason 3

• 1. Jackson, S. L., Vann, W. F., Kotch, J. B., Pahel, B. T., & Lee, J. Y. (2011). Impact of Poor Oral Health on Children’s School Attendance and Performance. American Journal of Public

Health,101(10), 1900-1906. doi:10.2105/ajph.2010.200915

• 2. Blumenshine, S. L., Vann, W. F., Gizlice, Z., & Lee, J. Y. (2008). Children’s School Performance: Impact of General and Oral Health. Journal of Public Health Dentistry,68(2), 82-87.

doi:10.1111/j.1752-7325.2007.00062.x

• 3. Oral Health in Texas Children and Adolescents: School Physical Activity and Nutrition Survey, 2015-2016. Data prepared by: DSHS, Maternal and Child Epidemiology Unit, Sept 2019.

Tooth Decay and Learning

• Poor nutrition from difficulty

eating and a lack of sleep contribute to an inability to focus and perform well in school.1,2

• At least twice in the past year,

23.3% of 4th graders had a sore mouth or teeth that made it hard to eat or chew 3

• Children with dental pain are

also more likely to feel worthless, unhappy, shy or embarrassed.4

• 1. Jackson, S. L., Vann, W. F., Kotch, J. B., Pahel, B. T., & Lee, J. Y. (2011). Impact of Poor Oral Health on Children’s School Attendance and Performance. American Journal of Public

Health,101(10), 1900-1906. doi:10.2105/ajph.2010.200915

• 2. Thikkurissy, S., DDS, MS, Glazer, K., DMD, MS, Amini, H., DDS, MS, MPH, Casamassimo, P. S., DDS, MS, & Rashid, R., DDS, MS. (2012). The Comparative Morbidities of Acute Dental Pain

and Acute Asthma on Quality of Life in Children. Pediatric Dentistry,34(4), E77-E80

• 3. Oral Health in Texas Children and Adolescents: School Physical Activity and Nutrition Survey, 2015-2016. Data prepared by DSHS, Maternal and Child Health Epidemiology Unit, Sept

2019.

• 4. Guarnizo-Herreño, C. C., & Wehby, G. L. (2012). Children’s Dental Health, School Performance, and Psychosocial Well-Being. The Journal of Pediatrics,161(6), 1153-1159.

doi:10.1016/j.jpeds.2012.05.025

This is 100% preventable!

What is DSHS doing to help?

Oral Health Improvement Program

• Part of Community Health

Improvement Division

• Surveillance, education,

prevention

• Priority populations:

children, infants and pregnant women

• Three major programs:
• Smiles in Schools
• Smiles for Moms and

Babies

• Oral Health by the

Numbers

Photo courtesy of Dr. Kimberly Melendez, DSHS Regional Dentist

OHIP: Smiles in Schools

• Screened 10,094 children

during FY19

• Contributed to another 7,152

through community collaborations

• Limited oral evaluations,

fluoride varnish, dental sealants, education

• Data collection (Oral Health

Basic Screening Survey)

• Collaborations with dental

schools, dental hygiene programs, nursing programs, community-based events, home visiting programs, etc.

Top: Cynthia King, Regional Dental Hygienist Bottom: Dr. Anita Albert, Regional Dentist

OHIP: Smiles for Moms and Babies

• Goals: Improved oral health for

pregnant women and first dental visit before age 1

• Training, resources and technical

assistance for home visiting programs

• Over 400 HVs trained to date
• Oral health videos, including newly-

released Baby Steps for Tiny Teeth in English and Spanish

• Oral Health Care During Pregnancy:

Practice Guidance for Texas Prenatal and Dental Providers, coming soon

OHIP: Oral Health by the Numbers

• Oral Health Basic Screening Survey data
• Analyze oral health data in other statewide surveys
• Add oral health questions to surveys
• Share data through presentations, data briefs, list serv,

Grand Rounds, etc.

Oral Health Basic Screening Survey (BSS)

• Developed by Association of State and Territorial Dental

Directors for uniform oral health data

• Statewide data that meets certain requirements is submitted

to the National Oral Health Surveillance System (NOHSS)

• 2 parts: parent questionnaire and direct observation of

child’s mouth

astdd.org/basic-screening-survey-tool/ Accessed 10/1/2019

Oral Health Basic Screening Survey (BSS)

Parent questionnaire:

• Demographics
• Type of dental insurance
• Free/Reduced School Lunch Program status
• Has your child ever been to the dentist for any reason?
• In the past 12 months, has your child seen a dentist for a

routine dental checkup?

astdd.org/basic-screening-survey-tool/ Accessed 10/1/2019

Oral Health Basic Screening Survey (BSS)

Direct observation:

• Untreated decay
• Treated decay
• Dental sealants on permanent first molars
• Urgency of need for dental care

astdd.org/basic-screening-survey-tool/ Accessed 10/1/2019

Oral Health Basic Screening Survey (BSS)

• OHIP enters data into Epi Info, developed by the Centers for

Disease Control (CDC) and the World Health Organization (WHO) http://wwwn.cdc.gov/epiinfo/

• Data quality:
• DSHS teams are calibrated
• Quality assurance measures built into database
• IRB-exempt: standard public health activity, not research
• Memorandums of Understanding with schools or school

districts

Oral Health Basic Screening Survey (BSS)

Sampling strategy:

• Probability proportional to size
• Stratified by geographic location
• Sorted by % of children eligible for free and reduced lunch

Study populations:

• Public elementary schoolchildren in kindergarten and third grade

Sampling frame:

• List of schools from Texas Education Agency

Time frame:

• 2017-2018 and 2018-2019 school years

Inclusion criteria:

• Parental consent
• Child’s willingness to participate
• Child being present on day of evaluation

Final data:

• Weighted to represent all public school kindergarten and third grade

children in Texas

BSS Results

Kindergarten Third Grade Sample size Sample size Participating Schools 139a 140 Class enrollment on screening day 13,687 14,191 Completed evaluations 4,722 4,630 Partial evaluations b 250 193 Returned consents c 4,972 (36.3%) 4,823 (34.0%) FRL status on day of screening d 2,278 (48.2%) 3,154 (68.1%)

a No consenting participants in one school (n=8); b Partials include absentees; c Includes positive consents

• nly; d Free/Reduced Lunch (FRL) status is self-reported

Source: DSHS MCH Epi Unit

Oral Health BSS: Results

• 10.7% had never seen a

dentist for any reason

• Almost 20% had no dental

coverage

• Compared to white non-

Hispanic children, those identified as Hispanic were 60% more likely to have a history of tooth decay, regardless of grade

• Nearly 25% did not have a

routine dental check-up in the past year

Source: DSHS MCH Epi Unit

Oral Health BSS: Results

• Regardless of grade, almost

20% of young children had untreated tooth decay

• More than 50% of young

children had a history of tooth decay

• Kindergarteners and third

graders of race/ethnicities

• ther than white has

significantly higher odds of untreated tooth decay than white children.

Source: DSHS MCH Epi Unit

Oral Health BSS: Results

• 36.0% of kindergarteners

have Medicaid dental coverage compared to 33.6% of third graders

• There is no significant

difference in Medicaid status between grade levels

• Chi-square, p=0.3

36.0 33.6 64.0 66.4 10 20 30 40 50 60 70 Kindergarten (SFY 19) 3rd Grade (SFY 18) Percent of Children

Percent of Public Schoolchildren in Texas, by Grade and Medicaid Status

Medicaid Dental Coverage No Medicaid Dental Coverage BSS: Basic Screening Survey SFY: State Fiscal Year Source: DSHS MCH Epi Unit

31.7 36.3 45.2 43.8 22.6 19.4 5 10 15 20 25 30 35 40 45 50 Kindergarten (SFY19) 3rd Grade (SFY18) Percent of Cildren

Percent of Public Schoolchildren in Texas, by Grade and Type of Dental Coverage

Private Dental Coverage Public Dental Coverage No Dental Coverage

*Relative Standard Error (RSE) for Multiple Coverage >30%; estimate not shown. There is no significant difference in the type of dental coverage between grade level, Chi-square, p=0.1.

Source: DSHS MCH Epi Unit

84.9 93.5 15.1 6.5 10 20 30 40 50 60 70 80 90 100 Kindergarten 3rd Grade Percent of Children

Percent of Public Schoolchildren in Texas, by Grade and Overall Dental Utilization

Ever Seen a Dentist Never Seen a Dentist

• A significant difference in

total dental utilization between grade levels

• Chi-square, p≤0.0001
• Kindergarteners are

significantly more likely to have never seen a dentist compared to third graders

BSS: Basic Screening Survey SFY: State Fiscal Year Source: DSHS MCH Epi Unit

• Over one-fifth of public

schoolchildren in Texas, regardless of grade, did not use the dental system for preventive care in the past year

• There is no significant

difference in dental utilization in the past year between grade levels

• Chi-square, p=0.2

78.0 75.1 22.0 24.9 10 20 30 40 50 60 70 80 90 Kindergarten (SFY19) 3rd Grade (SFY18) Percent of Cildren

Percent of Public Schoolchildren in Texas, by Grade and Routine Dental Visit in the Past Year

Dental Visit No Dental Visit BSS: Basic Screening Survey SFY: State Fiscal Year Source: DSHS MCH Epi Unit

52.9 67.1 47.1 32.9 10 20 30 40 50 60 70 80 Kindergarten (SFY19) 3rd Grade (SFY18) Percent of Children

Percent of Public Schoolchildren in Texas, by Grade and History of Tooth Decay

History of Tooth Decay No History of Tooth Decay

• History of tooth decay

affects nearly 53% of kindergarteners compared to 67.1% of third graders

• There is a significant

difference in history of tooth decay between grade levels

• Chi-square, p≤0.0001

BSS: Basic Screening Survey SFY: State Fiscal Year Source: DSHS MCH Epi Unit

19.7 17.5 80.3 82.5 10 20 30 40 50 60 70 80 90 Kindergarten (SFY19) 3rd Grade (SFY18) Percent of Children

Percent of Public Schoolchildren in Texas, by Grade and Untreated Tooth Decay

Untreated Decay No Untreated Decay

• Nearly 20% of kindergarten

children and almost 18% of third grade children have untreated tooth decay in Texas

• There is no significant

difference in untreated decay between grade levels

• Chi-square, p=0.1

BSS: Basic Screening Survey SFY: State Fiscal Year Source: DSHS MCH Epi Unit

• There is a significant

difference in past treatment between grade levels

• Chi-square, p≤0.0001
• In this population, it

appears that treated decay contributes more to the history of decay than current untreated decay

41.0 59.4 59.0 40.6 10 20 30 40 50 60 70 Kindergarten (SFY19) 3rd Grade (SFY18) Percent of Children

Percent of Public Schoolchildren in Texas, by Grade and Past Treatment

Past Treatment No Past Treatment BSS: Basic Screening Survey SFY: State Fiscal Year Source: DSHS MCH Epi Unit

Early vs Urgent Treatment Need

• Urgent Need:
• See a dentist as soon as

possible

• Signs/symptoms include

pain, swelling, or infection

• Early Need:
• See a dentist within

several weeks

• Caries without

accompanying signs or symptoms

• No obvious problem:
• See dentist at next regular

checkup

astdd.org/basic-screening-survey-tool/ Accessed 10/1/2019

80.8 82.7 17.7 14.2 1.5 3.1 10 20 30 40 50 60 70 80 90 Kindergarten (SFY19) 3rd Grade (SFY18) Percent of Cildren

Percent of Public Schoolchildren in Texas, by Grade and Treatment Need

No Treatment Need Early Treatment Need Urgent Treatment Need

There is a significant difference in early and urgent treatment need between grade levels, Chi-square p≤0.0001

Source: DSHS MCH Epi Unit

Discussion: Healthy People 2020

https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health, retrieved 9/25/2019

• Set of 10-year national objectives and targets developed by

US Health and Human Services

• Healthy People 2030 is being developed now
• History of tooth decay (3-5 yrs and 6-9 yrs)
• Untreated tooth decay (3-5 yrs and 6-9 yrs)
• Dental sealants on permanent molars (6-9 yrs)

Comparison of Texas to Healthy People 2020 Targets

2017-2019 National Targets Target Met?

Percent of children aged 3 to 5 years with history

• f tooth decay

52.9% 30.0% No Percent of children aged 6 to 9 years with history

• f tooth decay

67.1% 49.0% No Percent of children aged 3 to 5 years with untreated tooth decay 19.7% 21.4% Yes Percent of children aged 6 to 9 years with untreated tooth decay 17.5% 25.9% Yes Percent of children aged 6 to 9 years with at least

• ne dental sealant on a

permanent first molar tooth 41.4% 28.1% Yes

Source: DSHS MCH Epi Unit

Discussion: What are our take home messages?

• 1. Children with poor oral health are at a disadvantage in

school, and it’s a big problem.

• 2. The best way to prevent dental pain and infection is to

prevent tooth decay in the first place.

• Remember:
• Over half of Texas children have experienced tooth decay

by kindergarten.

• Tooth decay experience increases significantly from

kindergarten to third grade.

• Tooth decay is preventable, not inevitable.

Children need early and continued intervention to prevent tooth decay.

(How early?)

Improve the Oral Health of Pregnant Women

In 2016, only 32.8% of Texas women had their teeth cleaned during their most recent pregnancy.¹ Oral disease-causing bacteria are transmitted vertically from mother to child 2,3 Pregnancy is a good time to improve oral health literacy

1 Teeth Cleaning During Pregnancy in Texas: PRAMS 2012-2016. Prepared by DSHS Maternal and Child Epidemiology Unit, Feb 2019. 2 Kishi M, Abe A, Kishi K, Ohara-Nemoto Y, Kimura S, Yonemitsu M. Relationship of quantitative salivary levels of Streptococcus mutans and S. sobrinus in mothers to

caries status and colonization of mutans streptococci in plaque in their 2.5-year-old children. Community Dent Oral Epidemiol. 2009;37:241–249. doi: 10.1111/j.1600-0528.2009.00472.x. [PubMed] [CrossRef] [Google Scholar]

3 Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatr Dent. 2006;28:106–109. [PubMed] [Google Scholar]

Dental care is safe, important, and recommended for pregnant women

Oral Health Care During Pregnancy Expert Workgroup. 2012. Oral Health Care During Pregnancy: A National Consensus

• Statement. Washington, DC: National Maternal and Child Oral Health Resource Center.

Babies Need a Dental Home

• Baby to dentist before age 1
• THSteps begins coverage at 6

months old

• Fluoride varnish
• Dental sealants
• According to the CDC, sealants

protect against 80% of cavities for two years and continue to protect against 50% of cavities for up to four years.1

• Routine dental checkups

1 Centers for Disease Control and Prevention. (2019). Dental Sealants. Retrieved from: https://www.cdc.gov/oralhealth/dental_sealant_program/index.htm

Early and Continued Intervention: Who should help?

• Dental providers
• Medical providers, especially

prenatal and pediatric

• Nurses, especially school nurses
• Frontline health workers like

WIC, home visitors, community health workers and promotoras

• Health and phys ed teachers
• Health advocates
• Parents

How do I learn more about oral health in Texas?

• www.dshs.texas.gov/dental
• Subscribe for updates (lower

right corner of home page)

• Under Department of State

Health Services, Health and Wellness, select “DSHS Oral Health”

• Contact us at

dental@dshs.texas.gov

How do I learn more about Smiles in Schools?

• https://www.dshs.texas.gov/dental/School-based-clinics.aspx
• Or from home page, select “Smiles in Schools”
• Special section, “School Nurses and Administrators”
• New video about Smiles in Schools, coming soon

Special thanks to the following for the data shared today:

DSHS Central Office Debra Saxton, MS Jesse Jordan DSHS Regional Dental Teams Anita Albert, DDS Diana Beeman, RDH Rick Howard, DDS Teresa Hubbell, RDH Cynthia King, RDH Sondra McDonald, RDH Kim Melendez, DDS Matt Williams, DMD Shenice Williams, DDS

Peer-reviewed Articles

Agaku IT, Olutola BG, Adisa AO, Obadan EM, Vardavas CI. Association between unmet dental needs and school absenteeism because of illness or injury among U.S. school children and adolescents aged 6-17 years, 2011-2012. Prev Med. 2015 Mar;72:83-8. Detty AM, Oza-Frank R. Oral health status and academic performance among Ohio third-graders, 2009-2010. J Public Health

• Dent. 2014 Fall;74(4):336-42.

Niederman R, Huang SS, Trescher AL, Listl S. Getting the Incentives Right: Improving Oral Health Equity With Universal School-Based Caries Prevention. Am J Public Health. 2017 May;107(S1):S50-S55. Seirawan H, Faust S, Mulligan R. The impact of oral health on the academic performance of disadvantaged children. Am J Public

• Health. 2012 Sep;102(9):1729-34.

Suggested Readings

• U.S. Department of Health and Human Services. Oral Health in

America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. (A new report is in development.)

• Otto, Mary (2016).Teeth: The Story of Beauty,

Inequality, and the Struggle for Oral Health in America. New York NY: The New Press.

Thank you for your interest in oral health!

Rhonda Stokley, DDS

Rhonda.Stokley@dshs.texas.gov