# Presentation: 505500

## Measuring the Oral Health of Washington’s ChildrenChallenges and Practical Solutions

## Beth Hines, RDH,MPHWashington State Department of HealthJune 28, 2000

## Outline

- Challenges and Practical Solutions
- Tools for ***direct ***primary data collection
- Smile Survey 1994 and 2000

**Notes:**
Washington is among many states that have struggled with the challenges presented by the need to collect data on the oral health of children.  This presentation is specific to primary data collection.  Secondary data including information about access to dental care, demographics, Medicaid utilization and other indicators will not be covered.

## Tools for indirect primary data collection:
Lead Poisoning Prevalence Survey
PRAMS
Disability Survey

- Lead Poisoning Prevalence Survey
- PRAMS
- Disability Survey

## Challenges

- HP 2010 Objectives
- MCH Block Grant Indicator on Sealants

**Notes:**
The challenges are many.  The Healthy People 2010 objectives include 17 oral health indicators aimed at preventing and controlling oral and craniofacial diseases, conditions and injuries and improve access to related services.
We in Maternal and Child Health concentrate on those that influence children.  But parents’ health, attitudes and behavior influence children don’t they?  That extends our thinking about need for data.
The MCH Block requires that we report data on the number of children who have sealants at age 8 on an annual basis.
In order to do this, a state must have the resources to provide training, materials, staff, a direct in-mouth screening survey of a representative population each year.

## Oral Health surveys are:
time intensive
staff intensive
expensive

- time intensive
- staff intensive
- expensive

## Practical Solutions

- Screening versus examination
-  Screening models:
- Smile Survey 1994
- BSS and STP 2000

**Notes:**
Facing the challenge of implementing an in-mouth oral health screening survey to produce data that is useful can be daunting - particularly to states with small or focused oral health programs such as Washington State.
When faced with this situation in 1993, I contracted with Dr. Kathy Phipps, an epidemiologist with experience in conducting surveys.  We began by asking one question, “ Why do we need data” and secondly, “ What will we do with it?”  We determined that program planning and increasing awareness of need were our goals for data collection.
We collected secondary data and presented a plan for targeting the survey to that population that national and regional NHANES identified as high risk - those with low SES, minorities and residing in areas with low access to dental care.
Then, we determined that tooth surface data was not relevant to our goals.  We wanted to know about kids and teeth.  We wanted to know who needed our services.  We also wanted to be able to inform the public an policy makers about the needs of our at risk children.  Those20% who are know to have 80% of dental disease.
We screened visible decay, need for treatment, presence of sealants as well as the use of English as a second language.
This became the first Smile Survey...not an NIDCR research survey but a practical model for state based and community based data collection.

The Surgeon General reminds us that oral health is not only part of general health but has a real influence on health outcomes.  Thinking about tieing data collection to other health surveys may be more possible in the future.

## Piggybacking on other surveys:
Lead
PRAMS
Disability

- Lead
- PRAMS
- Disability

## Smile Survey 1994

- 10 Counties

**Notes:**
Secondary data was collected and a report was published giving us a base from which to draw a sample.
10 counties were chosen based on their profile as having a large populations of low income and minorities.  They were also selected based on an access to dental care criteria that included dentist/client ratios and number of Medicaid dental provider/client ratios.
The sample also included representation from 3 regions in the state: coastal, I-5 and eastern as well as urban and rural.
It was an oversample of high risk children

## Smile Survey 1994

- Random selection of schools in targeted high risk counties w/ urban & rural rep.
- 6,590 children screened
- 6,399 sample analyzed

**Notes:**
The sample included a total of 6,590 children:
the age cohorts included:
1,063 Headstart and Early Childhood Education and Assistance Program ECEAP
4,635 Elementary students in second grade
701 High School students age14-16

## 1,063 Headstart and ECEAP (mean age 4.3)
4,635 Elementary School (mean age 6.9)
701    High School ( mean age 15.1)

- 4,635 Elementary School (mean age 6.9)
- 701    High School ( mean age 15.1)

## Headstart Kids% Needing Treatment

**Notes:**
38% of Hispanic Headstart kids needed restorative dental treatment.
 Almost 36% of Asian and30% of American Indian kids needed fillings.

Urgent treatment for visible abscessed teeth was needed by 23 % of the American Indian kids.  

Overall, over 7% of these kids had abscesses requiring urgent dental treatment.

## Age 6-8% Needing Treatment

**Notes:**
The second grade children looked much like the rest of US children regarding having experienced tooth decay, fillings or missing teeth.

The disparities in this age group became apparent however.

40% of American Indian children in second grade needed restorative dental treatment.
Over 34% of Hispanic kids also needed to see a dentist for treatment.

The urgent needs of this age group were not as serious as those of the Headstart population.

## Percent with Sealants / Ages 6-8

**Notes:**
We were able to tell the MCH Bureau in our grant application for 1995, that in 1994, only 19.2% of children in second grade had sealants on one or more permanent molar teeth.

A survey of third grade children implemented by the University of Washington found that by third grade around 30% of our kids had dental sealants.

## Smile Survey 2000

- Washington State
- Assessment of Children’s
- Oral Health Status

**Notes:**
Five years later, we are fortunate to be able to do another Smile Survey.  We were able to do this because of state funds that were allocated to our program following a legislative committee recommendation addressing the lack of access to dental care for children in the state.

In 1994, the first Smile Survey cost approximately  $50,000.
The Smile Survey 2000 will cost about $100,000. We’ve doubled our costs in five years time.

## Sampling

- Random sample of  elementary schools w/ 25 or more in 2nd & 3rd grades
- 7960 children in 56 schools
- Convenience sample of 12 Headstart/ECEAP and Early Headstart

**Notes:**
This is a random sample of all public elementary schools including all grades 2 and 3 in selected schools.
It provides a convenience sample of Headstart/ECEAP and Early Headstart

and follows the protocol established by the ASTDD/CDC 
STP and Basic Screening Survey.

Also provided is training and technical assistance to counties that are able to conduct community-based Smile Surveys using the basic screening tools.

## Protocol

- Smile Survey
- ASTDD/CDC
- STP - BSS Basic Screening Survey
- County Based Tools
- Training and Calibration

## Access to Care Questions

- Parent questionnaire
- dental insurance
- time since last dental visit
- reason for last dental visit
- problems accessing dental care

**Notes:**
The questionnaire include items regarding access to care.  These are patterned after the BRFSS survey.

## ESL

- ask elementary school children - *What language does your family speak at home?*
- ask Early/Head Start teacher -* What language does this child’s family speak at home?*

**Notes:**
Unique to our Smile Survey in both 1994 and 2000 is a question we are testing and intend to follow up on regarding the child’s family’s use of language.

We ask: 
“What language do you speak at home?”

We are using this indicator to give us information on immigrant status as well as information pertinent to program planning of promotional materials etc.

In 1994, we were able to associate higher disease rates to children of families who do not speak English at home.

## School children
Count number of primary & permanent teeth with cavities
Range: 0-24	
If a child has 5 cavities

- Count number of primary & permanent teeth with cavities
- Range: 0-24
- If a child has 5 cavities

- Coding for Untreated Cavities

**Notes:**
Epi Info is the program used for data entry.

Data is either recorded on hard copy or may be entered on a lap top computer.

It is incredibly simple, with mechanisms to prevent usual entry errors built in.

Dr. Phipps facilitated training for all screeners as well as for oral health coordinators at local health jurisdictions.

## Lead Poisoning Prevalence Survey

- And Oral Health Assessment Survey

**Notes:**
The indirect method for collecting useful data is by 
Piggy backing onto another survey.

In this case, we were able to partner with the Lead Poisoning Prevalence Survey.

We were able to offer support for the lead survey by soliciting support from CDC for the oral health data collection.  We also provided materials for the infection control necessary for the blood stick procedure.  
We were required to be approved by Human Subjects Review for this survey because of client identification and follow up.  We provided assistance to families with children identified as needing urgent dental treatment.

## Sampling

- Age cohort: age 1-2 years
- Stratified random sample of birth certificates

**Notes:**
Of great importance to us, is the ability to survey children for early caries at age1-2.
The advantages of being included in a random sample of  a population  from birth certificates are amazing to say the least.
This survey enables us to look in the mouths of very young children and associated findings with demographic and health information on the mothers.
It also oversamples Hispanics which is an identified high risk group for dental disease.

## 2 strata by census tract:

high risk: 9 counties (high Hispanic pop) N:540
low risk: remaining  30 counties N: 360
oversample Hispanics and children of farmworkers 

- high risk: 9 counties (high Hispanic pop) N:540
- low risk: remaining  30 counties N: 360
- oversample Hispanics and children of farmworkers

## Methodology

- Questionnaire / Demographics , Access, Risk for lead exposure, Injury prevention
- Finger Stick - blood sample

**Notes:**
The survey teams were composed of a nurse and a health assistant.
Each child received a finger stick for blood lead analysis and a dental screening for early caries.

Visible ‘frank’ caries were noted.  White spot lesions were determined to be too difficult for the screeners to detect in this situation.

A pipette was used to draw a sample of saliva to be analyzed for Strep Mutans.

A sample of water was taken from the tap for fluoride analysis.

## Dental Exam / Visible Caries

Saliva Sample / Strep Mutans Count

Water Sample / Fluoride Content

- Saliva Sample / Strep Mutans Count
- Water Sample / Fluoride Content

## Statewide estimate of Early Childhood Caries

Relationship between blood lead levels and caries

- Relationship between blood lead levels and caries

- Purpose:

**Notes:**
The primary purpose of this survey for oral health is to
provide a statewide estimate of early childhood caries

Second, we want to see if there is an association between high blood lead levels and caries.  It appears that the number with high levels will be too low to provide significant data.

We will also attempt to provide information on risk factors for early childhood caries by association with:
Strep Mutans
Fluoride exposure
Feeding patterns
Variables associated with the birth.

## Purpose

- Potential risk factors for caries:
- Strep Mutans levels
- Fluoride exposure
- Feeding patterns
- Variables associated with birth mother

## PRAMSPregnancy Risk Assessment Monitoring System

- And Oral Health...

**Notes:**
Another piggyback that the CDC has approved is the inclusion of oral health questions in the Pregnancy Risk Assessment Monitoring System or PRAMS survey.

I have been trying to become a part of this survey since it’s inception and am thrilled that oral health is now included.

Perhaps the associations being drawn between preterm low birth weight babies and the mother’s state of oral health influenced this decision.

## 1. This question is about the care of your teeth during your most recent pregnancy.

I needed to see a dentist for a problem  Y/N

- I needed to see a dentist for a problem  Y/N

**Notes:**
There are two questions approved for inclusion in PRAMS

## I went to a dentist or dental clinic Y/N

A dental or other health care worker talked with me about how to care for my teeth and gums Y/N

- A dental or other health care worker talked with me about how to care for my teeth and gums Y/N

## 2. How long has it been since you had your teeth cleaned by a dentist or a dental hygienist?

			______ Months

- 			______ Months

**Notes:**
I would like to see question that asks about the present state of the mother’s oral health...one that refers to decayed teeth and gum problems like bleeding or soreness etc.

## Washington StateDisability Surveillance Survey

- And Oral Health....

**Notes:**
The Washington State Disability Surveillance Survey is supported by a grant from the CDC.

We are being included for the first time in 2000

## How long has it been since your child with disabilities last visited the dentist or a dental clinic?

**Notes:**
The oral health module includes four questions that are patterned after BRFSS oral health questions and tailored to children with disabilities.

## What is the reason you have taken your child to the dentist in the last year?

Does your child have untreated tooth decay or gum disease?

- Does your child have untreated tooth decay or gum disease?

## 
Do you have any kind of insurance coverage that pays for some or all of your routine dental care, including dental insurance, prepaid plans such as HMOs, or government plans such as Medicaid?

- Do you have any kind of insurance coverage that pays for some or all of your routine dental care, including dental insurance, prepaid plans such as HMOs, or government plans such as Medicaid?

**Notes:**
The oral health module includes four questions that are patterned after BRFSS oral health questions and tailored to children with disabilities.

## Assessment

- must
- be
- a
- priority

**Notes:**
It is challenging to collect relevant and current data on the oral health needs of children in the state.
It requires a healthy budget and a commitment to the needs assessment process.

Fortunately, the Office of Maternal and Child Health here in Washington is committed to evidenced and outcome based program planning for oral health.

I would encourage states to use the tools provided by ASTDD and CDC, including the STP/BSS model and the ASTDD Seven Step Model for Needs Assessment.  The groundwork has been done.  The process has been simplified and the practical solutions are within our reach.

Thank You.