MINNESOTASTATE ORALHEALTH PLAN
2020-2030

Building Collaboration
for Collective Action

Contents
Contents  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2Message from the Commissioner of Minnesota Department of Health  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4Contact Information .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5Introduction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6Acknowledgments  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7Honoring an oral health champion: Dr . Amos S . Deinard Jr .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 8Executive Summary  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 9What we know  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10
What we have achieved so far  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10
Our work for the next decade  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
Oral health is intrinsic to overall health  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .13Disparities in Minnesota compound the burden of oral disease .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14
How disparity in oral health shows up in populations  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .15Barriers to optimal oral health .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .17Making inroads to optimal oral health .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .19Reflecting on work since Minnesota’s first State Oral Health Plan  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20
Achievements since the first State Oral Health Plan in Minnesota .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .21Evaluation of Minnesota’s first State Oral Health Plan  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 23
Minnesota State Oral Health Plan for 2020–2030 .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
Framework and structure  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 26
Best practices  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 27
How strategies are organized in the Minnesota State Oral Health Plan  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 28
FOCUS AREA 1: Oral Health Infrastructure  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
Best practices  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 30
Strategy actions for Focus Area 1: Oral Health Infrastructure  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .31FOCUS AREA 2: Access to Oral Health  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 34
Best practices  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 36
Strategy actions for Focus Area 2: Access to Oral Health  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 37
FOCUS AREA 3: Health Systems Integration  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40
Best practices  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 41
Strategy actions for Focus Area 3: Health Systems Integration  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 42
FOCUS AREA 4: Disability, Special Care Needs, and Inclusion  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 46
Best practices  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 49
Strategy actions for Focus Area 4: Disability, Special Care Needs, and Inclusion  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 44
FOCUS AREA 5: Data  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .51Best practices  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 52
Strategy actions for Focus Area 5: Data  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 48
Future Directions  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 55
How to move forward .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 57
Outcomes  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 57
Citation References  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 58
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Contents (continued…)
Reference Page  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 59
Appendix  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .61Medicaid Barriers  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 62
Strategies Specific to Minnesota Health Care Programs (MHCP)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 63
Focus Area 5: Additional Strategies and Activities  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 66
Emerging findings from community input on Minnesota oral health strategic planning (full summary) .  .  .  .  .  .  . 68
Healthy Teeth . Healthy Baby .: Minnesota’s Legislative Commitment to Prevent Early Disease  .  .  .  .  .  .  .  .  .  .  .  . 73
Healthy Teeth . Healthy Baby .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 74
Healthy Aging Includes a Healthy Mouth: Minnesota’s First Basic Screening Survey for Older Adults  .  .  .  .  .  . 75
Collaboration + Relationship Building: Cornerstones of Dental Sealant Program Expansion  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 76
Models of Collaboration Minnesota  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 77
Survey Results . Dental Hygienists at Work: Collaborative Agreements  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 78

3

Protecting, Maintaining and Improving the Health of All Minnesotans

Dear Minnesotans,
The last year has been unprecedented. COVID-19 has impacted every aspect of our lives as we re-imagined
life events and mourn loved ones lost. The impacts of the individual, community, and statewide sacrifices
made in response to this global pandemic will reach far into the future. This includes the not-yet-known
long term health burden of COVID-19 recovery. Dental professionals are among those who have made great
sacrifices and are an example of rising to meet the challenge of care delivery in this “new normal.”
Oral health disparities in Minnesota are well known and have existed for many years. The pandemic has
served to magnify disparities and inequalities of all types, including oral health. It has also served to increase
need, as many more Minnesotans find themselves facing new or heightened economic burden directly linked
to the pandemic. It is noted here that solving the dental access problem is not simple or easy. Many havebeen working to address oral health disparities for years. It takes intentional, concerted work by all of us.
I am encouraged by the successes Minnesota’s network of dental providers has achieved since the last State
Oral Health Plan. These partners work tirelessly to address the unmet dental needs and improve access todental health care services. They cannot do it on their own. Today’s call to action asks each of us to play a rolein systems improvement towards oral health care access for every Minnesotan.
It is with pleasure and hope that I present Minnesota’s 2020-2030 State Oral Health plan. The Plan outlines
strategies and goals for our state to advance oral health equity, increase access to care, prevent dental
disease and improve overall oral health for Minnesotans. It includes five key focus areas:•

Oral Health Infrastructure•

Access to Oral Health Care•

Health Systems Integration•

Disability, Special Care Needs, and Inclusion

•

Data

As we rebuild from the devastation of the COVID-19 pandemic, I am hopeful that this plan will act as acatalyst for positive change, healing, and growth. I encourage you to commit to partnership and advancing
this work so we can create a community that protects, maintains and improves health for all.
Sincerely,

Jan K. Malcolm
Commissioner
P.O. Box 64975
St. Paul, MN 55164-0975
www.health.state.mn.us
An equal opportunity employer.

4

Contact Information
Prasida Khanal, B.D.S., M.P.H.
State Oral Health Director
Oral Health Program
Minnesota Department of Health651-201-3538
prasida .khanal@state .mn .us
Linda Maytan, D.D.S., M.P.H.
Dental Policy Director
Minnesota Department of Human Services
651-431-3314
linda .m .maytan@state .mn .us
Oral Health Program
PO Box 64882
85 E . Seventh Place
St . Paul, MN 55164-0882
651-201-3749
health .oral@state .mn .us
www .health .state .mn .us/oralhealthINTRODUCTION

Acknowledgments
We would not be able to publish this document without the tremendous support ofdiverse state agencies, associations, boards, medical-dental partners, stakeholders
and community members. Thank you to the following partners who spearheaded
stakeholder engagement to inform the Minnesota State Oral Health Plan for
2020–2030:

D E N TA L S E R V I C E S A DV I S O R Y CO M M I T T E E“In 2018, the Dental Services Advisory Committee (DSAC)1 provided intensive input into thedevelopment of this Plan . DSAC is comprised of dental and public health professionals and consumers
from across Minnesota . These oral health specialists encounter the real challenges facing Minnesotans
to access oral health care through their fieldwork . The combined experience and expertise of DSAC
members and participants informed the creation and development of this Minnesota Oral Health Plan
for 2020-2030 . The DSAC supports and endorses this Plan .”—Sheila Riggs, D.D.S., M.S., DMSc, Chair of DSAC
M I N N E S OTA O R A L H E A LT H C OA L I T I O N (M O H C)

“The Minnesota State Oral Health Plan was one of the first activities involving people who would
later comprise the Minnesota Oral Health Coalition (MOHC) .2 When the MOHC was granted its
nonprofit status, the State Oral Health Plan was recognized as a guiding document . We are proudof the contributions of the MOHC Board of Directors and membership to the development of theMinnesota Oral Health Plan for 2020–2030 . We look forward to the Plan serving as a tool for better
access and healthier mouths for all Minnesotans .”—Nancy Franke Wilson, M.S., Executive Director, Minnesota Oral Health Coalition

7

Honoring an Oral Health Champion
Many of the successes and opportunities to improve
Minnesotans’ oral health are due to the hard work of oral healthadvocates and champions across the state .

December 2020: The Minnesota Department of Health
Oral Health Program and the Minnesota Oral Health
Coalition jointly awarded Dr. Amos S. Deinard Jr., MD MPH with a lifetime
achievement award for his unwavering commitment to the oral health of
Minnesota’s children.
Dr . Amos’ motto is: “Go forth and Varnish .” He and his team have spent years educating and engaging physicians
to provide oral assessments and fluoride varnish for kids during their encounters with the doctor’s office . He is anunwavering advocate for underserved children’s health needs in Minneapolis, Minnesota, and beyond, and his passion isperhaps best exemplified by his work with the Minnesota Oral Health Project .3

Dr . Deinard, or Amos, as he prefers to be called, is well known in the health care field as an Associate Professor at the
University of Minnesota Medical School Department of Pediatrics and School of Public Health . He is also known as“The Fluoride Guy .” Amos launched the ambitious Childhood Caries Prevention Project that focused on oral healthcare anticipatory guidance and fluoride varnish treatments in Minnesota’s primary care medical clinics . The project
aimed to improve access to dental services for children insured through public health plans . What began with one
staff member in Southwest Minnesota is now a statewide team of 15 Minnesota Oral Health Project (MNOHP)
professionals, representing diverse public health and clinical backgrounds, who work with oral health providers, publichealth educators, and community advocates throughout the state to provide essential oral health care .
Amos’ initial goal of implementing Childhood Caries Prevention in medical clinics is nearly achieved, with more than99 percent of clinics providing this service through well-child and children and teen checkups . MNOHP staff andteam members deliver Amos’ messages about preventive care and fluoride varnish treatments to parents, schools,
and communities across Minnesota via community presentations, social media opportunities, website education andmaterials, and stakeholder meetings .
Amos’ legacy in improving oral health for all Minnesota children continues today through the work of the current
MNOHP . In 2016, Amos received the National Lifetime Achievement Award for Public Health Dentistry—the firsttime a pediatrician was given this national recognition . His timeless message, “Go forth and varnish,” continues to beheard throughout Minnesota, as well as nationally among oral health leaders .

The content for this section was adapted (with permission) from Minnesota Oral Health Programs’ Crush Cavities article “The Story of the Minnesota Oral Health
Project” on Dr. Amos S. Deinard Jr., M.D., M.P.H. located at: https://crushcavities.com/the-story-of-the-minnesota-oral-health-project-sharing-our-outcomes/

8

Executive Summary
State Plans, such as this one, are cornerstones of public health practice . These plans
guide state and local health departments, as well as partners, clinicians, policy makers,
and funders . There exists a strong dental public health landscape in MN; providers
and leaders who have a strong commitment to service, their fellow citizens, andmotivation to Do the Right Thing . This document serves to uphold, support, promoteand encourage Minnesota’s Oral Health Champions . Each are heroes on their own .
Together, they are Minnesota’s Superstars .

Minnesota’s first State Oral Health Plan is the foundation for this Plan . Extensive engagement of statewide
stakeholders produced the first Plan . We could not have succeeded in the production of this update withoutthat strong foundation . The development team for this Plan consisted of many of the same stakeholders, andsome new ones . The lessons learned and experiences of statewide stakeholders informs the future . We hope wehave collectively built a user-friendly, actionable, attainable dental public health road map for the next decade .
This Plan is organic, subject to course adaptations and alterations along the way . Not all good things can bedone at once . Priorities are impacted by the society in which they exist . Available opportunities drive projects .

Now, more than ever, we are called to flexibility, adaptation, creativity.
This Plan was created and drafted before SARS-CoV-2 appeared. In these
unprecedented times, fluctuation has become a constant.
Proven and common methods for oral health care delivery have been turned upside down . In spite of theunknowns, we believe this Plan will support the new challenges ahead .
It is easy to get discouraged in this work . At times, the acute needs of real people seem much greater than theability to resolve them . Some of our heroes have diligently worked on the recommendations contained in thisPlan for decades . Yet, decay and tooth loss are relentless . Health determinants are known and studied, howeverachieving solutions is an on-going struggle . Even Superstars get tired .
We have to keep trying . Our state depends on it .

9

WH AT WE KN OW

Co-occurring barriers impede people’s ability to access dental care:

Disparities in Minnesota
mean some populations bear
more of the burden of oraldisease.
While Minnesota ranks sixth in the nationin national health measures,4 a closer lookshows Minnesotans experience significant
inequalities in the social determinants ofhealth, including income, education, andhome ownership . Minnesota also hosts
some of the most severe health disparities
among people of color and American
Indians compared to whites .5 These
institutionalized inequalities have led to
low-income children and adults, people ofcolor and American Indians, and people
with disabilities to disproportionally sufferfrom dental diseases and oral conditions .

• Insufficient insurance coverage for health and dental needs;• Disconnection across multiple disciplines in healthinfrastructure;• A complex oral health system that is difficult to navigate,especially for people with low literacy; and• Workforce shortage .
The SARS-CoV2 pandemic has spotlighted disparities in oral health .
Communities facing barriers to oral health care are the same as thosemost at risk of complications from COVID-19, including older adults,
people of color, and low-income adults and children . Dental officesin Minnesota were temporarily closed by order of the Governor tolimit the spread of COVID-19 . The burden of delayed and foregonecare rests on those already suffering the most . The global pandemic
has made clear disparities in our communities, and underscores theimportance of equity in improving oral health .

W H AT W E H AV E A C H I E V E D S O FA R

In the years since Minnesota’s first State Oral Health Plan in 2013, the Minnesota Department of Health (MDH) and partners
have collaborated to achieve major milestones . These included establishing a coalition of oral health experts, development andmaintenance of a central oral health statistics system, and developing collaborative practice as a strategy to increase accessto oral health care . The Plan has contributed to the mandate for fluoride varnish application at Minnesota’s Child and Teen
Checkups5b, and the designation of MDH as the administrator of the Early Dental Disease Prevention Initiative (EDDPI) .

A 2015 assessment of the first State Oral Health Plan 2013 identified additional successes and provided recommendations.
The assessment found the Plan informed project design and funding proposals; strengthened external communication; brought
awareness to oral health disparities; aided in assessing opportunities for policy change; and provided a basis for emerging
workforce models and medical-dental integration projects . A key recommendation was for MDH to be more methodical in
ascribing ownership and commit to gathering inclusive input from various stakeholders .

10OUR WORK FOR THE NEXT DECADE

The Minnesota State Oral Health Plan for 2020–2030 builds on the2013 Plan . It serves as a blueprint for decision-makers and calls forcollaboration to achieve oral health for all Minnesotans . MDH worked
closely with Minnesota’s Dental Services Advisory Committee; assessednational and state data; and received more than 200 comments fromstakeholders to identify priorities for the Plan . This led to five focus areas,
defined below . Each contain the strategy action categories of clinical,
education, finance, policy, and workforce:

1

Oral Health Infrastructure: Strengthen, stabilize, and sustain
Minnesota’s oral health infrastructure.

2

Access to Oral Health Care: Increase access to timely, culturally
appropriate, geographically suitable, and financially viable dental
$
care.

3

Health Systems Integration: Improve integration of medical anddental care systems to provide more holistic care.

4

Disability, Special Care Needs, and Inclusion: Make oral healthcare is accessible, safe, respectful, and timely for all Minnesotans
who seek it.

5

Data: Share oral health data and indicators to inform datadriven strategies and actions.

$
$
$

11

Building collaboration will continue to be key for collective impact. The collaborative nature of our work to ensure oral
health for all must mirror the interrelated ways social determinants of health can affect oral health for Minnesotans .
Partnerships and collaboration across disciplines, agencies, and communities is a strong theme across the Minnesota
State Oral Health Plan for 2020-2030 .

The MDH Oral Health Program, stakeholders,and communities will continue to partner andcollaborate on efforts to impact and advancethe oral health of all Minnesotans, to put an
end to dental diseases, and other oral healthproblems.

12

ORAL HEALTH IS INTRINSICTO OVERALL HEALTHOral Health is Intrinsic to Overall HealthIf the mouth is the window to the body, oral health status gives great insight into overall
health . Oral health is no stranger to the public health approach; in fact, community
water fluoridation is considered one of the most successful public health strategies
in the 20th century . The idea of oral health being essential to overall health has
gained considerable traction over the past two decades . In 2000, the Office of theSurgeon General published Oral Health in America, a landmark report emphasizing theimportance of oral health as an indicator of overall health and presenting an association
between poor oral health and other chronic illnesses, such as heart disease and diabetes .
Based on the emerging research supporting oral health as vital to overall health, Healthy People
2030 focuses on reducing tooth decay and other oral health conditions and helping people get oral
health care services .

“Oral health can impact a patient’s quality of life, how they manage
daily necessities. Not having access to dental care, for ANY reason,
not only negatively impacts the patient, but those around them in a
myriad of ways. — Stakeholder
6

Poor oral health can lead to significant pain and discomfort . Tooth decay, gum disease, craniofacial diseases,
cleft lip and palate, traumatic injury, or even cancer can contribute to poor oral health . Fortunately, many ofthese conditions are preventable, saving individuals from their accompanying pain and costs associated withuntreated dental care . MDH takes a “health in all policies approach,” acknowledging that health is created in
the clinic, but also where people live, work, and play .
D I S PA R I T I E S I N M I N N E S OTA CO M P O U N D T H E B U R D E N O F O R A L D I S E A S E

Minnesota ranks sixth7 in the nation in national health measures .4 Although Minnesota has long enjoyed top
rankings, a closer analysis of statewide outcomes indicates that this is not the reality for all Minnesotans . Minnesota
experiences significant inequalities in the social determinants of health, including factors such as income, education,and home ownership . It also hosts some of the most severe health disparities with people of color and American
Indians compared to whites . In 2014, Advancing Health Equity in Minnesota: Report to the Legislature illustrated thestate’s severe racial health disparities, asserting that these significant and persistent disparities cannot be explained bybiogenetic factors or individual choice . Rather, the report states those disparities are products of social and economic
inequities, including factors such as poverty, unemployment, home ownership, and education, many of which are tied
to structural racism in the state .

14

Oral diseases and poor oral health conditions can adversely impact a person’s ability to eat, speak,smile, as well as affecting confidence and quality of life . Although several oral conditions are generally
preventable, many Minnesotans still suffer from the adverse effects of poor oral health . Much of thisburden impacts low-income children and adults, people of color and American Indians, and people
with disabilities . These populations disproportionately suffer from dental diseases and oral conditions
due to structural barriers like limited access to and availability of oral health services, and absent orinadequate health and dental insurance .
H OW D I S PA R I T Y I N O R A L H E A LT H S H OW S U P I N P O P U L AT I O N SChildrenTooth decay is the most common chronic childhood disease; it is five times more common thanasthma .7 Based on the Basic Screening Survey (BSS)8 of 2015, about half (49 .5 percent) of Minnesota
third graders either had a history of tooth decay or displayed tooth decay at the survey time . This rate
was slightly higher than the Healthy People 2020 goal of 49 percent; however, the 2015 rate of tooth
decay declined from 2010 BSS data that showed a rate of 55 percent of Minnesota third graders withtooth decay . Also, the percentage of Minnesota third graders with untreated tooth decay declined
from 18 percent in 2010 to 16 .6 percent in BSS 2015, which is lower than the Healthy People 2020
target of 26 percent .

“Research shows that there are more and more systemic issues and illnesses
that have a direct link to oral health conditions. — Stakeholder
6

While overall rates declined, children from low-income households, rural communities, or communities of color beara higher burden of tooth decay . Third graders eligible for free/reduced-price lunch program were 1 .6 times more likely
to have tooth decay than non-eligible students . Students living in rural communities were 1 .3 times more likely tohave tooth decay than students in urban areas . Moreover, Hispanic third graders were 1 .4 times more likely to havetooth decay than White, non-Hispanic third graders .9 There is also disparity in preventative measures . Dental sealants(plastic resin applied to molars and premolars) are evidence-based to mitigate dental caries in school-aged children by
preventing tooth decay and cavities .10 2015 BSS data show that 60 percent of third graders—a much higher rate than
the national target set by Healthy People 2020 of 28 percent—had at least one sealant on their permanent molars .
However, third graders in public schools with low free/reduced-price lunch eligibility (i .e ., higher-income households)
were 1 .5 times more likely to have dental sealants than third graders in public schools with high free and reduced-pricelunch eligibility (i .e ., lower-income households) .
15

“As a safety net pediatric clinic, we
frequently see the devastating effects
of inadequate oral health resources
and access among our patients,
especially low-income children andchildren of color. — Stakeholder 6

AdultsYearly dental visits are essential to maintain healthy gums and teeth, prevent dental disease, and identify any treatment
needs . According to the Behavioral Risk Factor Surveillance System (BRFSS), in 2016, 73 percent of Minnesota adults
reported visiting a dentist or dental clinic within the previous year, compared to 65 percent of US adults . The BRFSS
data reveal racial and socioeconomic disparities, with Hispanic adults, adults from low-income households, and adults
without a higher education less likely to visit the dentist each year . Hispanic adults were 1 .4 times less likely to havevisited a dentist or dental clinic within the past year compared to non-Hispanic white adults .
Adults from homes with household incomes below $35,000 were 1 .4 times less likely to report visiting a dentist or
dental clinic than adults from homes with a household income of $35,000 or more . Adults with a high school degree
only were 1 .6 times less likely to visit a dentist or dental clinic within the previous year than adults with a higher
education degree .

“I work with individuals who are of low-income
and see how desperate some of them are to get
dental work and a general cleaning done but
can’t find a provider in their community tocomplete the work. —Stakeholder 6Older Adults
Older adults are at risk of poor oral health due to limited workforce availability for
geriatric oral health care, preventive care, and a lack of dental benefits through Medicare .
Yearly dental visits continue to be integral to our oral health as we age, but over half of Minnesota
adults aged 65 and older do not have dental insurance . Data from 2017 show that 32 percent of
Minnesota adults over age 55 enrolled in a Minnesota Health Care Program (MHCP)11 saw a dentist
within the year .
2016 BSS data12 showed that 40 percent of adults aged 65 and older and living in long-term carefacilities had untreated tooth decay that was not filled or restored . Older men were 30 percent more
likely to have untreated decay than women . The survey also showed that 59 percent of older adults had
impaired dental function, defined as having fewer than 20 teeth . The 2016 BRFSS data showed that
overall, 10 percent of Minnesota adults aged 65 and older had lost all their teeth .13

16

P E O P L E WH O A R E I N C A R C E R AT E D

The Minnesota Department of Corrections (DOC) provides health and dental care services to about 8,000
incarcerated adults and juveniles in 10 facilities throughout the state . Nearly 18 full-time dental professionals provide
care to this population with an annual budget of $2 .5 million . Many incarcerated individuals entered the corrections
system with urgent or emergent dental treatment needs . Sometimes, a pending release date also creates an urgency,
as the individual may not have dental care access after leaving DOC . Providers work to complete treatment plans,
including the completion of removable prosthodontics, before the release date . Because DOC prioritizes these needs
ahead of routine care (such as cleanings and fillings), routine care may be delayed for incarcerated individuals seeking
routine care unless offsite dental services can be provided .

“To improve access, provider reimbursement for Medicaid
needs to be like commercial patients. This is the only way
the access issue will be improved. The current provider
reimbursement structure is promoting discrimination forour state’s most vulnerable populations. — Stakeholder 6

B A R R I E R S TO O P T I M A L O R A L H E A LT H

Several external and internal barriers occurring simultaneously influence people’s ability to access dental care . An
example of these barriers affecting access to dental care is that only about 40 percent of children (ages 1-20) eligible for
Minnesota Child and Teen Checkups had at least one dental service during the federal fiscal year 2018 .14 Overall, in thepast five years, 31-36 percent of MHCP enrollees received at least one dental service . While MHCP provides low or nocost insurance for Minnesotans in need, many dentists face administrative barriers which prevent them from accepting
MHCP-enrolled patients .15
Several structural barriers impede people’s ability to access dental care:• Insufficient insurance coverage for health and dental needs;• Disconnection across multiple disciplines in health infrastructure;• A complex oral health system that is difficult to navigate, especially for people with low literacy; and• A workforce shortage .
These barriers further compound with language, transportation, childcare, work release, scheduling/appointments, andpersonal mobility . Individuals who receive dental benefit through Minnesota Health Care Programs (MHCP) facedifferent challenges in accessing dental care than the populations on private insurance .
The workforce shortage is another large-scale barrier to dental care . Over half of Minnesota counties are designatedas dental health professional shortage areas (Dental-HPSAs) . This means the population of the county does nothave adequate dental providers to care for them . Minnesota is no exception to the Health Resources and Services
Administration’s prediction that the excess growth in demand for dentists would result in a national shortage ofapproximately 15,600 dentists in 2025 .
The unique barriers directly linked to the Medicaid program are included as Appendix: Medicaid Barriers .

17

“People with special needs tend to not havethe best insurance, therefore there are notmany options for them. They can also have a
hard time at the dentist and may need tohave more options available to them than
the general public. — Stakeholder 6People with disabilities have endured great difficultly during the pandemic .
Diminished or eliminated services and supports have had, and will continue to have,negative consequences on independence, quality of life, and overall health maintenance .
Underlying medical conditions make some individuals with disabilities at higher, or much higher, risk of
Covid-19 infection; and at higher risk of severe infection . The long-term effects of isolation, lack of services,and post-Covid recovery, are unknown .
The COVID-19 pandemic has already impacted the dental care
workforce and thus, availability of services . Dental care providers areconflicted about caring for their patients, yet keeping themselves
and their own loved ones safe . In the short term, some dental careproviders have pressed pause on delivering patient care . Some ofthose may not return to clinical roles . A portion of the workforce
might not return to clinical, or retire sooner than intended .

“We see people in our Emergency Roomwith dental problems because there isn’t adentist available on weekends or because
they can’t get an appointment on a short
notice. This is [an] inappropriate use of
emergency room visits and medical dollars.
— Stakeholder 618

MAKING INROADS TO
OPTIMAL ORAL HEALTHMinnesota has implemented innovative
workforce models such as advanced dental
therapists, dental therapists, and dental
hygienists in collaborative practice tostrengthen its oral health workforce’s capacity
to increase access to oral health care.

MDH’s Health Care Workforce Planning Unit of the Office of Rural Healthand Primary Care collaborates with the Minnesota Board of Dentistry to
conduct an annual mandated workforce survey to track and analyze the trends
among the licensed oral health workforce . It surveys dentists, dental assistants,
dental therapists, advanced dental therapists, and dental hygienists, including
dental hygienists in collaborative practice16 at the time of their license renewal—
oral health professionals have a two-year renewal cycle . The survey asks about theirwork status, location, future work plans, job satisfaction, education, future training
plans, specializations, and roles and responsibilities .
Survey data as recent as January 2020 show there are 4,191 licensed dentists, 100 licensed dental therapists andadvanced dental therapists, 5,770 dental hygienists, and 7,418 dental assistants to serve 5 .6 million state residents .17,18
Fifteen percent of dentists are near retirement age and 24 percent of dentists plan to only practice for the next five
years or less . In Minnesota, the metro area has a concentration of dentists and rural areas do not have enough . Of
practicing dentists, 63 percent are concentrated in the Minneapolis and Saint Paul metro area, home to about 54
percent of the state population . The number of potential patients that would be served by one dentist is smaller in urban
areas (1,601 residents to one dentist) than in rural or isolated areas (3,938 residents to one dentist) . A likely reason
for the higher ratio is that while retirement creates job openings for recent graduates, it is challenging for these newdentists to realize the economic and practice opportunities in rural Minnesota .

R E F L E C T I N G O N WO R K S I N C E M I N N E S OTA’S F I R S T S TAT E O R A L H E A LT H P L A N

Minnesota’s first State Oral Health Plan, illustrated a shared vision for oral health for all Minnesotans . The Plan fulfilled
three of the five core conditions for collective impact; it served as a common agenda among stakeholders, provided data
for shared measurements for some oral health measures, and encouraged mutually reinforcing activities . It addressedcross-cutting issues and the Centers for Disease Control and Prevention’s (CDC) four chronic disease prevention andhealth promotion domains: epidemiology and surveillance, environmental approaches to promote health, health systems
interventions, and community clinical linkages .

20

AC H I E V E M E N T S S I N C E T H E F I R S T S TAT E O R A L H E A LT H P L A N I N M I N N E S OTA

MDH along with its oral health partners used the Plan as a framework to catalyze innovation in oral health care . Some ofthe success stories are highlighted below:

1

2

$

Minnesota Oral Health Coalition (MOHC)

The MOHC is a 501(c) organization that brings together oral health professionals, policymakers,
and various stakeholders through statewide, regional, and local level conferences, discussion
forums, and events to present and share successes, challenges, and solutions to oral health in thestate . It was founded in 2009 through a cooperative agreement among the CDC, the HealthResources and Services Administration (HRSA), and the MDH Oral Health Program thatappointed directors to advance oral health in Minnesota . In the coalition’s early stages, MDH
provided expertise and staff time to conduct evaluation activities . MDH provided significant
resources to the coalition for staff time, meeting rooms, conference lines, virtual meeting
services and maintain the coalition’s webpage on the MDH website, membership database, andwritten products .

$Minnesota Oral Health Statistics System (MNOHSS)MNOHSS, pronounced “minnows”, provides timely, accessible, easy-to-navigate,
understandable, and actionable online state and county oral health data through the Minnesota
Public Health Data Access portal . Delta Dental of Minnesota Foundation funded the initialinfrastructure for MNOHSS . Administered by the MDH Oral Health Program, this interactive
platform informs users of health disparities, trends in disease and service use, and unmet needs sothat they can more efficiently target resources . Currently, the CDC supports its staffing .

3$

Collaborative Practice Authorization for Dental Hygienists in Community Settings.
In Minnesota, dental hygienists who enter into a collaborative practice agreement with alicensed dentist may work in limited community settings without the dentist being present,
thus allowing providers to meet people where they are (e .g ., at a school, nursing home, or
hospital) . Dental hygienists require less training time than dentists to provide collaborative
services . Adopting collaborative practice aligns with Rural Health Advisory Committee 2018’s
strategies for improving access to quality oral health care among underserved populations andthose least likely to access routine preventive dental care in a private practice setting . Thismodel allows more people receive the care they need and save on the cost of oral care delivery,
while mitigating the challenges of an insufficient workforce to meet Minnesotans’ oral healthneeds .

21

4$

Mandatory Fluoride Varnish Application in the Child and Teen Checkups (C&TC) setting.
Fluoride varnish application is now mandated at all Child and Teen Checkups (C&TC) visits,
starting at the first tooth’s eruption or no later than 12 months of age, and continuing through 5
years of age .19 MHCP will cover four fluoride varnish applications per member in medical settingsfor 0-20 year olds .
In addition to the fluoride varnish application mandate, the following are the oral health requiredcomponents for a complete C&TC visit:
1 . Include the mouth and teeth as a part of the comprehensive physical exam .
2 . Include oral health and caries prevention in anticipatory guidance .
3 . Refer every C&TC-eligible child at every C&TC visit for routine dental care, beginning at
the first tooth’s eruption and no later than 12 months of age .
Prevention of early dental disease starts prenatally and is most effective in the first two yearsof life . Infants are far more likely to see a primary health care provider than a dental provider
in their first two years of life . The American Academy of Pediatrics (AAP) stresses the role ofthe primary health care provider play in preventing early dental disease . The implementationof fluoride varnish application in the primary care setting along with referral to a dental homeprevent early decay among children especially those who are at high risk for caries .

5

Early Dental Disease Prevention Initiative (EDDPI)
Minnesota’s legislature designated MDH as the administrator for EDDPI . MDH developed
a health integration prenatal-to-three program (P-3) called Healthy Teeth . Healthy Baby .
The program has been collaborating with diverse communities, experts and partners to build
integrated maternal and early childhood oral health systems of care that are equitable,
sustainable, comprehensive, and inclusive of the health system . Healthy Teeth . Healthy Baby .
promotes prevention of early dental disease and increases family-centered access to oral healtheducation and care .
MDH has administered mini-grants, provided technical assistance, engaged communities todevelop communication materials and distributed oral hygiene kits as incentive to promote P-3
oral health . MDH engages pregnant women, parents and caregivers to tailor the program to meetthe unique cultural needs of Minnesota’s communities .
MDH continues to work with key audiences to increase state-level infrastructure and capacity tostrengthen statewide maternal and early childhood oral health systems of care .
Professional organizations, local public health, maternal and child health experts, and others
continue utilizing campaign materials in their daily work .

22

E VA L U AT I O N O F M I N N E S O TA’ S F I R S T S TAT E O R A L H E A LT H P L A N

In 2015, MDH assessed the quality and the initial impact of the first State Oral Health Plan (2013), finding that it:• Informed project design and funding proposals;• Helped in communication with donors and policymakers;• Brought awareness to oral health disparities;• Aided in assessing opportunities for policy change; and• Provided a basis for emerging workforce models and medical-dental integration projects .
MDH determined that the 2013 State Oral Health Plan had the necessary components to support implementation of
the Plan’s strategies: stakeholder buy-in, comprehensiveness, and use of evidence on which to base strategies . However,the state’s limited budget for dental services, the absence of oral health policies, and a lack of integration of oral diseaseprograms with other chronic disease prevention programs were notable barriers to successful implementation of the2013 State Oral Health Plan .
The stakeholders encouraged the MDH to be more methodical in ascribing ownership and commit to gathering inclusive
input . Furthermore, the evaluation indicated a need for aligning goals and objectives with Healthy People goals as well as
creating and sharing summaries of progress on the goals and strategies .
The full evaluation report is available upon request .

23

MINNESOTA STATEORAL HEALTH PLAN
FOR 2020-2030

2020–2030 Oral Health Plan
The Minnesota State Oral Health Plan 2020-2030 is a road map for decisionmakers in public health, oral health policy, dental care, and oral health education
to improve patients’ oral health.
The Plan presents oral health priorities for the next decade, identifies best practices to be adopted by stakeholders, andensures principles of health equity, health literacy, and cultural competence are included in oral health priorities for thestate .
Development of State Oral Health Plan 2020-2030 was built on the revisions of the first SOHP and therecommendation received by evaluating the first state oral health plan . Objectives and strategies were developed
through extensive stakeholder engagement, national and state indicators, and the use of data available on MNOHSS .
MDH worked with the Dental Services Advisory Committee (a state-mandated committee to advise the Commissionerof Human Services), the Minnesota Oral Health Coalition, and other oral health stakeholders to identify opportunities,
priority areas, and strategies that inform this Plan . MDH received feedback through more than 200 public comments,
including input from professional organizations, academic institutions, state and local public health agencies andprograms, nonprofit organizations, and the community . Appendix: Emerging Findings: Survey Input on Minnesota Oral
Health Strategic Planning (pg 63-67), summarizes responses from that survey .
25

FRAMEWORK AND STRUCTURE

Goal
Through collaborative efforts on objectives and strategies outlined in this Plan, ourgoal is to improve and maintain the optimal oral health of patients . The goal of thisPlan aligns with national priorities including Healthy People 2030 and the Centers for
Medicare and Medicaid Services’ measure inventory .

Approach
The Plan’s strategies follow the Life Course Approach . As a result, strategies are developed for specific age groups:
childhood, adolescence, adulthood, and older adulthood based on the Life Course Approach theory .20 This approach
generates a better understanding of individuals’ oral health and incorporates both life span and life stage concepts that
determine the oral health trajectory . While envisioning a decade that moves the oral health of Minnesotan’s forward,these strategies were also developed with three foundational pillars at the core of the Plan .
H E A L T H E Q U I T Y : Achieving the conditions in which all people can attain their highest possible level of health .
Every person can realize their health potential—the highest level of health possible for that person—without limits
imposed by structural inequities .21
H E A L T H L I T E R A C Y : Title V of Patient Protection and Affordable Care Act of 2010 defines health literacy as“the degree to which an individual can obtain, communicate, process, and understand necessary health information andservices to make appropriate health decisions .”22 It is also thought of as “a patient’s ability to obtain, understand, andact on health information; and the capacity of health care providers and health care systems to communicate clearly,
educate about health and empower patients .”23
A C K N O W L E D G I N G D I V E R S E N E E D S A N D P R I O R I T Y P O P U L A T I O N S : Many communities

have had less access to oral health care due to challenging circumstances . Oral health disparities continue to exist
for many historically marginalized populations based on racial, socioeconomic, gender, sexual orientation, age, andgeographical areas (e .g ., rural compared to urban), among other factors . Some communities have access to moredentists, healthy options, and other factors, which makes its community members less likely to have significant oral
health problems . Cost of dental services can also be a barrier for low-income or homeless community members, who
disproportionately identify as a person with a disability or Black, Indigenous, and/or as people of color and are also more
likely to be underinsured or not insured . Other people are more likely to be at increased odds of facing oral health issues
due to the stage of life that they are in, such as being pregnant or advanced age . Limited language interpretation is also
a barrier to accessing services, as is a lack of culturally relevant messages . Therefore, the strategies in this Plan strongly
emphasize efforts to reach all populations equitably and make culturally relevant services and materials .

26

Any individual, family, caregiver, or community that self identifies or represents the following
population groups: children (aged 0-17), pregnant women or expectant mothers, young adults(aged 18-25), older adults (aged 65+ years), the homeless, rural residents, low-income, uninsured
or underinsured, people of color and American members of Lesbian, Gay, Bisexual or Transgendercommunities immigrants and refugees, people with Limited English Proficiency (LEP), people withdisabilities, mental illness, chronic disease, and other special needs, and anyone facing challenges which
restrict access to health care . Please note that this is not an exhaustive list of diverse population groups,
and we acknowledge all forms of identity and lived experience .
BEST PRACTICESA Best Practice Approach is defined as a public health strategy that is supported by evidence
for its impact and effectiveness . Evidence includes research, expert opinion, field lessons,and theoretical rationale . The term “Best Practice Approach” is intended to emphasize there
is more than one “best” implementation strategy that may produce successful outcomes .
The context of community programs, and the environment in which they are developedand implemented, may impact whether an implementation strategy is successful . Variables toconsider are: leadership, political acceptability, available resources, feasibility, and implementation
constraints that are specific to a program’s environment . These variables will influence the acceptability
and adaptability of best practice approaches .

MDH worked extensively with the Dental Services Advisory Committee (DSAC),a state mandated committee to advise the Minnesota Department of Human
Services (DHS), the Minnesota Oral Health Coalition (MOHC), and other oral
health stakeholders, to identify opportunities and priority areas for 2020–2030.
National and state indicators and MNOHSS data informed this Plan . Additionally, MDH received more than 200
public comments, including input from professional organizations, academic institutions, state and local public healthagencies and programs, nonprofit organizations, and community members about what is important to refine priority
areas and goals for improving oral health . Where relevant, quotations from the public input survey are presented in thisPlan .6 MDH and its plan development partner, The Improve Group, created a full inventory of potential strategies andidentified gaps where additional strategies were needed .
Ultimately, this Plan is a mutually agreed upon tool for the entire state; it is not just a plan for MDH . Everyone needs
to collaborate for collective impact . This Plan represents feasible strategies that serve the state’s oral health goals
informed by many different stakeholders . Some of the input on strategies was modified for clarity or combined into one
aggregated strategy . Goals and strategies were refined based on CDC’s Framework for Comprehensive Oral HealthPlans, prioritizing setting data-driven goals, and selecting a capacity-driven feasible, science-based, and effective
strategy . It is noted that this Plan may not have identified or addressed every consideration . MDH plans to design an
outcome evaluation to measure implemented strategies . MDH will invite public comment, conduct roundtables, andwill update this Plan periodically .

27

H OW S T R AT E G I E S A R E O R G A N I Z E D I N T H E M I N N E S OTA S TAT E O R A L H E A LT H P L A N

Five focus areas
It is important that action to improve oral health throughout the state is multidisciplinary and from various places ofinfluence and expertise . Hence, this Plan presents strategies by focus areas:
Focus Areas
1.

Oral Health Infrastructure

2. Access to Oral Health Care

VisionStrategy for 2020–2030

An effective and sustained oral healthStrengthen, stabilize, andinfrastructure that better meets patients’sustain Minnesota’s oral healthneeds .

infrastructure .

All Minnesotans have equitable opportunities
to access oral health care .

Increase access to timely, culturally
appropriate, geographically suitable,
and financially viable dental care .

3. Health Systems Integration

Minnesotans receive holistic care throughintegrated medical and dental care systems .

Improve integration of medical anddental care systems to provide more
holistic care .

4. Disability, Special Care
Needs, and Inclusion

People with disabilities and special care needs
maintain a lifetime of good oral health .

Make oral health care accessible,safe, respectful, and timely for all
Minnesotans who seek it .

5. Data

Oral health infrastructure is data-driven, andthe diversity of stakeholders are consistently
well-informed to address oral health needs .

Share oral health data and indicators
to inform data-driven strategies andactions .

Five strategy action categories
Within each focus area are the following strategy action categories:
Clinical: Oral health or primary care professionals or settings responsible for delivering health care .
Education: Individuals, organizations, or systems that provide knowledge, training, and strategies that promote oral health .
Finance: Individuals or systems that influence funding at the local, state, and national level .
Policy: A definitive course of action taken by a group such as government, organizations, or the state Legislature . This
could include regulations, a norm, or a statutory mandate .
Workforce: Individuals engaged in or available for medical, oral health, or allied work at the community and state level, i .e .,the professionals accomplishing care delivery .

Oral health is important throughout our lives but there is special consideration
for age ranges and health status. Therefore, this Plan includes strategies that are
more relevant to one or more life stages.
28

FOCUS AREA 1: ORALHEALTH INFRASTRUCTURE

Focus Area 1: Oral Health Infrastructure
VISION:An effective and sustained oral health infrastructure that better meets patients’ needs.
S T R AT E G Y:
Strengthen, stabilize, and sustain Minnesota’s oral health infrastructure.
DEFINITIONThe Oral Health Program Infrastructure refers to an interconnected set of systems, people, relationships, andresources to meet the needs of all Minnesotans and provide 10 essential public health services . MDH Oral Health
Program must be sustained with long range vision in order to plan, establish, and carry out improved oral health for
all Minnesotans . Financial stability allows the Oral Health Program to plan and execute short to long term initiatives .
Sustained, it can coordinate the common agendas with the local public health agencies and enable communities to focus
on preventing and investing in long-term oral health outcomes . Yet, the current reliance on federal funding limits thecapacity and prioritization capability of the MDH Oral Health Program . There is a need to increase the dental publichealth infrastructure at the state and local levels to monitor the oral health status of Minnesota’s population, promote
evidence-based public health strategies, and ensure coordination and collaboration among stakeholders .
With support from earmarked state dollars, the MDH Oral Health Program will be well-positioned to meet the specificneeds of Minnesotans, especially at-risk populations . Designated state funding, along with federal and private funding
are critical for the MDH Oral Health Program to maintain qualified staff, use technological advances, provide detailed
surveillance and data storage, establish uniform data reporting, evaluate programs, and support partners to implement
projects and expand services .
Broadly, it is important to ensure that oral health remains strong among competing priorities and that a focus on oral
health is integrated with other health or disease priorities . Furthermore, it is essential to achieve parity between oral
health infrastructure and other public health infrastructure .
R AT I O N A L E

Improved oral health infrastructure is needed to meet patients’ needs, including support for priority populations .
One role of oral health advocates is to demonstrate the value of robust oral health infrastructure to decision-makers
and funders . In “making the case,” advocates should demonstrate what the existing infrastructure has been able toaccomplish, then identify gaps that could be addressed through more generous support .

BEST PRACTICES• Association of State and Territorial Dental Directors’ State oral health infrastructure and capacity: Reflecting on
progress and charting the future .
• The Network for Public Health Law’s Policy frameworks supporting school-based dental sealant programs .
• CDC’s Basic Strategies for Collective Impact .

30

Focus Area 1: Oral Health Infrastructure
S T R AT E G Y AC T I O N S F O R F O C U S A R E A 1: O R A L H E A LT H I N F R A S T R U C T U R E

The following actions are recommended for implementing Focus Area 1’s strategy: Strengthen, stabilize, and sustain
Minnesota’s oral health infrastructure .

A. Clinical actions for Focus Area 1: Oral Health Infrastructure
1 . Screen for oral health in multiple health care settings .
• Promote mandatory screenings in WIC programs .
• Increase oral health screenings performed by all health care professionals .
2 . Promote prevention .
• Include oral health in the efforts to prevent overall health problems .
3 . Collaborate with local public health agencies• Identify opportunities to better serve patients in the community .
• Share data .

B. Education actions for Focus Area 1: Oral Health Infrastructure
1 . Start early .
• Increase dental care and education available to students that are in preschools and/or Head Starts .
• Develop new or endorse existing continuing education programs about oral health (online and in-person) for
dental and medical care providers for pregnant women and their children .
• Enable oral health education and preventive services in schools with a higher need for oral health careinterventions .
• Partner with the Minnesota Department of Education for oral health education and intervention in schools .
2 . Raise awareness .
• Promote education about telehealth .
• Make public service announcements about simple self-exams for suspicious mouth lesions and provide
information about the next steps .
• Ensure that local health agencies, school nurses, clinics, and community centers have available patient
education resources/tools on oral health, including information about the impact of oral health on physicalhealth .
3 . Educate decision-makers .
• Educate legislators on the importance of having a sustainable oral health infrastructure within MDH to solvepressing issues about access to dental services and oral health care .
• Provide oral health communications and education to policymakers and the public to improve awareness about
oral health .

31

Focus Area 1: Oral Health Infrastructure
4 . Understand local issues .
• Examine oral health data to help determine gaps in local oral health systems and programs .
5 . Build capacity .
• Support community-level oral health interventions .

C. Finance actions for Focus Area 1: Oral Health Infrastructure
1 . Diversify funding .
• Seek earmarked state funds to support and sustain the MDH Oral Health Program, to decrease reliance on
grants and other external funding streams .
• Create new partnerships that ensure available and diversified funding for the MDH Oral Health Plan .
• Explore non-traditional financing options, like federal programs for priority populations, to support oral healthinitiatives .
2 . Seek connections in funding streams .
• Promote integration opportunities with other funded programs internally within MDH and other stateagencies and externally with public and private organizations .
3 . Fund education .
• Fund evidence-based strategies such as the School Sealant Program, community water fluoridation, andfluoride varnish application .
• Fund public education materials and campaigns focused on the benefits of oral hygiene at home, drinking
fluoridated water, and receiving dental sealants .
4 . Fund information-gathering .
• Designate funds to launch and sustain the statewide Fluoride Varnish Registry .
• Advocate for funds to support routine Minnesota oral health surveillance activities such as the Basic Screening
Survey (BSS) and the Behavioral Risk Factor Surveillance System (BRFSS) .
5 . Incentivize good oral health practices .
• Provide financial incentives to the creation of onsite dental operatory, fixed or portable, in facilities where
pregnant women and children gather .
• Promote incentive/loan repayment for those who enter into a collaborative agreement in rural Minnesota .
6 . Study costs and savings .
• Examine the cost savings of preventative dental services versus restorative services .
• Conduct an analysis comparing days missed from school for dental pain and/or restorative dental
appointments; pilot this with one rural school system .

32

Focus Area 1: Oral Health Infrastructure
D. Policy actions for Focus Area 1: Oral Health Infrastructure
1 . Ensure components for a stronger oral health infrastructure .
• Ensure recognition of oral health as a critical component of the public health infrastructure in Minnesota .
• Support the MDH Oral Health Program as the central program for oral health promotion, surveillance, andcoordination of oral health initiatives for Minnesota .
• Support national efforts to include dental coverage in Medicare Advantage Plans for dental and primary careproviders .
2 . Inform policy .
• Identify gaps to fill in oral health coverage across age groups, regions, and race/ethnicity .
• Inform policymakers at all levels of the need for sustaining oral health infrastructure .
• Endorse evidenced-based oral health strategies and best practices as a part of the oral health curriculum indental and hygiene schools .
• Include oral health in data gathering, community planning, and patient/client education .
3 . Advocate for more intervention .
• Call upon policymakers to demonstrate needed leadership to improve the oral health of residents residing in
supportive care facilities .
• Support legislation that requires all Minnesota children to receive age-specific oral health education deliveredby oral health professionals at school .
• Develop and promote integrated policies, such as maternal child and oral health protocols, to improve the oral
health of priority populations and to strengthen health systems .

E. Workforce actions for Focus Area 1: Oral Health Infrastructure
1 . Provide technical assistance .
• Help partners initiate sustainable oral health programs in schools and communities .
• Support community coalitions in implementation of oral health programs .
• Support dentists, dental therapists, and dental hygienists in collaborative practice to provide oral healthservices utilizing mobile equipment .
• Collaborate with non-dental partners on sustainable projects to promote oral health as a necessary component
for overall health .
2 . Ready the workforce .
• Engage the current dental workforce in the collaborative practice dental hygiene model .
• Work to expand the use of collaborative practice statewide and in non-traditional settings .
3 . Incentivize education .
• Partner with professional associations to create continuing education courses for oral health professionals
focused on health literacy and cultural competency .

33

FOCUS AREA 2: ACCESSTO ORAL HEALTH CARE

Focus Area 2: Access to Oral Health CareVISION:

All Minnesotans have equitable opportunities to access oral health care.
S T R AT E G Y:

Increase access to timely, culturally appropriate, geographically suitable, andfinancially viable dental care.

DEFINITION

Access to dental care is a critical and complex phenomenon .24 Improving dental care access means all Minnesotans canestablish a dental home (continuous access to non-emergency care), seek regular care, receive comprehensive services,and obtain referrals as needed . Oral disease is linked to systemic disease . Easing financial, geographic, physical, or otherbarriers to oral health access decrease missed school and work days and avoided inappropriate use of the emergency
room for dental emergencies . Access to consistent dental care improves whole-person wellness .

R AT I O N A L E

According to the Surgeon General and Healthy People 2020 reports,
oral health is integral to overall health, and access to dental care services
is essential for promoting and maintaining good oral health .24, 25 Several
co-occurring external and internal barriers influence people’s ability
to access dental care . Some of the barriers include the inability toobtain dental insurance/limited dental insurance or funds specificallyfor dental care due to poverty, low oral health literacy, perceptions
and misconceptions about preventive oral health care, complex oral
health system to navigate, especially for people with low literacy, lack ofinterdisciplinary professional collaboration and inadequate dental safety
nets . These barriers are further compound by transportation, childcare,work release, scheduling/appointments, and personal mobility .

35

Focus Area 2: Access to Oral Health Care

Some Minnesotans are less likely to access oral health services, particularly people of color; low-income populations;refugee and immigrant groups; individuals with low oral health literacy; people with special health care needs; older
residents living independently, in nursing homes, and assisted living residences; uninsured and underinsured individuals;
and people experiencing housing instability or homelessness . Using collaborative practice models for dental hygienists
25b
and therapists as the primary dental provider for triage and preliminary care helps Minnesota move upstream using
cost-effective resources to manage dental disease .
The MDH State Oral Health Program promotes access to oral health care by providing strategies that can strengtheninterdisciplinary team-based care, support collaborative practice workforce models, gather data to demonstrate theneed for administrative simplification, incorporate healthy literacy for family education, and conduct evaluation tomeasure successful implementation of strategies .

BEST PRACTICES• MDH’s “Impact through Innovation” pilot project utilized dental
hygienists in collaborative practice to improve access to care in a dental
health provider shortage area and where there are barriers due to limited
Medicare benefits . This project involved a bi-directional referral ofpatients with diabetes and gum disease . It enabled MDH to learn lessons
about improving access to care, develop tools and techniques to facilitatebi-directional referral models of care .
• Normandale Community College’s Dental Hygiene in Community
Settings: Collaborative dental hygiene practice .
• The Network for Public Health Law’s Access to oral health care in the US
remains an issue, but innovative workforce approaches can help .
• MDH’s Minnesota’ Dental Therapist Workforce .

Thank you to our partners at Ready, Set, Smile for sharing images of their work in community dental settings.

36

Focus Area 2: Access to Oral Health CareS T R AT E G Y AC T I O N S F O R F O C U S A R E A 2: AC C E S S TO O R A L H E A LT H

The following actions are recommended for implementing Focus Area 2’s strategy: Increase access to timely, culturally
appropriate, geographically suitable, and financially viable dental care .

F. Clinical actions for Focus Area 2: Access to Oral Health
1 . Increase access .
• Identify non-traditional clinical settings for dental and health care providers to perform oral health risk
assessment, fluoride varnish application, anticipatory guidance, preventive treatment, and referrals .
• Encourage dental providers to improve the oral health of underserved Minnesotans, especially people withdisabilities/special health care needs, or people who live in rural or dental health provider shortage areas .
2 . Ease patients’ experiences .
• Increase mobile access to oral health care .
• Make it easy for patients to use language interpretation services in clinic .
• Support the coordination of dental and medical health care appointments .
3 . Promote early intervention .
• Provide anticipatory guidance on sealants in WIC .
• Communicate the importance of children’s first dental visit by age 1 to parents and dental providers .
• Promote oral health risk assessment, fluoride varnish application, counseling, and referrals for oral care atprimary care settings .
• Promote the establishment of a dental home for all Minnesotans to ensure continuity of care .
• Maintain current evidence about silver diamine fluoride and sealants for primary teeth .

G. Education actions for Focus Area 2: Access to Oral Health
1 . Focus education .
• Collaborate with dental hygienists and dental assistant programs on teaching strategies and activities arounddental access issues .
• Add oral health education component as a requirement to health curriculum taught in public schools .
• Develop culturally relevant oral health educational materials for general and diverse populations, including people
with special health care needs .
• Continue to educate all dentists, specifically rural and outstate, about the benefits of adding dental therapists
and dental hygienists in collaborative practice to their traditional clinics .
• Leverage existing interdisciplinary continuing dental and medical education about common risk factor
approaches, interconnectedness, and treatment .
• Increase education and certification of all types of dental providers in pediatric and geriatric dental care .
37

Focus Area 2: Access to Oral Health Care2 . Build capacity .
• Provide training to medical and dental providers, nursing staff, and social services agencies on the relationshipbetween oral health and total health, specifically among pregnant women, children, and older adults .
• Train local public health departments to tailor oral health promotion to the specific needs of each community .
3 . Raise awareness .
• Develop mass media public service announcements about the importance of oral health to overall health .
• Inform oral health workforce planning and development activities about the economic impact of dental care at
the local level .

H. Finance actions for Focus Area 2: Access to Oral Health
1 . Target grants .
• Fund opportunities which improve access to preventive oral health education, school sealant programs, andcommunity water fluoridation for all Minnesotans, especially those at risk for dental disease .
2 . Study costs and savings .
• Develop research supporting quantifiable long-term financial and social return-on-investment (ROI) in thedelivery of oral health care for the underserved .
• Use existing data sources such as the All-Payer Claims Database (APCD) to determine the impact of the oral
health workforce shortage on dental care access .
3 . Ease financial burden .
• Redesign the dental education loan repayment system to be clinic-specific so that rural clinics can utilize thisopportunity for staff recruitment .
• Support other loan repayment and forgiveness programs .

I. Policy actions for Focus Area 2: Access to Oral Health
1 . Remove barriers .
• Eliminate administrative policy barriers on the workforce, including dental therapists and dental hygienists incollaborative practice .
• Support DHS to simplify Medicaid administrative processes and procedures for recipients and providers .
• Align state rules, regulations, and laws to support the virtual dental home .
• Support tele-dentistry in long-term care facilities, head start centers, WIC clinics, correctional facilities, etc .
• Ensure transportation, childcare, and/or work release to make dental care appointments .

38

Focus Area 2: Access to Oral Health Care
2 . Create opportunities .
• Promote inclusion of oral health care in non-traditional settings such as early childhood centers, schools,
nursing/assisted living facilities, etc .
• Develop regional dental service hubs through the creation of dental clinics in medical settings . Thesehubs would employ licensed dental providers and community health workers that provide care in clinics orcommunity settings .
• Engage the Collaborative Practice Dental Hygiene Advisory Committee to expand the utilization ofcollaborative practice in community settings .
3 . Build knowledge .
• Inform policymakers about the importance of including dental benefits in Medicare .
• Use dental insurance claims data to improve dental care access .
• Track services provided by dental therapists and dental hygienist in collaborative practice .

J. Workforce actions for Focus Area 2: Access to Oral Health
1 . Create avenues for providers to increase access .
• Support and promote opportunities that encourage diversity in the oral health workforce .
• Expose dental, therapy, and hygiene students to oral health care access, health literacy, and equity issues .
• Develop relationships with providers in older adult services (nursing homes, long-term care facilities, assisted
living, etc .) to connect providers with elderly populations .
• Encourage more advanced dental therapists to provide restorative care in rural areas .
2 . Train to inform and be effective .
• Partner with relevant stakeholders to develop and disseminate cultural competency educational materials fororal health professionals .
• Train oral health professionals to increase health literacy in communities and patients .
• Publish real-life case studies demonstrating the effectiveness of dental therapists and assistant dental
therapists .

39

FOCUS AREA 3: HEALTHSYSTEMS INTEGRATION

Focus Area 3: Health Systems Integration
VISION:

Minnesotans receive holistic care through integrated medical and dental care systems.
S T R AT E G Y:

Improve integration of medical and dental care systems to provide more holistic care.

DEFINITION

Health systems are the organization of people, institutions, and resources that deliver health care services to meet agiven population’s health needs . Integrated health systems can include medical and dental clinics, adjunctive healthservices, clinicians, administrators, and payers . Integrated care refers to the coordinated provision of care to meet agiven individual’s needs . This focus area intends to promote activities and initiatives within the scope of health careprovision, which supports whole-person wellness .
R AT I O N A L E

According to The National Academies of Sciences, Engineering, and Medicine, formerly known as the Institute ofMedicine, the current oral health care system is comprised of two components: the private delivery system and thesafety net . Unfortunately, there is little integration of either sector with wider health care services . There is growing
evidence that interprofessional collaboration results in better care coordination, communication, and ultimately
improved patient and health care system outcomes .26
The past decades of research have provided evidence of the association between poor oral health conditions and chronic
diseases such as cardiovascular, diabetes, Alzheimer’s, and rheumatoid arthritis . Moreover, they also share common
risk factors such as poor nutrition, tobacco, and alcohol use . This increased understanding of the interconnectedness
has prompted the health care system and oral health care professionals to collaborate in identifying innovative ways
to address the common issues for improved patient outcomes . Despite increasing understanding and some ongoing
integration work, the two sectors need to create a common voice to address policies responsible for health inequities andincrease awareness in policymakers to make resources available for implementing projects aiming for integrated care andprofessional development .

BEST PRACTICES•MDH Models of Collaboration
Pilot Project, a bi-directionalreferral of patients with highblood pressure and gum disease
pilot was implemented in afederally qualified health center;
tools, techniques and metrics areavailable for use .

•The Network for Public Health Law’s Medical-Dental Integration in
Minnesota: Benefits from changes in law and policy .

•MDH’s “Impact through Innovation” pilot project which utilized dental
hygienists in collaborative practice to improve access to care in a dental
health provider shortage area and where there are barriers due to limited
Medicare benefits . This project involved a bi-directional referral ofpatients with diabetes and gum disease . It resulted in lessons learned, tools
and techniques to improve access to treatment .

•MDH’s Healthy Teeth . Healthy Baby . educational materials and trainingof trainer modules can be used for integration of oral health into theprimary care settings .

41

Focus Area 3: Health Systems Integration
S T R AT E G Y AC T I O N S F O R F O C U S A R E A 3: H E A LT H S Y S T E M S I N T E G R AT I O N

The following actions are recommended for implementing Focus Area 3’s strategy: Improve integration of medical anddental care systems to provide more holistic care .

K. Clinical actions for Focus Area 3: Health Systems Integration
1 . Integrate services and data .
• Co-locate dental and medical services .
• Integrate medical and dental records .
2 . Connect oral health care to prenatal care .
• Provide clinical training to dental providers on unique oral healthaspects of maternal-child health .
• Develop and coordinate a statewide oral health screening andeducation for pregnant women and new parents .
• Implement mandatory oral health screenings for infants at zerothree-month checkups with primary care/OB-GYN/pediatric visits .
3 . Broaden reach .
• Promote a dental home or provision of follow up care for children who receive preventive care via school oral
health programs .
• Promote tele-dentistry into health care centers, especially in dental health provider shortage areas .
• Increase preventive dental services offered within primary care .
4 . Screen and assess in all health settings .
• Encourage primary care providers to include oral health questions on health intake/history form, assess oral
health risk, ask about the age-one dental visit, and promote fluoride varnish application .
• Establish oral health as a prenatal health outcome .

L. Education actions for Focus Area 3: Health Systems Integration
1 . Build capacity of primary care providers to connect patients with oral health care providers .
• Train on making oral health referrals and coordinating care .
• Ensure that local health agencies have available patient education resources/tools on oral health, including theimpact of oral health on overall health .
• Train medical providers to triage with dental providers on urgent dental cases .

42

Focus Area 3: Health Systems Integration
2 . Increase awareness of the connection between oral and overall health .
• Help policy- and decision-makers understand the connection between oral health and overall health .
• Provide information to health care providers about the evidence-based oral and systemic links affecting general
health .
• Encourage continuing education centers for medical professionals to incorporate the importance of oral healthinto overall health into their curriculum .
• Create a statewide coordinated oral health curriculum for caregivers .
• Develop and promote consistent messages to educate providers and consumers on oral health and overall
health .
3 . Incentivize and bolster educational opportunities .
• Convene continuing education sessions and leadership institute for interprofessional education andcollaboration .
• Provide continuing medical and dental education credits .
• Encourage externship opportunities for oral health professional students in public health settings (e .g .,community health centers, federal qualified health centers, Head Start, WIC) .
• Utilize educational tools and other statewide coordinated oral health modules, paying attention to culturalneeds, health and overall literacy, and diversity, for use by any health care worker .
• Offer opportunities for medical and dental providers to discuss common concerns and opportunities regarding
the integration of oral health and systemic health .
• Expand continuing education opportunities that provide training for all dental professionals on the complex
treatment needs of persons with disabilities .
• Include nutrition education and promotion of overall health as a part of school oral health education
requirements .
• Provide technical assistance for the initiation of sustainable oral health programs in schools .
• Provide technical assistance to community coalitions as they implement oral health programs in theircommunities .
4 . Use and promote modules, research, and assessments .
• Promote Smile for Life modules and develop supporting hands-on modules .
• Utilize modules on health literacy, cultural sensitivity, and diversity .
• Promote the use of risk assessment (periodontal disease, diabetes, tobacco use, etc .) among medical and dental
providers .
• Promote and support research that examines the impact of preventative oral health care in the primary caresetting .
5 . Educate parents/caregivers of young children .
• Inform families about the association of oral health and chronic disease .
• Include nutrition information and obesity information as part of routine WIC services that are provided toyoung children and families .

43

Focus Area 3: Health Systems Integration
M. Finance actions for Focus Area 3: Health Systems Integration
1 . Invest and incentivize integration .
• Allocate state general funds for medical-dental integration and a statewide Fluoride Varnish Registry .
• Invest in medical-dental integration pilot projects .
• Provide financial support for programs that provide dental care in primary care settings .
• Implement a shared savings model to incentivize health systems to improve oral health and overall health .
2 . Revise payment structures to facilitate integrate .
• Incentivize medical-dental integration by revising Centers for Medicare & Medicaid Services payment
guidelines to include all dental professionals serving in integrated setting using ICD-10 (International
Classification of Diseases, Tenth Revision); convene a group of medical and dental providers to streamline thecoding system to ICD-10 .
3 . Increase understanding of costs and financial needs for integration .
• Use quality improvement measures to assess the quality of care in the centers or facilities where integrated
care is offered .
• Determine gaps in local oral health systems and programs .
• Continue researching the cost of overall health care delivery due to poor oral health .

N. Policy actions for Focus Area 3: Health Systems Integration
1 . Encourage legislative efforts to integrate oral health into primary care .
• Promote data collection through APCD (see above) linking chronic disease outcomes codes—such as
emergency department or hospitalizations for diabetic crises—and dental codes utilization .
• Incorporate results into outcome-based payment systems and convince actuaries to include this ininsurance product pricing .
• Review and revise state statutes and rules to promote interprofessional collaboration, health informationexchange, care coordination, and positive health outcomes .
• End regulatory burdens for health systems, allowing advanced dental therapists to be incorporated into
medical settings medicine .
• Collaborate with partners to support and make recommendations on policies that promote oral health andmedical-dental integration to the Legislature .
• Continue to provide the information to the legislature about the necessity of Early Dental Disease
Prevention Initiative .

44

Focus Area 3: Health Systems Integration
2 . Connect oral health efforts in education and public health .
• Require all Minnesota schools to have a policy that recommends an oral health exam or assessment to fulfill
school entrance requirements .
• Legislatively mandate annual oral health screenings into childhood screenings .
• Include oral health issues and considerations in early childhood education, Minnesota’s Child and Teen
Checkups and WIC programs, schools, nursing facility/assisted living rules, and regulations for health facilities .
• Implement a continuing medical education requirement for medical providers about oral health and encourage
providers to lead improvements in oral health .
• Help local public health agencies identify ways to better serve patients in the community, share data, andcollaborate .

O. Workforce actions for Focus Area 3: Health
Systems Integration
1 . Build integrated teams .
• Support dental hygienists in collaborative practice
to serve as a referral hub for community patients .
• Integrate medical and dental into single clinicalteams .
• Cross-train medical and dental providers toincorporate key primary care medical and dental
assessments and referrals .
• Staff assistant dental therapists and dental
therapists and embed collaborative practicedental hygiene in medical clinics .

• Add dental hygienists to prenatal and primarycare visits .
• Strengthen inter-professional care coordination,
health information exchange and communication,and referrals .
• Work with school districts and community
partners to recruit diverse applicants for dental
and hygiene schools and other oral healthprofessional programs .
• Enhance primary health care facilities (especiallyrural) by establishing an oral health component atgood checks, sports and school physicals, etc .

2 . Train and educate .
• Train community health workers in fluoride varnish application, oral health risk assessment, and educating about
oral health .
• Train a wide range of community providers and caregivers in various settings to screen for oral health, provide
education and referrals, distribute toothbrushes, and encourage drinking tap water .
45

FOCUS AREA 4: DISABILITY,
SPECIAL CARE NEEDS, AND
INCLUSION

Focus Area 4: Disability, Special Care Needs, and Inclusion
VISION:

People with disabilities and special care needs maintain a lifetime of good oral health.
S T R AT E G Y:

Make oral health care accessible, safe, respectful, and timely
for all Minnesotans who seek it.

About 61 million Americans (26 percentof the population) have a disability.27

DEFINITION

People with disabilities are often thought of as one population type . Nothing could be further from the truth . Instead,this large segment of the population represents a wide range of abilities and needs . Minnesota’s State Oral Health Plan
discusses differences in care needs for individuals as a matter of fact, not to discriminate . Health Care providers takea person-centered approach to care delivery . For individuals with complex needs, person-centered care is critical for
overall well being and improved outcomes .

People with disabilities are more vulnerable to the impacts of the social
determinants of health and the complex U.S. health care system. Because of
these and other factors, it is imperative that the Minnesota State Oral HealthPlan spotlight the importance of person-centered care delivery.
The International Classification of Functioning, Disability, and Health (ICF) is the World Health Organization (WHO)framework for measuring health and disability at the individual and population levels .28 It is considered the international
measurement standard for disability and health . In the U .S ., the Centers for Disease Control and Prevention (CDC)
uses this tool . The ICF standardizes language for classifying body function, structure, activity, participation levels, andconditions in the world around us that influence health . Here, activity is defined as the execution of a task or action by
an individual, and participation as a person’s involvement in a life situation .
47

Focus Area 4: Disability, Special Care Needs, and Inclusion
R AT I O N A L E

ADA was born . The ADA ensures equal treatment andequal access to people with disabilities to employment
opportunities and public accommodations . The ADA
prohibits discrimination based on disability in employment,
services rendered by state and local governments,
places of public accommodation, transportation, andtelecommunications services . The passage of the ADA isa significant milestone; however, changes in attitudes are
not driven by legislation . Thirty years after the passageof the ADA, people with disabilities continue to facediscriminatory barriers . This includes discrimination inaccessing health care, including dentistry .

The Americans with Disabilities Act (ADA) became
law in 1990 . The ADA is a civil rights law that prohibits
discrimination against individuals with disabilities in allareas of public life, including jobs, schools, transportation,
and all public and private places that are open to thegeneral public . The purpose of the law is to make surethat people with disabilities have the same rights andopportunities as everyone else .29 By 1995, the Atlanta
Legal Aid Society brought a lawsuit to the U .S . District
Court for the Northern District of Georgia on behalf of
two women . Both women had developmental disabilities
and mental health diagnoses and had received services
in a state facility . These women did not have access tothe same services in the community, which resulted in
prolonged institutionalization . The case escalated to the
U .S . Supreme Court, who ruled in 1999 in favor of the
defendants . Olmstead v. L.C.30 is a civil rights victory for
Americans with disabilities; the unjustified segregation ofpeople with disabilities is a form of unlawful discrimination
under the ADA .31

In 2011, the US District Court for the State of Minnesota
adopted the Jensen Settlement agreement, which isintended to bring “significant improvements to the careand treatment of individuals with developmental and otherdisabilities in the State of Minnesota .”32 Then-Gov . Mark
Dayton issued Executive Order 13-01 in January 2013 .
The Minnesota Olmstead Plan was approved by the federal
court in 2015 . The Minnesota Olmstead Plan is revisedannually .

The Disability Rights Movement in the United States iscommonly associated with the Civil Rights Movement of
the 1960s . Although the federal Civil Rights Act of 1964
did not include people with disabilities, the groundwork
had been laid . It took 26 more years, but in 1990, theEfforts are underway across the state to create a state thatis better for everyone . To realize an inclusive Minnesota, it
takes intentional work . Public, private, nonprofit, and otherorganizations can team up with each other, communities,
and individuals .

48

Focus Area 4: Disability, Special Care Needs, and Inclusion
BEST PRACTICES• The International Classification of Functioning,
Disability, and Health (ICF) is the World HealthOrganization (WHO) framework for measuring
health and disability at the individual andpopulation levels .28 It is considered the international
measurement standard for disability and health .
In the U .S ., the Centers for Disease Control andPrevention uses this tool . The ICF standardizes
language for classifying body function, structure,
activity, participation levels, and conditions in theworld around us that influence health .
• The American Academy of Pediatric Dentistry’s
report, Management of Dental Patients with Special
Health Care Needs .
• Virginia Department of Health’s Special Health Care
Needs Oral Health Program .
• Special Olympics’ resource, A Caregivers Guide toGood Oral Health for Special Olympics Athletes .

• University of Washington School of Dentistry’s
resources for patients and health care professionals
on patients with special needs .
• National Institute of Dental and Craniofacial
Research’s information on development disabilities
and oral health .
• Special Care Dentistry Association—an internationalorganization of oral health professionals and otherindividuals who are dedicated to promoting oral healthand well-being for people with special needs .
• Video, CNA Essential Skills—Mouth Care .
• American Academy of Developmental Medicine &Dentistry—a non-profit membership organization ofinterdisciplinary health professionals committed to
improving the quality of health care for people withintellectual and developmental disabilities .
• Special Care Advocates in Dentistry—hosts an annual
seminar and other events on providing oral healthcare for people with special needs .

S T R AT E G Y A C T I O N S F O R F O C U S A R E A 4: D I S A B I L I T Y, S P E C I A L C A R E N E E D S, A N D
INCLUSION

The following actions are recommended for implementing Focus Area 4’s strategy: Make oral health care accessible,safe, respectful, and timely for all Minnesotans who seek it .

P. Clinical actions for Focus Area 4: Disability, Special Care Needs, and Inclusion
1 . Create an inclusive clinical environment .
• Ensure person-centered care delivery .
• Disseminate oral health care guidelines for people with disabilities to medical and oral health professionals .
• Promote clinics that are accessible for people with disabilities .
2 . Offer service delivery options .
• Encourage practices to engage in more telehealth visits for their patients with special health care needs .

49

Focus Area 4: Disability, Special Care Needs, and Inclusion
Q. Education actions for Focus Area 4: Disability, Special Care Needs, and Inclusion
1 . Teach and train .
• Promote continuing education programs to dental providers in treating people with disabilities and diverse populations .
• Promote culturally relevant training for non-dental providers on oral health topics such as daily care, oral-systemic
connections, etc ., for populations with special health care needs .
• Create hands-on community-based clinical experiences for treating people with special health care needs and diverse
populations .
• Participate nationally with organizations and partners demonstrating best and promising practices .
2 . Promote data use .
• Promote the use of modified “Special Needs Screening Questions” with school sealant program grantees to identify
children with disabilities .
• Collect, analyze, and make publicly available the following datasets: National Survey of Children’s Health and Behavioral
Risk Factor Surveillance System for oral health indicators by people with disabilities and mental illness status .

R. Finance actions for Focus Area 4: Disability, Special Care Needs, and Inclusion
1 . Fund efforts that increase capacity for inclusivity .
• Pilot projects and educational materials to improve the oral health of people with disabilities and special care needs .

S. Policy actions for Focus Area 4: Disability, Special Care Needs, and Inclusion
1 . Set expectations .
• Endorse and support initiatives that promote comprehensive oral health programs for people with disabilities andchildren with special health care needs .
• Promote a state mandate for all insurance coverage to be comprehensive for individuals with congenital/lifetime
disabilities, including dental benefits .
• Promote inclusion of oral evaluation in care guidelines for people with special health care needs .
• Enhance and promote regional public and private collaboration to serve adults with special needs .
• Engage with members of disability communities .

T. Workforce actions for Focus Area 4: Disability, Special Care Needs, and Inclusion
1 . Build capacity and awareness .
• Develop and promote oral health education and culturally relevant materials for caregivers and providers .
• Partner with people with disabilities and special needs to train medical providers, direct support professionals,
residential leadership, and others involved in others’ care about the relationship of oral health to total health .
• Train and support dental therapists and collaborative practice dental hygienists to provide services to people withspecial health care needs in their most accessible setting .

50

FOCUS AREA 5: DATA

Focus Area 5: Data
VISION:

Oral health infrastructure is data-driven and the diversity of stakeholders are
consistently well-informed to address oral health needs.
S T R AT E G Y:

Share oral health data and indicators to inform data-driven strategies and actions.

DEFINITION

Data, measurement, surveillance tracking refers to primary and secondary data collection, analysis, and dissemination
through the Minnesota Oral Health Surveillance System (MNOHSS) . It also includes oral health and related data
available at the county, state, and federal levels .
R AT I O N A L E

Monitoring the status of oral disease in a state’s population is essential for setting achievable objectives and planning,
implementing, and evaluating public health programs . It is also important to illustrate the burden of oral disease and gain
support and funding for the state oral health program .
Data-driven decision-making is a process of formulating key questions, collecting and analyzing data, communicating
results to decision-makers, and refining processes, organizations, or systems . It leads organizations to act on evidence
than opinions or intuition . Moreover, it encourages organizations to be proactive in transforming data into knowledge
and actions instead of passively reporting data for compliance reasons . Becoming data-driven is also a process; theorganization begins its journey with a conceptual framework, such as a theory of change, a situation analysis, outcomeschain, or a logic model . Stakeholders then source and/or create and then prioritize performance measures or indicatorsthat align with the conceptual framework . Combined, this foundation informs data to collect, questions to ask, andactions to driven by interpretation .
Data sharing in data-driven decision-making benefits programs as it helps staff and providers understand populationneeds, inform performance, monitor progress, and improve . It also benefits people accessing services and care by making
it easier for individuals and families to navigate complexity and it supports appropriate and coordinated services . Datasharing agreements between departments and stakeholder groups ensure that information is securely and responsibly
exchanged . Data-driven organizations need to build capacity to understand the needs for and use of data and how tocollect it in an appropriate and timely manner . Leadership and people “championing” data-driven decision-making are
essential to building capacity, as are training, technology, data collection tools, use of secondary data sources, efficiency
strategies, and analysis and reporting skills . Collaboration, critical thinking, and communication are also essential for theorganization and/or group of stakeholders to be data driven .33

BEST PRACTICES• Minnesota Oral Health Surveillance System (MNOHSS)• MDH CDC Grant Surveillance Plan
• CDC Data and Statistics

52

Focus Area 5: Data
S T R AT EG Y AC T I O N S F O R F O C U S A R E A 5: DATA

The following actions are recommended for implementing Focus Area 5’s strategy: Share oral health data and indicators to
inform data-driven strategies and actions .

U. Clinical actions for Focus Area 5: Data
1 . Collect, share, use, and maintain data .
• Utilize Basic Screening Survey of third graders to provide school-linked sealants .
• Seek opportunities for primary data collection .
• Clinics share aggregate clinical data on fluoride varnish application and sealant .
• Promote a statewide Fluoride Varnish Registry with dental and non-dental providers .
• Dental hygienists file claims for risk-assessment and school sealants programs .
• Use oral health data to promote fluoride varnish application during well-child visits .

V. Education actions for Focus Area 5: Data
1 . Make educational resources relevant and accessible .
• Publish Minnesota oral health data and surveillance activities in peer-reviewed journals .
• Present Minnesota oral health data and MNOHSS activities at the national, state, tribal, and local levels .
• Develop data-driven educational and promotional material for diverse populations, considering their health literacy needs .
• Plan and prepare scheduled updates of MNOHSS, the Burden of Oral Disease in Minnesota Report, the MDH
Chronic Disease Dashboard, MDH Quick Facts, and other data-related communication materials .
2 . Model equity .
• Promote the use of oral health data to address oral health equity issues .
• Encourage the use of oral health data to develop age and diverse population-specific projects and programs .
• Update MNOHSS plans: surveillance; data management, evaluation, and communication .
3 . Build capacity .
• Train stakeholders on data security, confidentiality, and quality control measures as well as how to monitor andrespond to data requests .
• Promote the importance of and train on the use of oral health data and MNOHSS .
• Develop and promote the use of an oral health data measures guidebook .
• Annually convene the MNOHSS Advisory Group .

W. Finance actions for Focus Area 5: Data
1 . Secure funding .
• Explore opportunities to fund the development (staffing, technology) of a Fluoride Varnish Registry and its continued
maintenance .
• Ensure continuous funding for the enhancement and maintenance of the oral health surveillance system to assess theburden of oral disease .
• Find funding needed to increase data sharing with and among clinics .
2 . Use data .
• Integrate MNOHSS into existing grants and funding opportunities .

53

Focus Area 5: Data
X. Policy actions for Focus Area 5: Data
1 . Identify and fill gaps in data .
• Review and synthesize oral health data measures at the national, state, tribal, and local levels to ensure uniform
and consistent data collection practices and standards .
• Ensure oral health data quality and inclusivity of diverse populations .
• Collect and report on oral health data of diverse populations, spatial data, data that identify health disparities,
and data useful for program and policy purposes .
2 . Build capacity .
• Recommend an oral health data needs assessment every four years .
• Provide technical assistance to partners to develop needs-based measures and assessments .
• Demonstrate how to make data-driven, evidence-based decisions .
3 . Educate .
• Develop materials using current data to increase awareness in thelegislature about the oral health issues .

Y. Workforce actions for Focus Area 5: Data
1 . Collaborate .
• Engage key workforce stakeholders to identify and pursue datacollection opportunities, prioritize datasets, promote oral health data findings, and determine MNOHSS
quality improvement initiatives .
• Develop and maintain collaboration and data-sharing agreements with data stewards; specifically, acquire,
analyze, and interpret data together .
2 . Build capacity .
• Ensure staffing for the maintenance and expansion of MNOHSS .
3 . Collect data .
• Develop and track oral health surveillance system performance measures .
• Count and track the number of dental hygienists who have developed a collaborative agreement with a dentist
and dental therapist with a collaborative agreement .
A D D I T I O N A L S T R AT EG Y AC T I O N S A R E L I S T E D I N A P P E N D I X: F O C U S A R E A 5:
A D D I T I O N A L S T R AT EG I E S A N D AC T I V I T I E S (P G 65).

54

FUTURE DIRECTIONS

Future Directions
MDH officially launched the State Oral Health Plan for
2020–2030 during the Minnesota Oral Health Coalition’sannual conference in 2020. MDH Oral Health Program
partners will identify experts in priority areas and collaboratein the development and execution of action steps.
To ensure sustainability and create collective impact, the MDH Oral Health Program will act as
the backbone organization and be responsible for the coordination, communications, roundtables,and evaluation of the outcomes of this Plan . It will also maintain communications and strengthen
collaboration with current oral health partners, safety net clinics, rural oral health workgroups, caresystems, schools, diverse ethnic community centers, and oral health advocates .
This Oral Health Plan is the convergence of yearsof experience, committed and devoted partners,
creativity, fierce determination, an unmistakablecall to service, and the pledge to continuous
improvement .
The publication of this second State Oral HealthPlan signals the path forward . The MDH Oral
Health Program has strong partnerships . Leveraging
these to add additional experts, policy makers,
funders, and other stakeholders is critical for thedevelopment and execution of these action steps .
To ensure cohesion and collective impact, the
MDH Oral Health Program will play the role ofbackbone organization, responsible for coordination,communications, roundtables, and evaluation of theinitiatives and outcomes of this Plan .
An area that was particularly mentioned in theprevious evaluation was to have a dedicated groupof professionals whom identifies and implement
strategies about populations in rural areas as theneeds and challenges of those populations aredifferent from the urban populations . Therefore,
MDH intends to explore the opportunity ofseeking guidance from the Rural Health Advisory
Committee’s working group on oral health . This
group was formed to assess oral health outcomesand services in rural Minnesota and presented thereport Strengthening the Oral Health System
in Rural Minnesota . MDH will also reach out toother rural health advocates to discuss avenues forcollaboration .

E VA L U AT I O N

MDH has more than a decade of oral health project
evaluation experience, including the evaluation of theprevious Minnesota State Oral Health Plan . A specificevaluation plan for the State Oral Health Plan 2020-2030
is forthcoming . MDH intends to convene an evaluation
advisory committee and use a modified version of the State
Plan Index to assess the quality of the Plan .
Through our existing partnerships with local, state, andnational organizations such as the CDC and ASTDD, theMDH is well-positioned for Plan’s evaluation .
In the current milleu of a global pandemic, adaptation,
creativity, and grace will be key ingredients in project
evaluation, notably in how these listed Plan efforts areevaluated .

The MDH Oral Health Program,stakeholders, and communities haveworked together to advance the oral
health of all Minnesotans.
Remarkable dental public health milestones have beenreached . Yet we must strive for more . The ideals expressedin this Plan look at known problems to solve and look ahead
to innovation . Creativity, flexibility, and inclusive excellence
are necessary ingredients in our path forward . This Plan
seeks to unite public health and dental access for all whocall Minnesota home . No doubt there are challenges ahead .
We are confident we can solve them, together . MDH looks
forward to collaborating for collective impact!

56

How to move forward
The essential inputs for improving oral health in Minnesota are sustained funding, supportive legislative environment, androbust oral health infrastructure and data system. With these in place, a strong coalition of stakeholders is critical to program
success.
With the Minnesota State Oral Health Plan for 2020–2030 now in place, stakeholders will:• Develop work plans to implement the strategies;• Create a shared measurement system to track success and opportunities for improvement;• Identify, develop, and coordinate additional partnerships and collaborations;• Distribute, present on, and discuss the plan to increase awareness of the work ahead; and• Develop and sustain oral health surveillance system.

Outcomes
Implementing the strategies of the Minnesota State Oral Health Plan for 2020–2030, Minnesota will experience thefollowing changes over time:
S H O R T-T E R M O U TCO M E S• Stakeholders are more effective in addressing oral health issues.
• Increased leveraging of resources through partnerships, collaboration, and coalitions.
• Providers have increased knowledge and awareness of integrated medical-dental care.
• Dental and medical professionals train together more often.
• The Plan is disseminated to diverse state and national agencies.
• The Plan is shared with policy makers and oral health advocates.
• The Plan is updated based on the public comments• Roundtables are convened with key stakeholders.
• Dialogue for oral health promotion is fostered.
I N T E R M E D I AT E O U TCO M E S• Policies and standards sufficiently bolster oral health improvement efforts.
• Collaborative practice is more widespread and expected.
• Preventive dental services are used more frequently and evenly across populations, especially in children andunder-served populations.
• There is a reduction in emergency room visits for dental reasons.
• Improved collaboration and communication among oral health partners.
• Improved data sharing leading to data-driven decisions.
• Improved awareness of population oral health and preventative dental services.
• Improved landscape for sustainability and expansion of dental public health infrastructure.
• Improved system level changes for medical-dental integration.
LO N G-T E R M O U TCO M E S• Oral health services are highly accessible and affordable to priority populations (low-income, under-insured anduninsured, and people with disabilities).
• Oral health is improved (reduced tooth decay) equitably across populations.
• Increased proportion of local health departments implementing oral health prevention programs.

57

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with Disabilities in the Most Integrated Setting: Community Living andOlmstead. https://www.hhs.gov/civil-rights/for-individuals/special-topics/
community-living-and-olmstead/index.html
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Using Data to Inform Practice and Policy Decisions in Child Welfare
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Bulletin. Retrieved from Center for Medicaid & CHIP Services: https://www.
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childrenyouth/ctc/fluoridevarnish.html

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Oral Health in America. https://www.cdc.gov/oralhealth/publications/sgr2000_05.htm
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American Academy of Developmental Medicine & Dentistry. https://www.
aadmd.org/

Centers for Medicare and Medicaid Services’ measure inventory. https://cmit.
cms.gov/CMIT_public/ListMeasures
Best Practice Approaches. https://www.astdd.org/best-practices/
CDC’s Framework for Comprehensive Oral Health. https://www.cdc.gov/
oralhealth/state_programs/infrastructure/a3_framework.htm
10 essential public health services. https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html#:~:text=The%2010%20
Essential%20Public%20Health%20Services%20describe%20the,and%20
quality%20of%20personal%20and%20population-based%20health%20services
State oral health infrastructure and capacity: Reflecting on progress andcharting the future. https://www.astdd.org/docs/infrastructure-enhancementproject-feb-2012.pdf
Policy frameworks supporting school-based dental sealant programs. https://www.networkforphl.org/resources/policy-frameworks-supporting-school-baseddental-sealant-programs/

Special Care Advocates in Dentistry. https://www.saiddent.org/
Minnesota Oral Health Surveillance System (MNOHSS). https://data.web.
health.state.mn.us/oral-health
MDH CDC Grant Surveillance Plan. https://www.cdc.gov/datastatistics/index.
html
CDC Data and Statistics. https://www.cdc.gov/datastatistics/index.html
Strengthening the Oral Health System in Rural Minnesota. https://www.health.
state.mn.us/facilities/ruralhealth/rhac/docs/2018ruraloral.pdf
State Plan Index. https://www.cdc.gov/pcd/issues/2005/apr/pdf/04_0089.pdf
ASTDD. https://www.astdd.org/evaluation-and-quality-improvement/
https://www.cdc.gov/brfss/index.html

59References (cont…)
https://mn.gov/dhs/people-we-serve/adults/health-care/health-care-programs/
https://mn.gov/dhs/partners-and-providers/news-initiatives-reportsworkgroups/minnesota-health-care-programs/dental-committee/
https://www.who.int/standards/
https://www.cdc.gov/visionhealth/vehss/data/national-surveys/national-surveyof-childrens-health.html#:~:text=Iris%20Registry%20%20%20%20%20%20,%2095%2C000%20people%20%201%20more%20rows%20

60

APPENDIX

Medicaid Barriers
Minnesota Health Care Programs (MHCP), including Medical
Assistance (or Medicaid), the Children’s Health Insurance Program(CHIP), and Minnesota Care, are programs designed to provide low or
no-cost insurance to Minnesotans and can help partially address someof the financial constraints individuals may be experiencing . However,
coverage through MHCP does not fully address the access issues in
Minnesota . Over half of Minnesota counties are designated Dental
Health Professional Shortage Areas (Dental-HPSAs), indicating a lackof accessible dentists in these areas . In addition to an already constrained workforce, many dentists face administrative
barriers to accepting MHCP patients, limiting options . These factors may speak to the current underutilization of
Medicaid benefits .

“To improve access, provider reimbursement for Medicaid needs
to be like commercial patients. This is the only way the accessissue will be improved. The current provider reimbursement
structure is promoting discrimination for our state’s mostvulnerable populations. — Stakeholder 6

During the Federal Fiscal Year (FFY) 2018, only 4 out of 10 Minnesota Child and Teen Checkups (C&TC) Eligible
children aged 1 to 20 years (42 percent) had at least one dental service . Only 38% of Children, Age 1-20, enrolled in
Medicaid for at least 90 continuous days, received a preventive dental service during this time . Although not directlycomparable, 81 percent of children in Minnesota aged 1 to 17 years had at least one dental visit in 2016 . This prevalence
data comes from a web/mail-based survey (National Survey of Children’s Health) of parents and guardians .
In 2018, 36% of Minnesota Health Care Program (MHCP) enrollees received at least one dental service . MHCP
enrollee dental service use remains relatively unchanged over time (2017 = 32 .4%, 2016 = 31 .0%, 2015 = 32 .4% and2014 = 33 .7%) .
In 2020, the COVID-19 pandemic has proved an additional barrier to accessing care . Dental offices in Minnesota were
temporarily closed by order of the Governor to limit the spread of COVID-19 . Communities facing some of the mostconsiderable barriers to oral health care are the same as those most at risk of complications from COVID-19, including
older adults, people of color, people with disabilities, and low-income adults and children . This pandemic has made clear
the many disparities in oral health and underscores the importance of equity in improving oral health .

62

Strategies specific to Minnesota Health Care Programs (MHCP)
Medicaid provides health coverage to millions of Americans, including low income eligible adults, children, pregnant
women, elderly adults, and people with disabilities . Medicaid is administered by states, according to federal
requirements . Medicaid is funded jointly by states and the federal government .34
In the 2018 federal fiscal year, Medicaid accounted for about three percent of the federal Gross Domestic Product(GDP) . In Minnesota, Medicaid is known as Medical Assistance (or, MA) and the largest health care program in thestate . CHIP, the federal Children’s Health Insurance Program, is administered in Minnesota congruously with Medicaid .
This program is jointly funded by states and the federal government . In Minnesota, the Department of Human Services
is the state’s Medicaid administrator, and CHIP is administered congruously with MA . Minnesota Care is Minnesota’s
Basic Health Plan (BHP), which provides low-cost health insurance coverage to working families with income at or
above 138 percent federal poverty level (FPL) . Together, MA and Minnesota Care are called Minnesota Health Care
Programs (MHCP) . Eligibility criteria must be met in order to qualify for these benefits . Non-pregnant adult dental
benefits are optional for states to provide . This can be interpreted by some to mean “non-essential” health coverage .
States who choose to provide this optional benefit have flexibility . In the MN Medicaid program, the non-pregnant
adult dental benefit is considered “limited”, which is defined as a benefit set inclusive of up to 100 CDT (Current Dental
Terminology) codes . Minnesota Statute and Rule delineate which services are included, as well as the methodology
for calculating reimbursement rates for those services . Increases to the number of CDT codes covered, or the rate ofreimbursement for those services, require action by lawmakers . It is important to note that Medicare (federal healthinsurance for older adults and certain other criteria) does not include a traditional dental benefit .
Under the Affordable Care Act, Minnesota became a Medicaid expansion state in 2014, increasing the upper-income
limit for Medicaid eligibility to 138 percent of the FPL . The expansion also meant more options for low-income
Minnesotans whose income surpasses 138% FPL but is at or below 200% FPL . Minnesota Care fills this coverage
gap, as the states’ Basic Health Plan (BHP) .34 Coverage for Minnesotans enrolled in Minnesota Care, with eligibility
income limits of 138–200 percent of the FPL, resulted in a 22 percent increase in MHCP enrollment, but not a parallel
increase in MHCP dental providers .
As of 2015, Medicaid insured about 24 percent (about one million) Minnesotans per month . In the same timeframe,
about five percent of Minnesotans were uninsured . The rest of Minnesota’s population held private
insurance . Uninsured rates are higher than the state average in the metro, central
Minnesota, and southwestern Minnesota . Disparities also exist for race and ethnicity
among people who identify as American Indian, Hispanic, Black, and multiracial, who
are more likely to be uninsured than the general population . The uninsured rate ofAmerican Indians is more than four times the state average . Strategies specific to
MHCP are:63

Clinical
1 . Connect patients with oral health services .
• Ensure that children insured by Medicaid andCHIP receive dental care annually and have adental home .
• Develop best practices for oral health within
facilities and residences, including congregate
living, sheltered workshops, long term care, andcorrectional .

Education
1 . Educate dental professionals .
• Teach the basics of Minnesota’s Medicaid dental
benefit, such as how benefits and rates are set,
the federal-state cost sharing, and the role ofthe Minnesota Department of Human Services
as the Medicaid administrator .
2 . Educate the public .
• Engage the public and the private dental
community to identify and address barriers
to participation in publicly funded healthprograms .

Finance
1 . Improve reimbursements .
• Add dental hygiene screenings and assessments into the benefits set .
• Advocate for increased provider reimbursement across MHCP .
• Incorporate reimbursement policies which exist in medicine for dental (e .g ., pay for complexity) .
• Promote reimbursement that shares risk and rewards for improved health outcomes, such as value based care .
• Increase MHCP reimbursement for parental education and services .
• Participate in national efforts for revisions to CMS payment guidelines .
• Include oral health into Accountable Care Organization contracts .

$64

Policy
1 . Adjust benefits and coverage .
• Ensure optimal / tailored benefits for adults with disabilities and special care needs .
• Support comprehensive dental benefit for seniors enrolled in MHCP .
• Change state statute to add dental sealant placement on deciduous teeth and permanent premolars forchildren at high risk of oral disease .
• Align the MHCP dental benefit with evidence-based dentistry, standard clinical practice, and incentivize preventive care .
• Change MHCP policy so that benefits include screenings and assessments .
• Encourage MHCP to reimburse for fluoride varnish application for non-pregnant adults with the same policy
as for children and pregnant women .
2 . Increase eligibility .
• Ensure adequate funding and encourage eligibility of seniors to have access to oral health insurance coverage .
3 . Make it easier .
• Utilize and enforce the DHS purchasing power to leverage providers (rule 101) .
• Promote dentists using ICD-10 codes, including the ability to bill for time for complex patients and/or
procedures .
• Simplify the application, enrollment and claim submission processes for dentists, dental therapists, and dental
hygienists to reduce administrative barriers to Medicaid participation .

Workforce
1 . Increase program participation .
• Work with oral health professionals to create feasible solutions for increased program participation by all oral
health providers across Minnesota .
• Develop an accountability system that makes provider participation public .

65Minnesota Oral Health Action Plan (2020-2030)
Focus Area 5: Additional Strategies and Activities
Goal: Increase the use of oral health data and the Minnesota Oral Health Statistics System(MNOHSS) to inform activities, programs and policies.
Strategy 1. Strengthen the Minnesota Oral Health Statistics System (MNOHSS).
•
•
•
•
•
•
•

Activity 1.1. Integrate MNOHSS into existing grants and funding opportunities.
Activity 1.2. Promote the importance of oral health data and MNOHSS with key
stakeholders.
Activity 1.3. Develop and maintain data sharing agreements with data stewards.
Activity 1.4. Acquire, analyze data and interpret the results in collaboration with data
stewards and other stakeholders.
Activity 1.4. Ensure staffing for the maintenance and expansion of MNOHSS.
Activity 1.5. Monitor and respond to data requests.
Activity 1.6. Maintain and implement updates to the MNOHSS Surveillance Plan, the
MNOHSS Data Management Plan, the MNOHSS Evaluation Plan and the MNOHSSCommunication Plan.

Strategy 2. Collaborate with key stakeholders to identify and pursue data collection
opportunities, prioritize datasets, promote oral health data findings and determine MNOHSS
quality improvement initiatives.
•
•
•
•
•

Activity 2.1. Conduct an oral health data needs assessment every four years.
Activity 2.2. Develop and maintain collaborations with data stewards.
Activity 2.3. Seek opportunities for primary data collection.
Activity 2.4. Develop and track oral health surveillance system performance measures.
Activity 2.4. Convene the Minnesota Oral Health Statistics System Advisory Groupannually.

Strategy 3. Ensure oral health data quality and inclusivity of diverse*populations.
••

Activity 3.1. Seek opportunities to collect and report on oral health data of diverse*
populations, spatial data, data that identifies health disparities and data useful for
program and policy purposes.
Activity 3.2. Uphold data security, confidentiality and quality control measures.

Strategy 4. Establish an MDH fluoride varnish registry.
•

Activity 4.1. Seek and apply to funding opportunities to establish and staff a fluoride
varnish registry.

MINNESOTA ORAL HEALTH ACTION PLAN

•
•
•
•

Activity 4.2. Develop platform elements of the fluoride varnish registry.
Activity 4.3. Build an online fluoride varnish registry.
Activity 4.4. Promote fluoride varnish registry with dental and non-dental providers.
Activity 4.5. Maintain fluoride varnish registry.

Strategy 5.0. Develop standardized methods to collect local-level oral health data.
•
•
•
•
•
•

Activity 5.1. Review oral health data measures collected at a local-level (e.g. community
health assessments).
Activity 5.2. Review of oral health data measures collected at the national, state andtribal levels.
Activity 5.3. Synthesize oral health data measures at the national, state, tribal and local
levels to ensure uniform and consistent data collection.
Activity 5.2. Develop an Oral Health Data Measures Guidance document.
Activity 5.3. Promote Oral Health Data Measures Guidance document with partners.
Activity 5.4. Provide technical assistance to partners to develop needs-based measuresand assessments.

Strategy 6. Disseminate oral health data to key stakeholders.
•

•
•
•

Activity 6.1. Plan and prepare scheduled updates of the Minnesota Oral Health Statistics
System (on the MN Data Access Portal), the Burden of Oral Disease in Minnesota
Report, the MDH Chronic Disease Dashboard, MDH Quick Facts and other data-related
communication materials.
Activity 6.2. Provide stakeholder training opportunities on use of the Minnesota Oral
Health Statistics System.
Activity 6.3. Seek opportunities to publish Minnesota oral health data and surveillance
activities in peer-reviewed journals.
Activity 6.4. Seek opportunities to present Minnesota oral health data and MNOHSS
activities at the national, state, tribal and local levels.

*Diverse in this document refers to any individual, family, caregiver or community that self
identifies or represents the following population groups: children (aged 0-17), pregnant or
expectant mothers, young adults (aged 18-25), older adults (aged 65+ years), the homeless,rural residents, low-income, uninsured or underinsured, people of color and American
members of Lesbian, Gay, Bisexual or Transgender communities immigrants and refugees,
people with Limited English Proficiency (LEP), people with disabilities, mental illness, chronic
disease and other special health care needs. Please note that this is not an exhaustive list ofdiverse population groups and we acknowledge all forms of identity and lived experience.

2

Emerging findings from community input on Minnesota oral
health strategic planning (full summary)
The Minnesota Department of Health (MDH) surveyed its stakeholders in 2019
to refine priority areas and goals for improving oral health throughout the state.
The following are results from 214 respondents.
Access to dental care is the top-cited topic of importance to stakeholders . Survey respondents first indicated which
topics were important to them and could select more than one . Two hundred (93%) of the 214 respondents selected“access to dental care .”Topic

Percentage and numbers of survey respondents
who selected the topic as importantAccess to dental care

93% (n=200)

Integrating medical care and dental care

68% (n=146)

Sustaining and expanding existing dental public health56% (n=120)

Commitment to diversity and inclusion, including disability rights
and oral health for people with special health care needs

44% (n=95)

Tracking and surveillance of oral health trends and data in Minnesota

39% (n=83)

The survey then asked two open-ended questions, “Why are these topics important to you or the state of Minnesota?”
and “What are some of the oral health challenges or barriers you would like to see addressed in a state oral healthplan?” The findings from stakeholder responses are as follows . However, because of the similarity and open-ended
nature of the survey questions, many of the responses to one question answered both; they spoke to the complexityof the problem and barriers to addressing it, and the urgency of improving oral health . Also, some responses lacked
specificity or clarity to be clearly grouped into whether something is important or is a barrier or a challenge . Therefore,
interpretation of these findings is important as it will help to better clarify the focus for the upcoming strategic plan .
Nonetheless, several themes from the stakeholder responses emerged to inform improvement to oral and dental
health in Minnesota . In summary, the lack of access to dental care is rooted in structural inequities . Impeding a healthy
Minnesota is the low reimbursement rate to oral care providers who treat people on Minnesota’s dental coverage plans,
thus creating a disincentive to taking patients on the State’s Plan . Additionally, stakeholders are concerned about the“siloing” or lack of aligning dental and medical care, both in terms of health care as practiced and health insurance
coverage . Stakeholders see a need for increasing understanding and awareness about the importance of oral health andoral health practices, especially preventative care . These findings described further in the following pages, presented inorder of the highest frequency in the dataset, and illustrated by selected stakeholder responses from the survey .
68

LOW AC C E S S TO D E N TA L C A R E I S T H E R E S U LT O F A S Y S T E M I C I N E Q U I T Y A N D H A S
P E R VA S I V E I M PA C T S .

The lack of access to dental care is rooted in systemic inequities that discriminate populations who are on Minnesota’s
dental coverage plans. Stakeholders are concerned that oral health issues will persist, especially among marginalized
populations, if the problem is not addressed. Costs and limited coverage, even for people with insurance, are prohibitiveto accessing appropriate care and lead to people forgoing the care they need.

As one stakeholder stated,“Access to dental care has become a privilege of higher income groups. It is expensive if you don’t have good dental
insurance. If you have state insurance, the benefits are terrible, and most clinics will not take you because they don’t
get paid enough.”
And another stakeholder commented,“We continue to have significant disparities in quality oral health care in those with complex health needs anddisabilities due to access barriers including low reimbursement and an inadequately trained dental workforce to carefor these individuals who are rapidly growing in numbers.”
As for impacts, one stakeholder wrote,“We see people in our emergency room with dental problems because there isn’t a dentist available on weekends or
because they can’t get an appointment on a short notice. This is inappropriate use of emergency room visits andmedical dollars.”“

And another stated,

Patients who are not seen regularly have higher rates of periodontal disease,caries, and fractured or broken teeth. This translates to poorer overall health.
Many stakeholders commented on the cost-prohibitive access to care, such as,“People are not getting the oral care they qualify for and are delaying treatments based on costs.”
And“Working with individuals with limited income on medical assistance it has been very difficult to get them theoral health care they need, and when they get into a dentist it ends up costing them a lot of money that they
don’t have to get things fixed, all because it took too long for them to get into a dental clinic .”69

R E I M B U R S E M E N T R AT E S A R E LOW, D I S I N C E N T I V I Z I N G O R A L C A R E P R OV I D E R S TO
T R E AT P E O P L E O N M I N N E S OTA’S D E N TA L COV E R AG E P L A N S.

The low reimbursement rate, a key part of the inequitable system, disincentivizes oral care providers from treating peopleon Minnesota’s dental coverage plans . Providers limit the number of or refuse patients on these plans altogether .

A stakeholder commented,“We have worked hard over the past several years. We bring it so far, then run into some form of a barrier. Mostoften, it is local dentists who deny people care, or waiting lists for those who do accept [Medical Assistance (MA)].
We must continue to look at different models.”
And another wrote,“To improve access, provider reimbursement for Medicaid needs to be similar to commercial patients. This is the only
way the access issue will be improved. The current provider reimbursement structure is promoting discrimination forour state’s most vulnerable populations.”
Referring to the relationship between private and public plans, one stakeholder wrote,“Access needs to be improved, reimbursement for dental needs to be evaluated, more services need to be coveredby [Department of Human Service (DHS)]. As the [Managed Care Organizations (MCO)] follow the DHS feeschedule, it all starts with the State.”
This systemic issue is more pronounced in rural areas and further compounded by a shortage of dentists in greater
Minnesota . Should they find a provider—and one that see patients on Minnesota’s dental coverage plans—patients inrural areas often travel up to three hours to receive care . The hardship in finding a local provider means that patients
must coordinate and pay for travel if they do not have their own transportation, and need take significant time off fromwork or other commitments to receive dental care .

“I work in public health where I see multiple children with dental decay who haveno access to dental care within driving distance. These are people who do nothave their own cars, extra money or ability to take time off from work to travel
up to 70 miles to see a pediatric dentist who will see children of all ages.

70

S E PA R AT I O N O R L AC K O F A L I G N M E N T O F D E N TA L C A R E A N D M E D I C A L C A R E
I M P E D E S O V E R A L L H E A LT H , E S P E C I A L LY A M O N G V U L N E R A B L E P O P U L AT I O N S .

Stakeholders frequently mentioned that the “siloing” of dental and other medical care and its insurance coverage is aproblem and that unmet needs in dental care exacerbate other health care needs, lowers quality of life, and increased
costs. Better alignment of both medical and oral care, as well as insurance coverage for both, would not only improvehealth care and its outcomes, but reduce costs over time.

As one stakeholder stated,“Research is showing that there are more and more systemic issues and illnesses that have a direct link to oral
health conditions.”
Another generalized,“Dental health IS part of medical health, as is vision, hearing and mental health.”
One stakeholder comment:“

Oral health can impact a patient’s quality of life, how they manage daily necessities.
Not having access to dental care, for ANY reason, not only negatively impacts thepatient, but those around them in a myriad of ways.
Illustrating the disconnect between oral and overall health, a s stakeholder observed,“Dental health is often not prioritized, especially for populations who already experience health disparities andinequities. I work with individuals with serious mental illness, which is a population that is especially underserved
and ignored regarding oral health.”
This siloing and the resulting lack of dental care is believed to negatively impact children and other vulnerable
populations, especially people from low-income backgrounds. If there is a lack of dental care access, children’s
preventative habits and dental health are impeded, which leads to cascading negative effects on their dental andoverall health over time. Additionally, preventative habits and access to early and ongoing dental care saves money inthe long run.
A stakeholder observed,“I work with individuals who are of low-income and see how desperate some of them are to get dental work and ageneral cleaning done but can’t find a provider in their community to complete the work.”
And another wrote,“As a safety net pediatric clinic, we frequently see the devastating effects of inadequate oral health resources andaccess among our patients, especially low-income children and children of color.”
Likewise, a stakeholder commented,“People with special needs tend to not have the best insurance therefore there are not many options for them. They canalso have a hard time at the dentist and may need to have more options available to them than the general public.”71

D E N TA L C A R E I S N O T A S VA L U E D A S I T S H O U L D B E .

Dental care outcomes are also affected by a lack of awareness, understanding, and valuing of the dental care and how itinterrelates with overall health. Stakeholder cited the need to raise awareness and understanding about the importanceof oral health and oral health practices, especially preventative care.

As one stakeholder wrote,“Education is huge. A large portion of the population does not see the importance of routine preventive dental
services, creating the need for immediate dental visits as well as [emergency department] visits for dental.”
Another commented,“We get so focused on access to care (which is VERY important), but I see a lack of VALUE in many patients thathave access to care and do not utilize it. This is very frustrating for those of us in health care.”
One stakeholder described the benefit of greater understanding, stating,“If people understand that dental care is part of medical care, parents may be more compliant with seeking care for
their children and long-term care facilities may have better plans for dental care.”

OPEN-ENDED RESPONSES

There were 71 responses to the final, open-ended question on the survey. While these responses varied, half wererecommendations and a small group of responses showed appreciation for being invited to share input on the state
plan. For example, one stakeholder wrote,“Thank you for conducting this survey. It is much needed and there are so many wonderful things that are donethat just need streamlining and support. So, thank you!”
Recommendations included ways to improve services, adopting or adapting models, and encouraging partnering/collaboration, as well as increasing data and information sharing.
Specific recommendations related the emerging findings discussed in this report included:“Using dental navigators or community health workers to help patients access services is a model that works andneeds more research.”“Build further capacity within safety net settings, reimbursing things like community health workers, carecoordination, transportation assistance, and such.”“I would like to see more traveling dental clinics for our area-there is no one covering us. I would like to suggest
we take dentists that are in school, when they have their practicum, to travel to the rural areas, gain some
information/training for the field and assist the dental world for the rural people.”“MDH should help convince funders to better support not just service delivery projects, but development,
implementation, and evaluation of new and better care models.”72

Minnesota ranked 5th among states with the lowest
percentage of children under age 6 receiving atleast one dental service in 2016. 3•

1. US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, US Public
Health Service. Oral Health in America: Report of the US Surgeon General. NIH publication no. 00-213. Washington, DC:
DHHS, NIDCR, USPHS; 2000.
2. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G et al. Trends in oral health status: United States, 19881994 and 1999-2004. National Center for Health Statistics. Vital Health Stat 11(248). 2007.
3. Centers for Medicare and Medicaid Services. Early and Periodic Screening, Diagnostic, and Treatment. FY 2016 Data.

References• EDDPI is solely funded through the State of Minnesota.

Funding

EDDPI also institutionalizes the core values of the American
Academy of Pediatrics and the American Academy of Pediatric
Dentistry to promote early dental intervention.

• Uses a dynamic combination of community-based social
marketing principles to educate the target population andempower them to improve the oral health of infants andtoddlers.

• Stresses the notion that early dental disease starts
prenatally and is most effective in first three years of life.

• Focuses on preventing dental disease in underserved
children up to three years of age.

• EDDPI is geared toward communities of color, ethniccohorts, recent immigrants and Minnesotans with limited
English proficiency and health literacy.

“To increase awareness among communities ofcolor and recent immigrants on the importance ofearly preventive dental intervention for infants andtoddlers before and after primary teeth appear.”

The State of Minnesota enacted legislation in 2015 creating
the Early Dental Disease Prevention Initiative (EDDPI), led by
the Minnesota Department of Health. The legislation’s purpose
is:PurposeIn 2016, less than 30% of Minnesota children aged
0-5 years enrolled in Medicaid for 90-continuousdays received their recommended annual dental
visit.3

Many children in Minnesota do not receive preventive dental
care, which disproportionately affects immigrants, people ofcolor and low-income families.

••

Early childhood caries (ECC) is the most common chronicchildhood disease.1, 2•

Background

Develop a “prenatal to three” model and fund 15
pilot projects to test the efficacy of different
preventive interventions and incentives aimed at
encouraging proper cleaning techniques and early
dental care.

•

More than fifty new partnerships were developed and 15 county
hubs for oral health promotion were established.
Approximately 200 nursing students were trained to provide
fluoride varnish application and oral health education.

••• Culturally-competent communications, marketing and educational
materials were developed and distributed by MDH and partners,
including 15,000 oral hygiene kits.

• More than 50 outreach events were conducted.

• Approximately 10,000 prenatal to three population and caregivers
received intervention.

Increased awareness and capacity in public health

EDDPI was integrated into the MDH Maternal and Child Health
Program.

•Five building blocks of EDDPI legislation

Accomplishment:• Minnesota Department of Health has established a statewide coordinated approach to prevent early dental disease.
Limitations:• Lack of : 1. baseline data for prenatal to three population, 2. adequate funding to distribute free oral hygiene kits and educational
materials, 3. resources to upscale the pilot projects, 4. capacity to address the social determinants of early dental disease.

Pregnant women, new mothers, caregivers of infants/toddlers, medical/dental workforce
Community-based social marketing (CBSM) .
Verbal instruction reinforced with printed instructional materials that are easy-to-read and visualmaterials, including models and illustrations.

Prenatal to three model
promotes preventive dental care
• Target audience:• Method:• Tools:

The peak burden of ECC on healthcare infrastructure was lowered.
The overall cases and impact of ECC was diminished througha combination of targeted health promotion and grassroots efforts.

••
Expanded collaboration and partnership

The onset and progression of ECC was prevented or delayed
through educational and restorative intervention.

•

Improved oral health

Outcomes

Prenatal to Three Model

Provide technical assistance, communications
materials, resources and general support to 15
grantees from July-December 2017.

Gather information about programming
preferences through focus group discussions withfamilies of different ethnic backgrounds including
African American, Caucasian, Hispanic, Hmong,
Karen and mixed races.

••

Educate new/expecting parents and caregivers
about the connection between parent/baby oral
health and motivate preventive behavior change,
especially in high-risk and underserved
populations.

•

MDH collaborated with health professionals andcommunity partners of the targeted communities to:

Methods

Discussion

Prasida.Khanal@state.mn.us, “Healthy Teeth. Healthy Baby.”

Apple Tree Dental, Community Health Service Inc./Migrant HealthServices, Children’s Dental Services, Community Dental Care, Early
Childhood Dental Network, MDH Child and Teen Checkups Program,Metropolitan State University, MN Oral Health Coalition, National
Children’s Oral Health Foundation, Olmsted County Oral HealthTaskforce, Rice Regional Dental Clinic, Rice Regional Health Foundation,
University of Minnesota School of Dentistry, Tri-County Head Start,
MDH Maternal and Child Program and statewide community partners.

Acknowledgements

Educational Tools• Prevention is best accomplished by timely identificationof risk factors and appropriate intervention.
• Early dental disease can impact the total well-being of achild and is largely preventable; thus, a healthy mouthwith a full dentition should be the goal for each andevery child.
• Professionals, both dental and non-dental, need to begin
to understand the importance of achieving andmaintaining good oral health as an integral part of total
health in order to address the emerging oral health crisis.
• To prepare for these changes, dentists and the providers
with whom they collaborate will need to know how tobest serve their multi-ethnic patients using low literacy
educational tools and practice applying their knowledge
in the community.
• Through early detection, proper counselling and the
involvement of health professionals and caregivers, theconsequences of ECC can be minimized and hopefully, inthe future, completely eliminated.

Prasida Khanal, MPH, BDS; Don Bishop, Ph.D.; Erin McHenry, B.A.

Healthy Teeth. Healthy Baby.
Minnesota’s Legislative Commitment to Prevent Early Dental Disease

Cavity-free kids enter preschool and kindergarten

Healthy Teeth. Healthy Baby.
S U CC E S S O F M I N N E S OTA’S L EG I S L AT I V E
C O M M I T M E N T T O P R E V E N T E A R LY D E N TA LDISEASE.

Early childhood caries (ECC) is the most common chronic childhood
disease ., Many children in Minnesota do not receive preventive dental
care, which disproportionately affects immigrants, people of color andlow-income families . Minnesota is one of five states with the lowest
percentage of children under age six receiving at least one dental
service . To address this, the State of Minnesota enacted legislation in 2015 to form the Early Dental Disease Prevention
Initiative (EDDPI) . It aims to increase awareness among communities of color and recent immigrants on the importanceof early preventative dental intervention for infants and toddlers .

Continuing investment in Healthy Teeth. Healthy
Baby. drives prevention in communities.
Since directed by the legislature, MDH, health professionals, and community partners:• Coordinated statewide with more than fifty partners and 15 county hubs to prevent early dental disease .
• Tailored the evidence-based model and reached communities at cultural gatherings, places of worship, rural
areas, and public spaces such as libraries .
• Funded 25 $5,000 grants .
• Created easy-to-read and picture-based materials for low-literacy populations .
• Designed information to “stick,” such as soaking crackers in acid for audiences to see the acidic effect in action .
• Distributed 20,000 oral hygiene kits at 50 outreach events, including baby showers, meals, and culturalactivities .
• Trained community health workers, nursing students, Head Start staff to promote prevention .
EDDPI improved oral health by preventing or delaying cases of ECC and lowered burden on healthcare infrastructure .
But there is more work to be done .
EDDPI needs:• capacity to better integrate the social determinants of early dental
disease;• data to better target intervention;• resources to scale up promising practices pilots; and• funding to distribute free oral hygiene kits and educational materials .

Supporting the EDDPI’s
prenatal to three model
will lead to cavity-free kids
entering preschool andkindergarten.

74

Adult annual dental visit: MN (74%) versus U.S. (66%).1
Adult partial tooth loss: MN (35%) versus U.S. (43%). 1
Adult complete tooth loss: MN (10%) versus U.S. (14%). 1
Prevalence of dental sealants among third graders inpublic schools: MN (60%) versus U.S. (44%).2• In 2016, the Minnesota Department of Health (MDH) Oral Health
Program carried out the state’s first BSS for Older Adults – an ASTDD
open mouth screening tool to assess the oral health of adults aged 65+
in long-term care facilities or congregate meal sites. MN’s samplingframe was licensed Medicaid/Medicare eligible nursing homes.
• MDH received IRB Approval, voluntary participation of nursing facilities
and patient and/or guardian consent.
• ASTDD implicit stratified sampling methodology was applied to a listof 373 skilled nursing facilities using Area Agency on Aging (AAA) and
Rural Urban Commuting Areas (designated as rural or urban area
based on RUCA-zipcode) as stratifying variables.
• Licensed dental hygienists trained and calibrated in the use of the BSS
instrument screened 1,032 adults aged 65+ in 31 skilled nursing
facilities with 30 or more beds resulting in 944 analyzable surveys.
• Data recorders steeped in EpiInfoTM recorded data electronically withvalidation protocols to prevent data entry errors.
• MDH collected all ASTDD recommended and optional oral healthindicators. The facility provided participant demographic data at timeof screening and were de-identified prior to leaving the facility.
• Data were weighted to account for the proportion of nursing homebeds and residents screened within AAA and RUCA.

Methods• In 2016, only 31% of Medicaid enrolled Minnesotans saw a dentist. 3• Older adults have an increased risk of aging and prescription
medication related dry mouth, coronal and root caries and periodontal
disease.
• A higher proportion of older adults have chronic disease (e.g. cancer,
heart disease, diabetes), arthritis and limited mobility, making oral
hygiene and travel for routine dental care challenging.
• Around 2020, Minnesota’s 65+ population is expected to eclipse the K12 children population for the first time in history.4• The Minnesota Demographer’s Office projects a doubling of older
adults with more than 1 in 5 Minnesotans reaching age 65+ by 2030.4
Older adults are, therefore, a growing patient demographic for dental
practices.
• Special dental public health focus on “healthy aging, includes ahealthy mouth” is necessary to ensure the oral health needs of thegrowing aging population are met, including increased quality of life
and independent living.

However, oral health disparities by geography, race/ethnicity and income
persist:••••Minnesota (MN) adults overall have good oral health:

Background• Assess and report on the oral health status of adults aged 65 and older
living in Minnesota nursing homes using the Association of State andTerritorial Dental Directors (ASTDD) approved Basic Screening Survey(BSS), and establish baseline data for Minnesota.
• Contribute data to the National Oral Health Statistics System for stateby-state and national comparisons.

Objective• Data shows older adults in MN nursing homes are in great need ofdental care.
• Tooth loss is more than double that of the general population(25% MN nursing homes versus 10% general population).
• Almost one quarter of adults in the state report not seeing adentist within the past year; and only 30% of Medicaid patients
had a dental encounter in the past year.
• These data coupled with a growing aging population demonstrates
the need for investment in dental disease prevention across thelifespan, particularly for those in rural areas, limited incomes,
chronic disease and disability.
• Part of this investment should include increased:• Oral hygiene education for older adults, caregivers andhealth care providers.
• Communication between health care providers anddental professionals, including patient referrals andfollow-up.
• Use of collaborative practice dental hygienists anddental therapists in long-term care facilities and othercommunity settings.
• States must strengthen Medicaid policy to include oral healthservices for older adults and invest in building community capacity
to address the social determinants of oral health that impact theavailability and utilization of dental services.

Funding• Linda Maytan, DDS, MPH, Oral Health
Consultant• Barbara Hann, BA, Data Coordinator• Dental Hygienists (screeners): Margaret(Peggy) Running, Sandra Eliason, Anita
Nygren, Deb Bouley and Theresa Aymond.
• Data Recorders: Cameron Dutt, Jacob
Jordan, Kallie Delveaux and Michelle
Adelmann.
• BSS for Older Adults Stakeholder Group• Participating nursing home residents,
administration and staff

Acknowledgements• Funded by Delta Dental of Minnesota
Foundation and the Centers for Disease
Control and Prevention Cooperative
Agreement grant (DP13-1307).
• Dental Research Fellows were funded by
the University of Minnesota School of
Dentistry.

References: 1. Centers for Disease Control and Prevention. BRFSS Prevalence & Trends Data. http://www.cdc.gov/brfss/brfssprevalence/index.html Retrieved September 13, 2017. 2. Minnesota Department of Health Oral Health Program (2015). Third
Grade Basic Screening Survey. Collected by the Minnesota Oral Health Program. St. Paul, Minnesota: Accessed from MN Public Health Data Access Portal. https://apps.health.state.mn.us/mndata/dental-sealants. Retrieved March, 2018. 3. Minnesota
Department of Human Services. Minnesota Health Care Programs Dental Services Recipients by County of Residence, Program Category and Age. 2016. 4. Minnesota State Demographic Center. https://mn.gov/admin/demography/data-by-topic/aging.

Strengths & Limitations• First statewide assessment of the oral health status of older adults in nursing homes.
• MDH collected all ASTDD approved recommended and optional oral health indicators.
• ASTDD implicit stratification methodology increases precision estimates and reduces
selection bias.
• Results are accessible on the public-facing, online MN Data Access Portal andincluded in Minnesota’s oral health surveillance system – Minnesota Oral Health
Statistics System (MNOHSS).
• Screening room configuration, screener-help lighting source and variability inresidents’ physical ability to open the mouth limited the dental hygienists ability forconsistent assessment.
• Cross-sectional (prevalence) survey design cannot determine causal associations.
• Any correlation between guardian or participant consent and outcome measures may
result in bias.
• Findings cannot be generalized to older adults in Minnesota who do not live innursing homes.
• Survey did not assess resident insurance status or access to dental care.
• Low proportion of Asian, African American, American Indian, Hispanic, Somali,
Hmong, Karen etc. residents in the sample does not allow for analysis on race andethnicity.
• The definitions of indicators established in the BSS manual enable systematic andcomparable data to be collected, but also make it hard to compare to data collectedwith different survey tools.

Discussion

Minnesota Oral Health Statistics
System (MNOHSS))The Oral Health Status of Adults Aged 65 and Older Living in Minnesota Nursing Homes

Prasida Khanal, MPH, BDS; Genelle Lamont, Ph.D., MPH; Megan Clare Craig-Kuhn, MPH; Clare Larkin, RDH, MSEd; Bilquis Khan, MS, MBA;
Merry Jo Thoele, MPH, GDH; Don Bishop, Ph.D.; Erin McHenry, B.A.

Healthy Aging Includes a Healthy Mouth:
Minnesota’s First Basic Screening Survey for Older Adults• MDH is building a collaborative partnershipguided by principles of community-based
participatory research (CBPR) 1 which
involves dimensions such as:• Successful collaboration between MDH andcommunity partners has empowered andinspired MDH to provide leadership toschool sealant programs across the state of
Minnesota.

• School sealant program education models
in collaboration with Community HealthWorker (CHW) program leaders.

• A sealant data reporting agreement withan existing SSP provider who serves ageographic area of interest to MDH.

• A SSP ‘school-readiness’ tool kit.

MDH funded four new partnerships to help
develop:

MDH developed multilevel strategies to 1)
advance a school’s capacity to implement asealant program, 2) address content-specificcultural issues, 3) foster collegiality, 4) reduce
a school’s isolation from dental communities,
and 5) lead schools to greater understandingof the educational components of a school
sealant program.

MDH recognized need for a paradigm shift indental public health planning to address theissues of resources, capacity, geographic
barriers, and complexities of working in Dental
Health Professional Shortage Areas.

•

•

•

•

•

•

The value of collaboration andrelationship building is often overlooked.
Funding opportunities most often target
providers/provision of clinical care;
there is less focus on empoweringschools, parents and communities.
A collaborative practice agreement isrequired for dental hygienists working inschool (community) settings
Uncertainty of continued grant funding
to cover program costs affects
development of new initiatives.
MN Medicaid pays for sealants onpermanent molars; reimbursement rates
are low to providers. Commercial plansvary in their reimbursement strategy.
Administrative budgeting to support data
sharing is often necessary.

Limitations

clare.larkin@state.mn.us | 651.201.4230

Contact

Centers for Disease Control and Prevention, State Oral
Disease Prevention Program: DP13-1307; Delta Dentalof Minnesota Foundation; Health Resources andServices Administration, Grants to States to Support
Oral Health Workforce Activities: T12HP30311

Funding

Center; University of Michigan School of Public
Health http://www.detroiturc.org/about-cbpr.html

1 Detroit Community-Academic Urban Research

References• To be sustainable, programs needstrong relationships among partners
and institutions. Partnerships must also
be configured to include diverse
community representatives who willdevelop a vision for long-term change.
• Incremental relationship building
between the MDH OHP and its partners
shows progress toward a state-wide
coordinated school sealant program.
The strong relationships formed
underpin collaborative efforts anddemonstrate movement of eachprogram toward success.
• There is more to collaboration andrelationship building than justquantitative data.
• The rich collaborations that haveensued through this fully engaged
MDH-community partnerships canfacilitate action and policy change
where needed.

• Reviewed literature to gain understandingof models of collaboration andrelationship building.
• Identified opportunities to form newcommunity partnerships.
• Strengthened existing relationships to
support “SEAL Minnesota.”• Developed innovative tactics to support
sealant programming across the state,including technical assistance aroundcalibration, infection control, school
readiness toolkits, data sharing,
communications tools, and educational
support materials.
• Identified increasing need for access topreventive and restorative services.

• Develop a collaborative state-wide,
coordinated school sealant program (SSP)
known as “SEAL Minnesota.”• Develop trust among community partners
by employing multilevel strategies.
• Build infrastructure and capacity of schools,
parents and communities to ensure longterm sustainability of school sealantprograms.

For years, various organizations have provided
school sealant programs in areas of Minnesota.
These programs operate independently of one
another and outside the scope of theMinnesota Department of Health (MDH) Oral
Health Program (OHP). Wide-scalecollaboration and relationship building areuncommon elements of Minnesota school
sealant initiatives. For this reason, the numberof school sealant program providers in thestate, total number and location of schools andstudents served, and services renderedremains unknown.

Methods

Discussion

Preliminary Outcomes

Goals

BackgroundC l a r e L a r k i n , M S E d R D H ; P ra s i d a K h a n a l , M P H B D S ;E r i n M c H e n r y, B A

Collaboration + Relationship Building: Cornerstones of Dental
Sealant Program Expansion

Advisory Panel: Jeff Forslund, Gary Hanovich, Shirlynn LaChapelle, Nancy Franke Wilson (Chair),Park Dental St. Louis Park: Dick Diercks, Jean Lind, Jeff Remakle, Kumarie Sookdeo

MDH HPCD Division Leadership: Don Bishop, Mary Manning, Chuck StroebelWest Side Community Health Services: April Arnold, Lois Berndt, Paige Bowen, Silvya Diaz, Lynn Janssen

MDH Staff: Jim Bluhm, Megan Clare Craig-Kuhn, Claudia Fercello, Laura Hutton, Bilquis Jiwani Khan, Erin McHenry, Stan Shanedling, Patty Takawira, Merry Jo Thoele

This project was wholly funded through the CDC 16-1609 Models of Collaboration cooperative agreement. The Minnesota Department of Health Cardiovascular Health and Oral Health Programs staff worked jointly.

Acknowledgments• There is interest in the pursuit of medical-dental integration in Minnesota• External and internal partners attended and were engaged with the symposium• The sharing of successes and challenges is empowering and brings issues into conversation. These conversations
stimulate brainstorming.
• Attendees want more symposia-style meetings• Stories shared are a powerful call to action

It is noted here that the American College of Cardiology / American
Heart Association released new blood pressure guidelines in
November 2017. As the new clinical standard, the pilot project metric
was updated and approved by the Advisory Panel, and each pilot sitetrained their staff and implemented the updated metric.

Execution of proposed work plan may not yield intended results
The periodontal self-assessment is designed to be used in a medical clinic by medical providers
Inability of electronic dental records at our pilot sites to sort patient encounters by age of patient
Staff changes, internal processes, and communication barriers, can be prohibitive
Having a medical and dental clinic co-located does not guarantee successful bi-directional referral
Minnesota Health Care Programs (MN Medicaid): the non-pregnant adult dental benefit set is limited, and does notinclude coverage for periodontal therapy

Lessons Learned

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Patient encounters at dental clinic 42,577
Patient encounters where BP recorded 26,536
Patients referred to a physician 3,646
Patients who attended medical appointment 648

Dental Clinic

Improved communication and workflow between the Oral Health and Cardiovascular Health Programs at MDH
MN Cardiovascular Health Alliance members actively participated on the Models Advisory Panel
The Executive Director of the MN Oral Health Coalition, Nancy Franke Wilson, served as the Advisory Panel Chair
Concluding “Medical Dental Integration Symposium” held with the collaboration of partners
Members of the pilot sites and the Advisory Panel presented or participated in the symposium
Our partners are engaged and committed to this work
Other states have reached out to us about our Models project, for support and technical assistance in similar pilots

Challenges

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Successes

Discussion

Patient encounters at medical clinic 80,954
Patients who completed periodontal self assessment 844
Patients referred to a dentist 417
Patients who attended dental appointment 323

Medical Clinic

Our participating medical clinics asked adults with known
hypertension to complete the periodontal self-assessment (Eke andGenco 2007), facilitated by a licensed dental assistant (LDA). If theself-assessment showed dental health concerns, the hypertensive
patient was referred to a dentist. We acknowledge that theperiodontal self-assessment tool is designed to be administered bynon-dental personnel. A constraint of this project was the need to use
dental assistants instead of medical providers to administer this selfassessment.

MDH intentionally identified two different care delivery models forthis project; a private group dental practice, and a multi-specialty
FQHC. A blood pressure –periodontal disease metric was developed
and approved by the Advisory Panel. The metric pairs blood pressure
readings and periodontal self-assessment results. In our project, thedental clinics obtained and recorded blood pressure readings for adultpatients. If blood pressure was high, patients were educated on thehealth risks. A medical referral was made for blood pressure follow
up. If the blood pressure was critically high, the dental appointment
was stopped and the patient was referred to their medical provider ora collaborating medical provider for same-day triage and treatment.

Project Description

This two year project fostered intradepartmental collaboration between theOral Health and Cardiovascular Health units, both located within the
Minnesota Department of Health’s Division of Health Promotion andChronic Disease, Center for Health Promotion. An Advisory Panel wasformed, meeting quarterly. Two pilot projects were launched,demonstrating the clinical application of bi-directional referral between
dentistry and medicine.

Background

Integrity, Collaboration, Respect, Science, Accountability

Linda Maytan DDS MPH
Prasida Khanal MPH BDS, State Oral Health Director
Division of Health Promotion and Chronic Disease, Center for Health Promotion, Oral Health Program

Models of Collaboration Minnesota

ToolSource: MDH Dentist Workforce Questionnaire, 2016-2017. Percentages are based on 2,130 valid responses.

Only about 11 percent of dental hygienists have a collaborative agreement with a dentist (data not shown above). Of those who do have a collaborative
agreement in place, only about four percent report practicing under the agreement all the time while 72 percent never use it.

All the Time

4%•

Frequently2%

A collaborative agreement is a signed document between a licensed dentist and a licensed dental hygienist that allows the dental hygienist to work in a nontraditional setting like schools or other community-based setting without the presence of a dentist on site. Providing oral health services in community settings
is one way to address access to care challenges.

Occasionally

23%

•

Never

72%

Dental Hygienists’ Utilization of Collaborative Agreements

12

Dental Hygienists at Work: Collaborative Agreements