Oral Health in Missouri 2014 A Burden Report by the Missouri Department of Health and Senior Services Oral Health in Missouri – 2014 A Burden Report by the Missouri Department of Health and Senior Services For more information contact: Missouri Oral Health Program Office of Primary Care and Rural Health Missouri Department of Health and Senior Services [email protected] health.mo.gov/oralhealth This report is also accessible via the internet at: http://health.mo.gov/living/families/oralhealth/oralhealthsurv.php Suggested Citation: Missouri Department of Health and Senior Services (2014). Oral Health in Missouri – 2014: A Burden Report by the Missouri Department of Health and Senior Services. The following Missouri Department of Health and Senior Services staff contributed to this report: Office of Primary Care and Rural Health: Rachel Foster Ben Harvey, M. Ed Amy Kelsey, MPH Susan Liley Christopher Talley, MSW State Dental Director: B. Ray Storm, DDS, MBA Section of Epidemiology for Public Health Practice: Venkata Garikapaty, PhD Andrew Hunter, MA David Litchfield, BS Arthur Pashi, MA, MS, PhD Ray Shell, BS Craig Ward, MSW Janet Wilson, M. Ed, MPA Shumei Yun, MD, MPH, PhD Preventive Services Program within the Oral Health Program: Karen Bassford, RDH Jeffrey Bellamy, RDH Audrey Hendee, RDH Charles Highland, BS Ann Hoffman, RDH Sharlet Kroll, BS Molly McBride-Mooty, RDH Cindy Platter Acknowledgements: Special thanks to the schools and community partners that participate in the Preventive Services Program and Basic Screening Surveys (also called the Show-Me Your Smile Survey). MO HealthNet data provided by the Missouri Department of Social Services. Community water fluoridation data and map provided by the Missouri Department of Natural Resources. Federally Qualified Health Center dental site locations provided by Karen Dent of the Missouri Primary Care Association. Executive Summary Oral Health in Missouri – 2014 is the first comprehensive report containing all available oral health data produced by the Missouri Oral Health Program (MOHP). The purpose of this report is to describe oral health trends and disparities in Missouri and to disseminate those findings to citizens, stakeholders, partners, and decision makers. The format of this report is based on the model of an oral health “burden report” as defined by the Centers for Disease Control and Prevention and the Association of State and Territorial Dental Directors, and includes context, national comparisons, and trends over time for each finding. Oral Health in Missouri – 2014 will be used internally by the MOHP to develop Missouri’s new state plan, to improve oral health surveillance, and to guide interventions. This report is also available for organizations, communities, and decision makers to guide their programs and initiatives. Key Findings  Currently, 76.4% of Missourians served by community water systems receive optimally fluoridated water, which is better than the percentage for the nation as a whole.  Missouri adults with higher educational attainment and higher annual income are twice as likely to visit the dentist as individuals from the lowest socioeconomic group.  Missouri adults older than 65 years of age from the lowest socioeconomic group were three times more likely to have lost all of their permanent teeth due to tooth decay or gum disease than individuals from higher socioeconomic groups.  About 41% of Missouri adults who smoke and visited a dentist were advised to quit by their dentist; about 55% of chewing tobacco users who visited a dentist were advised to quit.  Among Missouri residents, only 42.3% of women visited a dentist and 37% had their teeth cleaned during their most recent pregnancy.  There are approximately 60,000 emergency department (ED) visits due to non-traumatic dental complaints among Missouri residents annually; based on national estimates, these visits cost approximately $17.5 million per year.  Inpatient hospitalizations due to non-traumatic dental complaints are associated with about $13.5 million in hospital charges annually. Recommendations  Oral health initiatives should focus on preventive measures such as fluoride varnish, dental sealants, and community water fluoridation.  All Missourians should receive more education about the need for regular dental visits and the importance of oral health for their overall health, but this is especially important for those of lower socioeconomic groups and individuals with chronic disease. 1  Dentists, dental hygienists, and medical providers should be leveraged to educate patients about key issues, such as oral cancer and dental care during pregnancy.  Improvements to the distribution and availability of oral health professionals, especially those that serve low income individuals, are recommended in order to decrease tooth loss in adults and reduce the use of hospitals for non-traumatic dental complaints. 2 Introduction The Surgeon General’s report Oral Health in America states that oral health is essential to general health and well-being. The consequences of poor oral health range from difficulty eating, speaking, and learning in children to missed work, adverse diabetes and pregnancy outcomes, and risk of heart disease and stroke in adults. The report also states that good oral health is achievable by all, but not everyone is achieving the same degree of oral health. The most vulnerable individuals are more affected by poor oral health, including poor children, the elderly, and members of racial and ethnic minorities.1 The Missouri Oral Health Program (MOHP) has been conducting oral health surveillance for many years. The MOHP collects and reports data on fluoridation of community water systems, conducts the Basic Screening Survey (BSS) on school-aged children every five years, and coordinates the collection of oral screening data on each child that participates in the Preventive Services Program (PSP), an oral health education and prevention program. The MOHP is housed within the Office of Primary Care and Rural Health, which collects and analyzes oral health workforce statistics. Additionally, the MOPH receives data from other programs within the Department of Health and Senior Services (DHSS) that coordinate the collection of multiple rich data sources that are directly and indirectly related to oral health. Ultimately, the purpose of Oral Health in Missouri – 2014 is to compile and contextualize all available oral health data, identify gaps where additional data need to be gathered, disseminate findings to the public and stakeholders, and use the information to guide interventions and policies within DHSS. Methodology Oral Health in Missouri – 2014 is based on the format of a “burden report” using guidance from the Association of State and Territorial Dental Directors (ASTDD) and the Centers for Disease Control and Prevention (CDC). Whenever possible, state-specific findings are compared to national data to depict what the status of oral health is for Missourians. Some national data are based on a median for all states and territories or all states that participate in a particular type of surveillance activity while other data have national percentages or rates that are directly comparable to Missouri findings. Trend data are also displayed when available to determine if findings are changing over time. Comparisons to relevant Healthy People 2020 oral health objectives are included whenever possible. Disparities by age, sex, race, ethnicity, and socioeconomics are also reported when available. The CDC’s Water Fluoridation Reporting System (WFRS) collects data on community water fluoridation (CWF) for all states. The system allows for comparisons between Missouri’s current status and that national percentage of individuals on community water systems that receive optimally fluoridated water. The Missouri Department of Natural Resources provides the MOHP with CWF data from its State Drinking Water Information System, which the MOHP enters into the WFRS system on a quarterly basis. The BSS that is used to conduct a standardized oral health screening on children in selected populations was implemented in Missouri in 2005 and 2010. The decision was made to report 2005 findings rather than the more recent 2010 BSS due to inconsistencies in random sampling methods. 3 Compliance with random sampling methodology allows for results to be generalized to the population as a whole within Missouri and allows for valid comparisons with findings from other states and nationally. The 2005 BSS was conducted on both third and sixth grade students, however, only the results for the third grade students have been adjusted.2 Please visit http://health.mo.gov/living/families/oralhealth/pdf/OralHealthReport.pdf for more information on the 2005 report. The distinction between adjusted and unadjusted findings is clearly noted on each figure for third and sixth grade students. For national comparisons, a median was calculated from statistics on third grade students provided by 43 states (including Missouri) in the National Oral Health Surveillance System (NOHSS) for a variety of time frames dating back to 1998. It is important to note that a new BSS is planned for the 2014-2015 school year, to be carried out according to ASTDD- approved guidelines. PSP results for the 2012-2013 school year are compared alongside the 2005 BSS results to provide additional context. PSP screenings follow the BSS template; however, the PSP is a voluntary program rather than a subset of randomly selected schools. Although PSP data are not from a random sample, the population is large: out of roughly 72,000 children screened, 9,863 (14%) were third graders and 3,525 (5%) were sixth graders. Additionally, the PSP includes participants in nearly every Missouri county.3 Additional PSP findings for all grade levels including analysis by race, ethnicity, sex, and age group are also included. For more information on the PSP, the demographics of its participants, and additional screening results from the 2012-2013 school year, please visit http://health.mo.gov/blogs/wp-content/uploads/2013/05/OralHealthReport2012-2013.pdf. The Behavioral Risk Factor Surveillance System (BRFSS) is an important source of information on oral health status and related risk factors. Randomly selected adults (18 years of age and older) are asked to participate in a telephone interview; due to this random selection, the results are generalizable to the population as a whole.4 All available oral health trend data are reported, however, the 2012 results are not reported on the same trend line as previous years due to a major change in sampling methodology. National data for several years are provided by CDC for comparison to state-specific findings.5 The median for all 50 states, District of Columbia, and two territories (n=53) was selected for this national comparison. Missouri also conducted a special County-Level Study using methods and techniques compatible with the BRFSS which allows for county level data, provides more community- level information for local assessment and decision making. Data from the BRFSS and County-Level Study are each reported as age-adjusted rates except in the case of age-specific analyses. The Youth Risk Behavior Survey (YRBS) provides risk factor data for high school students (ninth through twelfth grades). The YRBS is also the product of a sampling design that allows for information to be generalized to the population at large.6 National data are also available for comparison. Missouri participates in the Pregnancy Risk Monitoring System (PRAMS) which collects data on a sample of all women who have had a recent live birth in order to answer questions about pregnancy and the first few months after birth. The sampling methods employed ensure the findings are generalizable.7 PRAMS data were obtained from internal DHSS partners as well as from a CDC site that presents Missouri’s data alongside findings from other states, allowing for a national median to be calculated for comparison. 4 Data on cleft lip, cleft palate, and other craniofacial defects included in this report were provided by the DHSS Birth Defects Registry and were selected from Missouri resident live births during a specific period of time. Missouri and national statistics for oral and pharynx cancer were obtained from the CDC’s National Program of Cancer Registries; the Missouri Cancer Registry contributes to this data system which allows for comparisons at state and national levels by sex, race, and ethnicity. Missouri is fortunate to have the Missouri Information for Community Assessment (MICA) system which displays Patient Abstract System data, including inpatient hospitalizations and emergency department (ED) visits. These data include figures by payment source, race, ethnicity, age, sex, and county of residence for ED visits and inpatient hospitalizations, charges and days of care. MICA data are age-adjusted using the 2000 standard population; data for specific age groups are crude rates. Missouri Demographics Approximately six million individuals reside in Missouri. About a quarter of Missourians are children younger than 18 years of age. About 62% are adults 18 to 64 years old, and 14.7% are 65 years and older. There are slightly more females than males statewide, especially among adults 65 years and older.8 Missouri Population by Age Group and Sex, 2012 Population Estimates Age Group Female Male Both Sexes Under 18 Years of Age 11.4% 11.9% 23.3% 18 to 64 Years of Age 31.3% 30.7% 62.0% 65 Years and Older 8.3% 6.4% 14.7% All ages 51.0% 49.0% 100% Data Source: Missouri Information for Community Assessment The majority of Missouri’s population is white; 12.4% are African American and about 3% are other races (including Asians, Pacific Islanders, and Native Americans). Only about 4% of Missourians are of Hispanic ethnicity. 8 Missouri Population by Race, 2012 Population Estimates White 84.9% African American 12.4% Other Races 2.7% Data Source: Missouri Information for Community Assessment Missouri is comprised of 14 urban and 101 rural counties, based on population density and proximity to a Metropolitan Statistical Area. Even though the majority of Missouri’s geographic area is considered rural, only 37% of Missouri’s population lives in a rural area. The majority of the population is urban (63%).9 5 About 16.2% of Missourians are living in poverty, defined as 100% of the Federal Poverty Level (FPL) established by the United States Department of Health and Human Services (HHS) poverty guidelines; this is slightly higher than the percentage reported for the United States as a whole (15.9%).10 According to 2012 statistics from the Missouri Department of Elementary and Secondary Education, 61% of schools (by building) reported having at least 50% of students eligible for free or reduced school lunch fees.11 Community Water Fluoridation Tooth decay occurs when bacteria on the teeth produce acids that dissolve tooth enamel. Fluoride in various forms has been demonstrated to slow this process called demineralization; fluoride also increases remineralization. This process of decreasing demineralization and increasing remineralization is essential for the prevention and control of dental caries, also called tooth decay.12 Community water fluoridation (CWF) is a safe and effective way to prevent tooth decay. It is also the most cost effective way to provide protection from cavities to individuals of all ages and socioeconomic groups.13 Missouri communities have been participating in CWF since 1954. Current national data show that about 74.6% of all individuals served by community water systems are receiving optimally fluoridated water. That is, fluoride levels within water that are adjusted to ensure they are within the 0.7 to 1.2 parts per million (ppm) range recommended by HHS. A slightly higher percentage is reported for Missouri, at 76.4%, which is just below the current Healthy People 2020 objective of 79.6%.13,14 This target is within reach for Missouri, provided that attention and support are given to this important preventive measure. Please see Appendix 1 and visit http://health.mo.gov/fluoride for more information on fluoride in specific communities. Percent of Population Served by Community Water Systems Receiving Optimally Fluoridated Water, Missouri and Nationwide - 2012 76.4% 74.6% Missouri Nationwide Data Source: CDC’s Water Fluoridation Reporting System 6 Children Dental caries have been called the single most common chronic childhood disease.1 Left untreated, tooth decay can result in problems with eating, speaking, and learning. Poor oral health may lead to inadequate nutrition, pain, infection, missed school, depression, and low self-esteem – all of which impact the ability to learn. Children from low-income families are at greater risk for poor oral health and its consequences.15 Fluoride Varnish Fluoride varnish can help reduce a child’s risk of developing dental caries. The fluoride varnish is topically applied to the outer surfaces of teeth and it is safe to apply outside of a dental office, such as in community-based fluoride varnish programs. Fluoride varnish programs have been recognized by the ASTDD as an evidence-based approach, especially when the product is applied every six months. The ASTDD also states that fluoride varnish programs should integrate education as well as the application of topical fluoride.12 Missouri’s PSP follows the model of an evidence-based fluoride varnish program. Participants receive oral health education, supplies (such as toothbrush, toothpaste, and dental floss), an oral health screening, and an application of fluoride varnish. The varnish is applied twice per school year for each child. The PSP is a voluntary program that is provided to any school, day care center, Head Start, or other group that wishes to participate. The MOHP employs five regional Oral Health Consultants who coordinate PSP events in nearly every Missouri county. This strategy has been successful; the PSP has been growing each year since its inception during the 2005-2006 school year, with more than 72,000 children served in the 2012-2013 school year. Number of PSP Participants by School Year 2012-2013 72,088 2011-2012 63,949 2010-2011 64,657 2009-2010 54,187 2008-2009 35,949 2007-2008 18,976 2006-2007 8,362 2005-2006 4,377 The PSP is a voluntary program; however, as noted in the methodology section, results from third and sixth grade PSP screenings in the 2012-2013 school year are reported alongside the 2005 BSS, which 7