Oral Health Environmental Scan Final Report

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Oral Health
Environmental Scan

Final Report


Prepared for the Funding Collaborative of the Oral Health Environmental Scan:
Delta Dental of Colorado Foundation

Colorado Department of Public Health and Environment

The Colorado Trust

Rose Community Foundation

Colorado Community Health Network

HealthONE Alliance

Prepared by:
The Colorado Health Institute
1576 Sherman St., Suite 300
Denver, CO 80203

September 26, 2005

Oral Health
Environmental Scan

Final Report

Prepared for the Funding Collaborative of the Oral Health Environmental Scan:
Delta Dental of Colorado Foundation

Colorado Department of Public Health and Environment

The Colorado Trust

Rose Community Foundation

Colorado Community Health Network

HealthONE Alliance

Prepared by:
The Colorado Health Institute
1576 Sherman St., Suite 300
Denver, CO 80203

September 26, 2005


The Colorado Health Institute (CHI) wishes to thank the collaborative that funded this oral health environmental scan. On May 17, 2005, CHI entered into a contract with Delta Dental of Colorado Foundation on behalf of Delta Dental of Colorado Foundation, the Colorado Department of Public Health and Environment, The Colorado Trust, Rose Community Foundation, the Colorado Community Health Network and HealthONE Alliance. CHI greatly appreciates their financial support and guidance in shaping the framework of this report.

CHI staff also is grateful to the 16 individuals who served as members of the Project Advisory Panel (see Appendix A). Their participation in meetings, advice and feedback were invaluable.

The CHI team that researched, analyzed data, created maps and wrote this report included: Reid T. Reynolds, PhD, director for policy and research and project manager: Amy Downs, MPP, senior research analyst; Jeff Bontrager, MSPH, research analyst; Carol Reagan, research associate; and Valerie Orlando, intern. Pamela Hanes, PhD, president and CEO; Sherry Freeland Walker, communications director; and Kindle Fahlenkamp-Morell provided editorial guidance and support.

Table of contents

Table of contents 5

Executive summary 1

I. Introduction 3

II. The prevalence of dental disease and availability of dental insurance 7

III. Colorado oral health initiatives, programs and dental safety net clinics 38

IV. Evidence-based dentistry and oral health best practices 75

V. Promising initiatives from other states 86


A. Methods A1

B. Colorado initiatives, programs and dental safety net provider network B1

C. Oral health best practices – interventions and evidence C1

D. Other state initiatives D1

E. Maps E1

Executive summary

The oral health status of Coloradans has discernibly improved in recent years. Whether this is true for the vulnerable populations of the state is less clear. The visibility of oral health as a public health concern, however, has been clearly elevated in the public’s consciousness as a result of a variety of public and private funding and programmatic initiatives, particularly apparent since the late 1990s.

The Colorado Health Institute (CHI) was commissioned by a consortium of funders to conduct an environmental scan of the state of oral health, oral health initiatives and oral health policy in Colorado. This is a report of our findings.

CHI reviewed and analyzed a range of secondary data sources and found that:

  • Colorado is one of only a dozen states participating in the National Oral Health Surveillance System, and, in spite of this participation, timely and routine epidemiological data on the oral health status of Coloradans are still relatively limited.

CHI inventoried a comprehensive array of oral health initiatives, programs and dental safety net dental clinics and providers and found:

  • An impressive commitment of funding for oral health programs, particularly for low-income and underserved children, by many of Colorado’s health care foundations.

  • Publicly funded dental programs that have significantly expanded dental coverage for children through the Medicaid program and the dental benefit added to the CHP+ program in 2002.

  • A range of policy and program development activities that have been undertaken by community collaboratives and public-private partnerships, including the Colorado Commission on Children’s Dental Health in 2000, Oral Health Awareness Colorado!, which led to the development of a State Oral Health Plan released in August 2005, and others too numerous to mention here.

  • A sizeable group (43) of dental safety net clinics that is serving a growing number of low-income children, families and individuals in 26 counties around the state.

CHI reviewed evidence from professional journals and studies from other states, and sought counsel from dental practice experts in Colorado and elsewhere to identify tested best oral health practices. We found:

  • A broad consensus with regard to the efficacy and effectiveness of several prevention-oriented dental interventions and programs. The practices have a growing body of evidence to support their broad dissemination into clinical practice and school-based settings, and yet many Coloradans who could benefit do not currently have access to these programs.

  • Innovative programs in other states that are producing promising oral health outcomes, many of which could improve the oral health of Coloradans if implemented in the state.

CHI was also asked to highlight policy considerations and identify possible policy and program options that public and private policymakers could pursue in true public-private partnership. To summarize the thrust of these considerations and options (which are strategically located throughout the report), we have outlined the four broad categories of interventions that derive from the environmental scan.

  • With serious levels of untreated disease and untapped opportunities for expanding preventive programs, additional resources could be targeted to areas and populations in greatest need of dental care. This report identifies many prevention-oriented interventions and treatment services that reflect best practices. An enhanced focus on the systematic evaluation of existing initiatives, leading to strategic planning decisions for resource allocation that optimize evidence-based public and private investments, is needed.

  • Colorado is not alone among states seeking new strategies for reducing the prevalence of dental disease among vulnerable populations. The state could explore innovations proven to be effective in other states.

  • Improvements can be made in the area of performance monitoring and disease surveillance about the oral health status of children and other vulnerable populations in Colorado. Improvements in these areas could enhance the state’s ability to target resources more precisely to identified pockets of greatest dental health need.

  • With some notable exceptions, Colorado funders and program developers may be under-investing in the evaluation of promising dental health practices under way in the state.

Finally, in recognition of the voluminous and technical nature of this report, CHI staff has proposed a dissemination plan to make available one or more publications, including a white paper and policy brief for dissemination to a broader audience. Further, it intends to work with the funding collaborative to disseminate study findings to policymakers in alternative venues such as roundtable discussions and targeted presentations as appropriate.

I. Introduction

As a result of improvements in diet, self-care, fluoridation of public water systems and broadening access to dental care, the oral health of Americans is better than ever before.1 Nevertheless, dental disease still plagues large numbers of Americans, especially those with low incomes and limited access to dental care. The 2000 Surgeon General’s report, Oral Health in America,2 represented a landmark study in furthering the public’s awareness of disparities in the prevalence of dental disease and highlighting that the most prevalent dental diseases – caries and periodontal disease – are fully preventable. The Surgeon General’s report also firmly established the integral relationship between oral and general health.

In Colorado, public agencies and private foundations in the late 1990s began focusing increased attention on the disproportionate prevalence of dental disease among low-income children. In 2000, the Colorado Commission on Children’s Dental Health3 released a series of recommendations on ways to improve the current system of oral health for Colorado’s children.4 Since the release of this report, there have been an impressive number of public and private initiatives implemented to improve the dental health of Colorado’s children.

In spring 2005, several organizations, spearheaded by Delta Dental of Colorado Foundation, asked the Colorado Health Institute (CHI) to undertake an oral health environmental scan to systematically survey the policy landscape and the conditions and activities that are affecting the availability, accessibility and quality of dental health care in Colorado. In particular, the organizations were interested in learning what has happened in the state with oral health since the commission.

The time period covered by the scan includes 2000 to 2005. The year 2000 was chosen as the start point because a number of notable events occurred in that year, most importantly the release of the Surgeon General’s report and a companion report released by the Colorado Commission on Children’s Dental Health. CHI also identified a number of salient activities related to dental health in the late 1990s and therefore has included select information during this period to include in this report.

The principal objectives of the scan were to:

  • Summarize information on the prevalence of dental disease, especially among vulnerable populations in Colorado;

  • Inventory oral health initiatives and ongoing programs, and identify dental safety net providers serving vulnerable populations in Colorado;

  • Identify evidence-based dentistry and oral health best practices (EBD/OHBP) that have proven to be effective at preventing and treating dental disease;

  • Determine the extent to which EBD/OHBP have been incorporated into initiatives and programs and used by dental safety net providers in Colorado;

  • Identify promising dental health practices in other states; and

  • Identify policy options for consideration by public and private policymakers in Colorado.

The CHI team employed a variety of methods in conducting the scan, including:

  1. Conducting an extensive literature review;

  2. Interviewing 40 key informants;

  3. Convening a Project Advisory Panel of 16 experts, funders and advocates who participated in three meetings during the course of the project;

  4. Inventorying a broad range of public and private initiatives, programs and safety net dental providers; and

  5. Analyzing secondary data sources such as the Behavioral Risk Factor Surveillance Survey sponsored each year by the U.S. Centers for Disease Control and Prevention.

The final report consists of five sections:

  1. Introduction

  2. The prevalence of dental disease and dental insurance

  3. Recent oral health initiatives in Colorado

  4. Evidence-based dentistry and oral health best practices

  5. Promising initiatives from other states.

In addition, it includes five appendices:

  1. Study methods

  2. Colorado initiatives, programs and an inventory of Colorado’s dental safety net provider network

  3. EBD/OHBP fact sheets

  4. Other state oral health initiatives

  5. Maps.

As defined in the Surgeon General’s report, “oral health” encompasses a wide range of craniofacial conditions, including oral cancers, cleft lip and cleft palate in addition to dental disease. This study focuses more narrowly on dental disease, its prevalence among vulnerable populations and current efforts to reduce its prevalence among vulnerable populations. For this study, vulnerable populations refer to those segments of the general population that lack access to dental care or that rely solely on publicly funded programs such as Medicaid and Child Health Plan Plus (CHP+), Colorado’s version of the State Child Heath Insurance Program (SCHIP). While vulnerable groups include low-income children and adults, the scan focuses primarily on dental care access and practices available to Colorado’s children. Whenever possible, we include data about the prevalence of dental disease among adults and describe a number of initiatives and providers that treat low-income adults. Unfortunately, there is a dearth of data about the dental health status of low-income adults, and limited resources exist to meet their dental health care needs.

II. The prevalence of dental disease and availability of dental insurance

The practice of dentistry is primarily concerned with the treatment of three disease types. Two of these are infections caused by micro-organisms; the third is developmental.

Dental decay is an infectious disease in which bacteria in the mouth process simple sugars into acid, which erodes the enamel structure and causes tooth decay (cavities). The term “dental decay” is used for both the disease process and the disease by-product.

Tooth decay is caused by specific bacteria named Streptococcus mutans and is accelerated by:

  • The quantity of bacteria in a sticky substance called plaque which adheres to teeth and is only partially removed by toothbrushing and flossing;

  • The consumption of simple sugars which serve as fuel for the bacteria in their acid production;

  • The length of time that bacteria actively produce acid and remain in contact with the tooth; and

  • The relative hardness of the tooth structure.

Periodontal disease (pyorrhea or gum disease) is a destructive infectious disease affecting the gums and bone surrounding the teeth. If this interface becomes infected, an otherwise healthy tooth can be lost. Like dental decay, periodontal disease is a multi-faceted disease process that is influenced by type and amount of bacteria in the mouth, smoking and overall health status.

Occlusal conditions are developmental and affect the jaw relationship and alignment of teeth. These problems can significantly complicate the other two disease processes, as well as cause difficulty with eating and speaking. They are commonly treated with orthodontic interventions and, in severe cases, with jaw or joint surgery. Occlusal conditions, oral cancer, cleft palate and cleft lip are all included in the broad definition of “oral health” but excluded from this study.

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