The Texas Oral Health Coalition is pleased to present the Collaborative Oral Health Plan for Texas 2012. This document serves as a supplement to the Oral Health Plan for Texas, 2012 and provides essential steps to effectively address the oral health of all persons living in the state.
Oral health affects every person through all stages of the lifespan. Too often, oral health is ignored as an insignificant health risk, but in reality, it is linked to overall health and well-being. Additionally, oral diseases have economic and social implications, often inducing unnecessary costs to society. The inability to receive preventive oral health care relates to increased medical costs, lost time at work and school, and decreased quality of life. Because of these costs to society, the work of the Coalition is of upmost importance to the health of Texas.
The Department of State Health Services Oral Health Program (DSHS OHP) has a cooperative agreement with the Centers for Disease Control and Prevention (CDC). Through this agreement, DSHS OHP contracts with the Texas Oral Health Coalition (TxOHC) to perform state level oral health coalition activities that shall:
• continue to enhance, and sustain an active, independent statewide oral health coalition that
gathers information regarding oral health efforts and activities across the state, acts as a
resource for information and referral to other sources, and reports to DSHS and its members.
• focus coalition efforts to sustain statewide and local oral health infrastructure through
and serving as a community resource for support and education regarding community water
fluoridation efforts and school-based/linked dental sealant programs.
The Texas State Oral Health Plan is a roadmap for accomplishing the goals and objectives that have been developed by the state oral health program in collaboration with partners and stakeholders, including the state oral health coalition and members of the public health and dental communities. Surveillance data is needed to evaluate oral health strategies and activities to assess a program’s effectiveness and ensure the successful implementation of sound public health policies.
An overall objective of the Texas Oral Health Coalition is to seek collaborative opportunities with other organizations to promote optimal oral health over the lifespan for all Texans by actively supporting evidence-based, community-based prevention strategies.
Utilizing a Policy Development Tool Developed by the Children’s Dental Health Project (CDHP) in Cooperation with the CDC Division of Oral Health facilitator’s from the CDHP hosted a workshop for approximately sixty individuals, representing organized dentistry and dental hygiene, public health professionals, community health advocates, and others where participants identified policy and systems change priorities. Participants voted on the top five priorities and they were:
Fluoridate all Community Water Systems
Support the development of the Dental Home through professional education
Improve OralHealthLiteracyacross Texas
Create a statewide Oral Health Surveillance System to collect oral health data across the lifespan
While the Texas State Oral Health Coalition supports school-based dental sealant programs as a proven strategic prevention measure to reduce the dental caries burden, the policy committee of stakeholders that convened in March 2012 did not identify this as a policy goal for the coalition, and therefore will not be mentioned in this oral health plan.
The oral health plan below is meant to serve as a supplemental working document that outlines the five (5) policy goals reached by consensus that provides essential steps to effectively address the oral health of all persons across their lifespan. As a living document it will be necessary to revisit and modify accordingly, as new findings and changes are addressed. Each policy goal contains an overall objective, strategy and lists action plans for state oral health coalition stakeholders and local grass root persons to utilize in their promotion of optimal oral health for all Texans. Various organizations, professions and institutions are all considered stakeholders and are identified on the TxOHC membership framework.
The Oral Health Plan for the State of Texas recognizes that improving the oral health of all Texans requires input and support from the public sector, private sector, nonprofit sector, and other key stakeholders. The plan provides a framework that allows that collaboration to occur in the future by having Policy Workgroups update their portion of the plan in the future. It is paramount that all parties work together collaboratively to achieve our common goal, which is optimal oral health for all Texans.
Community Water Fluoridation
Community water fluoridation involves adding fluoride (which prevents dental cavities) to community water sources, then adjusting and monitoring the amount of fluoride to ensure that it stays at the desired level. The scientific evidence is irrefutable that community water fluoridation is effective in reducing tooth decay in adults and children. Texas currently reports 79.3% of the population drinking fluoridated water. There are still many communities in Texas which have never fluoridated the public water supply, have allowed community water fluoridation to cease, or who have actively opposed fluoridation.
The Texas Oral Health Coalition supports optimal community water fluoridation as a primary preventive practice against dental caries with sufficient evidence and efficacy to justify the continuation and expansion of state fluoridation projects.
The Texas Oral Health Coalition recommends continued support through current DSHS administration to assist communities in the design and implementation of water fluoridation systems by qualified water fluoridation engineers, so that the Healthy People 2020 goal of 79.6% can be reached and maintained in Texas.
C. Action Plans
Organize a Community Water Fluoridation Committee/Workgroup of various stakeholders across the TxOHC membership framework to:
Alert local stakeholders when their community is in danger of losing fluoridation.
Write letters and disperse fluoridation tool kits containing fact sheets and materials to local officials when their community comes under attack.
Try to arrange a local oral health professional speak in favor of fluoridation at any hearings or meetings. Encourage and recruit grass root non-dental professionals to speak in favor of community water fluoridation.
Make fluoridation took kits and other pro cwf website links, like www.Ilikemyteeth.org and www.FluorideScience.org available on the TxOHC website. Collaborate with local coalitions and the Rural Water Association to put the information and links on their websites as well.
Help identify sources of funding for operational fluoridation equipment
Collaborate with DSHS OHP and the Fluoridation Project to develop a reference table for the TxOHC website where anyone can view the current water fluoridation levels in their community. This will help assist medical and dental professionals in identifying whether or not their patients are serviced by water systems with naturally-occurring or adjusted fluoride levels and to help base their recommendations to patients regarding fluoride supplementation or application.
Collaborate with the State Fluoridation Project Engineer to provide spokespersons for their annual meetings and to develop the criteria for a recognition award from TxOHC.
A Dental Home is “[t]he ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate”(32).
According to the Institute of Medicine’s, Improving Access to Oral Health Care report “[t]o date, dental homes have centered on providing care to children. However, the medical home model on which dental homes are based, has been used with all populations to provide acute, chronic, and preventive medical services thus, there may be an opportunity to expand the dental home beyond the pediatric population.”
The DSHS First Dental Home (FDH) strategic initiative provides routine preventive dental services to infants and very young children enrolled in Medicaid to reduce the incidence of dental caries in early childhood and to avoid additional dental health issues or dental procedures, such as restorative and oral surgery (e.g., extractions) in an operating room. Parents or caretakers accompany their young children during FDH examinations and this provides dental professionals the opportunity to provide parental education and anticipatory guidance based on national standards. This project is expected to meet all four strategic initiative objectives of the Frew v. Suehs corrective action plan including improving participation and utilization of Medicaid services among clients and providers, improving appropriate utilization of medically necessary services, and improving coordination of care.
The Frew v. Suehs lawsuit (48) resulted in several dental-related initiatives, including the DSHS First Dental Home program and the Oral Evaluation and Application of Fluoride Varnish (OEFV) in the Medical Home. The OEFV utilizes certified medical providers to provide oral health assessments, apply preventive fluoride varnish treatments and referrals to a Dental Home with their own Medicaid reimbursement insurance code.
The DSHS began the First Dental Home (FDH) provider education for pediatric dentists in March, 2008, and for general dentists in May, 2008. The target population is children who are six through 35 months of age and are enrolled in Medicaid.
DSHS continues to offer FDH in-person education to senior dental students and pediatric dental residents at the three Texas dental schools and to dentists working in private practices. These professional education efforts are held in conjunction with collaborations offered at the three dental schools and through continuing education programs coordinated at annual meetings of Texas dental professional organizations. In June 2010, the FDH on-line module became available, which offers dental providers and their staff members an additional continuing education option.
In several states, physicians, nurse practitioners, and physician assistants are taught to perform a risk assessment, provide a fluoride varnish application and anticipatory guidance to the parents, and refer, if necessary, to a dentist for care (38). These programs have been shown to be effective since children will often visit the pediatrician before visiting the dentist. Opportunities to utilize an interprofessional model of oral health care should be considered for Texas, building upon the Oral Evaluation and Fluoride Varnish in the Medical Home (OEFV) initiative.
The Head Start (HS) Texas Dental Home Initiative (TxDHI) led by the TDA has been working on aligning every HS center with a Dental Home. To date, the TxDHI has matched dentists to 761 HS centers throughout Texas. This includes 196 HS centers classified as “high-need,” 215 centers that are “medium-need,” and 350 out of the 390 “low-need” centers.
The Dental Home should be promoted through professional education according to the recommendations outlined by attendees of the Policy Workshop. [. . . ] Promotion of this concept by individual health care professionals and professional dental organizations is encouraged to promote dental homes for working adults and the elderly as well as children not included in the Head Start First Dental Home initiative.
The Texas Oral Health Coalition should facilitate the Dental Home concept through its communications and website presence in collaboration with the Texas Dental Association (TDA), Texas Dental Hygienists’ Association (TDHA), Texas Academy of General Dentistry (TAGD), and other professional organizations.
C. Action Plan
Develop a Dental Home Committee/Workgroup of various stakeholders across the TxOHC membership framework to:
Educate the public on the dental home concept and its importance as part of total body health
Work with TDA, TAGD, DSHS, Texas Head Start Centers and the Texas Academy of Pediatric Dentistry (TAPD) to continue and broaden their efforts from the Head Start First Dental Home Initiative to align every Head Start Child with a Dental Home to include children in private and public day care facilities without a Dental Home
Work with DSHS OHP to continue and broaden the Oral Evaluation and Fluoride Varnish (OEFV) program that certifies medical professionals to provide oral health assessments, fluoride varnish preventive treatments and refer to a Dental Home with its own Medicaid bundle code.
Work with DSHS OHP to continue and broaden the First Dental Home Program that certifies general dentists to provide oral health risk assessment and anticipatory guidance, parental education, and routine preventive services to infants and very young children enrolled in Medicaid.
Collaborate with TDA, TAGD, TDHA, DSHS OHP, and Texas American Medical Association, to develop and utilize an inter-professional model of oral health care for Texas.
Collaborate with the medical schools and medical associations to increase competency of healthcare professionals in graduate programs/training to assess the oral health status of a patient, look for signs that oral health care is needed, and discuss oral health with their patients.
Provide medical students in training information on what local and state-wide resources for information and care are available for their patients.
Collaborate with DSHS OHP to develop a training course that would include CE credits for medical professionals who have completed their training to assess the oral health status of a patient, look for signs that oral health care is needed, and discuss oral health with their patients to learn about the importance of oral health and their patients. Training courses could be conducted at professional conferences held across the state.
Partner with various entities such as the TDHA, TDA, TAGD, TAMA, etc. to help conduct training courses and similar educational opportunities. May could also utilize retired dental professionals for trainings and outreach efforts.
Health literacy in dentistry is “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate oral health decisions”(59). Nearly nine out of ten U.S. adults have difficulty understanding and using everyday health information that is generally available in health care facilities, retail outlets, media and communities. The average American reads at the 8th to 9th grade level; however, health information is usually written at a higher reading level (60).
Change perceptions and increase awareness of oral health and hygiene practices through the use of linguistically appropriate, culturally competent materials and methods, to improve the oral health for all Texans. Promote collaboration of public-private partners to enhance interprofessional and culturally competent community-based prevention strategies. To increase public awareness that the oral health and overall health are linked, about the importance of tobacco cessation, eating healthy with better dietary choices, and improving sports gear and safety measures to reduce head and neck injuries are the purview of public health dental practitioners and dental professionals.
The Texas Oral Health Coalition should serve as a clearinghouse for information that can be disseminated to a broader oral health audience. Other stakeholders can be identified to participate in this activity. Encourage the use of electronic conferencing, social networking sites, webinars and periodic electronic newsletters to engage stakeholders, improve meeting attendance, and reach a broader audience. Simplify by making written materials easier to understand; improving providers’ communication skills; and improving patients’ self-management skills.
C. Action Plan
Develop an Oral Health Literacy Committee/Workgroup from various stakeholders across the TxOHC membership framework to:
Provide consistent messaging with the “Health Literacy in Dentistry Action Plan 2010-2015” promoted by the American Dental Association.
Establish media messaging that encourages the social desirability of good oral health, good dentition, and healthy living/lifestyles.
Collaborate with the Academy of General Dentistry (AGD), TAGD and the Jack Clark Foundation to develop oral cancer literature targeting teens and young adults to educate them on the relationship between the Herpes Papilloma Virus (HPV) and oral cancer.
Disseminate oral health education materials to the public via website, social networks, and hard copy brochures through medical, dental, educational and health and wellness facilities and various health related organizations on various topics like tobacco cessation, eating healthy with better dietary choices and improving sports gear and safety measures to reduce head and neck injury.
Disseminate Dental Home Information to the public and healthcare professionals
Provide dental and medical clinicians with talking points for patient education about population-based preventive oral health services.
Provide education on cariogenic foods and beverages to parents and caregivers through multiple outlets, including but not limited to, school newsletters, day care locations, PTA meetings, Head Start.
Provide education on dental emergencies and the necessity of mouth protection during sports to parents at outlets like sports camps, with registration for school sports, at YMCAs and other youth camps.
Develop talking points for dental and medical clinicians to conduct chair-side education for parents on caring for their child’s teeth, avoiding giving children cariogenic foods and beverages, and having their child use mouth protection.
Work with Texas Education Agency to improve oral health component of the health curriculum used in schools.
Ensure that oral health is included in the wellness policies being developed by schools across the state.
Sponsor a state-wide poster contest for National Children’s Dental Health Month, Winning poster design(s) will be produced into display posters for WIC clinics, and similar outlets.
Develop information for age specific groups: 1st grade (mixed dentition, nutrition, brushing habits), 6/7th grade (braces, sport protection, acid wear, oral cancer, 10th grade (wisdom teeth, oral piercing, acid wear, oral cancer, periodontal disease)
Establish unified messaging about tobacco use
Partner with local, state, and national organizations that share an interest in healthy living (i.e. tobacco-free, anti-obesity, wellness entities) to pool resources in message marketing.
Statewide Surveillance System
Monitoring (surveillance) measures the prevalence and burden of oral diseases; describes the potential risk factors that impact the disease burden and other associated factors, and identifies available preventive services, workforce capacity, and other factors that impact the burden of oral diseases in the State of Texas. This process provides oral health information for stakeholders and policymakers to evaluate current systems and identify potential resources needed to improve the oral health of all Texans in the future and enables comparisons with other data such as the National Oral Health Surveillance System (NOHSS), jointly developed by the CDC and the Association of State and Territorial Dental Directors (ASTDD), and Healthy People 2020 (HP2020), which is maintained by the US Department of Health and Human Services (19). Moreover, the data help policy makers and public health personnel target available resources to best meet the state’s oral health needs (20).
Maintain and expand a statewide Oral Health Surveillance System to monitor the status of oral disease in Texas, to improve oral health outcomes through implementation of evidence based strategies, and to guide policy changes that will improve oral health for all Texans.
Support, enhance, and expand the statewide, ongoing Oral Health Surveillance System with a common set of data, uniform collection and reporting methods managed by the Department of State Health Services in consultation with the Texas Oral Health Coalition and its designated consultants. The creation and implementation of the state oral health surveillance program should include key stakeholders and experts in the field of oral epidemiology.
C. Action Plan
Develop a Surveillance and Evaluation Committee/Workgroup from various stakeholders across the TxOHC membership framework to:
1) Help ensure that oral health assessments are being monitored with improved auditing efforts of the Minimum Data Set.
2) Advocate to legislators and policy makers to budget sufficient funds for a statewide surveillance system to include all Texans over the lifespan and to contract with Texas Dental Schools that possess dental public health expertise to provide support for an oral health surveillance program. The Dental Schools could be contracted by collaborative interagency agreements to fill ‘gaps’ within the existing state program and should not be used to circumvent the state surveillance system. This should not be ad hoc, but part of a multi-year plan developed in a partnership with the dental schools.
3) The HHSC and Oral Health Program should build collaborations with existing local health departments and not-for-profit agencies that collect valid and reliable data to enhance the state date collection infrastructure.
4) Collaborate with the DSHS OHP and Dental Schools to develop a uniformed framework to guarantee the integrity of the collected data, data collection, and methodologies from outside DSHS pre-approved sources that provide secondary data to the DSHS OHP for reporting purposes.
5) Encourage collaborations with existing local health departments and not-for- profit agencies that collect valid and reliable data to enhance the state data collection infrastructure
6) Explore opportunities to use secondary data to supplement the surveillance plan for the state.
Integrate Oral Health into all Elder-Care services and facilities
Prevention models for the vulnerable institutionalized elderly are nonexistent and must embrace integrated approaches which include medical and social services rather than isolated strategies.
Providing oral care to medically complicated elderly must overcome unique and complex logistical barriers that require multidisciplinary strategies. The Texas Oral Health Coalition should establish a Long Term Care Workgroup that consists of representatives and key stakeholders from private, public, and nonprofit state and local organizations and agencies working on aging issues including long term care industry representatives.
In Texas, Medicaid eligible residents in long term care with an incurred medical expense account (IME) may use the Medicaid IME process to access medically non contraindicated dental care. The reimbursement process is inconsistent among the 11 regions (52).
Federal requirements include the provision of dental care for nursing homes receiving Medicare and Medicaid funding (53). Subsequent amendments included dentistry (54). Each nursing home resident must undergo a Nursing Home Resident Assessment with an instrument called the Minimum Data Set (MDS), which includes sections on Oral/Nutritional Status and Oral/Dental Status (55). Nursing homes must assist residents in obtaining routine and emergency dental care (56). Routine care requires an annual exam (57). An emergency involves an episode of pain or other dental problem that requires immediate attention (57). Nursing homes can arrange services by hiring a local dentist or by having an agreement with a local dentist to treat residents (57). If a resident’s dentures are lost or damaged, the nursing home is required to make a prompt referral to a dentist and to aggressively work at replacing the dentures (57).
Nursing facility residents continue to have significant oral health care needs. Katz et al. described an operational definition of oral neglect in institutionalized elderly in the United States (58). Another gap is that despite the mandate that nursing facilities must make emergency dental care available for their residents, there is no well-defined process for obtaining reimbursement for residents who do not have an applied income.
Increase access to quality, comprehensive, and continuous oral health services for all Texans throughout their life stages
Promote oral health for the most vulnerable elderly by facilitating initiatives and communication with state and local aging agencies and organization which are involved with long term care facilities and other key aging services.
Support conducting needs assessments for elders in the state, particularly those residing in nursing homes, and support the appropriation of funds to provide preventive care to nursing home residents enrolled in Medicaid by qualified dental health personnel, as permitted by the Texas Occupations Code.
C. Action Plans
Develop a Long Term Care Committee/Workgroup from various stakeholders across the TxOHC membership framework to:
Develop a program to provide daily oral health care to all residents of long term care facilities
Continue support and broaden efforts to survey the oral health status of elders living in assisted living centers. Adult Basic Screening Surveys are currently being conducted in the Dallas-Fort Worth region initiated by the Texas A & M Health Science Center, Baylor College of Dentistry through a grant provided by Delta Dental to assess quality of life issues and oral health needs of this population group.
Support the concept of “dental home” for the elderly in long term care.
Promote the inclusion of a licensed dental professional in the multidisciplinary team (Nursing Facility Dental Program Director) which helps coordinate the individualized oral care plan for residents in long term care.
Explore the utilization of Registered Dental Hygienists in long term care facilities to educate, train and monitor Certified Nursing Assistants providing daily oral health care to residents. May require a slight rule change in the Texas Dental Practice Act. Will need to collaborate with TDA, TAGD, SBDE, TDHA, etc.
Support mentoring opportunities in oral health across medical and social service disciplines and programs involved in long term care and other key aging services.
Continue to support policies that allow for resources to support the provision of dental care to nursing home residents through coordination with the Texas Department of Disability and Aging (DADS), and residents of group homes through the Intermediate Care Facilities-Mental Retardation program, as well as the Children with Special Health Care Needs program (CSHCN) in DSHS.
Support and participate in special events which provide access to dental care for the adult and elderly population
Collaborate with other stakeholders to provide educational opportunities and oral health literature to increase knowledge on oral health care and denture care among the adult and elderly population as well as to caregivers of these populations.
Coordinate with Councils on Aging, churches and their respective health ministries, and physicians practicing geriatric medicine to distribute information on denture care and oral health care for the elderly.
Encourage stakeholders to guest lecture to the following, but not limited to, nursing assistant programs, AARP, Texas Silver-Haired Legislature, social clubs for the elderly on denture care and oral health care for the elderly.