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__, 2013 Despite being a preventable disease, tooth decay is the leading chronic disease facing children in the United States – affecting five times more children than asthma. Tooth decay is a significant public health concern and causes needless pain and suffering for many of our children in Oregon. Children who have tooth decay are more likely to experience oral pain and infection, which can affect a child’s school attendance and performance. It may also lead to impaired speech development, poor nutrition, low self-esteem, and increased health care costs. The 2012 “Oregon Smiles and Healthy Growth Survey” is an important step in understanding and addressing this problem. This survey is the third in a series of assessments and presents the findings of oral screenings of first-, second- and third-graders attending Oregon public schools in the 2011-2012 and 2012-2013 school years. Surveys were also conducted in 2002 and 2007. Assessing the current oral health status of Oregon’s children is crucial to identifying populations at high risk. Information collected is used to target evidence-based preventive interventions in order to reduce the amount and severity of tooth decay. Preventive services may include increased access to oral health care and community-based prevention strategies such as fluoride varnish and dental sealants. In addition to addressing current problems, an accurate assessment of the oral health of Oregon’s children is important for reducing the challenges of the future. Untreated tooth decay worsens with age and can lead to poor overall general health into adulthood. Chronic oral infections have been associated with an array of other health problems such as heart disease, diabetes, and unfavorable pregnancy outcomes. Preventing tooth decay will also lower health care costs over a lifetime. In Oregon, adults and children frequently seek dental care at more expensive emergency departments. In 2010, there was a 31% increase in dental-related emergency department visits by Oregon’s Medicaid enrollees compared to 2008. Implementing targeted evidence-based interventions will reduce Medicaid spending and the number of dental-related emergency department visits. This year’s report provides an important opportunity to assess the current oral health of Oregon’s children and gauge changes over the past ten years. Results guide the planning, implementation, and evaluation of policies and programs intended to prevent tooth decay. The information found in this report can be used to develop and implement evidence-based prevention strategies designed to ensure all of Oregon’s children have a healthy smile. Sincerely, Shanie Mason, M.P.H., C.H.E.S. Bruce Gutelius, M.D., M.P.H. Oral Health Program Manager Title Oregon Public Health Division Oregon Public Health Division

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Acknowledgements The Oral Health Program would like to thank these individuals for their involvement in the 2012 “Oregon Smiles and Healthy Growth Survey”: Shanie Mason, M.P.H., C.H.E.S. Mary Masterson, M.P.H., M.P.A., R.D.H. Laurie Johnson, M.A., R.D.H. Jennifer Young, M.P.H., R.D. Koneng Lor, M.P.H. Kathy Phipps, Dr. P.H. Amy Umphlett, M.P.H. Susan Castillo, Former Superintendent of Public Instruction Rob Saxton, Deputy Superintendent of Public Instruction A special acknowledgment is extended to dental screeners who participated in the survey:

Danielle Abel Shirlee Nash Sheila Boerste Virginia Olea Verena Caudle Karen Phillips Shanda Dunten Carol Poe Ashly Grams Mike Poe Kristin Grenke Lalit Rodich Laurie Johnson Jessica Steele Laurie Kelly Heidi Thompson

We would also like to thank the principals and staff of participating schools. Without their assistance, this report would not have been possible. If you need this document in an alternate format, please contact the Oral Health Program at 971-673-0348.

Oregon Health Authority Public Health Division

Center for Prevention and Health Promotion Maternal and Child Heath Section

Oral Health Program

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Table of Contents Acknowledgements ......................................................................................................................

Executive Summary .....................................................................................................................

Methodology ................................................................................................................................

Fast Facts .....................................................................................................................................

Survey Findings ...........................................................................................................................

Decay Experience ............................................................................................................

Untreated Decay...............................................................................................................

Rampant Decay ................................................................................................................

Dental Sealants.................................................................................................................

Access to Dental Care ......................................................................................................

Focus on Disparity .......................................................................................................................

Recommendations ........................................................................................................................

1. Oral Health Care in Coordinated Care Organizations .....................................................

2. Community Water Fluoridation .......................................................................................

3. Early-Childhood Cavities Prevention ..............................................................................

4. School-Based Fluoride Supplement Programs ................................................................

5. School-Based Dental Sealant Programs ...........................................................................

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Executive Summary Oregon’s Oral Health Program began using national Basic Screening Survey (BSS) criteria recommended by the Centers for Disease Control and Prevention and the Association of State and Territorial Dental Directors in 2002, conducting Smile Surveys every five years. In 2007, Oregon scored worse in every major measure of oral health for children compared to 2002. At that time, Oregon ranked 25th – or 7th from the bottom – in percentage of children with untreated decay compared to 32 other states with similar data. Results of the 2012 “Oregon Smiles and Healthy Growth Survey” (Smile Survey) indicate that the oral health of 6 to 9 year old children in Oregon has improved, particularly in comparison to 2007, but also compared to the first Smile Survey conducted in 2002. Specifically, the 2012 results show improvement in the measures that worsened in 2007. While this is encouraging, results from 2012 indicate there is still considerable room for progress in Oregon, as tooth decay rates remain higher than the national average and above the goals set by Healthy People 2020. In particular, the 2012 Smile Survey showed that a little over half of children 6 to 9 years old have already had a cavity. This rate is an improvement from 2007, when nearly two-thirds of children aged 6-9 years old had already had a cavity. However, it is still unacceptably high, since tooth decay is 100% preventable. The survey also revealed that almost one-fifth of children 6-9 year olds had untreated decay. More than 17,000 children were found to have rampant decay, where the child had 7 or more teeth with treated or untreated decay. The survey demonstrated that many children do not receive the oral health care they need. More than 24,000 children need access to professional care, while 3% of children had pain or infection that needed urgent treatment the day they were examined by the survey dental hygienist. The good news is that just over half of all third-graders have dental sealants, which is a highly effective, safe, and low-cost method that prevents cavities. In 2012, 52% of third-graders had dental sealants, compared to 43% in 2007. While improvements have been made, results of the survey indicate that oral disease disparities in Oregon still exist for children based on geographic residence, race and ethnicity, socioeconomic status, and primary language spoken at home. The Oral Health Program has focused on ensuring that statewide systems are in place to implement evidence-based prevention strategies, and these efforts have increased the capacity to provide evidence-based preventive services in Oregon. For example, the state School-based Dental Sealant Program has expanded every year since its inception in 2006, with 140 schools served in 2012 compared to 43 in 2007. Programs such as “First Tooth” are targeting infants and toddlers so that tooth decay can be prevented before children reach school-age. Medical and dental providers are receiving training on how to provide early childhood cavities prevention services that includes applying fluoride varnish.

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The Oral Health Program will continue to work to expand the availability of evidence-based preventive practices that will improve the oral health status of Oregon’s children, with the aim of reaching the Healthy People 2020 benchmarks for improving the oral health of all Americans. Meaningful collaboration between dental and medical providers, public health programs, schools, and others with a strong interest in oral health will be needed to champion policies and programs to prevent dental disease in children. With that goal in mind, the Oral Health Program recommends five community-based preventive measures that can be effective in reducing tooth decay through public-private partnerships:

• Oral health care in Coordinated Care Organizations • Community Water Fluoridation • Early-Childhood Cavities Prevention • School-Based Fluoride Supplement Programs • School-Based Dental Sealant Programs

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Methodology The 2012 “Oregon Smiles and Healthy Growth Survey” (Smile Survey) was conducted during the 2011-2012 and 2012-2013 school years. 5,258 children in first, second and third grade were screened from a representative sample of 82 public elementary schools in Oregon. Specially trained dental hygienists performed a brief, simple visual screening of each child’s mouth and recorded the height and weight of each child for a body mass index (BMI) calculation. This was the first statewide standardized collection of height and weight monitoring data for school-age children in Oregon. BMI data from this survey will be reported separately. Sampling was based on third grade enrollment and stratified by six geographic regions. Schools were sorted within each region based on the percentage of children participating in the federal free or reduced lunch (FRL) program. A systematic sampling system was used to originally select 84 elementary schools with third grade children. Three of the schools had closed, leaving 81 schools in the sample. Two of the elementary schools selected did not have first or second grade students, so the appropriate “feeder” schools were added to the sample for a total of 83 schools. After contacting the sample schools for participation, 70 replacement schools were randomly selected that matched the schools they replaced. From a total of 151 schools contacted, 81 schools with third grade plus 1 “feeder” school participated in the Smile Survey for a total of 82 schools. Student participation was achieved using a passive consent approach. Letters in English, Spanish, Russian, Vietnamese, and any other language, as requested, were sent home to parents explaining the purpose of the survey and that all information would be kept confidential unless an urgent dental need was identified. Child information about urgent dental needs was shared with appropriate school staff that could help ensure prompt treatment. Parents were instructed to return a signed form only if they did not want their children screened. All children enrolled and present on the day of the screening were examined unless a parent/guardian returned the consent form specifically requesting that the child not take part in the survey. Prior to the beginning of data collection (screening), the Oregon Health Authority’s Oral Health Program contracted with registered dental hygienists from the state school-based dental sealant program. Dental hygienists attended a one-day training that included a review of the diagnostic criteria along with a hands-on calibration session. The Basic Screening Survey (BSS) clinical indicator definitions and data collection protocols were used. Whenever possible, screenings for the “Oregon Smiles and Healthy Growth Survey” were coordinated with the school schedules of the state school-based dental sealant program. On the screening day for each school, dental hygienists screened the children using gloves, dental mirrors, and an external light source. Information on grade, age, sex, and language spoken at home was obtained from the school or children directly. Race and ethnicity were assessed by screeners if not provided by the school. Information on participation in the federal free or reduced lunch (FRL) program was obtained from the school only. Presence of treated decay (defined as fillings, crowns, or teeth that have been extracted because of decay); presence of

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untreated decay (defined as dental cavities in the primary or permanent teeth that have not received appropriate treatment); urgency of need for dental care (defined as treatment for cavities or other health concerns in the mouth); and presence of dental sealants was determined by the dental hygienists. Data were collected using scanable forms. Data analysis was completed using the complex survey procedures within SAS 9.3. Sample weights were used to produce population estimates based on selection probabilities. The survey design was based on grade rather than age; therefore, children between 6-9 years of age in grades other than first, second and third were not screened. Since nine year olds may be in fourth grade, the survey underrepresented 9 year old children. However, national oral health data collected using identical methods are used to represent 6-9 year old children nationwide. Because these data are used for comparison, Smile Survey results are used to represent 6-9 year old children in Oregon. Data Limitations

• Data collected for the Smile Survey are representative of the state of Oregon and specific regions of the state.

• Data are not representative for any individual school.

• Data from the Smile Survey represent the overall burden of oral health issues related to tooth decay for 6-9 year old children in the state and specific regions of the state.

• Information collected from the Smile Survey is used to better target evidence-based prevention initiatives in the state of Oregon and to compare the burden of disease with other parts of the country.

• Data are not meant to measure the effect of any particular intervention.

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Fast Facts—2012 Smile Survey Decay Experience

• Despite being a 100% preventable disease, tooth decay remains a significant public health concern and causes needless pain and suffering for many of our children in Oregon.

• More than 1 in 2 children (52%) between 6-9 years of age already have had a cavity, representing more than 66,000 Oregon school children.

• Children’s overall decay experience has improved since the last Smile Survey. In 2012, tooth decay in primary (baby) or permanent (adult) teeth was lower than in the previous Smile Survey in 2007, as was the rate of decay in permanent teeth.

• The 52% rate of tooth decay among 6-9 year olds throughout Oregon is above the national average and Healthy People 2020 goals, so there is more progress to be made in preventing tooth decay.

Untreated Decay

• 1 in 5 children (20%) between 6-9 years of age had untreated decay in their primary or permanent teeth; 5% had untreated decay in their permanent teeth.

Rampant Decay

• More than 17,000 children had rampant decay – seven or more teeth with treated or untreated decay.

Dental Sealants

• Just over half of all third-graders have dental sealants, leaving more than 20,000 third-graders without this highly effective, safe, and low-cost intervention that protects against cavities.

Need for Dental Care

• 19% of children between 6-9 years of age were in need of routine or urgent dental care. • 3% of children had pain or infection that needed urgent treatment.

Disparities

• Children who live in rural or frontier regions of Oregon have higher rates of poor oral health than children in metropolitan areas. Children living outside metropolitan areas are more likely to have treated or untreated tooth decay.

• Children in metropolitan areas still have unacceptably high rates of tooth decay.

• Lower-income children compared to higher-income children are almost twice as likely to have had a cavity and untreated decay, and more than twice as likely to have rampant decay.

9

• Rates of decay are higher for Black/African American, Hispanic/Latino, and Asian children compared to White children

• Hispanic/Latino children saw untreated decay decrease by almost half from 2007 to 2012, and there was a large increase in the number of children with dental sealants in 2012.

• Hispanic/Latino children have a disproportionately high rate of rampant decay when compared to other race/ethnicity categories.

• Black/African American children saw rampant decay decline by over 50% from 2007 to 2012, but had fewer dental sealants compared to 2007 and 2002.

• Children who do not speak English at home are at a much greater risk of having poor oral health outcomes compared to children who only speak English at home. They not only have higher rates of dental decay and rampant decay compared to children who only speak English at home, but their rates increased from 2007 to 2012, while rates declined for those who only speak English at home.

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Decay Experience Decay experience includes tooth decay in the primary (baby) and/or permanent (adult) teeth across the lifespan. Decay experience can be past (fillings, crowns, or teeth that have been extracted because of decay) or present (untreated tooth decay or cavities). In Oregon, 52% of 6 to 9 year old children already have had a cavity, representing more than 66,000 Oregon school children.

Many children get their first cavity before they lose their first tooth. Tooth decay can be painful and lead to infection. Left untreated, tooth decay often has serious consequences that can negatively impact a child’s development and school performance. It may be difficult to chew (which compromises children’s nutrition), difficult to speak (which can lead to impaired speech development), cause low self-esteem, increase the number of missed school days, and increase health care costs.

Cavity-free

48%

Have already

had a cavity

52%

Decay Experience, Children 6-9 years old, Oregon, Smile Survey 2012

1 in 2 children age 6-9 years old have

already had a cavity

Cavities are 100% preventable

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In Oregon, children’s overall decay experience has improved since the last Smile Survey. In 2012, tooth decay in primary (baby) or permanent (adult) teeth was lower than it has been in any prior Smile Survey (52%), as was the rate of decay in permanent teeth (10.3%).

Between the ages of 6 and 12, a child has a mixture of both primary teeth and permanent teeth in his or her mouth. The first set of permanent molars usually erupts by second grade and the second set by sixth grade. If left untreated, decay in permanent teeth may lead to expensive dental treatment and possible removal of teeth. While Oregon is making progress, more work needs to be done before Oregon reaches the average decay rate of the general U.S. population of the same age (45%) and the Healthy People 2020 target for decay experience in 6-9 year olds (49%).

57% 64%52%

12%17%

10%

0%

20%

40%

60%

80%

100%

2002 2007 2012

Percentage of

Children 6-9 years old

with Decay

Experience

Smile Survey Year

Decay Experience, Children 6-9 years old, Oregon, 2002 - 2012 Smile Surveys

Decay in Primary or

Permanent Teeth

Decay in Permanent Teeth

52%

45%49%

0%

20%

40%

60%

80%

100%

Oregon Smile Survey

2012

U.S. Population

Group

Healthy People 2020

Goal

Percentage of

Children 6-9 years

old with Decay

Experience in

Primary or

Permanent Teeth

Decay Experience, Children 6-9 years old

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Untreated Decay Untreated decay describes dental cavities or tooth decay in the primary or permanent teeth that has not received appropriate treatment. In Oregon, 20% of children between 6-9 years of age had untreated decay in 2012. This indicates that over 25,000 Oregon children in first, second and third grade, have treatment needs.

Tooth decay in children is just as painful as it is in adults. If decay in a primary (baby) tooth is left untreated, it can cause damage to the permanent (adult) tooth that is growing underneath. A six-year-old child who loses a back baby tooth to decay has to wait 5 or 6 years for a permanent tooth to replace it. This premature loss leads to crooked permanent teeth. In Oregon, 5% of children between 6-9 years of age had untreated decay in their permanent teeth (adult teeth) in 2012. This decay is mostly seen in the molars, since 90% of cavities are found in the grooves and crevices of the molars (back teeth). To help prevent this decay, dental sealants (evidence-based intervention) can be applied to the grooves on the chewing surfaces of the back teeth. Unless tooth decay is treated in its early stages, it becomes irreversible. It can lead to infection of the teeth and gums, as well as tooth loss. Left untreated for a prolonged time, dental decay can become severe enough to require emergency department treatment.

Untreated

Cavities

20%

Treated Cavities

32%

Cavity-free

48%

Untreated Decay, Children 6-9 years old, Oregon, Smile Survey 2012

13

As shown below, about one-fifth of Oregon’s children between 6-9 years of age had untreated decay in 2012. This is an improvement compared to 2007 and 2002, but it still means that almost 40% of 6-9 year olds are not getting treatment when there is evidence of a cavity.

Oregon (20%) has already surpassed the Healthy People 2020 target (26%) for untreated dental decay in 6-9 years olds, but we are still lagging behind the general U.S. population of the same age group (17%).

In Oregon, children from low-income households and specific racial and ethnic groups have a higher prevalence of untreated decay compared to children from higher income households and White children, respectively. Children from low-income households are almost twice as likely to have untreated decay.

57%

24%

64%

36%

52%

20%

0%

20%

40%

60%

80%

100%

Decay Experience Untreated Decay

Percentage of Children

6-9 years old with

Decay Experience &

Untreated Decay in

Primary or Permanent

Teeth

Decay Experience & Untreated Decay, Children 6-9 years old, Oregon, 2002 - 2012 Smile Surveys

Smile Survey - 2002

Smile Survey - 2007

Smile Survey - 2012

52%

45%49%

20%17%

26%

0%

20%

40%

60%

80%

100%

Oregon Smile Survey

2012

U.S. Population

Group

Healthy People 2020

Goal

Percentage of

Children 6-9 years old

with Decay

Experience &

Untreated Decay in

Primary or Permanent

Teeth

Decay Experience & Untreated Decay, Children 6-9 years old

Decay

Experience

Untreated Decay

14

*Information on household income was not collected in this survey. A proxy for income was used instead – if the child participates in the federal free or reduced lunch (FRL) program.1 Children participating in the FRL program are characterized as being from lower income households and those not participating in the FRL program are characterized as being from higher income households for this report. Black/African American children are at particularly high risk for having untreated tooth decay in their primary or permanent teeth.

1 Eligibility for the Free and Reduced Lunch (FRL) program is a household income at or below 130% (Free) and between

130% – 185% (Reduced) of the federal poverty level.

25%

13%

0% 20% 40% 60%

Lower Income

Higher Income

Untreated Decay

Percentage of Children 6-9 years old with Untreated Decay by

Household Income*, Oregon, Smile Survey 2012

18%

28%25%

20%

0%

10%

20%

30%

40%

50%

60%

White Black/African

American

Hispanic/Latino Asian

Percentage of

Population with

Untreated Decay

in Primary or

Permanent Teeth

Untreated Decay among Children 6-9 years old by

Race/Ethnicity, Oregon, Smile Survey 2012

15

Rampant Decay Rampant decay occurs when a child has 7 or more teeth with treated or untreated cavities or tooth decay in the primary or permanent teeth. Almost one quarter of the mouth has tooth decay when rampant decay occurs. In Oregon, 14% of children in first, second and third grade had rampant decay in 2012. This represents more than 17,000 children who have had 7 or more teeth with treated or untreated decay. While Black/African American children are at higher risk for having untreated tooth decay than Hispanic/Latino children, Hispanic/Latino children have a disproportionately higher rate of rampant decay when compared to every race/ethnicity category.

Children who do not speak English at home are more than twice as likely to have rampant decay as children who only speak English at home.

11%10%

24%

14%

0%

10%

20%

30%

40%

50%

White Black/African

American

Hispanic/Latino Asian

Percentage of

Population with

Rampant Decay in

Primary or Permanent

Teeth

Rampant Decay among Children 6-9 years old by Race/Ethnicity, Oregon, Smile Survey 2012

26%

21%

11%

0%

10%

20%

30%

40%

50%

No English English Plus Another

Language

English Only

Percentage of

Population with

Rampant Decay in

Primary or

Permanent Teeth

Rampant Decay among Children 6-9 years old by Language Spoken at Home, Oregon,

Smile Survey 2012

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Dental Sealants Dental sealants are thin liquid coatings applied to the chewing surfaces of the back adult teeth. The coatings flow into the grooves and pits of these surfaces and effectively seal them off from decay-causing bacteria. Most tooth decay (90%) occurs in these grooves and pits. Sealants prevent 65% - 76% of decay in the treated teeth for about 9 years.2,3

In Oregon, just over half of all third-graders have dental sealants (52%). While more third-graders in Oregon have dental sealants compared to the last Smile Survey in 2007, there are still more than 20,000 third-graders currently without this highly effective, safe, and low-cost intervention that protects against cavities.4

2 Gooch BF, Griffin SO, Gray SK, et al. Preventing dental caries through school-based sealant programs: updated recommendations and reviews of evidence. J Am Dent Assoc. 2009;140(11):1356-1365.2 TBD 3 Beauchamp J, Caufield PW, Crall JJ, et al. Evidence-based clinical recommendations for the use of pit-and-fissure

sealants: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2008;139(3):257-68.

4 Third grade is the benchmark for dental sealants since most children get their first adult molars during the first and second grade. Third grade is a good time to check all children for sealants. National surveys use third-grade figures for reporting.

With Sealants

52%

Without

Sealants

48%

3rd Grade Children with Dental Sealants, Oregon, Smile Survey 2012

Before After

17

The state school-based dental sealant program has expanded every year since its inception in 2006 to reduce decay prevalence for children. In 2012, 140 schools were served, compared to 43 schools in 2007.

In Oregon, 38% of 6-9 years old have dental sealants, representing over 48,000 school children. Oregon has already surpassed the Healthy People 2020 target and the general U.S. population of the same age group, but has more work to do in order to reach the original goal of the Healthy People 2010 objective. The Healthy People 2010 goal for the nation was to increase the number of children ages 6-9 years old with dental sealants from 23% to 50%. By 2010, only 26% of 6-9 year olds had sealants. Therefore, the Healthy People 2020 target was lowered to a more achievable 28%. The average sealant rate of the general U.S. population of the same age group is 32%.

Dental Sealant Rates for Children 6-9 years old

32%

28%30%

38%

50%

0%

20%

40%

60%

80%

100%

Smile Survey

2007

Smile Survey

2012

Healthy People

2010 Goal

Healthy People

2020 Goal

U.S. Population

Group Average

Percentage of Children

6-9 years old with

Dental Sealants

Hispanic/Latino children are more likely to have dental sealants than White children, but improvement is needed in reaching Black/African American and Asian populations.

51%

43%

52%

0%

20%

40%

60%

80%

100%

2002 2007 2012

Percentage of

3rd Graders with

Dental Sealants

Smile Survey Year

3rd Graders With Dental Sealants, Oregon, 2002 - 2012 Smile Surveys

18

Dental Sealants among Children 6-9 years old by Race/Ethnicity, Oregon, Smile Survey 2012

28%

37%

24%

34%

0%

20%

40%

60%

White Black/African

American

Hispanic/Latino Asian

Percentage of Children

6-9 years old in

Population with Dental

Sealants

Children who do not speak any English at home are also more likely to have sealants than children who only speak English at home.

51%

37%

0% 20% 40% 60% 80% 100%

No English

Only English

Percentage of Population with Dental Sealants

Dental Sealants by Language Spoken at Home, Oregon, Smile Survey 2012

19

Access to Dental Care Many of Oregon’s children do not receive the oral health care they need. In Oregon, 19% of 6-9 year old children were in need of routine or urgent dental care. This represents more than 24,000 children who need access to professional care.

Overall, 3% of 6 to 9 year old children had pain or infection that needed urgent treatment. On any given day, as many as 3,800 children in Oregon may be in school and suffering from dental pain or infection. In Oregon, children from lower-income households are more than twice as likely to need treatment as children from higher income households.

*Information on household income was not collected in this survey. A proxy for income was used instead – if the child participates in the federal free or reduced lunch (FRL) program.5 Children participating in the FRL program

5 Eligibility for the Free and Reduced Lunch (FRL) program is a household income at or below 130% (Free) and between

130% – 185% (Reduced) of the federal poverty level.

In Need of

Treatment

19%

No

Treatment

Needed

81%

Children 6-9 years old Needing Early or Urgent Dental

Care, Oregon, Smile Survey 2012

25%

12%

0% 20% 40% 60%

Lower Income

Higher Income

Percentage of Population

Children 6-9 years old Needing Early or Urgent Dental Care by

Household Income*, Oregon, Smile Survey 2012

20

are characterized as being from lower income households, and those not participating in the FRL program are characterized as being from higher income households for this report. Focus on Disparities Regional Disparities Children 6 to 9 years old who live in rural or frontier regions of Oregon (Regions 3 through 6) have higher rates of tooth decay compared to those who live in metropolitan areas (Regions 1 and 2). However, children living in metropolitan areas also have unacceptably high levels of tooth decay, with about 50% of children experiencing at least one cavity by the time they are between 6 and 9 years old.

While progress has been made since 2007, nearly all regions have tooth decay rates that are higher for children of this age than the national average and higher than Healthy People 2020 goals. At the same time, there is evidence that rural vs.urban disparities have improved somewhat since 2007, with rural areas showing the largest reductions in decay experience, and more dramatic reductions in untreated decay since that time. Overall, this indicates that prevention of tooth decay has improved but remains a challenge, while more children are getting treatment once cavities have been identified.

Region 1

51% Region 2

48%

Region 3

51% Region 4

55%

Region 5

73% Region 6

58%

0%

20%

40%

60%

80%

100%

Percentage of

Children 6-9 years old

with Treated or

Untreated Decay

Region

Decay Experience by Geographic Region, Oregon, Smile Survey 2012

Region 1: Multnomah

Region 2: Clackamas, Washington

Region 3: Benton, Clatsop, Columbia, Lincoln, Linn, Marion, Polk, Tillamook, Yamhill

Region 4: Coos, Curry, Douglas, Jackson, Josephine, Klamath, Lane

Region 5: Baker, Crook, Grant, Harney, Lake, Malheur, Wheeler

Region 6: Deschutes, Gilliam, Hood River, Jefferson, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco

Oregon Overall

52%

21

Geographical Decay Experience

Decay Experience Untreated Decay

Year 2002 2007 2012 2002 2007 2012

Region #1 66% 56% 51% 36% 25% 21%

Region #2 50% 53% 48% 15% 19% 17%

Region #3 57% 68% 51% 22% 42% 16%

Region #4 56% 69% 55% 20% 46% 24%

Region #5 68% 80% 73% 38% 44% 20%

Region #6 62% 73% 58% 33% 45% 25%

Racial and Ethnic Disparities In Oregon, children’s overall decay experience has declined since 2007 for most race/ethnicity categories, with the exception of Asian children, who have experienced little change. Decay rates for Black/African American, Hispanic/Latino and Asian children have remained higher than those for White children and have not improved as much since 2007.

Disparities for both Asian and Black/African American children are more striking when considering decay found in permanent teeth. These groups have experienced little change in decay in permanent teeth, while White and Hispanic/Latino children have seen declines since 2007. Despite improvements, Hispanic/Latino children continue to experience higher rates of decay in permanent teeth than White children.

61% 61%

77%

54%

47%

57%68%

55%

0%

20%

40%

60%

80%

100%

White Black/African

American

Hispanic/Latino Asian

Percentage of

Population with

Decay in Primary or

Permanent Teeth

Decay Experience among Children 6-9 years old by Race/Ethnicity, Oregon,

2007 - 2012 Smile Surveys

Smile Survey - 2007 Smile Survey - 2012

22

Considerable progress has been made in reducing untreated and rampant decay in Black/African American children. In particular, rampant decay has declined by over 50% from 2007 to 2012. This is encouraging, but improvement is needed in the rate of dental sealants for this group, which decreased between 2007 and 2012.

16%

14%

20%

6%9%

15%14%

8%

0%

10%

20%

30%

40%

White Black/African

American

Hispanic/Latino Asian

Percentage of

Population with

Decay in Permanent

Teeth

Decay Experience among Children 6-9 years old by Race/Ethnicity, Oregon,

2007 - 2012 Smile Surveys

Smile Survey - 2007 Smile Survey - 2012

23

For Hispanic/Latino children, progress has been made since 2007 in regard to untreated decay, rampant decay, and dental sealants. Untreated decay has decreased by almost half from 2007 to 2012. In 2012, rampant decay saw a slight decrease from 2007, but more work needs to be done to lower the rate below the 2002 level. There has been a large increase in the number of 6-9 year olds who have dental sealants for this group. This is an important improvement because provision of dental sealants is an evidence-based practice that prevents tooth decay.

Household Income Disparities In 2012, children from lower-income households were almost twice as likely to have had a cavity and untreated decay, and more than twice as likely to have rampant decay, compared to children from higher-income households. Dental sealant rates were similar for children from higher- and

29%

16%

54%

37%

23%

63%

28%

10%

47%

0%

20%

40%

60%

80%

100%

Untreated Decay Rampant Decay Dental Sealants (3rd Grade)

Percentage of

Population with

Outcome

Oral Health of Black/African American Children 6-9 years old, Oregon,

2002 - 2012 Smile Surveys

Smile Survey - 2002 Smile Survey - 2007 Smile Survey - 2012

42%

20%

39%46%

28%

34%

25% 24%

53%

0%

20%

40%

60%

80%

100%

Untreated Decay Rampant Decay Dental Sealants (3rd Grade)

Percentage of

Population with

Outcome

Oral Health of Hispanic/Latino Children 6-9 years old, Oregon, 2002 - 2012 Smile Surveys

Smile Survey - 2002 Smile Survey - 2007 Smile Survey - 2012

24

lower-income households. School-based dental sealant programs have likely helped increase the dental sealant rate, particularly among children from lower-income households.

*Information on household income was not collected in this survey. A proxy for income was used instead – if the child participates in the federal free or reduced lunch (FRL) program.6

Disparities Related to Language Spoken at Home Children who do not speak English at home are much more likely to have poor oral health outcomes compared to children who only speak English at home. Disparities related to language spoken at home appear to have worsened since 2007. Not only do non-English-speaking children have higher rates of dental decay and rampant decay compared to children who only speak English at home, but their rates increased from 2007 to 2012. Children who do not speak English are more than twice as likely to have rampant decay as children who only speak English at home. 6 Eligibility for the Free and Reduced Lunch (FRL) program is a household income at or below 130% (Free) and between

130% – 185% (Reduced) of the federal poverty level. Children who qualify for the FRL program are characterized as being from lower-income households for this report

63%

25%19%

50%

38%

13%

8%

55%

0%

20%

40%

60%

80%

100%

Have Had a Cavity Untreated Decay Rampant Decay Dental Sealants (3rd

Grade)

Percentage of

Population

Oral Health Status of Children 6-9 years old by Socioeconomic Status*, Oregon,

Smile Survey 2012

Lower Income Higher Income

25

Oral Health Status of Children 6-9 years old by Language Spoken at Home, Oregon,

2007 - 2012 Smile Surveys

64% 64%

20%19%

49%

73%

26%11%

0%

20%

40%

60%

80%

100%

English Only No English English Only No English

Have Already Had a Cavity Rampant Decay

Smile Survey - 2007 Smile Survey - 2012

Summary Smile Survey results show that oral health has improved for 6 to 9 year olds in Oregon between 2002 and 2012, with notable progress made since the 2007 survey. The 2012 Smile Survey indicates that overall oral health of Oregon’s school children in grades 1 through 3 improved in every major measurement compared to 2002 and 2007. However, Oregon’s current decay rate remains unacceptably high, and many disparities persist for school-aged children in Oregon based on household income, race and ethnicity, and language spoken at home.

In addition, Oregon has progress to make to meet Healthy People 2020 goals. Healthy People 2020 established 10-year national objectives for improving the oral health of all Americans. In 2012, Oregon met the Healthy People 2020 objectives for reducing the proportion of 6-9 year old children with untreated dental decay and increasing the prevalence of dental sealants in this

57%

12%24%

16%

64%

17%

36%

20%

52%

10% 20% 14%

0%

20%

40%

60%

80%

100%

Already Had a Cavity Had a Cavity in Adult

Teeth

Untreated Decay Rampant Decay

Percentage of

Population

Oral Health Trends, Children 6-9 years old, Oregon, 2002 - 2012 Smile Surveys

Smile Survey - 2002 Smile Survey - 2007 Smile Survey - 2012

Percentage of

Population

26

group, but did not meet the Healthy People 2020 objective for reducing the prevalence of decay experience in 6-9 year old children.

Recommendations The progress that has been made since 2007 in the oral health status of school-aged children in Oregon has occurred in the context of existing community-based systems that allow for the implementation of evidence-based prevention strategies. Leadership from the Oral Health Program and others has helped lay the foundation for building community-based oral health resources. While this has increased the capacity of communities to provide evidence-based oral health interventions, there are still more areas where infrastructure is needed to provide preventive services to those children most in need. Continued improvements in oral health in Oregonwill require additional collaborative efforts of individuals, public health, dental and medical providers, and the community at large to champion policies and programs intended to prevent dental disease in children. The Oral Health Program recommends the following strategies that focus on public-private partnerships to address the oral health needs of children.

• Improve the oral health of infants, children and adolescents by setting guidelines for prevention and care.

• Improve the partnerships between dental professionals and other health professionals to promote the oral health of children.

• Create partnerships between dental care professionals and families to promote an understanding of the importance of oral health care.

• Create partnerships between dental care professionals and public health professionals. • Promote a seamless system of care that includes community-based health education and

evidence-based preventive interventions. There are five community-based preventive measures that can be effective in reducing tooth decay through partnerships with community-based resources.

• Oral health care in Coordinated Care Organizations • Community Water Fluoridation

28%

26%

49%

38%

20%

52%

0% 20% 40% 60%

Dental Sealants

Untreated Decay

Decay Experience

Percentage of Population

Oral Health of Children 6-9 years old Compared to

Healthy People 2020 Objectives, Oregon, Smile Survey 2012

Smile Survey 2012

Healthy People 2020

27

• Early-Childhood Cavities Prevention • School-Based Fluoride Supplement Programs • School-Based Dental Sealant Programs

Oral Health Care in Coordinated Care Organizations Incorporating oral health preventive services and early intervention into patient-centered primary care will help create the infrastructure needed to lower tooth decay rates and improve overall health outcomes. This approach fits ideally with the newly formed Coordinated Care Organization (CCO) model in Oregon. CCOs provide coordinated care that emphasizes prevention and evidence-based practice to some of the most disadvantaged populations in Oregon. Instead of waiting to seek dental care at more expensive emergency departments when oral health problems have become severe and painful, children would be able to receive routine dental care and preventive measures such as fluoride varnish for pre-school children and dental sealants from their CCOs. This would decrease costs of care for families, taxpayers, and Medicaid. The Oral Health Program recommends the inclusion of oral health preventive services in the variety of services that CCOs provide. Community Water Fluoridation Water fluoridation is the controlled addition of a fluoride compound to a public water supply to achieve a concentration optimal for tooth decay prevention. It is an effective, affordable and, most important, safe way to protect children from tooth decay. It is recognized as one of the 10 greatest public health achievements of the 20th century. Water fluoridation is also a valuable tool in our effort to reduce oral health disparities. Entire communities can benefit from it regardless of age, income level, or race/ethnicity. In Oregon, only some cities have chosen to add fluoride to their drinking water. Compared to the national average of 72.4%, only 27% of Oregon’s population has access to water fluoridation. The Oral Health Program recommends the fluoridation of community water supplies to reduce tooth decay. Early-Childhood Cavities Prevention Early childhood cavities are an infectious disease that can be prevented. Providing dental care for pregnant women and preventive care for infants and toddlers ages three and under has been shown to reduce tooth decay in young children. The Oral Health Program supports collaboration with dental and medical care providers for early-childhood cavity prevention programs. The Oral Health Program, in partnership with the Oregon Oral Health Coalition, launched a program called “First Tooth”, which provides no-cost training to medical and dental professionals on how to integrate oral health preventive services for infants and toddlers into their current practice. “First Tooth” follows best evidence-based practice for early childhood caries prevention (ECCP) that includes a risk assessment, anticipatory guidance, an intervention as appropriate (fluoride varnish application), and referral to a dental home. Research studies show that application of fluoride varnish can reduce tooth decay between 30% - 69% in primary teeth of high-risk children.7 Since 2010, “First Tooth” has been able to train over 1,400 participants from medical and dental practices in 25 different counties in Oregon. 7 Association of State and Territorial Dental Directors (ASTDD). Fluoride varnish policy statement. 2010, February 1.

http://www.astdd.org/docs/FluorideVarnishPolicyStatement(ECFebruary12010).pdf

28

School-Based Fluoride Supplement Programs For communities without community water fluoridation, participation in a school-based fluoride supplement program is recommended. Although community water fluoridation is the preferred method, children can receive fluoride by tablets or rinse. School fluoride programs can reduce cavities by 20% - 35% for the children who participate.8 The Oral Health Program, partnering with elementary schools around the state, recommends and implements a school-based fluoride program. The state school-based fluoride tablet and rinse program is administered to kindergarten through sixth grade in elementary schools with 30% or more of the students eligible for the federal free or reduced lunch (FRL) program. School-based fluoride tablets are delivered daily in the classroom by a teacher, aid, or onsite coordinator. Fluoride rinse is delivered in a similar manner once per week. Usage is tracked and reported annually to the Oral Health Program. During the 2011-2012 school year, over 14,400 children were served by the program. 42 schools participated in the tablet program and 40 schools participated in the rinse program. School-Based Dental Sealant Programs A dental sealant is a liquid coating applied to the chewing surfaces of molar teeth for the purpose of preventing tooth decay. School-based dental sealant programs are an evidence-based best practice in preventing tooth decay. Most tooth decay (90%) occurs in the molars, and dental sealant programs can reduce tooth decay by 65% - 76% in the treated teeth for approximately nine years.9,10 The Oral Health Program, in partnership with communities, elementary schools, and dental care professionals, promotes and implements a school-based dental sealant program. The state School-Based Dental Sealant Program provides screenings and dental sealants to eligible first- and second-graders in elementary schools with 50% or more of the students eligible for the federal free or reduced lunch (FRL) program. Students are eligible if they have parental permission. Dental sealants are delivered by registered dental hygienists onsite at participating schools using portable dental equipment. The program serves close to 7,000 children in 140 schools directly, providing over 18,000 dental sealants each school year. From those screened during the 2011-2012 school year, 5,104 students received 16,350 surface sealants. Statewide, the program reaches 30% of all eligible schools. When combined with locally-operated dental sealant programs, approximately 69% of eligible schools are served. There are still 31% of eligible schools in Oregon not participating in a dental sealant program.

8 Association of State and Territorial Dental Directors (ASTDD). Best practice approach report: useUse of fluoride:

schoolSchool-based fluoride mouth rinse and supplement programs. 2011, June 25. http://www.astdd.org/use-of-fluoride-school-based-fluoride-mouthrinse-and-supplement-programs/

9 Gooch BF, Griffin SO, Gray SK, et al. Preventing dental caries through school-based sealant programs: updated recommendations and reviews of evidence. J Am Dent Assoc. 2009;140(11):1356-1365.9 TBD 10 Beauchamp J, Caufield PW, Crall JJ, et al. Evidence-based clinical recommendations for the use of pit-and-fissure

sealants: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2008;139(3):257-68.