Preliminary Results of State Inquiry on Barriers & Knowledge Gaps

Barriers & Knowledge Gaps for Oral Health Program Development Survey of State Dental Directors

A. Survey Question

In May 2004, the ASTDD Best Practices Project emailed an inquiry to 51 state dental directors (50 states and District of Columbia). State dental directors included acting directors and lead contact persons of the state oral health programs. The following questions were asked:

(1) What are the 3 major barriers (not including staffing and funding requirements) that have hindered your overall oral health program development and implementation?

* Since staffing and funding requirements of oral health programs are well recognized as top barriers, the survey question wanted to identify other barriers.

(2) What are the 5 most critical knowledge gaps (information needed) that have hampered your program from developing, implementing and sustaining specific public health strategies and services? These would include, but not be limited to, the following:

Assessment: - Oral health surveillance systems - Oral health surveys Policy Development: - State oral health coalitions - State oral health plans - State mandate for an oral health program Assurance: - Community water fluoridation - Fluoride mouthrinse & supplement programs - Fluoride varnish programs - Dental sealant programs - Workforce development

B. Survey Responses

A total of thirty-seven (37) state dental directors responded to the inquiry. The response rate was 73%.

1 C. Barriers of State Oral Health Programs

Summary of Frequency:

Barriers of State Oral Health Programs States Citing Barriers 1. Access to care & care delivery system 4 2. Collaboration & partnerships 9 3. Data & information access 7 4. Government & agency environment 24 A. Integration (3) B. Priority (8) C. Processes (8) D. Program (5) 5. Infrastructure 6 6. Policies & planning 6 7. Social value & marketing 12 8. Workforce 13

Summary of State Responses:

Barriers of State Oral Health Programs States 1. Access to care & care delivery system 4 Fragmentation of the health delivery system Lack of and reduction in adult Medicaid coverage Access to care barriers 2. Collaboration & partnerships 9 Political turf wars (e.g., dental professional organizations) Limited coordinated effort and special interest lobbies with cross-purposes Lack of oral health coalitions and need for effective partnerships Local partners and public/private non-profit programs under-funded 3. Data & information access 7 Limited state oral health data to assess need and evaluate programs Lack of a comprehensive oral health surveillance system Lack of a statewide client based computer information system makes collecting clinical and population data difficult Studies/reports not readily available requiring time to do literature searches to respond to inquires, analyze legislation and address media contacts Lack of common dental diagnostic codes to make exam information available Need data to demonstrate efficacy of programs Increase capacity to make data-based decisions 4. Government & agency environment 2 A. Integration 3 Government agencies are not truly integrating oral health into general health. Fragmentation of oral health programs and activities at state agency B. Priority 8 Oral health is not a high priority in the state health agency and in the social/political environment Competing for priorities and resources with other chronic diseases Must re-educate upper management and legislators on oral health Limitations on being an effective state advocate for oral health regarding legislation sponsorship and policy develop Pressure to focus on access to care resulting in a struggle to invest in prevention and promotion. C. Processes 8 Getting policymakers/legislators involved Bureaucracy and red tape Lack of inclusion of oral health in public health performance standards Lack of communication at each level in the health agency Resistance of other health department offices/staff to do more Too many outside organizations doing the same activity with no clear results to support proposals, strategic plans, and goals Attitude towards dental health result in not being in the “loop” D. Program 5 Organizational status/placement of the state oral health program Level of control and influence by the state oral health program New state dental director has minimal experience in public health 5. Infrastructure 6 Lack of dental public health infrastructure at the state & local levels Geographic isolation with spread out population Inability to distribute resources to underserved population so that each region is represented Difficulty in implementing dental activities in counties without dental personnel Local dentists serving on health department boards resist sealant and fluoride varnish programs 6. Policies & planning 6 Need a state oral health plan with long term goals Need a clear State oral health policy. Need to have dental services mandated Need mandates for fluoridation and dental screenings 7. Social value & marketing 12 Lack of awareness of oral health in relation to total health Lack of importance of oral health among decision makers and the public State dental director cannot have any contact with legislators Sustaining the interest in oral health issues when funding and staffing levels cannot be altered Lack of information to the medical community to promote oral health as part of primary care 8. Workforce 13 Manpower shortages 3 Fail to recognize that oral health services as primary care Lack of expertise for public health functions Need for workforce training/education Restrictive scope of practice for dental hygienists and practice law changes Need for technical assistance Unable to reorganize staff to meet the demands of the oral health program

D. Knowledge Gaps and Information Needed to Develop/Implement Public Health Strategies and Services

Summary of Frequency:

Public Health Knowledge Gaps & Information Needed States Functions to Develop/Implement Strategies & Services Identifying Gaps Assessment 1. Oral health surveillance systems 15 2. Oral health surveys 12 3. Needs assessment 2 4. Specific data needs 6 Policy Development 1. State oral health coalitions 12 2. State oral health plans 14 3. State mandate for an oral health program 10 4. Oral health policies 3 Assurance 1. Community water fluoridation 15 2. Fluoride mouthrinse & supplement programs 3 3. Fluoride varnish programs 12 4. Dental sealant programs 14 5. Workforce development 24 6. Access to care 5 7. Integration 3 8. Social marketing 4 9. Oral health education 4 10. Socio-economic costs 1 11. Program & service development 4

4 Summary of State Responses:

Knowledge Gaps and Information Needed to States Develop/Implement Public Health Strategies and Services Assessment 1. Oral health surveillance systems 15 Mainstream oral health surveillance data with other health surveillance data Develop statewide client based computer information system Mandated dental screening Models for developing state oral health surveillance systems Develop, implement, evaluate, fund and sustain of oral health surveillance systems Indicators are being used for an oral health surveillance system Develop epidemiologic expertise Data analysis and report preparation Trends information 2. Oral health surveys 12 How-to’s of oral health surveys and survey models Technical assistance How to gain resources to implement surveys Sampling methodology Strategies on how to gear up for a statewide survey and collect more data How accurate is the Basic Screening Survey protocol How best to report state population oral health data that includes a large Native American population. How to get into schools to collect data and other ways of collecting school data 3. Needs assessment 2 Communicating assessment findings Developing, implementing and evaluating a state oral health needs assessment that identifies critical data elements & standards for planning and program development 4. Specific data needs 6 County and local Medicaid/SCHIP data Emergency room data Dental examination data Oral health indicators for agency performance and success How to collect and analyze data for oral cancer Policy Development 1. State oral health coalitions 12 How a coalition get things accomplished without dedicated staff or funding What is the value of a separate oral health coalition Lacking key oral health stakeholders for coalitions Need detailed steps in forming and running an oral health coalition Need technical assistance How to sustain stakeholder interest/participation in oral health coalition How to effectively coordinate multiple oral health coalitions and communities 2. State oral health plans 14 Definition of what is a state oral health plan Best way to develop a state oral health plan, especially if no funding & staff A model of a state plan Strategies to getting input and buy-in from stakeholders and the public 5 Building consensus among stakeholders with competing priorities Evaluating, updating, and revising a state plan Samples of other states oral health program plans 3. State mandate for an oral health program 10 Value of a state mandate for oral health programs Specific strategies that can be used to establish a state mandate Model of a mandate including language of the mandate Which states have a mandate 4. Oral health policies 3 Clear state policy to help oral health compete at the state and local levels for resources Policies allowing mid-level practitioners, e.g., dental hygienists, to provide additional services Assurance 1. Community water fluoridation 15 Educate policymakers on fluoridation as a public health (not political) issue Strategies to increase community water fluoridation Strategies to acquire a state fluoridation engineer Clear state legislation for fluoridation Acquire funding for water fluoridation Expand local efforts for fluoridation Need for more fluoridation information including fluorosis Checklist of federal and state regulations for community water fluoridation Knowledge to better educate the pubic 2. Fluoride mouthrinse & supplement programs 3 Strategies for developing programs Address the lack of compliance of program participants Expand local efforts to develop programs Program forms 3. Fluoride varnish programs 12 Evidence-based support & efficacy in the U.S. for use of fluoride varnish in the pediatric population in an off-label application Issue of too much fluoride exposure from fluoride varnish for young children Promoting fluoride varnish in the dental office and the medical clinic Medicaid/SCHIP reimbursement for fluoride varnish How dental hygienist ideally work under physicians and registered nurses to apply fluoride varnish Guidelines and standards of fluoride varnish programs Address turf issues Coding issues for fluoride varnish for Medicaid Increase involvement of primary care staff to deliver fluoride varnish Fluoride varnish programs for institutionalized elderly 4. Dental sealant programs 14 Educate private practice dentists on sealants as a population based measure Resources to implement a sealant program Identifiable sealant material for placing on teeth with incipient decay Manual to implement a model sealant program Expand local efforts to develop sealant programs Data comparisons on dental sealant products, technique and retention

6 New research and technology to address the “diagnosis” argument related to a population- based sealant program How to set the cut off when using free/reduced lunch program criteria in selecting participants and schools Effective program evaluation models for sealant programs 5. Workforce development 24 Evidence based strategies to provide incentives for providers to serve underserved populations and communities Comparative salary data for state oral health program staff State practice laws to expand general supervision laws for dental hygienists How could non-health professionals contribute to the workforce for surveillance, prevention, and promotion Train and work with pediatricians, OB/GYN and other medical staff to perform dental screenings and provide anticipatory guidance Develop a culturally competent dental workforce Information on dental providers such as providers’ knowledge and practice of current prevention modalities and view of alternative delivery systems Strategies to address severe future shortage of dentists/hygienists due to retirement Increase efficiency of the workforce For the dental public health professionals, no one in the pipeline coming down to take the place of people who will be leaving in the next few years Need program staff with expertise 6. Access to care 5 Access to care problems faced by disabled children and adults Obtain adequate resources at the state level to be able to provide services Diagnosis codes Develop an effective network of safety net facilities Needs of a high proportion of state population who are edentulous 7. Integration 3 Studies to continue to link oral diseases with other health problems Collaboration with other MCH programs 8. Social marketing 4 Investment in direct services programming is lacking Creating demand for state oral health program Effective messengers for a social marketing campaign 9. Oral health education 4 Oral health education of the general public? Confusion of the public and media about how to apply the research findings Deal with the media effectively Designing an effective website for oral health programs for policy, program advocates and the general public Policy makers that do not have a clue of the ramification of poor oral health and thus relegate it to low priority status 10. Socio-economic costs 1 Economic impact of poor oral health at the national, state, local and individual level? 11. Program & service development 4 Information on getting additional funding and grant writing Developing evaluation plans/integrating evaluation across multiple programs