5/2/2014 1 Menominee Tribal Clinic Overview Menominee Tribal

5/2/2014
Improving Children’s Oral
Health in Menominee County
& Reservation
Menominee Tribal Clinic
Keshena, WI
WPHA-WALHDAB 2014 Annual Conference
May 15, 2014
Ronald Freeman, DMD, Dental Program Director, Menominee Tribal Clinic
Tammy Keller, BSDH, RDH, CDHC, Menominee Tribal Clinic
Lauren Lamers, MPH, UW Population Health Service Fellow
Overview
Background: Oral health in American Indian
communities and local oral health needs
Development and implementation of Head
Start dental programs
Development and implementation of school-
based dental programs
Discussion
Early Childhood Caries (ECC) in
American Indian Communities
ECC: The presence of one or more decayed, missing
(due to decay), or filled tooth surfaces in any primary
tooth in a preschool-aged child between birth and 71
months of age1
Nationally, prevalence and severity of ECC is higher
among American Indian children than in the general
population2
ECC places a high burden on insurance, IHS,
Medicaid, tribal programs, and families
Severe ECC: $2,000-$8,000 per child3
1.
2.
3.
American Dental Association. Statement on early childhood caries. Chicago, IL: American Dental Association [cited 2014, April 29]. Available
from: http://www.ada.org/2057.aspx.
Phipps KR, Ricks TL, Manz MC, Blahut P. Prevalence and severity of dental caries among American Indian and Alaska Native preschool
children. J Public Health Dent 2012; 72: 208-15.
Indian Health Service. Oral health for Head Start children: best practices. Rockville, MD: Indian Health Service; 2012 [cited 2014, April 14].
Available from: http://www.ihs.gov/headstart/documents/OralHealthBestPractices.pdf.
Menominee Tribal Clinic
Population served is about 8,500
We are 45 miles NW of Lambeau Field
Menominee County/Reservation Schools:
Two Head Start centers
One primary school grades 4K-5
One middle school grades 6-8
One high school grades 9-12
One Tribal School (BIA) grades K-8
Local factors influencing
children’s oral health
47% of Menominee County children in poverty1
Limited access to fluoridated water in small
outlying communities
Limited access to preventive care
Low utilization of existing preventive resources
1. University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2014. Available
from: www.countyhealthrankings.org.
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5/2/2014
Dental care in school breaks down
social inequalities
Baseline Data – Decay Prevalence
“A new global survey conducted by the
Prevalence of Decay Experience and Untreated Decay Among
Children Ages 2-5 Years
Percent
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
84%
79%
68%
28%
53%
NHANES 1
1999-2004
IHS 1999
2
20%
MTC 2001
Decay Experience
University of Copenhagen and the World
Health Organization documents how dental
care in the school environment is helping to
assure a healthy life and social equity – even in
developing countries. But there are still major
challenges to overcome worldwide.”
Untreated Decay
1. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al. Trends in oral health status: United States, 1988–1994 and
1999–2004. National Center for Health Statistics. Vital Health Stat 11(248). 2007.
2. The 1999 Oral Health Survey of American Indian and Alaska Native Dental Patients: Findings, Regional Differences and National
Comparisons. Washington, DC: Dept of Health and Human Services, Indian Health Service; 2002.
University of Copenhagen. Dental care in school breaks down social inequalities. Copenhagen, Denmark: University of
Copenhagen; 2014 [cited 2014 April 15]. Available from: http://healthsciences.ku.dk/news/news2014/dental-care-in-schoolbreaks-down-social-inequalities/.
Development of Head Start Oral Health
Programs
Began as Tribal Clinic performance
improvement project
Overall goal: reduce the prevalence of
untreated decay among Head Start patients
to 31%
Development of Head Start Programs:
IHS Best Practices, Birth-5 years
Assess children for decay when first teeth erupt or by
12 months and yearly thereafter
Prevention through topical fluoride varnish and
brushing with fluoride toothpaste
Educate families about healthy dietary behaviors, the
benefits of fluoride, and prevention measures
Collaborate with providers to provide necessary
treatment
Head Start Program Development
1990’s: 3 & 4 year olds- bused daily to clinic for
prophylaxis, fluoride, x-rays, exams and operative
treatment
2001: Stopped daily operative treatment and
provided exam, x-rays, prophylaxis and fluoride at
Tribal Clinic 2 times per year
Increase hospital treatment
2002: Fall screening at Clinic with 3 fluoride varnish
treatments at Head Start
Started 0-5 Fluoride Program
Indian Health Service. Oral health for Head Start children: best practices. Rockville, MD: Indian Health Service;
2012 [cited 2014, April 14]. Available from: http://www.ihs.gov/headstart/documents/OralHealthBestPractices.pdf.
WIC, Medical, Daycare, H.S. Centers
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Head Start screenings completed
Untreated decay trends
Number of children screened, by age
Proportion of children ages 3-5 years with untreated decay
250
150
5 years
4 years
3 years
2 years
<2 Years
100
50
Percent
200
*
*
*
*
*
*
*
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
2
IH 01
S, 3
20
10
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
0
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
*Odds of untreated decay significantly lower than in 2001 (p<0.05)
Decay Experience Trends
Decay Severity Trends
Proportion of children ages 3-5 years with decay
experience
Mean DMFT and teeth with untreated decay among children
ages 3-5 years
60%
*
*
*
*
*
*
*
*
*
*
40%
20%
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
2
IH 01
S, 3
20
10
0%
8
7
6
5
4
3
2
1
0
DMFT
Teeth with
untreated decay
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
Percent
80%
Number of Teeth
100%
Year
*Odds of decay experience significantly lower than in 2001 (p<0.05),
controlling for age.
Decay severity trends
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
Percent
Proportion of children ages 3-5 years with >5 DMFT
70%
60%
50%
40%
30%
20%
10%
0%
Significant downward trend for DMFT (p= 0.011) and teeth with
untreated decay (p=0.004), controlling for age
Community Outreach
WIC
Medical-Well Child Visits
Daycare Center
Early Head Start/Head Start
County-Birth to 3 Program
3 Schools (K-8)
Health Fairs
Significant downward trend, controlling for age (p=0.031)
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Patient Encounters, Ages 0-5 Years
Patient encounters for children ages 0-5 years, Menominee
Tribal Clinic
2000
1754
1514
1500
1000
1418
1390
1529
1441
1559
1668
1453
1298
976
670
500
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
0
Hospital Cases
School-based programs - Background
Problem: Limited follow-up with children
Number of children treated in OR
Number of Children
140
115
120
100
beyond Head Start programs
130
111
99
122
113
120
102
97
84
Broad goal: Improve access to care and oral
79
80
health outcomes for older children
60
40
Action steps: Implement screening and
20
sealant programs in local elementary school
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
School-based programs - Background
Decay experience, untreated decay, and sealants
among 3rd grade children
WI, 20072008 (Total)
Percent
80%
60%
20%
2008-Applied for Mobile Dental Clinic
2009-Collaborated with school district/Bridges
100%
40%
School Program Development
87%
69%
55%
68%
40%
20%
0%
Decay
Experience
Untreated
Decay
51%
34%
10%
WI, 20072008 (>=75%
FRL*)
Menominee,
2009-2010
>=1 Sealant
Present
out of Poverty program for dental clinic in
elementary school
Hired a Dental Hygienist
Keshena Primary School-(4K-5) 415 students
180 School Days
*FRL = Free and Reduced Lunch
Wisconsin Department of Health Services. 2008-Make your smile count: the oral health of Wisconsin’s
children, current status, trends, and disparities. Madison, WI: Wisconsin Department of Health Services; 2008.
Available from: http://www.dhs.wisconsin.gov/publications/p0/p00095.pdf.
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Services Provided
School Programs Expansion
Oral screening by hygienist
Prophylaxis
Fluoride varnish treatment
Bitewing X-rays
Sealants
Oral hygiene instructions
2010-Tribal School (K-8) 200 Students
2011-Middle School (6-8) 150 Students
2014-First Impressions Pediatric Dentists
Exam by dentist
KPS
TRIBAL
SCHOOL
Menominee Indian Middle School, Grades 6-8
Advantages
No canceled or broken appointments
Children not missing a day of school for a
cleaning
Parents do not have to take off work
Increased access to preventive care
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Sealants Present among Elementary
School Students
Percent
Percent of MISD elementary students with at least one
sealant present, by grade
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2009-2010
2010-2011
2011-2012
2012-2013
1st
grade
Proportion of students with untreated
decay
Percent
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
3rd
4th
1.
2.
Untreated Decay, 3rd Grade Students
68%
60%
34%
10%
2010-2011
2011-2012
2012-2013
WI, 2007WI, 20122008 (>=75% 2013 (>=75%
FRL) [1]
FRL) [2]
Wisconsin Department of Health Services. 2008-Make your smile count: the oral health of Wisconsin’s children, current status, trends, and
disparities. Madison, WI: Wisconsin Department of Health Services; 2008. Available
from:http://www.dhs.wisconsin.gov/publications/p0/p00095.pdf.
Wisconsin Department of Health Services. 2013 – Healthy smiles/healthy growth: Wisconsin’s third grade children. Madison, WI: Wisconsin
Department of Health Services; 2013. Available from: http://www.dhs.wisconsin.gov/publications/P0/p00589.pdf.
Successes of Head Start and School
Programs
Decreasing decay severity among Head Start
students
67%
55%
40%
25%
Higher rates of dental sealants among
elementary students
2009-2010
2.
61%
86%
Some decreases in untreated decay rates
Percent of MISD and Wisconsin 3rd grade
students with untreated decay
1.
88%
5th
Grade
100%
80%
60%
40%
20%
0%
5th
grade
74%
2009-2010
2nd
4th
grade
Percent of MISD and Wisconsin 3rd grade students
with at least one sealant present
2009-2010
2010-2011
2011-2012
2012-2013
1st
3rd
grade
Sealants Present, 3rd Grade Students
Proportion of MISD elementary students with
untreated decay, by grade
80%
70%
60%
50%
40%
30%
20%
10%
0%
2nd
grade
2010-2011
2011-2012
2012-2013
WI, 2007WI, 20122008 (>=75% 2013 (>=75%
FRL) [1]
FRL) [2]
Improved access to preventive dental care
Wisconsin Department of Health Services. 2008-Make your smile count: the oral health of Wisconsin’s children, current status, trends, and
disparities. Madison, WI: Wisconsin Department of Health Services; 2008. Available
from:http://www.dhs.wisconsin.gov/publications/p0/p00095.pdf.
Wisconsin Department of Health Services. 2013 – Healthy smiles/healthy growth: Wisconsin’s third grade children. Madison, WI: Wisconsin
Department of Health Services; 2013. Available from: http://www.dhs.wisconsin.gov/publications/P0/p00589.pdf.
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Continued Challenges
Lessons Learned
Unable to provide restorative care onsite
Need to continuously assess and reevaluate
Difficulty ensuring follow-up for restorative
care
Continued need for parent education
efforts
School & community partnership and support
is crucial
Achieving and maintaining improvement is
difficult and requires long-term commitment
Acknowledgements
Jean Lund, RDH
Sarah Dittman, RDH
Mary Schoen, DA
Tom Walczyk, DDS
Jerry Waukau, Menominee Tribal Clinic
Wendell Waukau, Menominee Indian School
District
Gary Pyawasay, Menominee Head Start
Contact Information
Dr. Ronald Freeman, DMD
[email protected]
Tammy Keller, BSDH, RDH, CDHC
[email protected]
Lauren Lamers, MPH
[email protected]
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