MASTERS OF PUBLIC HEALTH (MPH) PRACTICUM

PROJECT, 2010 Presented by: Genevieve Braganza H.BSc, MPH(c)

OUTLINE Two Projects:

Cost of Treating Early Childhood Caries(ECC) in the Saskatoon Health Region (SHR) and Province of Saskatchewan

Oral health and Dental Service Needs for the

Vulnerable Population in Saskatoon (Quality Improvement Questionnaire)

Key Findings Recommendations

COST OF TREATING EARLY CHILDHOOD CARIES (ECC) IN THE SASKATOON

HEALTH REGION (SHR) AND PROVINCE OF SASKATCHEWAN

Reference: http://www.pediatricdentist.com/images/pagePhotos/early.jpg

BACKGROUND What is Early Childhood Caries (ECC)?

the presence of one or more decayed, missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months or younger.

Source- Canadian Dental Association (CDA), April 2010

http://health.state.tn.us/images/oralhealth/caries.gif

TREATMENT Dental treatment or dental surgery under

General Anaesthetic (GA) is most common.

Advantages: Safe* Efficient Less physical and mental stress on the child and

dental professionals

Source: Anderson H K, Drummond B K. Thomson W M 2004

TREATMENT Disadvantages:

Non-life threatening nausea and vomiting, fever, pharyngitis and swollen lips

Life threatening:

bronchospasms, anaphylaxis, cardiac arrest and respiratory failure

Source: Anderson H K, Drummond B K. Thomson W M 2004

WHY ARE WE INTERESTED? In Canada the prevalence of ECC is 6% to 8%

Disadvantaged populations: 25%- 72% In 2007, Prime Minister Stephen Harper

announced a Wait Times Guarantee, to reduce waiting lists for children awaiting surgery in pediatric hospitals, identified as one of the priorities was dental treatment under GA.

ECC is almost 100% preventable disease.

Source: Schroth RJ, Brothwell DJ, 2004

OBJECTIVES 1. To compare children under age 6 receiving

dental surgery under GA versus all other pediatric surgeries.

2. To determine the cost associated with treating preschool children with ECC under GA in Saskatchewan, specifically focusing on the Saskatoon Health Region.

3. Identifying if majority of children treated for ECC under GA are from northern/remote communities.

DATA SOURCES CIHI Portal Discharge Abstract Database,

collected April 1, 2008 to March 31, 2009.

The 2008-09 In-Province General Anesthesia costs obtained from Medical Health Service Branch (April 2010).

Cost estimation: The College of Dental Surgeons of Saskatchewan

(Fee Guide) NHIB Regional Dental Benefit Grid Supplementary Health & Family Health Benefits

Program.

RESULTS: PEDIATRIC SURGERIES

In Saskatchewan, of the 4858 provisions, 2105 cases (43%) were dental related cases & 57% were non- dental related cases.

In Saskatoon Health

Region: Of 2636 provisions,

1104 cases (42%) were dental related cases & 58% were non-dental related.

0500

10001500200025003000

Num

ber

of c

ases

Health Regions

All pediatric surgeries for children under age 6 compared to dental related surgeries by

health region (April 2008- March 2009)

All Services

Dental (incl OralSurgery)

RESULTS: COST Estimated average treatment for ECC under GA:

Exam, 2 bitewing x-rays, 4 two-surface amalgam fillings, 4 Stainless Steel Crowns, 2 pulpotomies and 4 extractions-deciduous teeth.

Dental Fee Guides to determine average cost. Cost of General Anaesthetic (GA): $ 324

RESULTS: COST In Saskatchewan:

In 2008- 009, the cost of treating ECC for children under age 6 was approximately 3.4 million*

In the Saskatoon Health Region:

Saskatoon had the highest number of cases and therefore highest cost of approximately 1.9 million (accounting for cases by postal code/ residence)

Reference: www.energeticforum.com/general-discusion/460...

RESULTS: COST COMPARISON In British Columbia:

In 2001- 02, the cost of treating ECC for 5000 children under age 4 was approximately 10 million.

In Toronto, Ontario:

In 1996, the cost of treating ECC for children between 1 and 4 years was approximately 3 million.

Reference: www.energeticforum.com/general-discusion/460...

RESULTS: PLACE OF RESIDENCE Saskatoon

Health Region

resident

Northern Health Region

resident

Other Health Region

resident

Saskatoon Health Region (Total)

Dental treatment

$1,236.40 $1,236.40 $1,236.40 $1,236.40

General Anaesthetic

$323.48 $323.48 $323.48 $323.48

Additional Cost ($)

-- $568.03 -- --

Total cost per child

$1,559.88 $2,127.91 $1,559.88 $1,559.88

Number of children that

received treatment

(under age 6)

398 345 361 1104

Total Cost (2008-09)

$620,832.24 $734,128.95 $563,116.68 $1,918,077.87

SUMMARY In Saskatchewan (2008-09), 43% of pediatric

surgeries were dental related and 57% were non-dental related. Saskatoon Health Region: 42% dental related

surgeries & 58% non-dental related.

In 2008-09, the cost associated with treatment of ECC under GA in Saskatchewan & SHR was approximately 3.4 million & 1.9 million respectively.

SUMMARY (CONT’D) In 2008-09, 398 children were Saskatoon

residents versus 345 were from Northern Health regions.

LIMITATIONS Limitation of data i.e. dental related surgeries

may not all be ECC related Limitations with data for disability code i.e.

unaware if disability code is a mandatory field in the database or an optional code.

Identification of provincial versus federal funds.

KEY RECOMMENDATIONS Establishment of a “dental home” or dental

check-up for children at age 1, as recommended by the Canadian Dental Association (CDA).

Parents and guardians with poor oral health to

have access to dental insurance and dental providers to be willing to provide care, in order to prevent poor oral health in families.

Source- Canadian Dental Association, 2005

KEY RECOMMENDATIONS To encompass oral health messaging and

screening as part of primary health care, whereby non-dental health providers ensure good oral health practices.

Develop new multidisciplinary follow-up

strategies between clinical team and parent/guardian and child, as current follow-up processes following treatment for ECC do not exist.

Reference: http://archive.student.bmj.com/issues/08/07/education/images/view_1.jpg

ACKNOWLEDGEMENTS Leslie Topola- Supervisor, Public Health Services- Oral Health Program Dr. Gerry Uswak- Dean, University of Saskatchewan, College of Dentistry Lisa Dietrich- Program Manager, Data and Statistical Services, Medical

Health Services Branch Janet Gray- Technical Dental Consultant/Dental Health Educator (DHE),

Population Health Unit Shirley Schweighardt- Health Information Analyst, Strategic Health

Information and Planning Systems (SHIPS) Lynne Warren- Library Technician, Public Health Services- Public Health

Observatory Cynthia Ostafie- Dental Health Educator, Public Health Services- Oral

Health Program

DENTAL HEALTH HUMOUR..

Reference: onedentalcenter.com

ORAL HEALTH AND DENTAL SERVICE NEEDS FOR THE VULNERABLE POPULATION IN SASKATOON

(QUALITY IMPROVEMENT QUESTIONNAIRE)

Reference: http://3.bp.blogspot.com/_kO5SLwNlPr8/SiWzBOHn-gI/AAAAAAAAAAc/VpoJp3IJNb8/s400/cartoon_dentist_things.gif

BACKGROUND In the last 3 decades in Canada, there have been

vast improvements in oral health, however vulnerable populations still suffer from poor oral health.

There is a strong positive correlation between

poor oral health and chronic disease i.e. coronary heart disease.

Source- Canadian Health Measures Survey, 2010

BACKGROUND Barriers to accessing oral health care:

Financial Geographic Social/ Cultural Legislative.

Source- Canadian Oral Health Strategy, 2004

THE PROJECT Quality Improvement Project A Dental Health Questionnaire was conducted in

the core neighbourhoods of Saskatoon. 29 mandatory questions & 11 optional questions

Timeframe: 10 questionnaire days, June 2010.

Reference: http://www.phha.mlanet.org/blog/wp-content/uploads/2010/02/survey.jpg

THE PROJECT Organizations:

AIDS Saskatoon Mobile Health Bus- Primary Health Clinic Westside Community Clinic Riversdale Immunization Clinic

Incentive: dental gift bag & optional dental

health consultation with licensed dental therapist.

THE PROJECT Dental Health Questionnaire was advertised at

multiple locations throughout core city of Saskatoon.

Sample size: 263 Descriptive statistics & frequency tables were

used using the software SPSS 17.0.

OBJECTIVES 1. Understand the specific needs of this population

based on self-reported dental health.

2. Determine the prevalence of good dental health habits among the vulnerable population

3. Determine specific barriers that prevent Saskatoon’s vulnerable population from accessing oral health care.

4. Understand specific health risks impacting the dental health of the vulnerable population.

DEMOGRAPHICS: Income (n= 236): 53% identified an income of

$12,000 or less per year.

Education (n= 246): 70% identified having an education of high school or elementary school.

Housing (i.e. Fixed address) (n= 248): 86% noted fixed address.

Ethnicity (n= 252): 82% identified themselves as Aboriginal/ First Nations/ Métis/ Inuit

OBJECTIVE #1: SELF- REPORTED DENTAL HEALTH & SPECIFIC DENTAL NEEDS Self- reported dental health (n= 263):

Approximately 32% of participants identified either “excellent” or “good” dental health

68% of participants identified their dental health as “fair” or “poor”.

020406080

100120

Excellent Good Fair Poor

Fre

quen

cy

Self- Reported Dental Health

Self- reported Dental Health in the vulnerable population

in Saskatoon (n= 263)

OBJECTIVE #1: SELF- REPORTED DENTAL HEALTH & SPECIFIC DENTAL NEEDS

Approximately 70% of participants (n= 262) were worried or concerned about their dental health: Females: 66% Males: 69%

Most reported concern (n = 263) and problem (n= 99) by participants were dental caries (or cavities), by 63% and 37% respectively.

OBJECTIVE #1: SELF- REPORTED DENTAL HEALTH & SPECIFIC DENTAL NEEDS

Dental Health Concerns identified by vulnerable population in Saskatoon (n= 263)

OBJECTIVE #2: GOOD DENTAL HEALTH HABITS Brush teeth (n= 262): 70% of participants

identified brushing their teeth 38% identified brushing once per day 46% identified brushing twice per day

Floss teeth (n= 262): 45% identified flossing their teeth Approximately 47% identified flossing once per day

Reference: http://1.bp.blogspot.com/_oYgi6XUmHiE/SHbQOXtvBnI/AAAAAAAAA-Q/hCKlyUTqNho/s320/Toothbrush.jpg

OBJECTIVE #2: GOOD DENTAL HEALTH HABITS Dental Office Visits (n= 263):

Approximately 65 % identified visiting a dental office Approximately 65% identified visiting dental office once per

year

OBJECTIVE #3: BARRIERS TO ACCESSING DENTAL CARE Barriers (n= 92):

Fear of Bad Experience: 28%

Transportation:27% Cost 26%

Use dental services

if they were free of charge: approximately 95% noted “yes”

0102030405060708090

100

Fre

quen

cy

Barriers to Accessing Oral Healthcare

Reasons for not visiting a dental office (n= 92)

OBJECTIVE #3: BARRIERS TO ACCESSING DENTAL CARE Of 90 participants that did not visit dental office:

60% had dental coverage 28% noted no dental coverage 12% did not know

Reference: http://fullcoveragedentalinsurancereview.com/wp-content/uploads/2010/08/full1.jpg

OBJECTIVE #3: BARRIERS TO ACCESSING DENTAL CARE Preferred dental services (n= 70):

Cleanings and check-ups :40% Good/ flexible dentist: 11% Dentures/ denturist: 11%

Location of services (n= 33):

Approximately 88% identified west side of Saskatoon Suggestions: 20th/ 22nd street, Ave U, Riversdale area,

Westside community clinic etc. Approximately 12% identified any location (east or

west side)

OBJECTIVE #3: BARRIERS TO ACCESSING DENTAL CARE Participants identified what they needed to have

good dental health:

27%

24% 16%

14%

9%

6%

2% 2%

Reported needs for Good Dental Health (n= 108)

Dental Services (i.e. check-ups, cavities fixed,extractions, dentures)Tools i.e. tooth brush, toothpaste, floss

Better habits (i.e. brush &floss more, stop smoking, eathealthier, more education)A good, respectful dentist(and an appointment)

Money

OBJECTIVE #4: HEALTH RISKS (TOBACCO USE) Tobacco use among

participants (n= 261): Approximately 75% of

participants identified using tobacco!

Saskatoon Health Regions prevalence: 26%.

Frequency of tobacco use (n= 192): Approximately 52%

noted 1- 10 cigarettes smoked per day.

0

20

40

60

80

100

120

1 to 10 11 to 25 More than 25F

requ

ency

Number of cigarettes/ cigars/ tobacco used

Frequency of Tobacco Usage among Participants (n= 192)

Reference: Health Disparity Report, 2006

OBJECTIVE #4: HEALTH RISKS (TOBACCO USE) Number of years smoked or use of spit tobacco

(n= 174): Approximately 78% identified using tobacco for more

than 5 years.

Number of participants that (n= 174): Used spit tobacco: 15% Engaged in both smoking and used spit tobacco: 14%

http://www.usabledt.com/wp-content/uploads/quit-smoking.jpg

OBJECTIVE #4: HEALTH RISKS (TOBACCO USE) Prevalence of smoking among participants by

location: Riversdale: approximately 53% identified tobacco

use. Other locations (AIDS Saskatoon, Mobile Health Bus,

Westside Community Clinic): approximately 82% identified tobacco use.

Possible explanations:

Demographics of participants Identified the “correct” answer Public Health Services provide 5A’s of brief tobacco

intervention

OBJECTIVE #4: HEALTH RISKS (STRESS RELATED HABITS) Stress related habits (n= 257) were noted by 55% of

the sample population. Type of stress related habits (n= 142):

Clenching Grinding Cheek biting Nail biting 21%

34% 11%

34%

Stress related habits among participants (n= 142)

Clenching your teethGrinding your teethCheek bitingNail biting

SUMMARY

Objective #1: Self- Reported Dental Health Overall the vulnerable population had a poor

perception of their dental health. Large percentage of the sample (70%)

identified concerns/ worry with respect to their dental health.

SUMMARY

Objective #2: Good Dental Health Habits High prevalence of brushing , flossing and

dental visits among the sample population. Erroneous results

SUMMARY

Objective #3: Barriers to Accessing Oral healthcare Fear or bad experience, transportation and

cost Dental services and tools were recommended

by participants to have good dental health

SUMMARY

Objective #4: Health Risks High prevalence of tobacco use among the

sample population (75%), however, Riversdale participants showed decrease in prevalence of tobacco use (53%).

High prevalence of stress related habits (i.e. grinding and nail biting) among vulnerable population.

LIMITATIONS 1. Bias based on location dental health

questionnaire was conducted.

2. Healthy Volunteer Effect.

3. Generalizability of results.

RECOMMENDATIONS Implement a monthly Dental Health Q&A

outside the Mobile Health bus. Dental office(s) should be located on the Westside

of Saskatoon. Oral hygiene tools (i.e. toothbrush, toothpaste

and floss) and preventative services should be available to the vulnerable population in Saskatoon.

RECOMMENDATIONS Expand 5 A’s of Brief Tobacco Intervention to other

organizations within the Saskatoon Health Region. Parents and guardians with poor oral health to

have access to dental insurance in order to treat oral health issues.

Present results of the Dental Health Questionnaire

to private practice dentists in the Saskatoon Health Region to receive feedback on the results of Quality Improvement Questionnaire i.e. how to link patients with specific dentists.

ACKNOWLEDGEMENTS Supervisors and Colleagues: Leslie Topola- Supervisor, Public Health Services - Oral Health Program Dr. Gerry Uswak- Dean, University of Saskatchewan, College of Dentistry Julie Laberge- Lalonde- Dental Health Educator, Public Health Services- Oral Health Program Joyce Birchfield – Administrative Assistant, Public Health Services- Oral Health Program Rhonda Richards- Desktop Publisher, Public Health Services Josh Marko- Epidemiologist, Public Health Services- Public Health Observatory

Contributing Organizations: AIDS Saskatoon Mobile Health Bus- Primary Health Clinic Westside Community Clinic Riversdale Immunization Clinic Other: Special thank you to all participants who took time to complete the Dental Health Questionnaire

and provide Public Health Services, Oral Health Program with valuable information.

QUESTIONS?

Reference: http://1.bp.blogspot.com/_a3MD-thA0QU/SxQVt2LjViI/AAAAAAAAABU/aDEwkQXtpAg/s1600/GuyThinkingRight.gif

REFERENCES Surgeon General (2000). Oral Health in America. A Report of the Surgeon General. Rockville, MD:

Department of Health and Human Services- U.S. Public Health Service. Lemstra M, Neudorf C. Health Disparity in Saskatoon: Analysis to Intervention, Executive Summary, June

2010. Retrieved from: http://www.saskatoonhealthregion.ca/your_health/documents/PHO/HealthDisparityExecSummary.pdf

Canadian Oral Health Strategy, June 2010. Retrieved from: http://www.fptdwg.ca/assets/PDF/Canadian%20Oral%20Health%20Strategy%20-%20Final.pdf

Health Canada, Canadian Health Measures Survey. Oral Health Statistics: 2007-2009, June 2010: http://www.hc-sc.gc.ca/hl-vs/pubs/oral-bucco/fact-fiche-oral-bucco-stat-eng.php

Canadian Dental Association. August 2010. Retrieved from: http://www.cda-adc.ca/_files/position_statements/Early_Childhood_Caries_2010-05-18.pdf

Canadian Dental Association. August 2010. Retrieved from: http://www.cda-adc.ca/en/oral_health/faqs_resources/faqs/dental_care_faqs.asp#4

Schroth RJ, Brothwell DJ. Prevalence of Early Childhood Caries in 4 Manitoba Communities. Journal of Canadian Dental Association 2005; 71 (8): 567a- 567d.

Ismail AI, Sohn W. A Systematic Review of Clinical Diagnostic Criteria of Early Childhood Caries. Journal of Public Health Dentistry 1999 (59) 3: 171-91.

Anderson H K, Drummond B K. Thomson W M. Changes in aspects of children’s oral- health- related quality of life following dental treatment under general anesthetic. International Journal of Pediatric Dentistry 2004; 14: 317- 325.

Schroth RJ, Morey B. Providing Timely Dental Treatment for Young Children under General Anesthesia is a Government Priority. Journal of Canadian Dental Association, 2007: 73 (3): 241- 243.

Association of Dental Surgeons British Columbia. Children’s Dentistry, Task Force Report. Vancouver BC: Association of Dental Surgeons British Columbia, 2001.