Service Area Strategic Plan
11/23/2009   5:04 am
Department of Health (601)
Biennium: 2008-10
Service Area 1 of 1
Local Dental Services (601 440 02)
Description

This service area provides a range of oral health services for the community including education, prevention, screening, diagnosis and treatment. The focus is primarily on the provision of quality services to the indigent population and other special population groups, especially children who, for various reasons, lack access to basic oral health care. In addition, the service area recruits volunteers or staff to administer the fluoride mouth rinse programs in schools where lack of fluoridated water places children at higher risk of dental caries. The service area also monitors the oral health status of the community using standard measures of need, including evaluation of demographic data, availability of fluoridated water supplies and supplemental fluoride programs, prevalence of dental disease both past and present, appropriate utilization of dental sealants, and availability and accessibility of dental education, prevention, screening, diagnostic and treatment services.
Background Information
Mission Alignment and Authority
  • Describe how this service supports the agency mission
    This service area directly aligns with the Virginia Department of Health mission to promote and protect the health of Virginians by educating the public about oral health and oral disease and improving oral health through population and individual dental services.
  • Describe the Statutory Authority of this Service
    Section 32.1-2 of the Code of Virginia requires the Virginia Department of Health to administer and provide a comprehensive program of preventive, curative, restorative and environmental health services, educate the citizenry in health and environmental matters, develop and implement health resource plans, collect and preserve vital records andhealth statistics, assist in research, and abate hazards and nuisances to the health and to the environment, both emergency and otherwise, thereby improving the quality of life in the Commonwealth.

    Section 32.1-11 of the Code of Virginia authorizes the Virginia Department of Health to formulate a program of environmental health services, laboratory services and preventive, curative and restorative medical care services, including home and clinic health services described in Titles V, XVIII and XIX of the United States Social Security Act and amendments thereto, to be provided by the Department on a regional, district or local basis.
Customers
Agency Customer Group Customer Customers served annually Potential annual customers
Dental Patients age 0 -18 (95% quality for Federal School lunch program 21,887 302,002
Dental Patients age 18 + yrs (98% less than 200% Federal Poverty Level) 3,683 447,190
Fluoride Rinse Recipients 45,000 75,000

Anticipated Changes To Agency Customer Base
Oral health education for all Virginians will continue to be a priority of local health districts. As the population ages, increased educational efforts targeting the elderly are anticipated, with a particular focus on oral cancer screening in people over age 50 years. Assessment of access to oral health services will continue to be a focus of this service area, the frequency or content of which may change (increase) to reflect changes in population and/or the number of providers and provider practice patterns.

Other population based interventions may be anticipated to change. It is expected that expansion of public water systems to more Virginians may decrease the need for fluoride mouth rinse programs and increase the need for monitoring of fluoridation of these new systems.

Demand for and growth in the provision of direct dental services to indigent children and adults is anticipated. Nationally, an increase of 300,000 children ages 0-19 is anticipated in the next decade, and this growth is expected to be greatest in lower socioeconomic groups at highest risk for dental decay. Growing numbers of adults who lack any health insurance, which is a strong predictor of access to dental care, portend an increase in demand for dental care, both emergency and non-emergency services, from public health dental providers. Low reimbursement from Virginia Medicaid leading to minimal participation in Medicaid by Virginia dentists is expected to continue to require the Local Health District to be a community partner in providing direct services. The downward trend in the number of dentists graduated from Virginia’s only dental school over the past two decades may continue to contribute to difficulty accessing dental care that some experience, particularly the non-white population and low-income children, causing more to seek out public health dental services. The availability of dental clinics offering free or discounted dental services (with the amount of the discount generally tied to the federal poverty level) in an area will certainly affect the demand for public health dental services.
Partners
Partner Description
[None entered]
Products and Services
  • Factors Impacting the Products and/or Services:
    Dental caries is the most common chronic disease of childhood, occurring five to eight times as frequently as asthma, the second most common chronic disease in children. More than half of all children have caries by the second grade; and by the time students finish high school, about 80% have caries. Since the early 1970s, cases of dental caries in permanent teeth have declined among school-aged children, largely a result of various preventive regimens such as water fluoridation and increased personal use of fluoride containing paste and rinses. To continue this, increased use of dental sealants, tooth brushing with fluoridated toothpaste, community water fluoridation and improved dietary habits are needed to further reduce decay. Data from National Health and Nutrition Examination Survey indicated that 30 percent of all adults had untreated dental decay, with insufficient dental services disproportionately affecting the poorly educated, minority and socioeconomically disadvantaged. Oral and pharyngeal cancers are newly diagnosed in approximately 31,000 people per year, leading to 8100 deaths annually. Most are detected in later stages contributing to low five year survival rates. Only 13 percent of US adults aged 40 years or older reported having an oral cancer examination in the past year.

    Factors affecting the provision of services include the reduced staffing levels particularly of dentists and dental hygienists in public health dentistry. In addition, the public health dentist workforce is aging. Approximately 15 of the 45 full time dentists (33%) currently employed by local health departments will be eligible for retirement within the next five years. Low salaries relative to alternatives for clinical dentists negatively impact recruitment and retention. Young graduates with substantial educational debt and mid-career dentists with the lure of private practice incomes are difficult to attract and retain. Recruitment efforts that have been in place over the last several years will need to continue, as well as agency management of scholarship and loan repayment programs to assure access to care in needed areas.

    An action by the Board of Dentistry in 2005 allowed dental hygienists to practice under the general supervision of dentists (i.e., the dentist does not have to be on-site when services are provided). Working within the prescriptive guidelines of signed plans of care for patients has the potential to improve access to preventive dental care. However, this service delivery model relies on the availability of dental hygienists, who are in short supply.

    Financial support for advanced, improved technology will be required to maintain public health dental practices that are in step with current standards of care and best practices (such as digital radiography, electronic billing, access to databases for verification of recipient eligibility, etc).

    Dental clinic environments include state and locality owned buildings and locally owned mobile dental clinics (trailers). There are 56 clinical dental facilities as of July 2007 including 17 trailers and 39 fixed facilities. Typical dental clinics are two or three chair facilities with x-ray units and major support equipment including compressors, vacuums, film developers and autoclaves. Much of this equipment has been replaced with dedicated General Funds for dental infrastructure needs over the last 2 years. Clinic items replaced in all fixed facilities included X-Ray unit (standard and panorex), delivery unit, vacuum pump, compressor, autoclave, film processor, chair and light. Many mobile units received similar upgrades.
  • Anticipated Changes to the Products and/or Services
    It is anticipated that updating delivery units will by design improve the productivity of the dental staff, reduce staff strain, facilitate infection control and reduce the potential for cross contamination. It will also affect the ability to attract and retain new dentists in the Virginia Department of Health positions, as many dentists are not prepared to work on older dental units if initially trained with modern equipment and technology. In order to utilize the technology new fiber optic drills will also be a portion of the expenditure when replacing a dental unit.
  • Listing of Products and/or Services
    • Dental education to inform parents and patients of recommended individual preventive oral health practices; to inform and educate other health professionals of recommended preventive dental practices, community resources, etc; to educate local government, community members about oral health status of community and the availability and access to population and individual dental preventive and restorative dental care; to function as a resource on oral health for schools, head start and other partners who serve children
    • Diagnostic dental services, including oral examinations, dental x rays, etc.
    • Preventive dental services, including sealants, fluoride application, prophy, etc.
    • Restorative dental services, including endodontic, peridontic, prosthodontic and oral surgery services
    • Fluoride mouth rinse programs administered to populations of children with no access to fluoridated water
    • Dental emergency care, primarily for indigent adult population, including emergency evaluation for dental pain, and required treatment including extraction(s)
    • Adult oral cancer screening targeting patients over 50 years of age
Finance
  • Financial Overview
    [Nothing entered]
  • Financial Breakdown
    FY 2009    FY 2010
      General Fund     Nongeneral Fund        General Fund     Nongeneral Fund  
    Base Budget $3,091,015 $6,135,132    $3,091,015 $6,135,132
    Change To Base $-120,752 $-112,882    $-28,418 $-130,973
               
    Service Area Total   $2,970,263  $6,022,250     $3,062,597  $6,004,159 
Human Resources
  • Human Resources Overview
    [Nothing entered]
  • Human Resource Levels
    Effective Date      
    Total Authorized Position level Ø    
    Vacant Positions Ø    
    Current Employment Level 0.0    
    Non-Classified (Filled)    
    Full-Time Classified (Filled)    breakout of Current Employment Level
    Part-Time Classified (Filled)    
    Faculty (Filled)    
    Wage    
    Contract Employees    
    Total Human Resource Level 0.0   = Current Employment Level + Wage and Contract Employees
  • Factors Impacting HR
    [Nothing entered]
  • Anticipated HR Changes
    [Nothing entered]
Service Area Objectives
 
  • Improve and maintain population based factors affecting oral health status
    Objective Description
    Oral health is an essential and integral component of health throughout life. Cultural values influence oral health and well-being and can play an important role in care utilization practices and in perpetuating acceptable oral health norms. Cultural norms influence decisions and priority setting related to seeking professional dental care and establishing the routine of dental self-care behavior. The burden of oral diseases and conditions is disproportionately borne by individuals with low socioeconomic status and/or minority membership at all ages. Community water fluoridation, an effective, safe and ideal public health measure, benefits individuals of all ages and socioeconomic strata. Unfortunately, nearly one in seven Virginians is without this critical public health component. Effective disease prevention and health promotion measures exist for use by individuals, practitioners, and communities. Virginia’s local health department dental programs monitor the oral health status of their communities using standard measures of need, measuring progress toward improving or maintaining the status, identifying the immediate factors affecting such status and communicating this information to individuals, non-dental health providers, and the community. Factors monitored include fluoridation levels of public water systems, percentage of populations served by optimally fluoridated public water, participation in fluoride mouth rinse programs, oral cancer rates, access and availability of direct dental care, and utilization of preventive dental services across age and population groups.
    Objective Strategies
    • Maintain a current roster of all public water supplies and the number of people served. Monitor the fluoridation of all public water supplies in the health district and determine the percent of district population served by community water supplies with optimum fluoridation, annually. Monitor the number of schools and participants in the local health district participating in fluoride mouth rinse programs. Compile demographic data for the local health district to include population by age, sex, race and indigency rate and number of children eligible for free and reduced school lunch. Determine the percent of children participating in the free school lunch program in grades K-8 who receive preventive and therapeutic dental services, including dental sealants, by evaluating a representative sample of participants in the local health district, every three years. Measure the number of new oral cancer cases annually in local health district and evaluate stage at diagnosis and mortality rates from oral cancer. Conduct school surveys determining DMFS (Decayed, Missing, Filled, Sealed) and percent sealants on first and second permanent molars for representative sample of students from grades 1,4,8, and 10 in each local health district. Survey conducted every 3 years. Maintain a list of licensed, practicing oral health providers in each district, including the status of participation in Virginia Medicaid. Determine the dental provider: population ratio, to aid in assessing qualification of a county or area for designation as a dental profession shortage area. Provide oral health education to increase public knowledge and practice of preventive oral health measures. Partner with primary care providers to increase knowledge of oral health disease and its impact on general health. Educate at risk populations in risk reduction, especially the provision of tobacco cessation programs.Train non dental health professionals in the community and in public health programs serving children ages 0-3 years in the indications for and proper application of fluoride varnish.
    Objective Measures
    • The number of Local Health Districts that monitor the fluoridation of all public water supplies in the health district.
      Measure Class:
      Other
      Measure Type:
      Output
      Measure Frequency:
      Annual
      Preferred Trend:
      Up
      Measure Baseline Value:
      14
      Date:
      12/31/2004

      Measure Baseline Description: Percent of local health districts

      Measure Target Value:
      43
      Date:
      6/30/2010

      Measure Target Description: Percent of local health districts

      Data Source and Calculation: Community water fluoridation is the procedure of adjusting the natural fluoride concentration of a community’s water supply to a level that is best for the prevention of dental decay. From the 1940s until the 1980s, the number of citizens in the United States served by fluoridated water systems increased and then stabilized at about 60-62%. In Virginia, approximately 81% of citizens are served by fluoridated public water systems, and approximately 5% of citizens have water naturally high in fluoride. In systems where fluoride is added, the level of fluoridation must be monitored carefully to assure that optimum fluoridation is achieved and maintained. Operators of municipal water plants strive to maintain targeted concentrations of fluoride in water in fluoridated communities. These fluoride levels are reported to the Virginia Department of Health, Office of Drinking Water and are available to local health districts. Local health districts that are not fully served by fluoridated public water systems (five districts are fully fluoridated) may monitor fluoridation levels and customer numbers to determine the percent of the district population served by optimally fluoridated water. Using this information, the local health department determines the need for alternative fluoride delivery for persons not served by fluoridated water. This measure may be monitored by counting the number of local health districts who monitor fluoride levels through data in the Division of Dental Health quality assurance review reports and contacts with the Division of Dental Health community water fluoridation coordinator.

  • Provide oral healthcare services targeting at risk populations, particularly low income children
    Objective Description
    Oral diseases are progressive and cumulative and become more complex over time. They affect our ability to eat, how we look and our ability to work at home, at school, or on the job. Health disparities exist across population groups at all ages. Over 50% of 5-9 year old children have at least one cavity or filling; that increases to 78% among 17 year olds. Poor children suffer twice as many dental caries than their more affluent peers, and their disease is more likely to be untreated. Children living below the poverty line have more severe and untreated decay. Professional care is necessary for maintaining oral health, but 25% of poor children have not seen a dentist before entering kindergarten. Children without dental insurance are three times more likely to have dental needs than children with either public or private insurance. Fewer than one in five Medicaid-covered children received a single dental visit in a recent year-long study. More than 51 million school hours are lost each year nationally to dental-related illness; poor children suffer nearly 12 times more restricted-activity days than children from higher-income families. Local health districts that provide direct dental services to individuals target low income, uninsured or Medicaid-covered children primarily, with secondary target populations including low income adults including elderly and special populations such as mental health, elderly, and homeless.
    Objective Strategies
    • Improve the quantity and quality of dental services to target populations. Achieve a child/adult ratio of patients of 75% minimum, with a goal of 90% (90% children,adolescents/10% adults). Achieve a patient no-show rate in clinic of less than 20%. See a number of patients per day consistent with the state average. Provide total services per day consistent with the state average. Achieve and maintain a patient base consisting of 95% or more Medicaid-enrolled or uninsured low-income patients. Achieve a reported waiting time to get an appointment under two weeks. Maintain access to translator services for non-English speaking or hard of hearing clients. Maintain dental equipment and keep service records and maintenance schedules up to date. Maintain compliance with Occupational Safety Health Administration, Clinical Laboratory Improvement Ammendments and other regulatory requirements. Maintain dental records and documentation according to published standards. Document and appropriately label prescription medication dispensed, according to all applicable laws and regulations. Maintain continuing education of professional dental workforce. Increase the number of sealants provided to children and adolescents. Develop a callback system to remind patients who received restorative care initially to return for follow up preventive services. Train dental assistants to place sealants under the direct supervision of a licensed dentist. Utilize dental hygienists under the recent provision for general supervision of a hygienist, to increase access to preventive dental care including sealants.
    Objective Measures
    • The number of low income children and adolescents receiving dental services provided by local health department public health dental staff
      Measure Class:
      Other
      Measure Type:
      Output
      Measure Frequency:
      Annual
      Preferred Trend:
      Up
      Measure Baseline Value:
      21317
      Date:
      6/30/2005

      Measure Baseline Description: Number of children and adolescents

      Measure Target Value:
      21504
      Date:
      6/30/2010

      Measure Target Description: Number of children and adolescents

      Data Source and Calculation: Local health districts that provide dental services target persons aged 1-4 years old with family income under 200% Federal poverty level or enrolled in Medicaid, and persons 5-18 years old who are eligible for Federal free school lunch program or who are enrolled in Medicaid. Local health district dental programs provide monthly statistics to the Virginia Department of Health, Division of Dental Health reporting demographic information on the patients served and the number and types of services provided. These data are compiled and reported semiannually and annually. The number of visits is tracked by age, gender, income and insurance status. Most health districts also enter dental data into the Virginia Department of Health data system, WebVision. Reports available from that source may also be useful in evaluating unduplicated patient counts by income or insurance status.

    • Number of dental sealants placed on teeth of low income children and adolescents by public health dental workforce
      Measure Class:
      Other
      Measure Type:
      Output
      Measure Frequency:
      Annual
      Preferred Trend:
      Maintain
      Measure Baseline Value:
      19940
      Date:
      6/30/2005

      Measure Baseline Description: Number of dental sealants

      Measure Target Value:
      17044
      Date:
      6/30/2010

      Measure Target Description: Number of dental sealants

      Data Source and Calculation: Local health districts that provide dental services target persons aged 1-4 years old with family income under 200% Federal poverty level or enrolled in Medicaid and persons 5-18 years old who are eligible for Federal free school lunch program or who are enrolled in Medicaid. Local health district dental programs provide monthly statistics to the VDH Division of Dental Health reporting demographic information on the patients served and the number and types of services provided. These data are compiled and reported semiannually and annually. The number of visits is tracked by age, gender, income and insurance status. Most health districts also enter dental data into VDH data system, WebVision. Reports available from that source may also be useful in evaluating unduplicated patient counts by income or insurance status.


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