Nebraska Oral Health Needs Assessment by Vulnerable Populations

Why Is This Important?

Nebraska had a 2013 total population of 1,868,516 residents in 93 counties.¹ Approximately one third (over 600,000) live in rural locations. In the 1940s, over half of Nebraska residents lived in rural areas, but now two thirds live in large cities or metropolitan areas.² Because many hospitals, dental clinics, and community centers are located in these urban areas, rural residents in Nebraska have limited access to dental care.

Sources:

1. United States Department of Agriculture Economic Research Service. Sate Fact Sheets. Updated 12/12/2014. Available at: http://www.ers.usda.gov/data-products/state-fact-sheets/state-data.aspx.

2. United State Bureau of the Census. 2010 Census; March 2011.

Why Is This Important?

Source: Nebraska Department of Health and Human Service BRFSS Age 18+ 2007-2010

The BRFSS survey from 2007-2010 found that 46.1% of rural residents over age 18 had lost at least one tooth to dental decay or gum disease, while only 35.6% of urban residents did. And more rural elder people had lost all of their teeth (18%) compared to urban (14.4%). Many of these people are ranchers or farmers, often located many miles from the nearest dental clinic, community center or hospital. Just 65.1% of rural adult residents had seen a dentist in the past 12 months compared to 73.7% of their urban counterparts. And city people were more likely to have their teeth cleaned annually (73.7%) than country residents (65.1%).

Why Is This Important?

The DHHS Office of Rural Health also tracks state general dental shortage areas and in 2013 there were 49 counties designated as shortage areas (over 50%) and 20 counties with no full time or only part time general dentist coverage representing about 35,000 people or 1.8% of our population.¹ These counties include: Sioux, Banner, Grant, Arthur, McPherson, Hooker, Thomas, Logan, Blaine, Loup, Keya Paha, Wheeler, Greeley, Gosper, Hayes, Fillmore, Frontier, Sherman, Stanton and Hitchcock.

Sources:

1. Nebraska Department of Health and Human Service, Rural health Advisory Commission. State-Designated Shortage Area General Dentistry; Corrected January 2015.

Story Behind the Curve

There are fewer dentists practicing in rural office locations to treat these higher disease rates. In 2012, there were 1,497 licensed dentists in Nebraska and 1,034 were actively practicing. About 80% were general practice dentists and 20% were specialists.¹ The majority of Nebraska dentists (61%) work in urban areas while only 39% work in rural settings.² There are about 800 general dentists reporting in Nebraska and almost 1/3 (239) are over the age of 60 and are approaching retirement age.¹ More than half of the state is considered a general dentist shortage area and that situation is more pronounced (almost 85%)^3,4 when concerning pediatric and oral surgery specialists. (see maps below). Higher disease, fewer providers, geographic challenges, lack of public transportation, weather conditions, and socioeconomic concerns make rural residents one of the largest and most vulnerable groups for dental disease in our state.

Sources:

1. University of Nebraska Medical Center. Health Professional Tracking System; 2012.

2. Chandak, A., McFarland, K., Nayar, P., Deras, Marlene, and Stimpson, P. J. (2013). Access to Oral Health Care in Nebraska. UNMC Center for Health Policy. Available at:http://www.unmc.edu/publichealth/hpts/news/2013-ac....

3. Nebraska Department of Health and Human Service, Rural health Advisory Commission. State-Designated Shortage Area General Dentistry; Corrected January 2015.

4. Chandak, A., McFarland, K., Nayar, P., Deras, M., and Stimpson, P. J. (2013). Access to Oral Health Care In Nebraska. University of Nebraska Medical Center. Available at: http://www.unmc.edu/publichealth/hpts/news/2013-ac....

Why Is This Important?

In 2013 the U.S. Census Bureau reported that 11.3% (approximately 125,000 people in the working class) of Nebraskans under age 65 were without health insurance. It has been estimated that more than twice as many lack dental insurance (approximately 250,000). By 2014, the Affordable Care Act had reduced these numbers for health insurance, but dental benefits were only mandated for children, still leaving a large gap in coverage for adults. Low family income can lead to a lack of opportunity, social difficulty and poverty status. Substandard housing conditions and living in medically underserved communities are additional obstacles to good oral health. In 2014, Kids Count Nebraska reported nearly 41% of our children are growing up in low-income families.

Story Behind the Curve

Source: Nebraska DHHS BRFSS Age 18+ 2007-2010

BRFSS Studies in Nebraska have shown that adults with lower income and education have higher rates of extractions while those with higher income and education visit their dentist more often and get cleanings more frequently (see above). The 2005 3^rd Grade survey found that students who participated in the free or reduced lunch program were more likely to have had fillings and untreated decay (see below).

FRL: Free/Reduced Lunch Program; Source: Nebraska DHHS 3^rd Grade Survey Age 8-11 2005

Story Behind the Curve

Federally Qualified Health Centers (FQHCs) provide urgent and basic oral care for millions of Americans who face barriers in accessing the private system. People deciding to access the health system through FQHCs often have more unmet oral needs, and may come from various underserved groups, including low income and uninsured. In Nebraska, there are seven FQHCs that serve over 60,000 patients, and all centers offer dental services, which represents about 28% of their patients.¹ The value of this care was nearly $8.5 million and the average cost per patient was about $355.² The One World Community Health Center and Charles Drew Community Health Center in Omaha both have mobile dental vans that increases access to dental care by going into several Omaha Public Schools. The annual activities of these Health Centers are reported through the Health Center Association of Nebraska, and can be seen below.

Sources:

1. Centers of Medicare & Medicaid Services. FY2013 Number for Children Ever Enrolled in Medicaid and CHIP; 07/23/14. Available at: http://www.medicaid.gov/chip/downloads/fy-2013-chi....

2. Health Center Association of Nebraska. Internal Information; 2014-2015. Webpage: http://www.hcanebraska.org/.

Story Behind the Curve

Centers for Medicare and Medicaid Services (CMS) launched the Oral Health Initiative (OHI) in 2010. OHI identified two specific national and state goals with the aim of improving the oral health of children enrolled in Medicaid and the Children's Health Insurance Program (CHIP). The following measures outline the two goals of the CMS OHI and the current data available around these objectives.

Click here to learn more about the OHI: https://www.medicaid.gov/Medicaid-CHIP-Program-Inf...

Strategy

Click here to learn more about CMS's strategy for meeting the Oral Health Initiative goals: https://www.medicaid.gov/Medicaid-CHIP-Program-Inf...

Story Behind the Curve

In 2014, Nebraska has an approximate population of 1,881,503 people. White people comprise 80% (1,514,386) and nearly 20% are from minority groups, about 367,117. This is lower than the overall U.S. average of 22.9% (however if current national trends continue, the minorities will outnumber the majorities by 2050). Approximately 10% of Nebraska's minorities are Hispanic or Latino, 5% African American, 2% Asian and 1% Native American. It is projected that Nebraska will also have a more diverse population in the future and that the Hispanic race may increase to more than 20 % of our residents by 2050.

Sources:

1. Lincoln Journal Star. Andersen, E. Graying Population Poses Problems for Nebraska Children. 1/14/2014. Available at: http://journalstar.com/news/local/graying-populati....

Story Behind the Curve

According to the 2005 Nebraska 3^rd Grade Survey, African American and Hispanic children and children from low-income schools had significantly higher rates of caries experience, untreated decay and rampant caries. They required more treatment needs and had a lower percentage of sealant placements compared to the Caucasian majority in higher income schools. Given the rapid growth of the Hispanic population in Nebraska, these ethnic disparities signal a growing need in both preventive and treatment dental services for these groups.

Source: 2005 Nebraska 3rd Grade Survey

Why Is This Important?

According to Nebraska BRFSS 2007 to 2010 combined data, compared to the White majority, Minority adults had lower percentages of visits to the dentist and a higher rates of permanent tooth extractions. Native American, African American and Hispanic Americans all demonstrated poorer overall dental health compared to Whites, while Asian Americans compared favorably. Minority people often face economic, language and cultural differences along with health literacy problems that make effective communication difficult and create barriers to access preventive and corrective health care. Culturally competent oral health literacy and dental care should be provided to reduce dental health inequities.

Story Behind the Curve

According to U.S 2014 census, the total number of Native Americans living in Nebraska was 15,459 (1% of total population). Eight American Indian Tribes are located in Nebraska, which are Santee Sioux Tribe, Omaha Tribe, Ogallala Sioux Tribe, Otoe Tribe, Pawnee Tribe, Ponca Tribe, Sac and Fox Tribe, and the Winnebago Tribe. In Nebraska, four clinic/health centers exist for Native Americans which are: the Carl T. Curtis Education Center in Macy, Fred Leroy Health Center in Omaha, Santee Dental Clinic in Niobrara, and Winnebago Dental Clinic in Winnebago Nebraska. In addition, many Ogallala Sioux, who live in northwestern Nebraska, receive their dental care at the Pine Ridge Hospital located just north of the border in South Dakota. Dental care is provided in a culturally sensitive manner utilizing respectful and effective approaches.

Much of the dental services for this population are managed and coordinated through the Indian Health Service (IHS). The IHS monitors American Indian and Alaska Native (AI/AN) dental information through their Dental Data System . Dental services are tracked and based on the extent of access to care to the service population. Nebraska is part of the Aberdeen Area along with North Dakota, South Dakota and Iowa. Local program managers and area dental directors establish guidelines, evaluation and future direction. IHS Headquarters uses this data as a whole in order to manage the overall IHS Area Dental Programs and to advocate on a national level for the oral health needs of American Indians and Alaska Natives.

According to Nebraska BRFSS 2007-2010 results, only 55.5% of Native Americans had preventive care in the form of teeth cleanings in the past year compared to whites in who had a rate of 70.2%. Native Americans had much higher rates of permanent tooth extractions due to dental decay or gum disease with 50.9% for adults and 23.1% for elders with all permanent teeth extracted. These results indicate much poorer dental health when compared with Whites that had 38.9% extraction rates for adults and 15.9% for elders.

Source: Nebraska Department of Health and Human Service Age 18+BRFSS 2007-2010

Most recent BRFSS data shows that American Indians compared to Whites were 19 percent less likely to have visited a dentist or dental clinic for any reason in the past year, 1.6 times more likely to report having any permanent teeth extracted due to tooth decay or gum disease among 45-64 year olds, and 2.9 times more likely to report having all their permanent teeth extracted due to tooth decay or gum disease among those 65 and older.

Why Is This Important?

It is estimated that 10.6% of Nebraska’s population has one or more disabilities, (about 200,000).¹ Among the top disabilities are: visual, hearing, physical, behavioral, self-care and independent living. Assistance care may be offered in numerous child care agencies, community outreach services and group homes located throughout the state. Developmental disabilities are further defined as a severe chronic disability that is attributable to a mental or physical impairment. Currently about 5,000 people of all ages receive services through the Nebraska Medicaid waiver program.² Nebraska does operate one large facility that houses 175 citizens at the State Development Center in Beatrice.

Disabilities can create difficulty in performing daily activities such as dressing, bathing and personal hygiene. People with a disability are more likely to experience dental problems due to these conditions. They may not have the motor skills needed to use a toothbrush correctly and they may not be able to cooperate with the dental staff for X-rays or fillings. They may have communication problems or require special medications. Few studies have been done on this group but, adults may have higher disease rates than the general public and children are at even more risk.

Sources:

1. United States Census Bureau. State & County QuickFacts; 2013. Available at: http://quickfacts.census.gov/qfd/states/00000.html.

2. Medicaid Waiver Program. Nebraska Medicaid Waiver Disability Services & Waivers. Retrieved Date: 03/10/2015. Available at: http://medicaidwaiver.org/state/nebraska.html.

Story Behind the Curve

It has been estimated that 11% of children that are enrolled in Head Start in Nebraska have a disability that qualifies them for special education and related services.¹ Fetal alcohol syndrome, cerebral palsy, Downs Syndrome and autism can affect children. Many adults can suffer from crippling diseases such as arthritis, dementia, Parkinson Disease or Alzheimer’s. The graphs below provide a general picture about disabled peoples’ oral health status in Nebraska. According to the results in 2005/06 and 2009/10, these children have higher need for prevention than the rest of the U.S. (91.7% to 89.6%) and these children have higher rates of other dental needs (28.4% to 26.7%) (See graph below).² The data shows an overall need for more emphasis in providing access to preventive and corrective dental care for these people. State dental disease prevention and health promotion programs should be designed to accommodate members of this group.

Sources:

1. Region 10 Education Service Center, Head Start/Early Head Start Disabilities. Retrieved Date: 2/5/2015. Available at: http://www.region10.org/preschool-services/early-h....

2. Child and Adolescent Health Measurement Initiative. Data Resource Center for Child & Adolescent Health. National Survey of Children with Special Health Care Needs. Retrieved Date: 1/21/2015. Available at: http://www.childhealthdata.org/browse/survey?s=2.

Source: National Survey of Children with Special Health Care Needs Age 1-17 (CHSCN)

What We Do

Each year hundreds of Special Olympic athletes in Omaha and Lincoln receive dental screenings, oral health education, sports mouth guards and proper follow-up dental referrals during their annual Special Olympic games. The Office of Oral Health and Dentistry supports these efforts through volunteer participation and material donations. Dental screening data is being collected and will be analyzed at a future time, which will provide us valuable data on this vulnerable population group.

Why Is This Important?

Nebraska Active Duty Military: Nebraska is home to almost 8,000 active duty Army, Navy, Marine Corps, Air Force, and Coast Guard personnel.¹ There are also over 9,500 Reserve and National Guard personnel.¹ In 2008, the Department of Defense conducted a nationwide Oral Health Study of over 5,000 Army, Navy, Air Force and Marine Corps recruits.² As part of their medical evaluation, each recruit undergoes a dental examination to determine their dental readiness classification. Service members who do not require urgent care now or in the next 12 months are considered worldwide deployable. Those members who require urgent or emergency treatment are considered non-deployable. The results of the 2008 DoD Recruit Oral Health Survey showed that over half (52.4%) of these young adult recruits had unmet dental needs that classified them as non-deployable, demonstrating the fact that oral health can even affect our military capabilities.² The majority of our Nebraska Military members receive their dental readiness examinations and routine care at Offutt Air Force Base in Omaha and the Army/Air National Guard facilitates in Lincoln.

Nebraska Military Veterans: There are approximately 5,500 Operation Enduring Freedom (OEF)/ Operation Iraqi Freedom (OIF) Veterans in the VA Nebraska-Western Iowa Health Care System who have recently returned from overseas.³ In addition, there are estimated to be over 140,000 Veterans of all ages living in Nebraska.¹ Dental benefits are more limited than medical benefits through the Veterans Administration and patients must go through an eligibility determination process. If they are not eligible, then they can receive assistance to be enrolled in the VA Dental Insurance program at a reduced cost. In 2013, over 17,000 dental visits were provided at three dental facilities located in Grand Island, Lincoln and Omaha.⁴ These clinics, staffed by four full time and 12 part time dentists produced over $8 million worth of care to their patients.⁴ The VA also sponsors advanced dental student residency training positions through the UNMC College of Dentistry. If eligible Veterans live more than 40 miles from a VA facility, they can get covered care in the local community. DHHS also manages four Veterans homes that serve approximately 650 disabled Veterans in Scottsbluff, Bellevue, Norfolk and Grand Island.

In 1992, the Homeless Veterans Dental Program was established by the VA. In surveys ranking the 10 highest unmet needs for homeless Veterans, dental care was consistently ranked as one of their top 3 unmet needs along with long term housing and child care.⁵ Studies have also shown that after dental care, Veterans report significant improvement in their perceived general health and overall self-esteem which helps them re-enter society as a productive member.

Sources:

1. Department of Veterans Affairs. State Summary, Nebraska and the U.S. Department of Veterans Affairs; November 2010. Available at: http://www.va.gov/opa/publications/factsheets/ss_nebraska.pdf.

2. Tri-Service Center for Oral health Studies. 2008 DoD Recruit Oral Health Survey; 2008. Available at: http://www.usuhs.edu/tscohs/pdf/2008DoDRecruitOralHealthSurvey.pdf.

3. U.S. Department of Veterans Affairs. VA Nebraska-Western Iowa Health Care System. Retrieved Date: 03/10/2015. Available at: http://www.nebraska.va.gov/features/Welcomes_Home.asp.

4. Nebraska Department of Veteran’s Affairs. Internal information; 2014.

5. U.S. Department of Veterans Affair. Office of Dentistry Homeless Veterans Dental Program. Retrieved Date: 03/10/2015. Available at: http://www.va.gov/homeless/dental.asp.

What We Do

In 2014, the Nebraska Association of Local Health Directors (NALHD) received a grant from Veterans Affairs (VA) to assist returning Veterans reintegrate into their families and communities. This project, VETSET, will provide resources and training to rural health departments to meet the distinctive needs of Veterans and assure that they can access the proper support services (including health) that they need to successfully make the transition from military to civilian life.¹

For more information about VETSET Nebraska visit: http://nalhd.org/our-work/vetset.html.

1. Nebraska Association of Local Health Directors. Bringing Resources and Training to Nebraska; 09/08/2014. Available at: http://www.nalhd.org/.

Story Behind the Curve

Foreign Born: According to the American Immigration Council, Nebraska foreign-born residents rose from 1.8% in 1990 to 6.6% in 2013 for an approximate total of 123,000. These people come from many respected but different cultural, religious, educational, and language backgrounds and they bring a rich diversity to our state. Members of this community can run into barriers when seeking health care. Effective communication, health system understanding, personal belief values and obtaining adequate dental insurance can all create initial difficulties.

Refugees: Nebraska is also home to many foreign refugees who are leaving emergency persecution situations in their countries (often war zones) and are seeking asylum protection in the United States. Since 2000, more than 8,000 refugees, mostly from the regions of SE Asia, Africa and the Middle East have resettled in Nebraska.¹ In 2015 alone, 1,309 refugees and persons with special immigrant visa people resettled in Nebraska.² There is also a large number of secondary refugee migrants who initially started in a different state but then moved to Nebraska. People with Refugee Status undergo an overseas medical screening and a domestic medical exam in Nebraska within 30 days of arrival (a dental screening is part of this process). Many of these people are referred to community dental clinics that utilize translators to help bridge some of the linguistic and cultural challenges these patients face.

More definitive dental data information is needed on these groups, but it can be assumed with their history and the current barriers that they face, they may have higher diseases rates and lower access to care than the majority of Nebraska people.

1. News & Information for Nebraska’s New Americans. How Many Refugees Are There in Nebraska? 05/04/2012. Available at: http://cojmc.unl.edu/mosaic/2012/05/04/refugees-ne....

2. Nebraska Department of Health and Human Service. Refugee Resettlement Program. Retrieved Date: 03/11/2015. Available at: http://dhhs.ne.gov/children_family_services/Pages/....

Partnerships

Collaboration efforts should be made by the OOHD through the DHHS Refugee Program Coordinator, the Omaha Refugee Task Force and the New Americans Task Force in Lincoln to learn more about the health care status and dental needs of the immigrant and refugee populations.

Why Is This Important?

Nebraska has approximately 25,000 new births each year.¹ Pregnancy is a time to take extra care of teeth and gums. Due to significant hormonal changes, the resistance level to oral disease can be lessened and it is important to increase individual oral hygiene efforts with brushing, flossing and professional cleanings during the second trimester to prevent opportunistic bacteria from causing dental infections. Common oral health problems during pregnancy include painful and hyperemic bleeding gums, swollen pregnancy granulomas, advancing periodontal disease, and increased risk for tooth decay for the mother.²

It is important to also remember the connection between the mother’s oral health and the oral health of her unborn baby. During this time the mother should receive perinatal nutrition counseling with special emphasis on calcium, protein, fruits, nuts and cheese with prenatal vitamins to help with the development of the baby teeth. Nationally, only about one fourth of women see a dentist during their pregnancy.³ The American Academy of Pediatric Dentistry is working to increase awareness of the importance of oral health care in expectant mothers.

Sources:

1. United States Census Bureau. State & County QuickFacts; 2013. Available at: http://quickfacts.census.gov/qfd/states/00000.html.

2. Nebraska Department of Health and Human Service. Pregnancy Risk Assessment Monitoring System Brochure; 10/17/2013. Available at: http://dhhs.ne.gov/publichealth/Pages/prams.aspx.

3. Silk, H., Douglass, A. B., Douglass, J. M., Silk, L. (2008) “Oral Health during Pregnancy.” American Family Physician. 77:8.

Why Is This Important?

Although cigarette smoking in the U.S. has been on the decline, surveys from the CDC show that the use of smokeless tobacco among youth has held troublingly steady.¹ Each year, more than 500,000 American youth ages 12-17 use smokeless tobacco for the first time.² In 2013, 14.7 percent of high-school boys and 8.8 % of all high school students reported current use of smokeless tobacco products.³ The use of cigarette, pipes and cigars can contribute to staining of the teeth, bad breath, intra-oral lesions, gum recession and periodontal disease, which can result in tooth loss. In addition, dental caries rates, particularly on the root surfaces of teeth, are higher for tobacco users than non-users.

Sources:

1. Centers for Disease Control and Prevention. Smokeless Tobacco in the United States. Retrieved Date: 03/10/2015. Available at: http://www.tobaccofreekids.org/research/factsheets/pdf/0231.pdf.

2. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The NSDUH Report: Trends in Smokeless Tobacco Use and Initiation; 07/24/2014. Available at: http://www.samhsa.gov/data/2K14/NSDUH189/sr189-smo...

3. Centers of Disease Control and Prevention. Youth Risk Behavioral Survey; 07/12/2014. Available at: http://www.tobaccofreekids.org/press_releases/post/2014_06_12_cdc.

Partners

The Office of Oral Health and Dentistry will work closely with DHHS Tobacco Free Nebraska to track our user trends and to increase public health campaign efforts to educate and protect our citizens.

Why Is This Important?

Chronic use of smokeless tobacco has been directly linked to cancer of the mouth, throat and larynx. Oral Cancer is the 12^th leading type of cancer in the U.S. and it represents 2.5% of all new cancer cases in the U.S. Over 30,000 Americans are diagnosed with oral or pharyngeal cancer each year and only slightly more than half will be alive in 5 years.¹ Survival rates are lower for African American men than white (36% vs 61%). It causes nearly 8,000 deaths annually and kills roughly one person per hour.² Historically, the death rate associated with this cancer is high because it is often discovered late in its development stage. Efforts should be made to increase early cancer screenings by dental professionals, which would lead to earlier detection and treatment of this cancer. Oral cancer rates for Nebraska can be seen below.

*Rates are expressed as the annual number of invasive diagnoses or deaths per 100,000 population. Age-adjusted to the 2000 U.S. standard population

Sources:

1. The National Cancer Institute, Centers for Disease Control and Prevention. More than 300 Million People in at Least 70 Countries Use Smokeless Tobacco; 12/15/2014. Available at: http://www.cdc.gov/media/releases/2014/p1215-smoke....

2. National Cancer Institute, Surveillance, Epidemiology, and End Results Programs. SEER Stat Fact Sheets: Oral Cavity and Pharynx Cancer. Retrieved date: 03/09/2015. Available at: http://seer.cancer.gov/statfacts/html/oralcav.html.

3. Nebraska DHHS Cancer Registry

Why Is This Important?

The average age of this population is approximately 35 years, and the average length of stay is about 2-5 years. While the percentage of people in prison decreased 4% between 2010-2012 nationally, Nebraska saw this rate increase 3% from 2010-2012. Basic diagnostic, preventive, corrective and emergency dental services are provided at several of the facilities. In Nebraska a staff of about 12 dentists hygienists and assistants provide this treatment to incarcerated persons in the state system.¹ No survey studies have been conducted on these people, but they would fall into similar rates of caries experience, untreated decay and gum disease for this U.S. age range. However, given their backgrounds and often difficult social economic situations, it is reasonable to assume that this population may have higher dental disease activity.

Sources:

1. Nebraska Department of Correctional Service. Internal information; 2014.