Public Testimony

	New York City Department of Health & Mental Hygiene Bureau of Intergovernmental Affairs

Good afternoon Chairperson Rivera and members of the Health Committee. I am Louise Cohen, Deputy Commissioner for Health Care Access and Improvement at the Department of Health and Mental Hygiene (DOHMH). On behalf of Commissioner Frieden, I thank you for the opportunity to testify regarding the Department’s efforts to restructure its oral health program. I will briefly discuss our improved service paradigm, and explain how the restructuring will enable more children to access better services and thereby achieve better oral health.

As you know, the Department has provided oral health services to the children of New York City for over one hundred years. In the early part of the 20th Century, DOHMH operated the only dental program to provide services free of charge to poor children. Since that time, the oral health program has operated continuously in DOHMH health centers, providing children with a variety of services including cleaning, sealants, fillings, and root canals.

In 1990, the Department reevaluated the program and created a new model designed to provide more flexibility, deepen roots in the community, increase access for children in need, and ultimately, to serve more children. This model relied on community-based, “portable” sites located primarily in schools to provide services to children in need. These sites had one dental chair and were supervised by regional dental offices throughout the city. Conversion of “fixed” school sites to 32 portable clinics in elementary, intermediate and high schools was completed by 1991.

One additional and very important development over the past one hundred years is that virtually all children are now eligible for either private or public health insurance, giving them greater access to dental care in their communities. Medicaid, Child Health Plus and Family Health Plus all cover pediatric dental services.

In our current dental service model, community sites have one dental chair, usually located in a public school. An available room with electricity and running water is converted into a dental operatory, staffed by a dentist and dental assistant. These sites are open an average of three days per week, for between four and seven hours per day, providing screenings, sealants, cleaning, fillings, and occasionally more complicated procedures such as extractions and root canals.

The health center sites are larger, with four to five chairs and multiple dentists, dental hygienists, and dental assistants. Open five days per week during regular business hours, these sites provide a full range of dental services including exams, application of sealants, restorative care such as cavity fillings, root canals, extractions and other surgical procedures.

The Department of Health and Mental Hygiene is committed to providing evidence-based public health programs. In 2002, the Centers for Disease Control’s Task Force on Community Preventive Services reported that the key interventions proven effective to prevent tooth decay among children are community-wide fluoridation programs and school-based sealant programs. School based oral health programs that emphasize sealant delivery have been associated with an average decrease in dental cavities of 60 percent. New York City has had fluoridated water since 1964, but the oral health program has only recently begun to focus its resources on the application of dental sealants as part of this evidence-based approach.

Sealants are – according to the American Dental Association – “a plastic material that is usually applied to the chewing surfaces of the back teeth—premolars and molars. This plastic resin bonds into the depressions and grooves (pits and fissures) of the chewing surfaces of back teeth. The sealant acts as a barrier, protecting enamel from plaque and acids. Thorough brushing and flossing help remove food particles and plaque from smooth surfaces of teeth. But toothbrush bristles cannot reach all the way into the depressions and grooves to extract food and plaque. Sealants protect these vulnerable areas by "sealing out" plaque and food.”

Despite the evidence for sealant use as a key preventive service, and the availability of public health insurance, New York City continues to have low rates of sealant coverage for at-risk children. Data from 2002 through 2004 shows that only 12 percent of New York City 3rd graders had one or more sealants, compared to the state-wide rate of 38 percent for all 3rd graders, and national rate of 27 percent for the same group. Healthy People 2010, the national health promotion and disease prevention initiative, has set a sealant target of 50 percent of all children by the year 2010.

Prevalence of sealants does vary somewhat among children by race and ethnicity, with white children having a slightly higher percentage of sealants applied than Asian, Black or Hispanic children. However, analyzing New York State data by socio-economic status shows a much greater disparity, with 41 percent of children with higher socio-economic status having sealants applied compared with 18 percent of those with lower socio-economic status. New York City’s poor children have an even lower sealant prevalence of only 11 percent.

Over the past several years, the Department has been exploring ways to reach our goals of delivering quality preventive dental care to the greatest number of underserved children, and reaching the HP 2010 goal of sealants for 50 percent of all children. With that in mind the Department is restructuring the oral health program in several important ways. First, we plan to move away from providing intensive, restorative procedures for older students, instead targeting primary and intermediate school students for primary and preventive care, including screenings and sealants.

Second, operating hours will be modified to better suit the schedules of students, teachers, and parents. Morning hours in schools tend to be more academic in nature, and teachers and principals are reluctant to have children pulled out for dental services during this time. The Department is currently working with Beacon schools that have after school programs to offer oral health services in the afternoon hours. We have received positive feedback, and are now exploring a program model that would include more afternoon, evening and even Saturday hours to better accommodate students, teachers, and parents.

Third, staffing will be improved so that the most effective dental teams work together in the community based sites and at the dental clinics. One model under consideration would involve a team of dentists, dental assistants and dental hygienists serving a school in a short-term campaign that would provide screening, sealants, and referrals. Parents would be given information on public health insurance programs and assistance in finding both a medical and dental home for regular health care. After some period of time, the team would then move on to another school and repeat this intervention.

Finally, the Department is creating new outreach strategies, including the development of new oral health informational materials, including literature about sealants, for dissemination to schools, parents, and community based organizations to generate awareness of the program. We are also revising our dental consent form to include information about sealants and questions about health insurance coverage, so that the Department’s facilitated enrollers can identify and assist eligible, interested parents in obtaining public health insurance.

To maximize oral health education and outreach in underserved communities, we are strengthening partnerships with other groups such as the NYU Dental School van, and the Colgate “Bright Smiles, Bright Futures” program. Locations and times for dental screenings by dental personnel in the vans will be coordinated with DOHMH staff, and referrals to health centers and community based sites will be followed up on and monitored.

We are also increasing our coordination with the DOHMH/DOE Office of School Health, which is helping the program enlist the support of principals, teachers, and parent coordinators to promote the dental programs in their schools. We will provide information and materials for school nurses and primary care physicians on oral health, especially sealants, and we will develop protocols for referring children to our school based dental providers.

While the original draft of our restructuring plan included the possibility of lay-offs, I’m happy to report the Department will proceed to restructure the program starting with the current complement of staff. We will increase core preventative services for kids, and in the medium term, attrition, administrative reassignments, and scheduling shifts during the summer months will allow us to best utilize our staff resources.

As we have done every year, and keeping with the original intent of instituting a program largely based on “portable” equipment, the oral health program is also reviewing community sites to make sure they are being effectively utilized. In doing so, we assess the number of students with parental consents on file, the amount of time that a dentist actually spends with children in his/her dental chair, and the location of the school in relationship to other dental sites. At the current time, we intend to reduce hours at high school sites in accordance with our change of prioritization from high schools to elementary and middle schools. Similarly, greater emphasis will be placed on preventive dental services, with those requiring more intensive procedures being referred to DOHMH health clinics and other community-based dental providers. I want to emphasize that the Department remains committed to completing treatment plans for all current patients.

The Department is also in the process of identifying new, more appropriate locations sites to add to the program mix. This process includes site visits and outreach to principals to gauge interest in the program. In addition, as I mentioned earlier, we are exploring alternative models, including a shorter, more intensive, relationship with individual schools.

As the City’s public health agency, the Department is committed to providing the best preventive dental care possible and to reaching the HP 2010 goal of 50 percent sealant application for children in elementary and middle schools. DOHMH will concentrate oral health resources on direct sealant applications; work with other New York City pediatric dental providers to improve rates of sealant application, and; improve awareness and acceptance of this important preventive measure among parents and physicians.

On behalf of Commissioner Frieden, I would like to thank the Council for its interest in the DOHMH oral health program. We look forward to working together to improve the public’s health. I am pleased to answer any questions you may have at this time. Thank you.

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