A. Definition of a Surveillance System
B. Public Health Surveillance Systems
For public health, surveillance is the ongoing systematic collection, analysis and interpretation of outcome-specific data for use in the planning, implementation, and evaluation of public health practice. A surveillance system provides the functional capacity for data collection and analysis as well as the timely dissemination of information derived from these data to persons who can undertake effective prevention and control activities (1).
In performing the public health core function of assessment, state oral health programs often engage in surveys, needs assessment and surveillance efforts. Although they may be related, these data-related activities are distinct. Surveys assess samples of a defined population (e.g., children, adults and special needs individuals) through clinical measures or the use of a questionnaire (2). A survey can provide a snapshot estimate of a defined population at a point in time. Needs assessment is a process that seeks to identify: a) the extent and types of existing and potential problems in a community, b) the current system of services available, and c) the extent of unmet needs, underutilized resources or shortcomings of the service delivery system (3). The three practices come together when point-in-time surveys are repeated and aggregated with other data sources into a surveillance system and when that surveillance system and/or individual surveys are used in a needs assessment.
C. National Oral Health Surveillance Systems
||Surveillance systems provide information necessary for public health decision making (4). A comprehensive public health surveillance system routinely collects data on health outcomes, risk factors and intervention strategies for the whole population or representative samples of the population (5). Such a system can be based on linkage of existing databases and collection of additional information to address data gaps. Surveillance systems are not just data collection systems, but involve at least a timely communication of findings to responsible parties and to the public and the use of data to initiate and evaluate public health measures to prevent and control diseases and conditions (4-8).
Data from a public health surveillance system can be used to (9):
- Guide immediate action of public health importance;
- Measure the burden of a disease (or other health-related event), including changes in related factors, populations at high risk, and new or emerging health concerns;
- Monitor trends in the burden of disease (or other health-related event);
- Guide the planning, implementation and evaluation of programs;
- Develop and evaluate public policy;
- Detect changes in health practices and evaluate the effects of these changes;
- Prioritize the allocation of health resources;
- Describe the clinical course of disease;
- Provide a basis for epidemiological research.
A public health surveillance system should effectively disseminate health data so that decision makers at all levels can readily understand the implications of the information. The audiences for these data can include public health practitioners, health care providers, members of affected communities, professional and voluntary organizations, policymakers, the press, and the general public (9). Options for disseminating data and/or information from the system include electronic data interchange; public-use data files; the Internet; press releases; newsletters; bulletins; annual and other types of reports; publication in scientific, peer-reviewed journals; and poster and oral presentations at community and professional meetings (9).
Desirable attributes of public health surveillance systems are (9):
- Simplicity: The system is as simple as possible (for structure and ease of operation) while still meeting its objectives.
- Flexibility: The system has the ability to adapt to changing information needs or operating conditions with little additional time, personnel or funding. Use of standard data formats that are readily integrated with other systems make a surveillance system flexible.
- Data Quality: Data used by the system are complete and valid.
- Acceptability: Persons and organizations are willing to participate in the system.
- Representativeness: The system accurately describes the occurrence of a health-related event over time and its distribution in the population by place and person.
- Timeliness: Information is available quickly.
- Stability: The system operates without failure and is available when needed.
- Sensitivity: The system identifies a very high proportion of cases (persons with a disease, such as caries, or other health-related event) and has the ability to detect outbreaks and monitor changes in the number of cases over time.
- Predictive Value Positive (PVP): The system has a high PVP, the proportion of reported cases that actually have the disease or health-related event under surveillance.
Public health surveillance systems vary in methods, scope, purpose, and objectives; therefore, some attributes that are important to one system might be less important to another. An oral health surveillance system should emphasize those attributes that are most important for the objectives of the system (9).
D. Building a State Oral Health Surveillance System
||The National Oral Health Surveillance System (NOHSS), developed through a joint effort between the Association of State and Territorial Dental Directors (ASTDD) and the Centers for Disease Control and Prevention (CDC), is designed to help public health programs monitor the burden of oral disease, the use of the oral health care delivery system, and the status of community water fluoridation on a state and national level (10). NOHSS includes eight basic oral health surveillance indicators reported at the state level: dental visits, teeth cleaning, complete tooth loss, fluoridation status, caries (tooth decay) experience, untreated caries, dental sealants and oral/pharyngeal cancer. This minimal set of indicators will be expanded in the future, depending on data sources and surveillance capacity available to most states. Communication of NOHSS information is accomplished through the Internet and the preparation of fact sheets and other materials. Access the NOHSS website at http://www.cdc.gov/nohss/.
Data sources for NOHSS include the following state and national surveys and surveillance systems:
Behavioral Risk Factor Surveillance System (BRFSS)
BRFSS is a state-based, ongoing data collection program designed to measure behavioral risk factors in the adult, non-institutionalized population 18 years of age or older. Oral health questions were fielded in all states in 1999, 2002 and 2004.
Pregnancy Risk Assessment Monitoring System (PRAMS)
PRAMS collects state-specific, population-based data on maternal attitudes and experiences prior to, during, and immediately following pregnancy. PRAMS sample of women who have had a recent live birth is drawn from the state's birth certificate file.
Youth Risk Behavior Surveillance System (YRBSS)
YRBSS is a school-based survey conducted biennially to assess the prevalence of health risk behaviors among high school students. YRBSS includes national, state, territorial and local school-based surveys of high school students.
Basic Screening Survey (BSS)
BSS is a standardized set of surveys designed to collect: a) information on the observed oral health of participants, b) self-reported or observed information on age, gender, race and Hispanic ethnicity, and c) self-reported information on access to care for preschool, school-age and adult populations. The surveys are cross-sectional and descriptive. Observations of oral health status are made by dentists, dental hygienists or other appropriate health care workers in accordance with state law.
Water Fluoridation Reporting System (WFRS)
WFRS is a management and tracking tool that helps states to manage the quality of their water fluoridation programs. WFRS information is the basis for national reports that describe the percentage of the U.S. population on public water systems who receive optimally fluoridated drinking water. The system was developed by CDC in partnership with ASTDD.
Synopses of State and Territorial Dental Public Health Programs (State Synopses) http://apps.nccd.cdc.gov/synopses/
The State Synopses
collect oral health program information provided to ASTDD annually by each state's dental director or oral health program manager. ASTDD, in conjunction with CDC's Division of Oral Health, presents that information with data from standard sources (U.S. Census, Department of Education, Bureau of Labor Statistics, etc.) on the State Synopses website. Each state has its own synopsis information on demographics, as well as oral health infrastructure, program administration, and oral health program activities.
State Cancer Registries
State cancer registries collect data about the occurrence of cancer (incidence), the types of cancer that occur, the cancer’s location in the body, the extent of disease at the time of diagnosis (Stage), and the kinds of treatment patients receive. Data collected by state cancer registries enable public health professionals to understand and address the cancer burden more effectively. CDC provides support for states to maintain registries that provide high-quality data through the National Program of Cancer Registries (NPCR).
National surveys collecting oral health data include the National Health and Nutrition Examination Survey [NHANES] (http://www.cdc.gov/nchs/nhanes.htm
) and National Health Interview Survey [NHIS] (http://www.cdc.gov/nchs/nhis.htm
). NHANES I (1971-1975), NHANES II (1976-1980), NHANES III (1988-1994), and NHANES IV (ongoing since 1999) provide snapshots of health and nutritional status of the U.S. population with data collected through physical examinations, clinical and laboratory tests, and personal interviews. NHIS (ongoing since 1957) is a cross-sectional household interview survey on the health of the civilian non-institutionalized population of the U.S.
In 1999, an ASTDD survey found that only eight (19%) of 43 responding states reported having “a state-based oral health surveillance system” (11). That number might have been even lower if the survey had further defined the required attributes of a surveillance system. In 2010, ASTDD Members Surveys and State Synopses showed that 40 states have a state oral health surveillance system.
Currently, all state programs can initiate oral health surveillance activities using existing data. For example, the BRFSS has oral health data available for all states in 1999, 2002, 2004, 2006 and 2008. Leadership, analytic capacity, infrastructure, and partnerships are needed to enhance program efforts to fully utilize data collected and to develop a comprehensive surveillance system.
The NOHSS can serve as a model for building state-based oral health surveillance systems. A state system would build upon the NOHSS indicators and with increased capacity, the system could collect additional state- or community-level data on an ongoing basis. Time intervals for collection of specific oral health indicators are based on several factors, including cost in dollars and other programmatic resources. Data collection intervals can range from annually to every 5 years.
Since “open mouth” screening surveys are resource intensive, states can seek less expensive data sources by acquiring data relevant to oral health from existing systems where data are already being collected and analyzed by the health department and partnering organizations. These would include data from the BRFSS, state cancer registries (oral and pharyngeal cancer deaths), state Medicaid agencies (percent of Medicaid enrolled populations with past year dental visit) and state water programs (fluoridation). Oral health questions can be added to other ongoing community or statewide surveys, such as the YRBS and PRAMS. When there is no other way to collect needed estimates (e.g., caries prevalence), the program can collect primary data through more expensive “open mouth” surveys among defined samples of populations (e.g., school age children, Head Start children and senior adults).
An oral health surveillance system for a state should:
- Have a clear purpose and objectives. The purpose of the system indicates why the system exists, whereas its objectives relate to how the data are used for public health action.
- Contain a core set of measures/indicators that describe the status of important oral conditions or behaviors to serve as benchmarks for assessing progress in achieving good oral health (5).
- Analyze trends when several years of data are available.
- Communicate to decision maker and to the public the surveillance data and information in a timely manner and that the communication should enable decision makers at all levels to readily understand the implications of the information.
- Strive to put surveillance data to action to improve the oral health of residents in the state.
A state’s capacity to build and maintain a state-level oral health surveillance system can be enhanced if the state program has secured an epidemiologist or other data analyst (.25 FTE or more). Such support can be contracted or hired by pooling resources with other programs or secured through partnership with academic institutions and other entities. An epidemiologist’s duties would include:
- Routinely analyze state and other available data for program decision making.
- Use BSS data collected according to the standard protocol and disseminate findings to key state audiences.
- Collaborate with other epidemiologists in the health department, to answer key questions of mutual interest (e.g., diabetes, tobacco, cancer, and maternal child health).
Developing an oral health surveillance plan will provide a written road map for establishing and maintaining a surveillance system (12). In developing the plan, think how best to effectively and efficiently build a simple, effective, flexible, and sustainable surveillance system. An oral health surveillance plan may have these components:
- Introduction/background (include a summary of previous data-collection experience in the state).
- The goals and objectives of the surveillance system (address data collection/analysis, dissemination of surveillance information, and use of surveillance data for programmatic decision-making and public health actions).
- Identification of the conditions (oral health indicators) to be included in the surveillance system (consider the primary/secondary data sources and data for age-groups and prioritize the list of indicators).
- Identification of stakeholders who can contribute surveillance data, support the surveillance system, and benefit from surveillance information.
- Resources needed to design, develop, implement and evaluate the surveillance system (e.g., human resources for planning/data collection/analysis/interpretation and infrastructure in collecting/managing/reporting the surveillance data).
- Other surveillance system information:
- Case definitions of indicators
- Target populations for the surveillance (representation of populations and age-groups)
- Key data sources
- Data collection timeline
- Data collection protocol
- Data management
- Data analysis
- Data gaps and additional data collection efforts needed
- Data dissemination (timing and reporting of surveillance findings)
- Privacy, data confidentiality and data release policy
- Evaluation plan for the surveillance system
E. Collecting Surveillance Data
F. Disseminating Surveillance Information
The following action steps will help guide the data collection needs in developing a surveillance system:
- Conduct an inventory of existing oral health data sources.
- Review oral health indicators used to report the oral health status and risk factors for the U.S. population (e.g., NOHSS, NHANES, BRFSS, YRBSS, Cancer Registry, etc.).
- Integrate the nine databases listed for the HP 2020 oral health objective OH-15 to increase the number of States and District of Columbia that have an oral and craniofacial health surveillance system. (The HP 2010 tracking document stated that at least six of the nine databases should be used to develop an oral health surveillance system.)
- Select a set of oral health measures or indicators (use an advisory committee or a coalition to provide broad-based input).
- Identify data gaps where data is not available or have not been analyzed for the selected indicators.
- Prioritize indicators that need data collection and analysis.
- Establish the relationship and agreement with data partners to share secondary data and/or collaborate on collecting primary data to fill data gaps.
- Develop a data management system to organize the surveillance data. (In general, a central database will be difficult and expensive to develop when data sources are provided by several partners and their data systems varied.)
Partners are critical for data collection. Collaborations observed among the states include combining efforts to collect data for oral health and data for childhood obesity, asthma and nutrition. For example, oral health screening is conducted with height and weight measurements and oral health questionnaires include questions on soda and milk consumption. Other partnerships observed include working with Head Start, Indian Health Service (IHS), dental schools, and dental and dental hygienists associations to collect oral health data.
National databases can provide information on oral health measures. Selecting some of these national measures for the state oral health surveillance system has the advantage of providing some level of comparison of the state data to national data. The NDICR/CDC Dental, Oral and Craniofacial Data Resource Center
), co-sponsored by the National Institute of Dental and Craniofacial Research (NIDCR) and CDC, Division of Oral Health, has made the data from NHANES and the NHIS accessible on the web (displaying summary tables and allowing data queries). Another example of a national database is the National Survey of Children with Special Health Care Needs
). This database provides national and state data (“Health Care Needs and Access to Care” available at http://mchb.hrsa.gov/chscn/pages/needs.htm
and “State Data Pages” available at http://mchb.hrsa.gov/chscn/pages/state.htm
). The survey assesses the prevalence and impact of special health care needs among children in all 50 States and the District of Columbia including the extent to which children with special health care needs (CSHCN) have medical homes, adequate health insurance, and access to needed services.
Collecting surveillance data needs to address the issue of privacy. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule provides the first national standards for protecting the privacy of health information and identifies who has access to what health care data, clarifies patients’ rights of control over their health care data, offers definitions of inappropriate access and use, and determines accountability for protecting patient privacy. The Privacy Rule permits covered entities (e.g., health care provider) to disclose protected health information (certain individually identifiable health data such as name and date of birth), without authorization, to public health authorities who are legally authorized to receive such reports for the purpose of preventing or controlling disease, injury, or disability. This would include, for example, the reporting of a disease or injury; reporting vital events, such as births or deaths; and conducting public health surveillance, investigations, or interventions. The Office of Civil Rights Guidance Explaining Significant Aspect of the Privacy Rule, published December 4, 2002, is available at http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html
and has a section addressing disclosure for public health activities. In addition, HIPAA Privacy Rule and Public Health – Guidance from CDC and the U.S. Department of Health and Human Services, released in April 2003, is a report to help public health agencies and others understand and interpret their responsibilities under the Privacy Rule (http://www.cdc.gov/mmwr/preview/mmwrhtml/m2e411a1.htm
). If HIPAA applies, an oral health survey can still be conducted by (13):
- Collecting only non-identifiable data (e.g., do not include a name on the form collecting data and ask for age instead of date of birth).
- Protecting confidentiality such as using privacy envelopes.
Another issue related to collecting surveillance data is to address whether an Institutional Review Board (IRB) is required. Federal and state laws require IRB approval for research. One definition of research is a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to the general knowledge. Requiring IRB approval for research is for the protection of human subjects (referred to as the “Common Rule”). IRB review is not required for a public health practice, which is not research. A public health practice includes proven methods to monitor health status, investigates occurrence of disease, and is used to implements prevention. The report, Public Health Practice vs. Research – A Report for Public Health Practitioners Including Cases and Guidance for Making Distinctions (http://www.cste.org/pdffiles/newpdffiles/CSTEPHResRptHodgeFinal.5.24.04.pdf
), prepared by the Council of State and Territorial Epidemiologists (www.cste.org
) and released in May 2004, provides clarification. For oral health surveys collecting data such as data collected through “open mouth” screenings, verbal interviews or written questionnaires, the Common Rule and HIPAA does not apply if the survey (a) does not collect identifiable health data, (b) has general legal authority to acquire health data needed to monitor health conditions in the population, (c) has specific intent that does not test a hypothesis, (d) provide participant benefits such as contribute to improving health, and (e) selects subjects without including a control group or randomly selects participants (an oral health survey that randomly selects schools and not participants is still a public health practice). It is advisable to submit a letter to IRB describing the oral health survey, asking the IRB to determine if the survey is a public health practice, and asking for a waiver (13).
G. Evaluating a Public Health Surveillance System
Disseminating surveillance information to key audiences includes print and electronic forms. Communications of surveillance information include published reports, website access to surveillance information and reports, policy briefs, fact sheets, newsletters, etc. Communications should consider the health literacy levels of different audiences. The target audience may include dentists, legislators, physicians, nurses, health policy makers, coalition members, other state and local partners, potential funding partners, the media, and the general public.
The burden of disease reflects the total significance of a disease for the society, beyond the immediate cost of treatment. An oral health burden document describes oral diseases, disparities, and unmet needs using the most recent data, preferably no more than 5 years old. The indicators of oral health status, monitored by the state-based oral health surveillance, provide needed data for preparing a burden document. A complete state burden document will provide a broad range of measures relating to national and state health objectives.
CDC, Division of Oral Health developed a tool to assist states with creating a comprehensive document that describes the state's burden of oral disease (14). This tool, available on the CDC website at http://www.cdc.gov/oralhealth/publications/library/burdenbook/, provides users with data on a broad range of indicators related to national and state health objectives about oral health. It focuses on the indicators contained in the National Oral Health Surveillance System (http://www.cdc.gov/nohss/) and other recommended elements using Healthy People 2010 indicators. The tool includes an outline, example text, national data, and references that can be used to document the prevalence of oral disease, unmet dental needs, and disparities in oral health. Chapters include background information on oral disease and conditions, as well as basic tables and examples of data displayed as bar charts. The Burden of Oral Disease tool organizes information as follows:
II. Executive Summary
III. National and State Objectives on Oral Health
IV. The Burden of Oral Diseases (includes disease prevalence,
unmet needs, disparities, and societal impact)
V. Risk and Protective Factors Affecting Oral Diseases
VI. Provision of Dental Services
IX. Appendices (includes indicators of oral health status,
calendar of expected data release dates, sample fact
sheets, and sample policy briefs)
This tool is not meant to be prescriptive. The text can be freely edited or supplemented and the methods of data presentation may be altered.
Submitting Data for the National Oral Health Surveillance System (NOHSS)
The state oral health surveillance system should enable the state to submit data for inclusion in the NOHSS (http://www.cdc.gov/nohss/). Currently, NOHSS include the following indicators (10):
1. Dental Visit
Adults aged 18+ who have visited a dentist or dental clinic in the past year
2. Teeth Cleaning
Adults aged 18+ who have had their teeth cleaned in the past year (among
adults with natural teeth who have ever visited a dentist or dental clinic)
3. Complete Tooth Loss
Adults aged 65+ who have lost all of their natural teeth due to tooth decay or
4. Lost 6 or More Teeth
Adults aged 65+ who have lost six or more teeth due to tooth decay or gum
5. Fluoridation Status
Percentage of people served by public water systems who receive fluoridated
6. Dental Sealants
Percentage of 3rd grade students with dental sealants on at least one
permanent molar tooth
7. Caries Experience
Percentage of 3rd grade students with caries experience, including treated
and untreated tooth decay
8. Untreated Tooth Decay
Percentage of 3rd grade students with untreated tooth decay
9. Cancer of the Oral Cavity and Pharynx
Incidence and mortality of oral and pharyngeal cancer
The purpose of evaluating public health surveillance systems is to ensure that problems of public health importance are being monitored efficiently and effectively (9). Evaluation of a public health surveillance system focuses on how well the system operates to meet its purpose and objectives. Public health surveillance systems should be evaluated periodically, and the evaluation should include recommendations for improving quality, efficiency and usefulness.
The Centers for Disease Control and Prevention (CDC) published Updated Guidelines for Evaluating Public Health Surveillance Systems (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm) in 2001. The evaluation of public health surveillance systems should involve an assessment of system attributes (simplicity, flexibility, data quality, acceptability, representativeness, timeliness, stability, sensitivity, and predictive value positive). Inherent in these attributes are public health informatics concerns that include comparable hardware and software, standard user interface, standard data format and coding, appropriate quality checks, and adherence to confidentiality and security standards. Evaluation of a public health surveillance system should focus on attributes that are most important for the objectives of the system. The Updated Guidelines describe tasks that can be applied in the evaluation of public health surveillance systems with the understanding that not all activities listed under the tasks may be appropriate for all surveillance systems (9):
Task A: Engage the stakeholders in the evaluation
Task B: Describe the surveillance system to be evaluated
- Describe the public health Importance of the health-related
event under surveillance
- Describe the purpose and operation of the surveillance system
- Describe the resources used to operate the surveillance system
Task C: Focus the evaluation design
Task D: Gather credible evidence regarding the performance of the surveillance system
- Indicate the level of usefulness
- Describe each system attribute
Task E: Justify and state conclusions, and make recommendations
Task F: Ensure use of evaluation findings and share lessons learned
Another resource document, Framework and Tools for Evaluating Health Surveillance Systems (http://www.phac-aspc.gc.ca/php-psp/pdf/i_Surveillance_Evaluation_Framework_v1.pdf), was developed in 2004 by Health Canada’s Population and Public Health Branch Health Surveillance Coordinating Committee. The document was designed to help managers of health surveillance systems identify and document issues relating to the rationale, implementation and effectiveness of their health surveillance systems. The framework and tools were intended to provide standard approaches for enhancing the ability of surveillance to provide relevant information. The document noted that an evaluation of a health surveillance system helps to answer the following questions:
- What are the successes and deficiencies of the surveillance system?
- Is the surveillance system meeting its public health objective?
- How does surveillance both support and benefit stakeholders?
- What measures could improve performance and productivity of the surveillance system and the program(s) that it supports?
H. Initiatives and Coordinated Efforts
CDC Cooperative Agreements
The CDC, Division of Oral Health is providing funding through cooperative agreements to 19 states to strengthen their oral health programs and improve the oral health of their residents (15). The cooperative agreements are renewable through fiscal year 2013. The grantees include: Alaska, Arkansas, Colorado, Connecticut, Georgia, Kansas, Louisiana, Maine, Maryland, Michigan, Minnesota, Nevada, New York, North Dakota, Rhode Island, South Carolina, Texas, Vermont, and Wisconsin. The CDC funding is designed to improve basic state oral health services including monitoring oral diseases and implementing and evaluating prevention programs such as community water fluoridation and school-based sealant programs. The funding supports the planning of a state oral health surveillance system. These grantee states are hiring or contracting an epidemiologist to develop a state-based oral health surveillance system, establish the indicators for surveillance, collect primary and secondary data, and disseminate surveillance findings including preparing a burden document.
SOHCS Grant Program
During 2003-2005, the Health Resources and Services Administration's (HRSA) Maternal and Child Health Bureau (MCHB), through its State Oral Health Collaborative Systems (SOHCS) grant program, awarded funds to state oral health programs (16). The purpose of these grants was three-fold:
- Support states in developing, implementing or enhancing efforts to integrate oral health into state Maternal and Child Health programs;
- Address Maternal and Child Health Bureau performance measures in oral health; and
- Stimulate action toward implementation of the Surgeon General’s “National Call to Act to Promote Oral Health” as it affects women and children.
States used the SOHCS funding to support the development of a state-based oral health surveillance system. For example, with the SOHCS grant, New Mexico established a set of oral health indicators for their surveillance system, conducted an inventory of available oral health databases in the state, and identified data gaps that required additional investment in primary data collection. Alaska, California and Missouri used the funding to conduct a Basic Screening Survey of children to provide surveillance data.
ASTDD, funded by a cooperative agreement with CDC, administers the National Oral Health Surveillance System (NOHSS). The ASTDD Data Committee oversees this effort and annually collects state data for the NOHSS. The ASTDD Data Committee plans to develop a template to help the state report their state oral health surveillance measures or indicators (17).
I. Future Considerations
Beltrán-Aguilar, et al. (18) reviewed and summarized U.S. efforts to collect data on oral diseases, conditions and behaviors implemented at the national and state level. The authors showed that there is an impending need to develop new techniques to build up oral health surveillance systems. Challenges in the immediate future should enhance the monitoring of oral diseases, conditions and risk factors. For examples, testing the validity of self-reporting and visual assessment in senior adults, developing a screening protocol for periodontal diseases, and implementing standardized codes for treatment claims data. Surveillance activities for oral diseases will require developing a permanent process to share information and having the support of the research community for validation of new surveillance tools.
Future considerations should also address the challenge faced by the states in obtaining resources (staffing and funding) to develop a surveillance system and to maintain a system that will continue to mature. Data collection for surveillance requires funding. States have reported cost-effectiveness approaches such as linking to existing surveillance systems for oral health data (e.g., BRFSS and YRBSS) and adding new oral health questions to an existing survey or surveillance system. However, substantial resources are needed to collect primary oral health data through “open mouth” screenings. Although the unit cost of a survey screening using the Basic Screening Survey (BSS) tool is more cost-efficient compared to an epidemiological survey using the Decayed Missing Filled (DMF) Index for teeth, states require ongoing resources to regularly and periodically collect oral health status data through screening surveys. These screening surveys will have to be repeated to monitor trends over time and to collect data for different population groups (e.g., preschool children, school-age children, senior adults, and special needs individuals). Future considerations will need to seek cost-effective alternatives to assess the level of oral diseases, such as techniques to estimate the level of disease among populations, counties or communities without having to expand the survey sample for primary data collection.
II. Guidelines & Recommendations from Authoritative Sources
The Surgeon General’s Report on Oral Health in America stated that having state-specific and local data that augment national data is critical in identifying high-risk populations and in addressing oral health disparities (19).
National Call to Action to Promote Oral Health, a report released by the Office of the Surgeon General, proposed that implementation strategies to overcome barriers in oral health disparities should include building and supporting epidemiologic and surveillance databases at national, state and local levels to identify patterns of disease and populations at risk (20).
Healthy People 2020 Objective OH-15 seeks to increase the number of states that have an oral and craniofacial health surveillance system (21).
The Centers for Disease Control and Prevention published guidelines for evaluating surveillance systems in 1998 (22) and updated those guidelines in 2001 (9).
III. Research Evidence
Generally, there is a lack of reporting on the impact and effectiveness of oral health surveillance in the scientific literature. Although the National Oral Health Surveillance System (NOHSS) has been developed, additional time is needed to evaluate the impact and effectiveness of this new system.
Effectiveness of public health surveillance (such as early warnings on emerging health problems and program development/evaluation of intervention strategies) has been reported in other fields including infectious diseases and occupational health:
- AIDS surveillance data provided an understanding of transmission risks and characterized communities affected by the epidemic. Later, these data provided the basis for allocating resources for prevention and treatment programs. New treatments have dramatically improved survival with declines in AIDS incidence and deaths (23).
- In European countries, health surveillance may be part of the national health system. Such health and hazard surveillance have been aimed at improving the health, ability to work, and well-being of workers. Reported benefits of health surveillance include improvement in worker satisfaction, improvement in relationships among stakeholders, early detection of health changes, and sickness absence reduction (24-26).
- Hospital-based surveillance programs of wound infection resulted in significant reduction in the infection rate of clean wounds and facilitated the adoption of evidence-based practice. Other surveillance programs for surgical-site infections resulted in reduction in infection rates of 35% to 50% (27-28).
IV. Best Practice Criteria
For the best practice approach of a State-based Oral Health Surveillance System, the ASTDD Best Practices Committee has proposed the following initial review standards for five best practice criteria:
- A state-based oral health surveillance system contains a core set of measures that describes the status of important oral health conditions and behaviors. These measures serve as benchmarks for assessing progress in achieving good oral health.
- An oral health surveillance system communicates data and information to responsible parties and to the public in a timely manner.
- Data and information from the surveillance system are used for public health actions.
- Data collection is managed on a periodic but regular schedule.
- Cost-effective strategies are used in collecting, analyzing and communicating surveillance data.
3. Demonstrated Sustainability
- A mature surveillance system shows several years of data and analyzes trends.
- Partnerships are established to leverage resources in data collection for the surveillance system.
- Data and findings from the surveillance system are used to integrate oral health into other health programs.
- A state-based oral health surveillance system has a clear purpose (i.e., why the system exists) and objectives that specify how the data will be used for public health action.
V. State Practice Examples
States have submitted descriptions of their successful practices to share their experiences and implementation strategies. The following practice examples illustrate various elements of the best practice approach for a State-based Oral Health Surveillance System. These reported success stories should be viewed in the context of the state’s and program’s environment, infrastructure and resources. End-users are encouraged to review the practice descriptions (click on the links of the practice names) and adapt ideas for a better fit to their states and programs.
A. Summary Listing of Practice Examples
Table 1 offers several practices as examples of state efforts in the development of a state-based surveillance system, as well as examples of surveillance strategies for data collection, dissemination of surveillance findings, and use of surveillance data for public health actions. These practice examples share lessons and ideas in designing a surveillance system and conducting surveillance.
Practice Examples of the Development of a State-based Oral Health Surveillance System and of Oral Health Surveillance Strategies
B. Highlights of the Practice Examples
1. Development of an Oral Health Surveillance System:
In 2000, the Illinois Department of Public Health, Division of Oral Health began developing the Illinois Oral Health Surveillance System (IOHSS) with the support of an advisory committee of stakeholders and experts in oral health and epidemiology. The goal of the IOHSS is to monitor the state’s oral disease burden and trends, measure changes in oral health program capacity, and monitor and report community water fluoridation. Funding from the Illinois’ cooperative agreement with the Centers for Disease Control and Prevention allowed hiring a full time oral health epidemiologist. The IOHSS indicators are listed in Attachment C
. The IOHSS has developed a network to share the data, provided a burden document, helped communities report oral health needs and prioritize their programs, expanded services to the high-risk populations, and contributed data at the national level to the NOHSS and the ASTDD Synopses.
The Michigan Oral Health Surveillance Plan was prepared to guide the development of the state oral health surveillance system. The planning process of the Michigan oral health surveillance system was a collaborative effort between the Michigan Department of Community Health and the Michigan Oral Health Coalition. The implementation of the surveillance plan has built an oral health surveillance system for Michigan. Michigan’s surveillance system integrates oral health into several population-based surveillance activities. Coordination with these data sources is made by a part-time oral health epidemiologist. Attachment D
provides a list of indicators reported by the Michigan Oral Health Surveillance System. The surveillance system provided oral health data for the development of Michigan’s Oral Health Plan and for prioritizing state activities to improve oral health.
New Hampshire’s oral health surveillance system began in 2000. With a focus on developing a system that is simple and manageable, New Hampshire modeled their state-based oral health surveillance system on the National Oral Health Surveillance System and used the same eight oral health indicators relying on four data sources. Attachment E
lists the indicators and data sources. The surveillance system enables the state to monitor progress towards Healthy People 2010 objectives and contributes data to the National Oral Health Surveillance System. New Hampshire’s state and local stakeholders have used the surveillance data for developing the state oral health action plan, for setting performance measures for organizations receiving oral health funding from the state, for establishing Healthy New Hampshire 2010 objectives, and for prioritizing oral health program activities.
As a result of the state oral health program’s commitment to data collection and use, an oral health surveillance system has been incrementally developed in North Dakota since 1993. The system has grown to include 44 indicators from primary and secondary data sources. Data is collected on a rotating basis. Attachment F
provides a listing of the surveillance system’s oral health indicators and data sources. Surveillance data is used for program planning and implementation, assessing program effectiveness, guiding policy planning and advocacy and improving program accountability. This resulted in the implementation of oral health components in local maternal and child health programs; targeted fluoride mouthrinse, fluoride varnish and dental sealant programs to high risk children; establishment of a dental loan repayment program to expand the dental workforce; and expanding the scope of practice to allow medical professionals to apply fluoride varnish to high-risk children. A Surveillance Plan has been written, which includes a timetable for data collection, a question matrix, a data indicator grid to track trends, and a data communication plan.
2. Oral Health Surveillance Strategies (Data Collection, Dissemination and Use):
In FY 2004-05, the Iowa Department of Public Health (IDPH), Oral Health Bureau conducted its annual survey to measure the prevalence of dental sealants on permanent molars of third-grade children in Iowa. This is the seventh year of collecting sealant prevalence data. The survey expanded data collection and for the first time included recording the presence of gross tooth decay and filled teeth. The survey involved a new process to train dental hygienists in the field as survey examiners via high quality/full-motion video, high-speed Internet connections, and telephones. In FY 2005-06, the survey was again repeated. The FY 2005-06 overall sealant rate (45.5 percent) was higher than FY 2004-05 (43.4 percent) and FY 2003-04 (39.9 percent). Compared to the previous year, fewer children in FY 2005-06 have tooth decay (13.2 percent vs. 17.5 percent) and more children have a filled tooth (42.8 percent vs. 40.4 percent).
The Oral Health Program at the Nevada State Health Division utilized the ASTDD Basic Screening Survey to conduct a statewide screening of third graders in 2003. The Healthy Smile - Happy Child Screening Survey sampled a cohort of 51 elementary schools throughout the state as a representative sample of the state as a whole. Utilizing volunteer dentists, the Nevada State Health Division screened 2,472 children. Materials costs of the screenings totaled $12,968 ($5.25 per child). The survey contributes data to the state oral health surveillance system. In 2006, the survey of third graders was repeated. The survey of third graders will be conducted every three years.
The Healthy Smile - Happy Child Screening Survey was first conducted in 2003 to collect oral health data on third graders in Nevada. In the subsequent year 2004, the survey focused on children ages 3 to 5 who were enrolled in the Head Start Program. Survey findings indicated that there are large unmet oral health needs in the Head Start population. A report of the 2004 survey was disseminated to policymakers, funders, educators, and stakeholders throughout the state. The survey findings led to the Nevada Head Start Association and the Oral Health Program/Nevada State Health Division convening three regional Head Start Oral Health Summits to establish goals and strategies to improve the oral health of Head Start children. The survey of Head Start children will be conducted every three years for surveillance (completed the first survey in 2004 and the second survey in 2007).
The Centers for Disease Control and Prevention, in collaboration with the ASTDD, developed the Water Fluoridation Reporting System (WFRS), a surveillance system to collect and edit data on-line to monitor fluoridation in the United States. With the introduction of WFRS in 2001, New Hampshire Department of Health and Human Services’ Oral Health Program hired an intern to enter updated state fluoridation information in the WFRS. Using WFRS, the updated numbers showed that 67% of New Hampshire residents received water from a public supply. Of the residents on public water supply, only 43% received fluoridated water. This information was used to update publications and to monitor progress towards achieving the Healthy New Hampshire 2010 objective for water fluoridation.
The Arizona Community Oral Health Profiles are a series of fact sheet used to provide Arizona communities with information on the oral health status of their residents. The Arizona Department of Health Services, Office of Oral Health developed the profiles in 1997 to organize available surveillance and other oral health data for communities and to provide easier access to the data. The purpose of the Profiles is to provide community-specific data to support communities in raising awareness of oral health needs, planning and developing solutions to meet the needs of their residents, and/or justifying resources. Public access to 173 community profiles is provided online. Communities have used the profiles for grant proposals and to support community water fluoridation.
Use of Epidemiological Studies and Surveillance to Direct State and Local Oral Health Programs
The Oral Health Section, North Carolina Division of Public Health, determines the oral health of a community in three ways: a) dental assessments – measuring specific oral conditions such as the average number of decayed, missing and filled teeth and proportion of children with dental sealants, b) dental screenings – identifying children in need of dental care and referring them for care, and c) statewide epidemiological surveys – scientifically measuring the quantity and types of oral disease in a population. For surveillance, over 280,000 elementary school children participate in either assessments or screenings annually. Epidemiological surveys are conducted approximately every 15 years. The North Carolina oral health program has been enhanced based on epidemiological studies and surveillance. For example, the 1986-87 survey of school children resulted in a major programmatic change in the oral health program shifting emphasis from restorative treatment services to preventive services.
This report is the result of efforts by the ASTDD Best Practices Committee to provide information on developing and improving a state-based oral health surveillance system.
This publication was supported by Cooperative Agreement U58DP001695 from CDC, Division of Oral Health and by Cooperative Agreement U44MC00177 from HRSA, Maternal and Child Health Bureau.
Suggested citation: Association of State and Territorial Dental Directors (ASTDD) Best Practices Committee. Best practice approach: state-based oral health surveillance system [monograph on the Internet]. Sparks, NV: Association of State and Territorial Dental Directors; 2008 Jul 14 (Updated 2011 May 17). 27 p. Available from: http://www.astdd.org.
Attachment A: Strength of Evidence Supporting Best Practice Approaches
Attachment B: Logic Model for Oral Health Surveillance
Attachment C: Illinois Oral Health Surveillance System - Indicators and Data Sources
Attachment D: Michigan Oral Health Surveillance System - Indicators and Data Sources
Attachment E: New Hampshire's Oral Health Surveillance System - Indicators and Data Sources
Attachment F: North Dakota’s Oral Health Surveillance System - Indicators and Data Sources
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