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Oral Health Florida

Based on "Florida's Roadmap for Oral Health" - reviewed and updated annually

Narrative Florida's Roadmap for Oral Health
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Executive Summary

The future prosperity of any society depends on its ability to foster the health and well-being of the next generation. When a society invests wisely in children and families, the next generation will pay back through a lifetime of productivity and responsible citizenship.

The Problem

Since 2010, Florida has received poor ratings on multiple oral health indicators for children including an “F” for meeting policy benchmarks to ensure dental health and access for disadvantaged children and a “D” for the percentage of high need schools with access to sealant programs (less than 25%). The most recent study from the Pew Center on the States found that 75.5% of Florida’s Medicaid enrolled children did not receive dental care in 2011. Florida’s 75.5% places it as the lowest ranking state in the country, falling a full eight points behind the next lowest ranking state at 67%.

In addition, the DentaQuest Foundation-funded, Florida Public Health Institute’s 2014 study, Hospital Emergency Department Use for Preventable Dental Conditions: 2011 & 2012 found that more than 139,000 Floridians were treated in 2012 in hospital emergency departments for oral health conditions considered avoidable with proper preventive and restorative dental care. Charges for these visits exceeded $141 million. The 2012 visits represent a one-year 6.4 percent increase while charges climbed 22 percent yielding a cost increase of over $25 million. Among the reasons Floridians do not receive regular preventive care include lack of dental coverage for adult Medicaid patients, lack of private-practice dentists willing to accept Medicaid’s low payment rates, lack of county health department resources, lack of affordable dental insurance or inability to meet high co-pays, and lack of awareness of the importance of dental health to overall health.

The health status of Floridians through a health equity lens is largely unknown. This is developing, implementing, monitoring, and evaluating work using the definition of health equity described as “the opportunity for everyone to attain her/his full health potential. No one is disadvantaged from achieving this potential because of his or her social position or socially assigned circumstance.”

The Solution

In response to these troubling trends, between January 2013 and April 2014, with facilitation from the Florida Public Health Institute, the Oral Health Florida Leadership Council developed a results-based strategic plan using the evidence-based Results-Based Accountability™ (RBA) framework, a highly disciplined process developed by Mark Friedman and introduced in his book, Trying Hard is Not Good Enough. This model has been used internationally to help groups move from talk to action in order to achieve measureable results. This plan, Florida’s Roadmap for Oral Health, supports the achievement of the result: “All people in Florida have optimal oral health and well-being” by addressing two areas of focus:

1) Improved access and utilization of quality oral health care

2) Increased access to community water fluoridation.

Headline indicators that will be used to measure success in these areas include:

•Percentage of Medicaid/SCHIP eligible children receiving any dental services

•Total emergency room costs and number of visits due to preventable oral health conditions

•Percentage of Florida schools with school-based sealant programs

•Total eligible receiving a sealant on permanent molar tooth

•Percentage of population on community water systems receiving fluoridated water

Florida’s Roadmap for Oral Health takes into consideration existing Florida oral health plans and initiatives. A living document, it will serve as a blueprint for action by Oral Health Florida over the next three to five years.

The Process

From January 2013 through February 2014, during a series of four face to face meetings and numerous conference calls, the Florida Public Health Institute provided the Oral Health Florida Leadership Council with the consultation, facilitation and support needed to develop this roadmap using the framework of Results-Based Accountability™. In January 2013, the Oral Health Florida Leadership Council was introduced to the framework and began its work to develop this strategic plan.

Prior to January 2013, the Oral Health Florida Data Action Team through the development of the Florida Oral Health Surveillance Plan (State Oral Health Improvement Plan, Recommendation 3) performed a scan of all available data to measure the status of Florida’s oral health. The Institute and Oral Health Florida leadership began discussing the need for a revised roadmap and then the Data Action Team identified the best available data and formed trend lines to include a forecast assuming no change in current efforts. In December 2013, during a face to face meeting facilitated by the Results Leadership Group, the Oral Health Florida Leadership Council decided that the plan would remain at the population level in order to maintain focus on the improvement of oral health for the entire state. During this January meeting, the Leadership Council confirmed the roadmap’s result and decided upon three preliminary areas of focus (later consolidated into two).

In August 2013, the Leadership Council used the best available data to identify and rate population-level data indicators according to communication, proxy and data power. In December 2013, the Leadership Council began using a structured data-driven decision making process that included the identification and prioritization of factors that contributed to and restricted progress for the first headline indicator, Percentage of Medicaid/SCHIP eligible children receiving any dental services. They identified partners to engage and listed previously implemented successful interventions. Using this information, the group developed strategies for each prioritized factor and began to list action steps for each of these strategies.

Between December 2013 and February 2014, smaller work groups repeated this process for the indicators of community water fluoridation, emergency department oral health visits and spending and dental sealants. On February 13, 2014, the Leadership Council reconvened to confirm and refine the plan’s strategies and action steps using a formalized proposal-based decision making process. The final first draft was completed in March and presented to the Leadership Council for confirmation in May 2014. Final document was approved in June 2014.

Oral Health Florida and the Florida Public Health Institute aim to present Florida’s Roadmap for Oral Health to the Florida Department of Health and multiple stakeholders in order to garner their support and facilitate strategy implementation.

The Florida Public Health Institute and Oral Health Florida would like to thank Deitre Epps from the Results Leadership Group for her facilitation and guidance as well as the following members of the Leadership Council for hosting face to face meetings throughout this process:

•Palm Beach State College, Nancy Zinser, RDH, MS

•University of Florida College of Dentistry, Frank Catalanotto, DMD

•Special Olympics Florida , Nancy Sawyer, MEd

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Story Behind the Curve

The Planning Process Using Results-Based Accountability™

What is Results-Based Accountability?™

RBA is a disciplined way of thinking and taking action that can be used to improve the quality of life in communities and the performance of programs, agencies and service systems.

Why use it?

  • Moves groups from talk to action quickly
  • Provides and promotes the use of a common language among stakeholders
  • Addresses barriers to innovation • Builds collaboration and consensus
  • Uses data to ensure accountability for populations and programs

How does it work?

RBA starts with the ends (results) and works backwards to the means to achieve the results

What do we mean by “result”?

The quality of life conditions of well-being that we want for the community as a whole.

Population Accountability and Performance Accountability

  • Population accountability: The system or process for holding people in a geographic are responsible for the well-being of the total population or a defined subpopulation
  • Performance accountability: The system or process for holding managers and workers responsible for the performance of their programs, agencies and service systems The strategies in this plan were developed at the population level and not at a program or agency level – meaning that this plan focuses on the improvement of oral health at the statewide and community level. As we move forward in the implementation of the plan, we will track the performance accountability of programs, agencies and the oral health service system to ensure they run efficiently and effectively.

Our Common Language

  • Result: Conditions of well-being for an entire population
  • Indicator: How we measure these conditions; the data that indicates achieving our result
  • Baseline: What the measures show about where we’ve been and where we’re headed: 1) 5-year historical trend line and 2) forecast if we maintain current level of effort
  • Story behind the baseline (or data): The positive and negative factors that contributed to the data
  • Strategy: A coherent set of actions that has a reasoned chance of producing a desired effect
  • Performance measure: Measure that tells us if our program, agency or service system is working by answering
    • 1) How much did we do
    • 2) How well did we do it
    • 3) Is anyone better off

Friedman, M. (2009). Trying Hard is Not Good Enough:. BookSurge Publishing

Creating the Strategic Plan: Our Results-Based Accountability™Process

Result: All people in Florida have optimal oral health and well-being
Focus area #1: Improved access to and utilization of quality oral health care
Focus area #2: Increased access to community water system fluoridation

Decision-making process:

  • Chose and confirmed result
  • Identified two areas of focus that will lead to the result
  • Identified existing and missing data
  • Created historic and forecasting baselines (data trend lines)
  • Created data development agenda
  • Chose headline indicators according to criteria
  • Told the story behind the baseline (trend line data), including a root cause analysis
  • Listed partners
  • Identified what works to improve the indicator and achieve the result
  • Formed strategies according to Results Based Accountability criteria
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Why Is This Important?

“How to” guide for reading the indicator pages.

Why is this important?

Background and rationale for focusing on the indicator or result.

How will we know the result has been achieved?

The achievement of our result will be measured by progress on 3 – 5 community indicators in each focus area. The goal is to choose indicators that communicate well, are of central importance to the result and for which good data is available.


  • Depending on the indicator, an up or down direction may be good or not. For example, we want to see untreated tooth decay go down, but preventive dental care go up.
  • In addition to the direction of a trend, the current status of an indicator may or may not be at an acceptable level. For example, the number of communities with fluoridated water may be going up, but still has not reached an acceptable level that we want to see in our community.
  • Specific data charts for each headline indicator not on the Data Development Agenda are available in the Data Appendix.
  • Performance measures for statewide oral health programs will align with and contribute to improving community indicators; however, programs are accountable only for their participants’ improvements, not for community indicator improvements.

Stories behind the baseline (data):

  • Factors or causes for the baseline/data.
  • What positive factors have contributed to improving the baseline/data?

What works: Our best ideas:


What critical stakeholders do we need to address the underlying factors?

Focus Areas - for best results view in Chrome or Mozilla
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Story Behind the Curve

Innovative states and communities have been able to design programs that connect families with the preventive care needed to stay healthy. These programs have solved problems of health access and shown significant long term improvements for children and families – but many places still don’t have access to these innovations.

Why is this important?

Background and rationale for focusing on the indicator.

A 2000 report by the U.S. Surgeon General called dental disease a “silent epidemic.” Overwhelming numbers of individuals exhibit serious dental diseases , contributing to poor overall health, hospital emergency room visits for preventable dental conditions, missed school and work days and other consequences (1). Access to oral health care services is one of the important determinants of oral health status. The American Dental Association recently presented a data summary (2) that stated: “Utilization of dental care has declined among working age adults, particularly the young and the poor. Dental benefits coverage for adults has steadily eroded the past decade, again particularly for young and poor adults. Not surprisingly, more and more adults in all income groups are experiencing financial barriers to care”. The result of this lack of access to oral health care has been labeled as a “dental crisis in America” by the United States Senate (3). Studies show that patients who are able to access dental care and receive preventive and therapeutic dental services are better able to prevent and control dental diseases such as dental caries (3). We have chosen three indicators to illustrate the level of access to oral health care services for one high risk patient group of children in Florida and one indicator to illustrate the effects of lack of access to oral health services for the general population in Florida.

How will we know this has been achieved?

Data Development Agenda:
Priorities for new or improved data Focus Area: Improved access to and utilization of quality oral health care

  • Percentage of Florida schools with school-based sealant programs
  • Percentage of untreated decay in vulnerable populations (3rd Grade, Head Start, Older Adults)
  • Percentage of public with access to dental care • Rate of oral health program development
  • Present all data through the health equity lens
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Story Behind the Curve

Indicator 2.1: Percentage of population on community water systems receiving fluoridated water

Past generations have solved many problems of infectious disease for our people. Problems like small pox and measles are a thing of the past. Today, we have the tools to prevent the most common infectious diseases affecting children and families, including tooth decay. Preventing this disease will avoid expensive treatments, missed work, school and missed opportunities later in life.

Why is this important?

Background and rationale for focusing on the indicator.

According to the Centers for Disease Control and Prevention (CDC), studies show that water fluoridation reduces tooth decay by about 25 percent over a person's lifetime. Community water fluoridation is safe, effective, economical and available to all consumers of a fluoridated community water supply regardless of age, income, education, or socioeconomic status. Income and the ability to access regular dental care are not barriers to receiving fluoride's protective benefits. In addition, the CDC reports that “every $1 invested in this preventive measure yields approximately $38 savings in dental treatment costs.” The CDC has recognized water fluoridation as one of 10 great public health achievements of the 20th century.

The Centers for Disease Control and Prevention Community Water Fluoridation. (July 2013) Accessed from on May 15, 2014.

How will we know this has been achieved?

Data Development Agenda: Priorities for new or improved data

  • County level data collection
  • Present all data through the health equity lens
  • Stories behind the baseline (data) Focus Area: Community Water Fluoridation:

    Factors that have contributed to improving the data:
  • Team approach of stakeholders (FDHA, OHF, FDOH, UFCD, local coalitions)
  • State and local legislative policies: Surgeon General, Local budgets for fluoridation systems (resources)
  • Advocacy/PR/media: Public hearings, articles, speakers, education materials
  • Research to offset anti-fluoridation (CDC, ADA)

  • Factors that restrict the data:
  • Anti-fluoridationists are communicating false information about fluoride chemical
    • Generates confusion/fear/doubt/lack of trust
    • Lack of information, common language and health literacy
    • Providing resources to maximize search engine optimization (SEO-Google)
  • Lack of consumer engagement at community level
  • Economics
    • Municipal budgets decree
    • Easy to cut fluoride budget – belief that removing fluoride will cut costs
    • Optional service - not a high priority
    • Don’t understand Return on Investment
  • Politics
  • Arguments regarding small government interfering in person life
  • Belief that removing fluoride will cut costs
  • Unknown status of health equity
  • Potential Partnerships:

    Partial list of critical partnerships identified to address underlying factors and garner support:

    �Florida Association of Counties


    �Water operators


    �Local dental groups

    �Dental insurance companies

    �Florida Department of Health

    �Florida Dental Hygiene Association

    �University of Florida School of Dentistry

    �Nova Southeastern University College of Dentistry

    �Florida League of Cities

    �Oral Health Florida

    �Local Coalitions

    �County Health Departments

    �American Dental Association

    �Centers for Disease Control and Prevention (CDC)

    �American Academy of Pediatrics Campaign for Dental Health (

    �Pew's Children's Dental Campaign Project

    �Children's Dental Health Project

    �Association of State and Territorial Dental Directors

    �Tribal Councils

    �National Dental Association

    �National Hispanic Association

    �Urban League

    Partners to Improve Progress
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    Why Is This Important?

    The work of the Florida Head Start State Collaboration Office depends upon both national and state priorities. The Florida Head Start Collaboration Office engages in a number of projects and activities designed to enhance early learning systems and services for children, families, and communities.

    • Serves on various planning committees: Early Childhood Education Framework, Healthy Families Florida, Child Abuse Prevention and Permanency Advisory Council,
      McKinney-Vento Homeless Education Committee, Home Visiting Coalition, Oral Health Florida, Expanding Opportunities for Inclusion of Children with Disabilities Workgroup, and Florida Transition Project.
    • Facilitates a Migrant Oral Health Subcommittee of Oral Health Florida to address the unique needs of Migrant and Seasonal Head Start programs.
    • Partners in the development of a research agenda within Head Start programs that has resulted in the nationally recognized report, "Florida Head Start: A Portrait of Our Head Start Children's Outcomes."
    • Collaborated with the University of Florida College of Dentistry and Oral Health Florida and the American Dental Education Association to convene the first Oral Health Advocacy Day.
    • Sponsored, with the State of Florida Office of Adoption and Child Protection, an informative session for policymakers on the Strengthening Families Initiative to support positive outcomes for families.
    • Presented to Florida’s Children and Youth Cabinet, in partnership with Early Childhood Comprehensive Systems Project staff, a proposal promoting the creation of a State Advisory Council on Early Education and Care.
    • Coordinated with professional development partners, a draft statewide comprehensive cross-sector professional development plan with the intent to ensure an increase of quality community based options for children with disabilities in Florida.
    • Represented Head Start on the State of Florida Early Childhood Standards revision steering committee and the steering committee for the Florida Professional Development Initiative.

    Clear Impact Suite is an easy-to-use, web-based software platform that helps your staff collaborate with external stakeholders and community partners by utilizing the combination of data collection, performance reporting, and program planning.

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