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Surveillance Systems for Oral

Health Hard Tissue Diseases


P R E S E N T E D BY:
D R. Z O H A I B A H M E D
BDS, MPH, DPH RESIDENT
C O LU M B I A U N I V E R S I T Y C O L L E G E O F D E N TA L M E D I C I N E

Oral Health Surveillance


to monitor broad-based oral diseases
and conditions, along with strategies
associated with oral health outcomes,
particularly access to dental care and
community water fluoridation
The purpose of Oral Health Surveillance
is to protect and promote populationwide oral health using available data
Phipps K, Kuthy R, Marianos D, Isman B. State-based oral health surveillance systems: conceptual
framework and operational definition. Council of State and Territorial Epidemiologists, Atlanta, GA, 2013.

Factors influencing Oral


Health Outcomes
Access
to Care

Workforce,
Infrastruct
ure,
policies

Oral
Healt
h

Risk
factors

Interventi
on
Strategies

Phipps K, Kuthy R, Marianos D, Isman B. State-based oral health surveillance systems: conceptual
framework and operational definition. Council of State and Territorial Epidemiologists, Atlanta, GA,

The Surveillance Cycle


Plan
Evaluation

Collect

Link to
practice

Dissemina
te

Analyze

Interpret

Phipps K, Kuthy R, Marianos D, Isman B. State-based oral health surveillance systems: conceptual
framework and operational definition. Council of State and Territorial Epidemiologists, Atlanta, GA, 2013.

Oral Health Indicators NOHSS


Council of State and Territorial Epidemiologists (CSTE)
approved nine oral health indicators for state based public
health surveillance in 1998-1999;
Dental visits within past year Data available through
Behavioral Risk factor
Teeth cleaning within past year

Surveillance System (BRFSS)

Tooth loss among adults


Data available through

Incidence from Oropharyngeal cancers


National Cancer Institutes
Surveillance; SEER; NPCR
Mortality from Oropharyngeal cancers
Phipps K, Kuthy R, Marianos D, Isman B. State-based oral health surveillance systems:
conceptual framework and operational definition. Council of State and Territorial

Oral Health Indicators


(Cont)
Dental caries experience
Untreated tooth decay
Dental sealants among

Basic Screening Survey


(BSS)
kindergarten

students through Grade 3


Percentage of population
served by optimally fluoridated

CDCs Water
Fluoridation reporting
water
System (WFRS)

Revised Oral Health


Indicators - 2012
Oral Health Indicators revised upon release of HP2020 by work group made
up of state dental directors, epidemiologists from ASTDD, CDC, and CSTE.
1) Dental Visits within past year
a) Adults (18 years and above) Existing, no changes
Frequency: every 2 years
Source: BRFSS
HP2020 Objective: OH-7
b) Children and adolescent (1 17 years) Existing, source revised
Frequency: every 3 years from 2003 to 2012 (yearly from 2016)
Source: YRBSS (last included in 2007), NSCH (new source)
HP2020 Objective: OH-7
Proposed New and Revised Indicators for the National Oral Health Surveillance System [Internet]. CSTE.
2013 [cited 25 October 2016]. Available from:

Revised Oral Health


Indicators (Cont)
c) Federally Qualified Health Center (FQHC) patients
New
Frequency: every year
Source: HRSA Uniform Data Set (UDS)
HP2020 Objective: OH-11
d) Adults with diabetes who had dental visit New
Frequency: every 2 years
Source: BRFSS
HP2020 Objective: OH-7

Revised Oral Health


Indicators (Cont)
2) Teeth Cleaning
a) Adults (18 years and above) Existing, lost data source
Frequency: every 2 years
Source: BRFSS last asked in 2010
HP2020 Objective: OH-4 and OH-5
b) Women 12 months before most recent pregnancy New
Frequency: every year
Source: Pregnancy Risk Assessment Monitoring System
(PRAMS)
HP2020 Objective: OH-4

Revised Oral Health


Indicators (Cont)
3) Tooth Loss
a) Older Adults who lost all teeth (> 65 years) Existing, no
changes
Frequency: every 2 years
Source: BRFSS
HP2020 Objective: OH-4.2
b) Older Adults who lost 6 or > teeth (> 65 years) Existing,
no changes
Frequency: every 2 years
Source: BRFSS
HP2020 Objective: OH-4.1

Revised Oral Health


Indicators (Cont)
4) Water Fluoridation
a) Population served by optimally fluoridated water
Existing, no changes
Frequency: every 2 years
Source: Water Fluoridation Reporting System (WFRS)
HP2020 Objective: OH-13

Revised Oral Health


Indicators (Cont)
5) Caries History or Caries Experience
a) Caries experience in children attending Head Start (3 5
years) New
Frequency: every 5 years*
Source: BSS
HP2020 Objective: OH-1.1
b) Caries experience in children attending Kindergarten (3
5 years) New
Frequency: every 5 years*
Source: BSS
HP2020 Objective: OH-1.1

Revised Oral Health


Indicators (Cont)
c) Caries experience among 3rd graders (6 9 years)
Existing, no changes
Frequency: every 5 years*
Source: BSS
HP2020 Objective: OH-1.2

Revised Oral Health


Indicators (Cont)
6) Obvious signs of tooth decay
a) Untreated tooth decay among children attending Head Start (3
5 years) New
Frequency: every 5 years*
Source: BSS
HP2020 Objective: OH-2.1
b) Untreated tooth decay among children attending Kindergarten (3
5 years) New
Frequency: every 5 years*
Source: BSS
HP2020 Objective: OH-2.1

Revised Oral Health


Indicators (Cont)
c) Untreated tooth decay among 3rd grade children (6 9 years)
Existing, no change
Frequency: every 5 years*
Source: BSS
HP2020 Objective: OH-2.2
d) Untreated coronal and root caries among older adults residing in
long-term care or skilled nursing facilities (Vulnerable Older Adults) New
Frequency: every 5 years*
Source: BSS
HP2020 Objective: OH-3.2 and OH-3.3

Revised Oral Health


Indicators (Cont)
e) Untreated coronal and root caries among older adults attending
congregate meal sites (Vulnerable Older Adults) New
Frequency: every 5 years*
Source: BSS
HP2020 Objective: OH-3.2 and OH-3.3

Revised Oral Health


Indicators (Cont)
7) Preventive dental visits
a) Children enrolled in Medicaid (0 20 years) New
Frequency: every year
Source: CMS Form 416
HP2020 Objective: OH-8
b) Children enrolled in CHIP (0 20 years) New
Frequency: every year
Source: CHIP Annual Reporting Template System (CARTS)
HP2020 Objective: OH-8

Revised Oral Health


Indicators (Cont)
8) Dental Sealants
a) Third grade students who received sealant on 1 or more of
their first permanent molars (6 9 years) Existing, no changes
Frequency: every 5 years*
Source: BSS
HP2020 Objective: OH-12.2
b) Children enrolled in Medicaid who received sealant on 1 or
more of their first permanent molars soon after eruption (6 9 years)
New
Frequency: every year
Source: CMS Form 416
HP2020 Objective: OH-12.2

Revised Oral Health


Indicators (Cont)
c) Children enrolled in Medicaid who received sealant on 1
or more of their second permanent molars soon after eruption
(10 14 years) New
Frequency: every year
Source: CMS Form 416
HP2020 Objective: OH-12.2

Revised Oral Health


Indicators (Cont)
9) Dental Treatment Needs
a) Need for restorative dental treatment among children
attending Kindergarten (3 5 years) New
b) Need for restorative dental treatment among children
attending Head Start (3 5 years) New
c) Need for restorative dental treatment among children
attending 3rd Grade (6 9 years) New
d) Need for restorative dental treatment among older adults
attending residing in long-term care or skilled nursing facilities
New
e) Need for restorative dental treatment among older adults
attending congregate meal sites

Revised Oral Health


Indicators (Cont)
10) Dental Treatment Visit
a) Medicaid enrolled Children (0 20 years) - New
b) CHIP enrolled Children (0 20 years) - New

Revised Oral Health


Indicators (Cont)
11) School based dental services
a) School based health centers that offer dental sealants - New
Frequency: every three years
Source: School Based Health Center Capital (SBHCC)
HP2020 Objective: OH-9.1
New

b) School based health centers that offer restorative services


Frequency: every three years
Source: School Based Health Center Capital (SBHCC)
HP2020 Objective: OH-9.2

Revised Oral Health


Indicators (Cont)
c) School based health centers that offer topical
fluoride New
Frequency: every three years
Source: CMS School Based Health Center Capital
(SBHCC)
HP2020 Objective: OH-9.3

Revised Oral Health


Indicators (Cont)
12) Oropharyngeal Cancers
a) Incidence of oral and pharyngeal cancer Existing, no
change
Frequency: Every year
Source: United States Cancer Statistics, SEER, and NPCR
Cancer Registries
HP2020 Objective: OH-6, OH-14.2, C-6
b) Mortality from oral and pharyngeal cancer Existing, no
change
Frequency: Every year
Source: National Vital Statistics System (NVSS)
HP2020 Objective: C-6

STATE LEVEL DATA


SOURCES

Behavioral Risk Factor


Surveillance System (BRFSS)
Developed in 1984 by CDC
Collects data annually from more than 400,000 U.S
adults (> 18 years) through telephone interviews
Collects data on oral health related rotating core
questions every two years.
Currently, there are 5 measures for 2 oral health
indicators that are being calculated

Behavioral Risk Factor Surveillance System 2014 Codebook Report Land - Line and Cell - Phone data
[Internet]. CDC - BRFSS. 2015 [cited 30 October 2016]. Available from:

BRFSS (Cont)

BRFSS (Cont)

BRFSS (Cont)

BRFSS (Cont)

BRFSS (Cont)

BRFSS (Cont)
The question about, teeth cleaning among adults aged
18 years and above within the past year has been
discontinued as of 2010.
It is unclear when this question will be asked again.
Adults with diabetes who had dental visit in the past
year, was recommended by CSTE in revised Oral Health
Surveillance Indicator measures 2012.
It is unclear when this question will be added under
calculated variable.

Assessment
Monitoring System
(PRAMS)
Developed in 1987 by CDC and participating States
Currently 47 States are participating except California,
Idaho, and Ohio.
Uses mixed-mode methodology; self-administered
through mail, and interviewer administered through
telephone
Same questions are asked by interviewer to facilitate
questionnaire completion
1300 to 3400 women who gave live birth are sampled
each year using states birth certificate file

PRAMS Questionnaires - Pregnancy Risk Assessment Monitoring System - Reproductive Health [Internet].
CDC. 2015 [cited 30 October 2016]. Available from: https://www.cdc.gov/prams/questionnaire.htm

PRAMS (Cont)
The Questionnaire has two parts; Core Questions, and
Standard Questions
Core Questions collect information on; attitude and feelings
about most recent pregnancy, source of prenatal care,
maternal alcohol and tobacco consumption, physical abuse
during pregnancy, pregnancy related morbidity, infant
healthcare, contraceptive use, knowledge of pregnancy related
health issues including adverse effects of tobacco and alcohol
The remaining questions are included in the section of
Standard Questions
Dental questions were added from phase 6 (2009 2011)
Currently, following 6 measures for 1 oral health indicator are
being calculated in phase 7 (2012 Current)

PRAMS (Cont)

PRAMS (Cont)

PRAMS (Cont)

PRAMS (Cont)

PRAMS (Cont)

PRAMS (Cont)

PRAMS (Cont)

Behavioral
Surveillance System
(YRBSS)
School based survey developed in 1990 by CDC to monitor 6
categories of priority health risk behaviors including, tobacco
use, alcohol and drug use, sexual behaviors that contribute to
unintended pregnancy and STDs including HIV, unhealthy dietary
behaviors, physical inactivity, and behaviors that contribute to
unintentional violence or injury
Conducted every 2 years nationally by CDC and locally statewide by department of health and education to provide
representative sample of 9th through 12th grade students
CDC provides representative data for 9 th through 12th grade
students from public and private schools
State level data provides representative sample for 9 th through
12th grade students from public high schools

Youth Risk Behavior Surveillance System (YRBSS) Overview [Internet]. CDC. 2016 [cited 31 October 2016].
Available from: http://www.cdc.gov/healthyyouth/data/yrbs/overview.htm

YRBSS (Cont)
Several methodological changes have been proposed
since 1991
Currently dental visit question is asked under other
topics section in both National (CDC) and Standard (State
and local) questionnaire
Question about last dental visit was included in 1999,
2001, 2003, 2015, and 2017

YRBSS (Cont)

National Survey of
Childrens Health
(NSCH)
National Survey of Childrens Health (NSCH) is nationwide state level survey sponsored by Maternal Child
Health Bureau of the Health Recourses and Services
Administration in partnership with CDC, and Child and
Adolescent Health Initiative
Telephone Survey (landlines only) of households with at
least one resident children aged of 0 17 years
Collects data on physical and mental health, access to
quality healthcare, and childs school, family,
neighborhood, and social context
For 2016, survey will be conducted by Census Bureau,
and integrate two surveys; NSCH, and National Survey of
Children with Special Health Care Needs (NS-CSHCN)
National Survey of Children's Health [Internet]. Data Resource Center for Child and Adolescent Health.
2016 [cited 31 October 2016]. Available from: http://childhealthdata.org/learn/NSCH

NSCH (Cont)
Have been conducted three times since 2003; first in 2003, second
in 2007, and third in 2011/2012
Will be conducted yearly from 2016 with data expected in early
2017
For 2016, following dental questions are included and
recommended by ASTDD as preferred source of data to monitor
these indicators;
- Overall dental health,
- Decay or cavities, bleeding gums, toothache, in the past
12 months
- Dental visit in the past 12 months

NSCH (Cont)

NSCH (Cont)

Basic Screening
Survey (BSS)
Developed by Association of State and Territorial Dental
Directors (ASTDD) in collaboration with the Ohio Department
of Health, and the CDC in 1999
Conducted every 5 years by each state individually*
Two basic components; direct observation of persons mouth,
and questions asked of or about the individual being screened
Direct observation model is required, while questionnaire is
optional
Until 2008, NOHSS encouraged states to obtain information
on at least 3rd grade students but as of 2012 revision of oral
health indicators, states are recommended to collect
information on pre-school (attending head start programs),
kindergarten, and 3rd grade.
The Basic Screening Survey: A tool for Oral Health Surveillance Not Research [Internet]. ASTDD. 2011
[cited 31 October 2016]. Available from: http://www.astdd.org/docs/bss-what-is-oral-health-

BSS (Cont)
All screeners are trained by the State Health Department
before actual screening
Collects data from pre-school (attending head start
programs), school children (kindergarten and 3 rd grade)
on oral health indicators including;
- Caries Experience/treated decay: Percentage of
students with caries experience, including treated and
untreated tooth decay.
- Untreated Tooth Decay. Percentage of students with
untreated tooth decay.
- Dental Sealants. Percentage of students with dental
sealants on at least one permanent molar tooth. (3rd
grade)

BSS (Cont)
Collects data from older adults residing in long-term care or
skilled nursing facilities and those attending congregate meal
sites on oral health indicators including;
- Dentures and Denture use
- Number of natural teeth present
- Untreated tooth decay
- Tooth loss
- Root fragments
- Time Since last dental visit/Frequency of Dental Visits
- Access to Dental Care
- Obvious tooth mobility/need for periodontal care
- Urgency of need for dental care

BSS Preschool and


School Children

Untreated decay detected by visual inspection only,


explorer are not used

Basic Screening Surveys: Preschool and School Children [Internet]. ASTDD. 2008 [cited 31 October 2016].
Available from:

BSS Preschool and


School Children (Cont)
If breakdown of enamel surface or cavity is observed, it
is considered as untreated decay - applies to both smooth
surface and pits fissure.

BSS Preschool and


School Children (Cont)
Staining of pits and fissure with no apparent breakdown
of enamel, and white spot lesions are not considered
untreated decay.

BSS Preschool and


School Children (Cont)
Broken or Chipped teeth are considered sound unless a
cavity is found.
Tooth with broken filling without recurrent decay is
classified as treated decay rather than untreated
A retained root is assumed to be destroyed by caries,
and classified as untreated decay

BSS Preschool and


School Children (Cont)

Missing tooth or replacement crown in anterior tooth due


to reason other than caries such as injury, trauma or
orthodontic treatment are considered to be sound.

BSS Preschool and


School Children (Cont)
Any type of fillings, amalgam, composite, or temporary
are considered treated decay
A tooth that is missing or extracted due to decay is
considered treated decay
Presence of at least one crown as a result of decay in the
childs mouth will be classified as treated decay.

BSS Preschool and


School Children (Cont)

Sealants on permanent molars collected for elementary,


middle, and high school children.
Children with sealant on at least one permanent molar is
classified as having sealants.

BSS Preschool and


School Children (Cont)
Molars with either transparent, opaque, fully or partially
retained sealants are classified as having sealants.
To facilitate identification of
sealant on a tooth, an adjunct
such
as tooth pick or cotton
tipped applicator is
recommended
to be used by dental screener only
to
differentiate between smooth
and rough area.

BSS Preschool and


School Children (Cont)

Only used for pre-school children


Child with one or more of six anterior maxillary teeth decayed,
filled, or missing are classified as having early childhood caries
(ECC)
Cause for missing teeth is confirmed from guardian either on site
or through questionnaire

BSS Preschool and


School Children (Cont)

Urgent need for dental care Children who need dental care
within 24 to 48 hours because of sign and symptoms
including pain, swelling, or infection
Early dental care Within next several weeks or before their
regular dental appointment, such as untreated decay
without symptoms of pain or swelling

BSS Preschool and


School Children (Cont)
Rampant Decay: Those with 7 or more untreated or
treated tooth decay (Yes/No)
Number of Quadrants with Untreated Decay:
Number of quadrants with untreated decay (0, 1, 2, 3, 4)

BSS Preschool and


School Children (Cont)
Optional questionnaire that States may or may not integrate
collects demographic information about age, gender, eligibility
for free or reduced price meal program, race and ethnicity
Toothache in the past 6 months
Time since last visited dentist (6 months, 6 to 12 months, 1 to
3 years, more than 3 years, never)
Reason for visiting dentist
Other questions include, access and coverage for dental care
services for preventive or emergency surgical visits

BSS Older adults


ASTDD recommends inclusion of one or both of the following high
risk groups;
a) Congregate meal program participants (or elderly Nutrition
programs or senior meal sites) who are;
- 60 years of age and older and their spouses regardless
of age
- Under the age of 60 years with disabilities, who reside
in facilities where meals are served
- Age for participation may vary by tribal organization
b) Resident of long-term care facilities
The results cannot be generalized to all older adults, it can only be
generalized to high risk older adults

Basic Screening Surveys: Older Adults [Internet]. ASTDD. 2010 [cited 31 October 2016]. Available
from: www.prevmed.org/wp-content/uploads/2013/11/BSS-SeniorsManual.pdf

BSS Older adults


(Cont)

Presence of full or partial upper or lower denture followed by


question about use while eating
For long-term care facility residents, who may or may not be
wearing denture on visual examination, staff is asked for denture
location
All participants who have denture, are classified as having denture
regardless of their use while eating food

BSS Older adults


(Cont)

BSS Older adults


(Cont)

Number of teeth in each arch; third molars, retained


primary teeth, and root fragments are included (range 0
16 per arch)
All types of overdentures, with abutment either from
retained roots, natural teeth or implants are classified as
no natural teeth

BSS Older adults


(Cont)

BSS Older adults


(Cont)

Untreated decay detected by visual inspection


only, explorer are not used

BSS Older adults


(Cont)
If breakdown of enamel surface or cavity is observed, it
is considered as untreated decay - applies to both smooth
surface and pits fissure.

BSS Older adults


(Cont)
Staining of pits and fissure with no apparent breakdown
of enamel, and white spot lesions are not considered
untreated decay.

BSS Older adults


(Cont)
Broken or Chipped teeth are considered sound unless a
cavity is found
Broken filling without recurrent decay is also not
classified as untreated decay
Root fragments unless restored are considered as
untreated decay

BSS Older adults


(Cont)

Fractured crown at or below gum line is considered as


root fragment
It could either be restored or unrestored root fragment

BSS Older adults


(Cont)

BSS Older adults


(Cont)

If participant needs periodontal care before scheduled


routine dental appointment, then classified as in need of
periodontal care

BSS Older adults


(Cont)

BSS Older adults


(Cont)

Suspicious soft tissue lesions subjective to examiners


understanding that should be evaluated by a health
professional
Includes red and white lesions and conditions/infections
such as Candidiasis

BSS Older adults


(Cont)

BSS Older adults


(Cont)

Urgent need for dental care Dental care within next week because of
sign and symptoms including pain, swelling, or infection; Candidiasis
or suspicious soft tissue lesion is also classified under this category
Early dental care Within next several weeks or before their regular
dental appointment, such as untreated decay without symptoms of
pain or swelling; broken or missing filling and ill fitting denture is also
classified under this category

BSS Older adults


(Cont)

BSS Older adults


(Cont)

To determine functional posterior (premolar and molar)


contacts of natural or non-natural teeth for proper
functioning while eating
Mouth mirror is used to retract cheek to visualize
functional posterior contacts

BSS Older adults


(Cont)

BSS Older adults


(Cont)

Based on Oral Hygiene Index


Distinguished from recommended need for periodontal
care by identifying abundance of soft or hard matter
covering more than 2/3 of any tooth surface

BSS Older adults


(Cont)

BSS Older adults


(Cont)

Based on Gingival Index; Mild or moderate is not recorded


If participant has marked redness and edema, ulceration or a tendency to
spontaneous bleeding, they are classified as severe gingival inflammation
Gingival Index Categories:
- Normal Gingiva
- Mild Inflammation: slight change in color, slight edema
- Moderate inflammation: redness, edema, glazing
- Severe inflammation: marked redness and edema, ulceration, tendency to
spontaneous bleeding

BSS Older adults


(Cont)

BSS Older adults


(Cont)

Teeth that are obviously mobile are marked as mobile


Suspicious mobility is confirmed by placing gloved finger
on either occlusal or incisal surface and gently wiggling
the tooth

BSS Older adults


(Cont)

BSS Older adults


(Cont)

A participant is classified as severe dry mouth if dry


cracked lips, dry cracked fissured tongue, or tissue
sticking to teeth due to lack of saliva are identified

BSS Older adults


(Cont)

BSS Older adults


(Cont)
Optional questionnaire that States may or may not integrate collects
demographic information about age, gender, race and ethnicity
Race and gender can also be recorded at the time of screening
Number of permanent teeth removed (if mouth screening was not performed)
Self reported Oral Health (Excellent, Very Good, Good, Fair, Poor)
Pain in mouth during last year (Very often, Occasionally, Hardly ever, Never)
Time since last visited dentist (6 months, 6 to 12 months, 1 to 3 years, more
than 3 years, never)
Reason for visiting dentist
Current Dry mouth
Oral Cancer Screening (ever and most recent)
Other questions include, access and coverage for dental care services for
preventive or emergency surgical visits

Water Fluoridation
Reporting System
(WFRS)
Developed by CDC in conjunction with ASTDD
Collected information about;
- Percentage of the population served by public water
systems who receive fluoridated water from 2000
present
Provides data for every state every 2 years
Currently provides county level data for water
fluoridation status for selected states
Proposed to provide data for every county served by one
or more community water systems

Water Fluoridation Reporting System (WFRS) [Internet]. Cdc. 2016 [cited 1 November 2016].
Available from: https://www.cdc.gov/fluoridation/data-tools/reporting-system.html

WRFS (Cont)
State fluoridation managers enter data into WFRS and generate
reports for state program use to improve quality
Data about each water system include facility location,
population served, fluoridation status, natural fluoridation
concentrations, system type. Laboratory testing, dates of facility
inspections, and other relevant information
About 54,000 community water systems included in WRFS. Of
these, about 18,400 systems are listed as either having fluoride
levels that are adjusted, are naturally occurring, or are
consecutively fluoridated (purchased from a neighboring system
that has optimally fluoridated water).
The optimal fluoride level in drinking water to prevent tooth
decay should be 0.7 milligrams of fluoride per liter of water, the
U.S. Department of Health and Human Services (HHS)

References
1) Phipps K, Kuthy R, Marianos D, Isman B. State-based oral health surveillance systems: conceptual framework and
operational definition. Council of State and Territorial Epidemiologists, Atlanta, GA, 2013.
2) Proposed New and Revised Indicators for the National Oral Health Surveillance System [Internet]. CDC. 2013 [cited 25
October 2016]. Available from:
http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/PS/12-CD-01FINALCORRECTEDOCT201.pdf
3) Behavioral Risk Factor Surveillance System 2014 Codebook Report Land - Line and Cell - Phone data [Internet]. CDC BRFSS. 2015 [cited 30 October 2016]. Available from: https://www.cdc.gov/brfss/annual_data/2014/pdf/codebook14_llcp.pdf
4) PRAMS Questionnaires - Pregnancy Risk Assessment Monitoring System - Reproductive Health [Internet]. CDC. 2015 [cited
30 October 2016]. Available from: https://www.cdc.gov/prams/questionnaire.htm
5) Youth Risk Behavior Surveillance System (YRBSS) Overview [Internet]. CDC. 2016 [cited 31 October 2016]. Available from:
http://www.cdc.gov/healthyyouth/data/yrbs/overview.htm
6) National Survey of Children's Health [Internet]. Data Resource Center for Child and Adolescent Health. 2016 [cited 31
October 2016]. Available from: http://childhealthdata.org/learn/NSCH
7) The Basic Screening Survey: A tool for Oral Health Surveillance Not Research [Internet]. ASTDD. 2011 [cited 31 October
2016]. Available from: http://www.astdd.org/docs/bss-what-is-oral-health-surveillance-4-26-2011.pdf
8) Basic Screening Surveys: Preschool and School Children [Internet]. ASTDD. 2008 [cited 31 October 2016]. Available from:
https://dphhs.mt.gov/Portals/85/publichealth/documents/OralHealth/BSSChildrensManual2008.pdf
9) Basic Screening Surveys: Older Adults [Internet]. ASTDD. 2010 [cited 31 October 2016]. Available from:
www.prevmed.org/wp-content/uploads/2013/11/BSS-SeniorsManual.pdf
10) Water Fluoridation Reporting System (WFRS) [Internet]. Cdc. 2016 [cited 1 November 2016]. Available from:
https://www.cdc.gov/fluoridation/data-tools/reporting-system.html
11) http://www.cdc.gov/oralhealth/data_systems/