Transcript Slide 1

The Critical Role of Oral
Health in Optimal Child Health
Why Should We Care?
What Can Be Done?
Susan A. Fisher-Owens, MD, MPH
Santa Barbara County
Children’s Oral Health Summit
June 25, 2010
Support and Disclaimer
• Supported by the National Institute for
Dental and Craniofacial Research
– RO3DE165701
– R21 DEO18523
– U54 DE142501 (CAN-DO I)
• No financial relationships to disclose
regarding this topic
Objectives
(What I am and am not intending to accomplish)
• Highlight why you should care
• Brief review of conceptual model
• Detail two examples of oral health
interventions in children
– Dental clinic
– Fluoride application
• Oral health in pregnancy
Why should we care?
• Why oral health?
• Why a pediatrician?
– Pt BR, JR, EM, …
– 1 year olds
• 89% seen a pediatrician/FP for an “annual exam”
• 1.5% seen a dentist
• 6-8% have caries
MEPS, 2000-2005
Common Chronic Disease
>5 times as common
as a reported history of
asthma
>7 times as common
as hay fever
Prevalence increases
with age

The majority (52%) of
children aged 5-9 years
had at least one carious
lesion or filling in the
coronal portion of either
a primary or a
permanent tooth
In 17-year-olds: 78%
In adults (18+): 85%

(NCHS 1996, NHANES III)
Do baby teeth matter?
• Dental caries alone is the most common
chronic disease of childhood
– >50% of children by the second grade
– Nearly 80% by late adolescence
– 117,000 hours of school lost per 100,000
school-age children, with an additional 17,000
activity days beyond school time restricted per
100,000 individuals
Gift, 1992; Surgeon General’s Report 2000
Not just pretty teeth
Being free of chronic oral-facial pain
conditions, oral and pharyngeal (throat)
cancers, oral soft tissue lesions, birth
defects such as cleft lip and palate, and
scores of other diseases and disorders that
affect the oral, dental, and craniofacial
tissues
…As people with teeth
• Oral-systemic disease connections
– Heart and lung diseases
– Stroke
– Low-birth-weight, premature births
– Diabetes
• By end of life, nearly every American has
had complications with his/her teeth
(Health Care Financing Administration 2000)
…As people with hearts
Would you miss:
Eating salad?
Crunching on an apple?
Being allowed to play
outside?
Going to school?
Being able to get a job?
Photos courtesy of Operation Smile
What would it be
like, seeing yourself
for the first time?
…As people who pay taxes
• The nation’s yearly dental bill, 2000: >$60 billion in 2000
(Health Care Financing Administration 2000)
– Tens of billions of dollars in direct medical care and indirect costs of
chronic craniofacial pain conditions such as temporomandibular
disorders, trigeminal neuralgia, shingles, or burning mouth syndrome
– $100,000 minimum individual lifetime costs of treating craniofacial birth
defects such as cleft lip and palate
– Costs of oral and pharyngeal cancers and
Britain’s Book of Bad Teeth
autoimmune diseases
– Costs associated with the unintentional and
intentional injuries that so often affect the
head and face
– Social and psychological consequences
and costs…
Surgeon General’s Report 2000
…As pediatricians
• All of the above
• 3rd top priority of AAP
• Something we are not adequately
addressing now
– California’s grade for Oral Health by
ChildrenNow.org: D+
As public health practitioners
• Greatest area of health care disparities
– 80% of caries in permanent teeth occur in ~ ¼
of American children (Brown 1996; Macek 2004)
– SEP:
•Rates 4.4 times
higher in 12-23
mo for children <
125% FPL
•All cases in kids
<200% FPL
•12 times as many
restricted activity
days
Health People 2010, 2000;
… As public health practitioners,
cont’d
• Greatest area of health care disparities
– Race/ethnic
… As public health practitioners,
cont’d
• Greatest area of health care disparities--race/ethnic
– American Indian and Alaska natives ages 2-4 years have 5 times
the national average for caries, increasing to ages 15-19 years,
when 91% of the population has caries (Indian Health Service,
2002)
• 1/4th report not smiling for fear of teeth appearance
• 1/3rd miss school because of tooth pain
– Mexican-American children ages 2-19 years have almost twice
the rate of untreated dental caries as white or black nonHispanic children. Racial/ethnic disparities exist even in children
as young as 12-23 months old, with Mexican-American children
3.5-4.6 times more likely to have caries than children of other
racial/ethnic backgrounds.
– Similar for access
Disparities
• Socioeconomic
– Services: children near Federal Poverty Level (FPL)
are 50% as likely to have sealants as those >200% of
the FPL
• Race/ethnic
– Services: rates for sealants for black and MexicanAmerican children are 33% lower than those for white
children
• Clustering
– For children 2-5 years, 75% of caries occurred in 8%
of the population (non-Hispanic whites, non-Hispanic
blacks, or Mexican Americans)
Dye 2007
…As world citizens
Mouth’s Role in Body
• Integral to systemic
health
– Productivity
– Quality of life
• Portal/Pros
– Entryway of nutrition
– Source of communication,
pleasure, social interaction,
and cultural facial and
dental esthetics
Hollister, 1993; SGR, 2000
http://digestive.niddk.nih.gov/ddiseases/pubs/barretts/
Mouth’s Role in Body
• Portal/Cons
– Infection or
inflammation portal
SGR, 2000; Sheiham, 2000
http://digestive.niddk.nih.gov/ddiseases/pubs/barretts/
Oral-Systemic Disease
Connections
• Oral conditions (particularly periodontal
diseases) affect systemic
–
–
–
–
Heart and lung diseases
Stroke
Diabetes
Low-birth-weight, premature births
• Systemic conditions affect oral health
– HIV
– Diabetes
• Oral symptoms and salivary diagnostics can
identify systemic problems (e.g., HIV)
SGR, 2000
Oral-Systemic Disease
Connections, cont’d
• Common risk factors
– Poor diet, substance use, poor hygiene, and
stress
• Benefitted by nutrition, sanitation, hygiene
improvements
• For both, disparities often associated with
race/ethnicity, gender, income, education,
geographic location, insurance coverage,
chronic conditions, age, and health literacy
SGR, 2000; Seiham, 2000
Inequities in Oral and Systemic
Health
• While over 46 million Americans lack
health insurance, 108 million lack dental
insurance
• Adults, especially those with chronic
conditions, often cite oral health as their
top unmet health need
– Impact on California National Guard
SGR, 2000; Davidoff, 2005; Belt, 2005
• A few weeks after I started researching
this story, I developed a sore throat. My
glands were swollen, and I felt tired and
lightheaded. I'd been traveling a lot—by
planes, trains, and subway—and I had
spent time on college campuses and in
clinics. Since swine flu had just hit the
United States, I wondered whether I'd
picked up the virus somewhere along the
way…
June Thomas, Slate, Sept 28, 2009
• Then one morning, I bit into a piece of
toast and felt a sharp pain. It was as if I
had driven a pin deep into the gum…
• If the sickness was located anywhere
other than in my mouth, a visit to the
doctor would be covered by my medical
insurance. A trip to the dentist's office, on
the other hand, could cost me serious
money.
June Thomas, Slate, Sept 28, 2009
Picture taken from Huffington Post
Linda Davidson / The Washington Post
Ways to keep down germs
American Academy of Pediatrics
(AAP) Priority
AAP, Pediatrics, 2008
AAP Approach
• Risk assessment of parent by 6 months and referral
“no later than 6 months after the first tooth erupts, or
12 months of age (whichever comes first) for
establishment of a dental home:”
– Children with special health care needs
– Children of mothers with a high caries rate
– Children with demonstrable caries, plaque, demineralization,
and/or staining
– Children who sleep with a bottle or breastfeed throughout the
night
– Later-order offspring
– Children in families of low socioeconomic status
• “…The ideal approach to early childhood caries
prevention and management is the early
establishment of a dental home”
AAP, Pediatrics, 2008
Research Questions
• What child, family and community
variables predict oral health outcomes?
• What is the role of context or “place” in
explaining oral health outcomes?
– Understanding the sources of variation in
children’s oral health outcomes is critical to
the development of effective prevention
policies
Conceptual Model
A Multilevel Approach to
Understanding Oral Health
Outcomes for Children
Conceptual Model: Keyes’ Traditional
Epidemiologic Triad
Oral Health
Micro-flora
Host &
Teeth
Substrate
(diet)
Population Health Models
Field Model (Evans and Stoddart)
Dahlgren-Whitehead Model
IOM Model for Children
Most Models Identify 5 Main
Determinants
•
•
•
•
•
Genetic/Biologic Characteristics
Physical Environment
Social Environment
Health-Influencing Behaviors
Medical/Dental Care
Our Conceptual Model
• Our model builds on previous conceptual
models of population health:
– Incorporates multiple domains
(biological/genetic, physical environment,
social environment, health behaviors, health
care)
– Incorporates multiple levels (child, family,
community/society)
– Incorporates a time dimension
Conceptual Model: Keyes’ Traditional
Epidemiologic Triad
Oral Health
Micro-flora
Host &
Teeth
Substrate
(diet)
The Complete Model, with Time Dimension
Added
Time
Community Level
Influences
Family Level Influences
Community
Oral Health
Environment
Social
Environment
Dental Care
System
Characteristics
Health Care
System
Characteristics
Socioeconomic
Status
Child Level Influences
Social
Physical
Support
Use of Dental Care
Attributes
Development
Health Status
Health Behaviors
Oral Health
of Parents
and Practices
Dental
Family
Biologic and Insurance
Composition
Genetic
Endowments
Family
Function
Physical
Environment
Micro-flora
Health Behaviors, Practices,
and Coping Skills of Family
Physical Safety
Culture
Host &
Teeth
Time
Social Capital
Substrate
(diet)
Pediatrics, 2008
Empirical Analysis
Multilevel Results
What is the role of “place” or context in
explaining oral health outcomes?
What child, family and community level
variables predict oral health outcomes?
Child Influences, by construct
Biologic & genetic
endowment
Parental health index (physical
and emotional health)
Physical attributes
Race/ethnicity
Body mass index
Special health care needs
Use of dental care
Preventive dental care
Dental coverage
Health behaviors & practices
Sleep patterns
Exercise patterns
Protective sporting headgear
Child’s development
Age
Problems in school
After school activity index (sports,
religious,lessons)
Family influences
Family composition
Family structure
Family function
Frequency of family outings
Religious service attendance
Relationship with child
Attendance of child’s events
Knowledge of child’s friends
Socioeconomic position
Family income
Educational attainment
Frequency of residential moves
Parent’s health behaviors,
practices, & coping skills
Parental Exercise index
Parental health insurance index
Parental coping index
Family culture
Primary home language
Community Influences
Index of social capital
(neighbors help, watch out, counted on,trust,safety)
Physical safety
Child is safe in school
Child is safe at home
Summary of Key Findings:
Children’s Oral Health
Child Level
Family Level
Biologic and genetic
endowment
Family composition and Social capital
functioning
Physical attributes
Socioeconomic position Physical Safety
Health behaviors and
practices
Parent's behaviors,
practices, & coping
Child’s development
Family culture
Use of dental care
Community Level
Applying the Conceptual Model
Time
Community Level
Influences
Family Level Influences
Community
Oral Health
Environment
Social
Environment
Dental Care
System
Characteristics
Health Care
System
Characteristics
Socioeconomic
Status
Child Level Influences
Social
Physical
Support
Use of Dental Care
Attributes
Development
Health Status
Health Behaviors
Oral Health
of Parents
and Practices
Dental
Family
Biologic and Insurance
Composition
Genetic
Endowments
Family
Function
Physical
Environment
Micro-flora
Health Behaviors, Practices,
and Coping Skills of Family
Physical Safety
Culture
Host &
Teeth
Substrate
(diet)
Social Capital
Time
Conceptual/Empirical
Conclusions
• Understanding the sources of variation in
children’s oral health outcomes is critical to
the development of effective prevention
policies
• Multiple factors operating at multiple levels
are related to oral health outcomes
• This suggests intervention strategies can and
should incorporate a multi-factorial approach
Conclusions, cont’d
• Disparities in oral health are present at
the child/family level by education and
family income, even after controlling for
other confounding variables
• Socioeconomic position was not a
significant predictor at the state level
Extensions of Conceptual
and Empirical Model
• Edelstein Solving the Problem of Early
Childhood Caries: A Challenge for Us All Arch
Pediatr Adolesc Med, July 1, 2009
• Ismail et al Predictors of Dental Caries
Progression in Primary Teeth JDR March
2009
• Casamassimo et al Beyond the dmft: The
Human and Economic Cost of Early
Childhood Caries JADA Jun 2009
• Health Affairs—Giving Policy Some Teeth:
Routes To Reducing Disparities In Oral
Health March 2008
Practical Examples
• Embedded Dental Clinic
• Fluoride Clinic
• Oral Health in Pregnancy
Dental Clinic
• Monthly, half-day dental clinic, embedded
in pediatric clinic
• Residents/staff were trained in caries risk
assessment and referral protocols
With appreciation to
Samantha Stephens,
SFDPH, for her support
of this project
Dental Clinic Results
• Of the Pediatric Clinic population aged 6-36
months, approximately 12% (382 children) were
seen in the dental clinic, for a total of 554 visits
• Average patient age was 27.7 months (range 3
months-14 years)
• Ethnicity reflected that of the overall Pediatric
Clinic. Based on risk assessment at initial visit,
85% of patients were moderate to high risk.
External referral was needed for 36% of patients
due to severity of ECC.
Dental Clinic Results
• Improved propriety of referrals with time.
• Decreased risk factors, including for the
siblings
• Families loved it!
Fluoride Varnish
• AAP
http://www.camerab.com/main.cfm
http://www.gilroydispatch.com/photo/photoview.asp?p=4159
Fluoride Varnish in Clinic
• Acceptable to residents
• Appreciated by families
Referral Networks
• Two-way
• Patients more likely to go
• Refer all patients
Other Opportunities for
Engagement
•
Lobby
–
–
–
–
–
–
•
•
Workforce issues
Policies requiring screening without treatment
Dental in FQHCs
Fluoridated water
SCHIP and dental
Research funding
AAP committee
Referral lists
http://www.aap.org/ORALHEALTH/pdf/aapNews-Sink-your-teeth.pdf
Counselling
• http://1.bp.blogspot.com/_PXqKN8TJUZA/
SKXbaSaMKVI/AAAAAAAAABM/2Qp2a3f
_8Q4/s1600-h/fatkids.jpg
http://1.bp.blogspot.com/_PXqKN8TJUZA/SKXbaSaMKVI/AAAAAAAAABM/2Qp2a3f_8Q4/s1600-h/fatkids.jpg
www.healingdaily.com/conditions/cavities.htm
The Collaboratives
• Conceptual and Empirical • Oral Health in Pregnancy-Models--Paul W.
Jane Weintraub, DDS, MPH;
Newacheck, DrPH; J.
Kristen Marchi, MPH; Zhiwei
Weintraub, DDS, MPH;
Yu, MPH; Paula Braveman,
Stuart Gansky, DrPH; Larry
MD, MPH
Platt, MD; Mah-J Soobader, • The Health Affairs Team-PhD; Matt Bramlett, PhD
Judith Barker, Sally Adams,
• Embedded Dental Clinic—
Lisa Chung, Stuart Gansky
Irene Hilton, DDS;
and Jane Weintraub
Samantha Stephen, RDH, • Fluoride Varnish Team—
MS; Shannon Thyne, MD
Shannon Thyne