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Access to dental care for kids: implications for health and primary care 2008 Wisconsin Primary Care Research and Qualit

Access to dental care for kids: implications for health and primary care 2008 Wisconsin Primary Care Research and Quality Improvement Conference. Kenneth G. Schellhase, MD MPH Department of Family & Community Medicine Department of Population Health Medical College of Wisconsin Milwaukee, WI.

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Access to dental care for kids: implications for health and primary care 2008 Wisconsin Primary Care Research and Qualit

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  1. Access to dental care for kids: implications for health and primary care2008 Wisconsin Primary Care Research and Quality Improvement Conference Kenneth G. Schellhase, MD MPH Department of Family & Community Medicine Department of Population Health Medical College of Wisconsin Milwaukee, WI

  2. Confessions

  3. Introduction/overview • Biases • Limitations • Formal Objectives • Review oral health pathophysiology • Become familiar with oral health epidemiology • Understand the implications of poor oral health on general health and primary care practice • Discuss potential solutions

  4. February 28, 2007 Page B01 For Want of a Dentist: Prince George's Boy Dies After Bacteria From Tooth Spread to Brain Twelve-year-old Deamonte Driver died of a toothache Sunday. A routine, $80 tooth extraction might have saved him. If his mother had been insured. If his family had not lost its Medicaid. If Medicaid dentists weren't so hard to find. If his mother hadn't been focused on getting a dentist for his brother, who had six rotted teeth. By the time Deamonte's own aching tooth got any attention, the bacteria from the abscess had spread to his brain, doctors said. After two operations and more than six weeks of hospital care, the Prince George's County boy died.

  5. Dentistry in 3 5 minutes or less

  6. Dental Plaque • Definition: • Colorless bacterial matrix on teeth • Mechanism: Buildup of bacterial biofilm Deep layers convert to anaerobic respiration Acid production Gingivitis Demineralization Periodontitis Caries Bacterial pathogens—anaerobic or facultatively anaerobic (Strep mutans, lactobacilli, Actinomyces)

  7. Plaque Plaque revealed by “disclosing solution” Plaque revealed by electron microscopy

  8. Dental Caries • Definition: • Microbial destruction or necrosis of teeth. • tuberculosis of bones or joints (obsolete) • [Latin for “decay”] • Mechanism: fermentable sugars + bacteria in plaque = lactic acid Demineralization of tooth surface Tooth destruction

  9. Dental caries

  10. Caries Abscess

  11. Periodontitis • Definition: • Chronic bacterial infection affecting soft tissue and bone surrounding a tooth (“periodontium”) • US Adult prevalence 15% for significant disease • Mechanism: Plaque below gum line Gingivitis, local inflammatory mediator response Damage to periodontium Tooth loosening, eventual loss • Flora shift to more gram negative anaerobes (Actinobacilli, Prevotella, et al.)

  12. Periodontal disease

  13. Epidemiology • National data • Wisconsin data • Local data

  14. Burden of poor oral health on children • Prevalence • Dental caries is the most common chronic disease in childhood • 50% prevalence by 2nd grade • 80% prevalence by end of high school • vs. ~12% for asthma (NHANES age 0-17) U.S. Department of Health and Human Services (HHS). Oral Health in America: A Report of the Surgeon General. Rockville, MD: HHS, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2000. National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey III,1988–1994. Hyattsville, MD: Centers for Disease Control and Prevention (CDC), unpublished data.

  15. Concentration of disease 80% of caries in permanent teeth of children is found in 25% of population Burden of poor oral health on children Kaste, L.S.; Selwitz, R.H.; Oldakowski, R.J.; et al. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988–1991. Journal of Dental Research 75:631-641, 1996.

  16. Untreated caries in kids 6-8, by race/ethnicity and parental educational attainment

  17. Increasing caries rates across many groups, school age children (NHANES)

  18. Increasing caries rates across all groups, young children (NHANES)

  19. Untreated caries in children by age group and insurance status: Medicaid and uninsured much worse, but differ little from each other

  20. Rates of caries by insurance status over time: Medicaid getting worse (NHANES) 1988 to 1994 vs. 1999 to 2004

  21. Accessed dental care in past year, by insurance status (MEPS) Gradient of access depending on insurance status: Private > Medicaid > Uninsured

  22. Percentage of children with urgent dental need, by insurance status (NHANES): private insurance < Medicaid and uninsured

  23. Unable to access needed care by insurance status (MEPS) Gradient of poor access: Uninsured > Medicaid > Private

  24. Reasons for inability to access needed care, by insurance status

  25. Wisconsin survey 3rd graders 2002 At least 1 permanent tooth with filling or untreated decay At least 1 tooth with untreated decay Wisconsin Department of Health and Family Services, Overview of Oral Health in Wisconsin: Youth and Health Data Collection Report. 2001-2002.

  26. Treatment urgency, Wisconsin 3rd graders

  27. Racial/ethnic disparities in oral health status of Wisconsin 3rd graders

  28. Socioeconomic disparities in oral health status of Wisconsin children

  29. Sobering numbers: oral health in Wisconsin children

  30. Waukesha County data • Waukesha Oral Health Assessment 2006 • 3rd graders • 54% with history of dental caries • 19% with untreated decay • 18% in need of dental care • Head Start • 31% with history of dental caries • 24% with untreated decay • 23% in need of early dental care • About 1% of children have acute, urgent needs • Nearly 1000 visits/yr to county emergency departments for dental diagnosis

  31. Implications of poor oral health

  32. Implications of poor oral health • Immediate impact on children • Pain, disfigurement • Self-image, stigma • Functional implications • Nutritional effects • School attendance, performance • Effects on systemic health and therefore primary care • Cardiovascular disease and periodontitis (…downstream) • preterm/LBW and periodontitis (…hopefully downstream) • Diabetes (…now and downstream)

  33. Poor Oral HealthImmediate impact • Dental pain • Pain! • Disrupted sleep, poor concentration at school* • Nearly 11% prevalence of current dental pain in Waukesha Smiles study *Reisine, S., and Locker, D. Social, psychological, and economic impacts of oral conditions and treatments. In: Cohen, L.K., and Gift, H.C., (eds.). Disease Prevention and Oral Health Promotion: Socio-Dental Sciences in Action. Copenhagen: Munksgaard and la Fédération Dentaire Internationale, 1995, 33-71.

  34. Poor oral health:functional/nutritional implications • Missing teeth/poor dentition correlated with poor diet • soft, low nutrient density foods • At odds with need for a diet emphasizing fresh fruits and vegetables • Promotes obesity From: Oral Health in America: A Report of the Surgeon General. Office of the Surgeon General of the United States, 2000.

  35. Poor oral health:functional/nutritional implications • Chronic dental pain leads to loss of sleep, risk of depression • 3.1 days/year of school lost due to active dental issues (NHIS data) • Self-perception • Missing/decayed teeth affect child’s self-esteem From: Oral Health in America: A Report of the Surgeon General. Office of the Surgeon General of the United States, 2000.

  36. Poor oral health:Pathophysiologic Model of Systemic Effects Chronic Inflammatory mediator cascade Anaerobic oral infection local toxin release Local inflammatory cellular response Local release of inflammatory mediators (TNFά, interleukins, et al.) Chronic release into systemic circulation Systemic consequences

  37. Cardiovascular Disease • Increasing evidence of association between periodontal disease and poor cardiovascular outcomes • No causality determined yet—observational data only • Important downstream implications for managing cardiovascular risk in primary care

  38. Cardiovascular Disease • Meta-analysis by Janket et al., 2003 • summary RR for cardiovascular events (periodontal disease vs. not): RR =1.19 (95% CI, 1.08 to 1.32) • stratified analysis for </=65 years of age: RR = 1.44 (95% CI, 1.20 to 1.73) • If analyze stroke only: RR = 2.85 (95% CI, 1.78 to 4.56) Janket, S.-J., et al., Meta-analysis of periodontal disease and risk of coronary heart disease and stroke. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology & Endodontics, 2003. 95(5): p. 559-569.

  39. Cardiovascular Disease • Arbes et al., analysis of population-based NHANES data • Analyzed association between self-reported MI and degree of periodontal disease (PD) measured on NHANES exam • Found dose-response relationship between degree of PD and MI • Adjusted results for known cardiac risk factors • Lowest degree of PD vs. no PD • Odds ratio = 1.4 (95% CI: 0.8-2.5)—not significant • Moderate degree of PD vs. none • 2.3 (95% CI: 1.2-4.4) • Highest degree of PD vs. none • 3.8 (95% CI: 1.5-9.7) Arbes, S.J., Jr., G.D. Slade, and J.D. Beck, Association between extent of periodontal attachment loss and self-reported history of heart attack: an analysis of NHANES III data. J Dent Res, 1999. 78(12): p. 1777-1782.

  40. Cardiovascular Disease • CORADONT study, Spahr et al. 2006 • observational design • statistically significant association between CAD and: • overall periodontal pathogen burden odds ratio = 1.92 95% CI, 1.34-2.74; P<.001) 2. Actinomyces burden in periodontal pockets odds ratio = 2.70 95% CI, 1.79-4.07; P<.001) Spahr, A., et al., Periodontal infections and coronary heart disease: role of periodontal bacteria and importance of total pathogen burden in the Coronary Event and Periodontal Disease (CORODONT) study. Arch Intern Med, 2006. 166(5): p. 554-9.

  41. Preterm delivery/low birth weight • Increasing body of evidence showing association between periodontal disease and poor birth outcomes • Evidence is largely observational • Recent experimental studies • Implications for anyone providing obstetric or newborn care

  42. Preterm delivery/low birthweight • Vergenes et al., Am J Obstet Gynecol 2007 • Meta-analysis of 17 observational studies, pooled data of over 7000 women • overall odds ratio for preterm/low birthweight was 2.83 (95% CI: 1.95-4.10, P < .0001) for women with periodontal disease • Caution—higher quality studies showed weaker association Vergnes, J.N. and M. Sixou, Preterm low birth weight and maternal periodontal status: a meta-analysis. Am J Obstet Gynecol, 2007. 196(2): p. 135 e1-7.

  43. Preterm delivery/low birthweight • Xiong et al., British Journal Ob Gyn 2006 • Meta-analysis of 3 interventional trials • Treatment of periodontal disease led to 57% reduction in preterm low birthweight (pooled RR 0.43; 95% CI 0.24-0.78) Xiong, X., et al., Periodontal disease and adverse pregnancy outcomes: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology, 2006. 113(2): p. 135-143.

  44. Diabetes Diabetes Periodontal disease (PD) • Increased risk of PD in diabetes • Increased severity of PD in diabetes Periodontal disease Diabetes • Worse glycemic control in severe PD • Increased insulin resistance related to chronic infection • Relevant for primary care of diabetes Kuo, L.-C., A.M. Polson, and T. Kang, Associations between periodontal diseases and systemic diseases: A review of the inter-relationships and interactions with diabetes, respiratory diseases, cardiovascular diseases and osteoporosis. Public Health, 2008. 122(4): p. 417-433.

  45. Poor Oral Health:Effects on primary care practice • Increased cardiovascular events • Increased high-risk deliveries • Diabetic glycemic control more difficult to maintain • System effects: • High frequency of dental problems presenting in primary care office settings and in the ED

  46. Potential Solutions

  47. Potential Solutions • 1. community-based • 2. practice-based • 3. policy-based

  48. Potential solutions--community • Community coalitions • Example: Waukesha County Dental Coalition • Driving force: school nurse and a family medicine educator • Involvement of diverse group of concerned individuals, plus support of a couple key dentists • Product: Waukesha County Community Dental Clinic opened May 2008 • Has served > 1300 low-income patients, 75% children

  49. Potential solutions--community • Community-academic partnerships • “Blues” conversion-funded endowments • Wisconsin Partnership Program—UW • Healthier Wisconsin Partnership Program—MCW • Examples: • Waukesha Smiles: Dental Outreach to Low-income Waukesha Children • 3 yr grant to compare approaches to improving oral health status of 3rd graders at select schools • Making Milwaukee Smile • 3yr grant to establish in-school oral health promotion program

  50. Potential solutions--community • Community-academic partnerships • Under development and pending submission: • SW Wisconsin: in-school hygienist program in Grant and Crawford counties • Milwaukee: Periodontal disease intervention with high-risk Milwaukee mothers to reduce rates of preterm/LBW and ultimately infant mortality

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