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Prevention of periodontal diseases in children. Periodontal (gum) disease. A chronic bacterial infection that affects the gums and bone supporting the teeth Gingivitis: Early stage of disease Red, swollen, and bleeding gums Usually reversible through good oral hygiene and preventive care

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periodontal gum disease
Periodontal (gum) disease
  • A chronic bacterial infection that affects the gums and bone supporting the teeth
  • Gingivitis: Early stage of disease

Red, swollen, and bleeding gums

Usually reversible through good oral hygiene and preventive care

Not uncommon in young adults and even youth

  • Periodontitis: Advanced stage of disease

Chronic inflammatory response leading to irreversible destruction of tissues and bone that support the teeth

Treatment requires more aggressive surgical care

Periodontitis affects 8.5% of U.S. adults and is the most common cause of tooth loss.

Source: American Academy of Periodontology

natural history of periodontal disease progression

Figure 1. Natural History of Periodontal Disease Progression

Colonization of Disease-Promoting


Mediating Risk Factors






Plaque Promoting


Poor Oral Hygiene

Lack of Dental



Smokeless Tobacco

Teeth Grinding





Family History


-Inflammation of the gums

-Bleeding on probing

-Periodontal pockets (<4 mm)

-Periodontal pockets (>4 mm)

-Loss of clinical attachment around the tooth (>3 mm)

-Loss of supporting bone structure


evidence of

recent oral hygiene behavior

-Calculus (calcified plaque): evidence of chronic oral hygiene behavior

Natural History of Periodontal Disease Progression
type 2 diabetes and periodontal disease
Type 2 Diabetes and Periodontal Disease



Type 2 Diabetes

Periodontal Disease

oral health disparity ai an adults suffer from high rates of periodontal disease
Oral Health Disparity: AI/AN adults suffer from high rates of periodontal disease.

Source: 1999 IHS Oral Health Survey Report

significant periodontitis is present even in ai an 15 19 year olds
Significant Periodontitis is present even in AI/AN 15-19 year olds.

Clinical Markers

Source: 1999 IHS Oral Health Survey

obesity and diabetes disparities in ai an
Obesity and Diabetes Disparities in AI/AN
  • AI/AN pediatric obesity prevalence highest of any ethnic group (>20%)
  • Childhood obesity has more than tripled in last 30 years, but rates leveled since 2003 in all ethnic groups except AN/AN
  • In CA, obesity prevalence no longer rising except for AI and black girls (Madsen 2010)
  • 1,758 AI/AN adolescents have type 2 diabetes (T2D) (2005)
  • T2D increased 68% from 1994-2004 in AI/AN adolescents
  • 16.3% of AI/AN adults have T2D vs 8.7% of nonHispanic whites
  • 3 times higher death rate due to T2D for AI/AN compared with the general U.S. population (2004)
ethnic differences in pediatric diabetes
Ethnic Differences in Pediatric Diabetes

Source: SEARCH for Diabetes in Youth Study.NHW=Non-Hispanic White; AA=African American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian

very high rates of tobacco use in ai an
Very High Rates of Tobacco Use in AI/AN
  • Cigarette smokers have 2-4 times the risk of coronary heart disease as nonsmokers. (US DHHS, 1989)
  • Larger % (32%) of AI/AN adults smoke than any other racial/ethnic group (CDC 2006)
  • Smokeless tobacco also more prevalent than other ethnic groups, especially in girls
ai an adolescents are appropriate target population for periodontal disease prevention and control
AI/AN adolescents are appropriate target population for periodontal disease prevention and control.

Periodontal disease already prevalent1.

High metabolic risk trajectory increases risk for periodontitis. T2D is 4-8 times more common in some AI/AN groups2. Diabetes is an established risk factor for periodontitis and is increasingly common in AI/AN youth.

AI/AN youth and young adults also have high rates of obesity, stress3 and tobacco use1, particularly smokeless tobacco, other risk factors for periodontal disease.

The opportunity exists to promote and establish independent oral hygiene behaviors and healthy habits to prevent periodontitis in later adulthood, and to intervene while changes are still reversible.

1 IHS Oral Health Survey (1999) 2 Mealey and Ocampoa (2007) 3 Robin et al (1997)


Study to address Adolescent Urban AI/AN Periodontal Health in relation to Type 2 Diabetes and Obesity

Kristen Nadeau, Judith Albino, Terry Batliner, Lonnie Johnson, Anne Wilson, Angela Barega, William Henderson

specific aims of project
Specific Aims of Project

Aim 1:Assess periodontal health status of urban AI/AN adolescents

Aim 2: Assess modifiable oral health behavioral risk factors, knowledge, attitudes in urban AI/AN adolescents at high risk for T2D, and determine whether these factors are associated with severity of periodontal disease as assessed by attachment loss (periodontitis) and mean percent bleeding sites (gingivitis).

Aim 3:  Based on the findings from SA’s 1-2, and in partnership with the CNOHR and DIHFS Community Advisory Committees, develop a culturally-appropriate behavioral intervention focused on the factors identified as key mechanisms influencing periodontal disease in AI/AN adolescents and develop a protocol to evaluate its effectiveness.

  • Periodontal disease will be high in urban AI/AN youth
  • Unique modifiable risk factors contributing to periodontal disease can be indentified in this population
proposed study design
Proposed Study Design
  • Cross-sectional epidemiology cohort study
  • N ~ 200 urban AI/AN adolescents (age 12-20 years)

Three groups:

  • Nl weight
  • High risk for T2D (obese, prediabetes)
  • T2D
study measures
Study Measures
  • Clinical (age, sex, BMI, BP, diabetes history, glucose, HbA1c, total cholesterol, HDL, non-HDL cholesterol)
  • Behavioral and Attitudinal Questionnaires (oral health, smoking, smokeless tobacco use, dietary intake, stress and social/family support)
  • Behavioral Dyscontrol Scale (Executive functioning)
  • Dental Examination (periodontal disease and caries)
  • Free cleaning, oral hygiene instruction, given floss, toothpaste, toothbrush
  • Clinical recommendations for f/u care
  • F/U phone call in 6 weeks and asked to mail back dental floss
why urban clinic
Why Urban Clinic?
  • Health Care and especially Dental Care is less accessible to AI/AN not living on reservations and away from IHS clinics
  • Urban Youth lack social support and extended family, more frequently drop out of school, have cultural identity clash
  • Thus a particularly underserved population
urban american indians definitions
Urban American Indians: Definitions

Long term residents: in a city for multiple generations, some the descendants of people who traditionally owned land that became an urban center.

Forced residents: forced to relocate to urban centers by government policy or by the need to access specialized health or other services.

Medium and short term visitors: in a city to visit family or friends, to pursue an education, job.

urban american indians stats
Urban American Indians: Stats
  • The number of Indians living in urban settings greatly accelerated in the 1950s and 1960s, due to the Indian termination policy of that era. The Bureau of Indian Affairs (BIA) developed a "relocation" program which relocated >160,000 AI to cities. The program was abolished in the 1970s because of the coercion and ineffectiveness.
  • Since that era, many AI/AN people have moved to urban areas on their own for jobs, better opportunities, etc
  • The number of urban AI/AN is increasing: 1970 census 38% non-reservation or other Native lands; 2000 census 61%.[6]; 2007 67% urban (of 4.1 million)
social data in urban ai an
Social Data In Urban AI/AN
  • Poverty rate of 20.3%, vs. a general urban poverty rate of 12.7%.
  • Unemployment rate 1.7 times higher than the general urban population.
  • Homeownership <46%, vs. 62% for non-Indians.
  • Homes (owned or rented) significantly less likely to have plumbing (1.8 times more likely than non-Indian urban residents), kitchen facilities (2 times more likely) and telephone service (>3 times more likely).
  • 1.7 times less likely to have a high school diploma than non-Indians.
  • Three times more likely to be homeless than non-Indians.
  • A higher rate of child abuse and neglect (5.7 cases per 1,000 children per year, vs. 4.2 for the total U.S. population).[8]
health data in urban ai an
Health Data In Urban AI/AN
  • Urban AI/AN suffer from many of the same health problems as on the reservations. Rates of prenatal care are even lower than on reservations, and rates of infant mortality even higher. Furthermore, compared to the general population, urban Indians have:
  • 38% higher rates of accidental deaths
  • 54% higher rates of T2D
  • 126 % higher rates of liver disease and cirrhosis
  • 178% higher rates of alcohol-related deaths. [8]
health care in urban ai an
Health Care in Urban AI/AN

Some urban AI/AN are members of the 561 federally recognized tribes (qualifying only for health care on reservations)

Other urban AI/AN are from the 109 tribes “terminated” in the 1950’s and qualify for nothing

Only 1% of the Indian Health budget is allocated to urban programs despite 2/3 of AI/AN living in urban settings and even this 1% remains under threat

Barriers to care: time constraints; transportation issues; distrust of government programs; cost of traveling to receive government-provided health care; depression; few AI/AN providers; changing addresses if transient

data in urban adolescent ai an
Data In Urban Adolescent AI/AN
  • The oral health data form the IHS focuses on IHS clinics, so not clear what the rates are in urban populations, which are now the majority of AI/AN people, especially youth
  • Relatively little is known about CVD risk factors among urban AI/AN specifically.
  • Only one study identified of CVD risk factors among urban AI, conducted nearly 25 years ago.
  • It found that those living in Minneapolis had an extremely high prevalence of T2D, cigarette smoking and obesity and a moderately high prevalence of high BP and cholesterol. (Gillum et al., 1984)
urban american indians denver
Urban American Indians: Denver
  • Denver: relatively high urban AI/AN population because it was: an original relocation site, houses AI/AN veterans, and housed a former BIA office
  • Metropolitan area home to more than 20,000 Native Americans. These descendents of the Cheyenne, Lakota, Kiowa, Navajo, Ute, and at least a dozen other tribal nations are an integral part of the city’s social and economic life.
  • Many Denver AI/AN have lived here for over 30 years
  • Many Denver AI/An are 2cnd or third generation
  • Also houses large transient population who move to and from reservations on a regular basis
  • Ute reservation is in the SW corner of Colorado
research site
Research Site
  • Denver Indian Health and Family Services Clinic (DIHFS)
  • Incorporated in 1978 as a non-profit with some funding from IHS for outreach, staff of 2
  • Grew to include limited health care services with volunteer nurses and MD in agreement with Denver HHS
  • Could not handle the large number of uninsured, discontinued in 1991
  • 1996 tried to partner with an outside non-native community health clinic but not sufficient services and not liked by AI/AN clients
  • 1998 board of directors tried to start again, AI MD (Lori Kobrine) added in 1999, clinic became licensed, since 2000 staffed with full time NP and volunteer MD and rapidly expanded
  • Now 5,000 AI/AN patient base, in 2010 1681 unique people seen, 160 with T2D
  • T2D grant for 15 years, some get T2D care at Denver Health
research site dihfs
Research Site: DIHFS

Services: NP and volunteer MD, substance abuse, mental health, CDE, weight loss, exercise counseling, energy services, limited medication stock, low-cost dental, very simple labs (glucose, HbA1c, lipids)

Missing Services: subspecialists (in particular endocrinology, cardiology, psychiatry), more expensive medications, diabetes supplies, procedures, imaging, comprehensive laboratory

Main barriers: 77% of clients uninsured (many insured are vets), some waive benefits at work expecting IHS clinic to cover needs like on reservation, if insured, co-pays/deductibles high

Was not affiliated with HMO so couldn’t bill medicaid, lacked IHS funds for training and improvements; now Title V funded and now Medical Assistance site so can proccess medicaid

  • Recruiting
  • Who is caregiver?: in Urban setting child may be off of reservation and living with other family members
  • Hippa: access to lists of names at DIHFS
  • Advertising: Credibility
  • Working in a clinic that doesn’t typically do research
  • Lack of Centralized Place to disseminate information
  • Transportation for subjects
  • Lack of Data on urban AI/AN populations to design study

Community Health Advisory Board: tribal IRB head, health care workers, tribal college president, tribal education specialist, DIHFS coordinator, all AI/AN

Staff meetings of DIHFS: Clinic Coordinator, Diabetes educator, Physical Activity Trainer, psychologist, social services, CAN, lab tech


Denver Indian Center

JEFCO: AI/AN urban student coordinator,Pow-Wow

DIHFS newsletter

Cultural Immersion Program at UCD

ADA expo


Offering free cleanings to take burden off DIHFS staff

best practices for communications and partnerships
Best Practices for Communications and Partnerships
  • Address what the community needs, what the community perceives are its issues
  • Solicit partnerships from within the community to be involved on the project
  • Address consent, how the data will be collected, data sharing issues
  • Address dissemination of the data back to the community once the study is completed
  • Ask what the community would use as a measure of success
cultural appropriateness
Cultural Appropriateness
  • Gift Card- Target vs. Wal-Mart vs Visa: ask the community what they would prefer, don’t make assumptions
  • Name of Program that will be appealing
  • Using colors and icons
general approaches for preserving culture and promoting health among urban ai an
General approaches for preserving culture and promoting health among urban AI/AN
  • Traditional dance and running as a form of exercise
  • Healthier Native foods
  • Urban AI/AN much more likely to seek health care from urban Indian health organizations than from non-Indian clinics: Expand number of AI health professionals: work w/ local colleges; encourage UIHOs to serve as training sites to encourage AI students
  • Support integration of traditional medicine in health care
other successes to emulate
Other Successes to Emulate
  • Seattle Indian Health Board in Seattle operates Family medicine residency-training program
  • A special initiative was started in 1999 to address diabetes in AI. Urban Indian health organizations were a utilized to reach urban AI. Data for 2000-2005 show significant improvements in most urban areas, showing the ability of community-based organizations reach and better serve hard-to-reach populations.
  • Native American Cancer Research Corp (NACR) in Denver partnered with local urban Indian groups and the American Indian Clinic in LA to develop, test and implement programs that train female urban Indian volunteers (“Native Sisters”) to guide others through the often bewildering medical system
other successes to emulate1
Other Successes to Emulate
  • Research conducted in conjunction with the NACR project has expanded knowledge about urban Indian health.
  • NACR also developed a culturally appropriate American Indian tobacco education and cessation program in the Denver region, hosts an annual “wellness event” and powwow honoring local Native American cancer survivors, sponsors weekly weekend “health walks” at Denver public parks, and has launched a community obesity prevention initiative
  • The Alaska Native Medical Center in Anchorage offers patients traditional healing services and counseling by elders upon referral from a staff clinician
National Urban Indian Family Coalition (NUIFC), Urban Indian America: The Status of American Indian and Alaska Native Children and Families Today, The Annie E. Casey Foundation; National Urban Indian Family Coalition; Marguerite Casey Foundation; Americans for Indian Opportunity; National Indian Child Welfare Association, 2008. Online at{CCB6DEB2-007E-416A-A0B2-D15954B48600}, click to view PDF.
  • NIH/NIDCR for funding of the developmental project highlighted
  • UCD Center for Native Oral Health Research
  • UCD Centers for American Indian and Alaska Native Health
  • SEARCH for Diabetes in Youth