Public Oral Health Interventions for Mothers and Children: What Works

1. Public Oral Health Interventions for Mothers and Children: What Works ? Mark D. Siegal, DDS, MPH Ohio Department of Health

2. It’s not as easy as this anymore

3. Wrong!! For every complex problem, there is a solution that is: • Quick • Easy • Cheap, and

4. Now we look for an Evidence Base And the process often is not pretty

5. Levels of Evidence I: evidence from at least one properly randomizedcontrolled trial. II-1: evidence from well-designed control trials without randomization. II-2: evidence from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. II-3: evidence from multiple time series with or without intervention. III: opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees. Adapted from: U.S. Preventive Services Task Force.

6. “Tell Them What You’re Going to Tell Them” • Current evidence on oral-systemic health links (e.g., pre-term low birth weight) does not justify major intervention efforts at this time • Unfortunately, pregnant women tend not to get dental care • Evidence supports water fluoridation and school dental sealant programs for community-based prevention of dental caries

7. “Tell Them What You’re Going to Tell Them” • Nationally, there are some demonstration projects in place for preventing and/or arresting (Early Childhood Caries) with fluoride varnish • Access to dental care remains a problem for vulnerable populations • Stand on soapbox

8. 1. Current evidence on oral-systemic health links (e.g., pre-term low birth weight) does not justify major intervention efforts at this time

9. Some of the serious parts of this presentation were taken from: It’s Not “Just Teeth and Gums”:The Oral Health-General Health Connection A. Isabel Garcia, DDS, MPH National Institute of Dental and Craniofacial Research Presented at the Ohio Summit on Access to Dental Care November 14-15, 2001

10. Possible Mechanism of Action • Evidence supports the role of infections in preterm birth low birth weight (PLBW) • Transient bacteremia of oral origin (provoked by chewing, brushing, flossing, etc.) increase with severity of gingival inflammation • Maternal immune response to infection produces substances that may interfere w/ growth and delivery (cytokines, prostaglandins)

11. Gums Loss of Clinical Attachment Level Really bad Periodontal Disease 101-Macro Level Good

12. The PD conspiracy theories are at the micro(be) level • Infections by gram-negative bacteria • Gingival inflammation, pockets, ulceration of epithelium, destruction of collagen, ligament and bone • Chronic inflammatory process • Multifactorial – host response important contributor to susceptibility

13. Periodontal Disease and PLBW: Summary • Periodontal disease may have the potential to affect pregnancy outcomes • Findings from animal studies and case-control studies are intriguing and promising • More studies, including longitudinal, intervention trials, and research on mechanisms are needed • No evidence yet that treatment for PD will reduce the risk of preterm birth

14. Periodontal Disease and Diabetes: Summary • Diabetics have increased prevalence, extent, and severity of periodontal disease • Assumed that this is due to compromised ability to respond to infection • Insufficient evidence of a causal association • Unclear whether periodontal treatment can affect diabetic control

15. Oral Health - General HealthThe bottom lines at this time: • Insufficient evidence on whether PD is an independent risk factor for CVD, stroke, adverse pregnancy outcomes • Relationship of periodontal diseases and diabetes has the strongest evidence • Effect of periodontal disease on glycemic control is less clear

16. Rhetoric exceeding evidence? Some folks are overshooting the mark

17. Microbes that Bite

18. “Cigarette smoking, hypertension, hypercholesterolemia, and periodontal disease have been established as major risk factors for cardiovascular disease.” Periodontology Vol 23, 2000, 136-141

19. 11 May 2000 GUM DISEASE IN PREGNANCY LINKED TO PREMATURE BIRTH GUM disease in pregnancy could be a significant riskfactor in whether your baby is born pre-term, according to US researchers. A new study of 2000 pregnant women in the US confirms previous findings that women with gum disease and decay may be up to seven times more likely to deliver before full term, and for the babies to be of a low birth weight. The more decay and disease you have in your mouth, the bigger your risk.

20. 2. Unfortunately, pregnant women tend not to get dental care

21. PRAMS for 4 states that collected oral health data in 1998(AR, IL, LA, NM) • 23-35% received dental care during pregnancy • 12-25% (data from 3 states) reported having a dental problem • only 45-55% went for care

22. Oral considerations during pregnancy • American Dental Association recommends avoiding dental care during 1st trimester and last half of 3rd trimester • Lack of formal policies • Lack of studies examining relationship between dental care during pregnancy and pregnancy outcomes

23. Limiting factors • Professional recommendations (ADA) • Lack of insurance • Attitudes and beliefs about dental treatment during pregnancy • women • obstetricians • dentists

24. Common Sense Approach • Pregnancy is an opportune time for health education and overall health/oral health promotion • In the absence of dental care-pregnancy outcomes research and formal guidelines from professional organizations, use of the ADA recommendations and consultation with a given patient’s obstetrician, as necessary, makes sense

25. 3. Evidence supports water fluoridation and school dental sealant programs for community-based prevention of dental caries

26. Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries A Report on Recommendations of the Task Force on Community Preventive Services MMWR 50(RR-21) November 30, 2001 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5021a1.htm

27. School-Based Dental Sealant Programs S Title V-funded

28. Dental Sealants: Prevention that Works Pit and fissure surfaces account for at least 83% of permanent tooth surfaces affected by dental caries (1988-91)

30. Dental Sealant

31. Ohio School-based Dental Sealant Programs, 2002

32. School-Based Dental Sealant Programs: 2002 ASHTABULA LAKE LUCAS FULTON WILLIAMS Serving >28,000children (2000-01)  GEAUGA OTTAWA WOOD CUYAHOGA TRUMBULL HENRY SANDUSKY ERIE LORAIN DEFIANCE  21 Programs PORTAGE  SUMMIT MEDINA HURON SENECA PAULDING  MAHONING PUTNAM HANCOCK  ASHLAND WAYNE VANWERT CRAWFORD WYANDOT RICHLAND STARK COLUMBIANA   ALLEN  HARDIN CARROLL MERCER MARION HOLMES AUGLAIZE MORROW TUSCA-RAWAS KNOX JEFFER- LOGAN UNION SON COSHOCTON SHELBY HARRISON DELAWARE DARKE ODH Funded (Title V) (18)  LICKING CHAMPAIGN GUERNSEY MUSKINGUM BELMONT MIAMI  MADISON FRANKLIN  CLARK  PREBLE MONTGOMERY FAIRFIELD NOBLE MONROE  GREENE Ohio Health Priorities Trust Fund (Tobacco Settlement) (1) PICKAWAY PERRY FAYETTE MORGAN WASHINGTON HOCKING BUTLER WARREN  CLINTON Serving 44 Counties ROSS ATHENS  VINTON HAMILTON HIGHLAND    CLER- MONT PIKE  Locally Funded (2) MEIGS  JACKSON BROWN ADAMS GALLIA SCIOTO  LAWRENCE Programs travel to these counties  2/3 of high-risk elementary schools

33. Impact of Targeted School-Based Dental Sealant Programs in Reducing Racial and Economic Disparities in Sealant Prevalence Among Schoolchildren--Ohio, 1998-99 MMWR 8/31/01 3rd Graders

35. 4. Nationally, there are some demonstration projects in place for preventing (Early Childhood) caries with fluoride varnish

37. Fluoride Varnish • First introduced in Germany in 1964 under the trade name Duraphat • Over 30 years of clinical study • “Reports of 25-45% caries reduction” • You may have heard about it • Approach for “pre-cooperative” kids • There’s a big “But”

41. N=1

42. Iowa Fluoride Varnish Program in Head Start Preschool Classrooms

43. But... • Off-label use • Evidence on caries-inhibiting effect in primary teeth is “insufficient” to recommend for or against varnish use in preschool-age children at this time • Mixed findings on cost-effectiveness • Programs experimenting with application by dental and by medical staff • CA, NC, IA, WA

44. 5. Access to dental care remains a problem for vulnerable populations

45. “When all you do is what you’ve done…” “…then all you’ll get is what you’ve got.” -Jackie “Moms” Mabley

46. Access to Dental Care Dental Disease Haves Have nots Have nots Haves What We’ve Got is Dental Disease & Disparity

47. …and it isn’t pretty

49. 6. Standing on Soapbox

50. Some policymakers’ misguided ways of thinking about state and local dental programs: • “They’re just teeth” • “It’s not my job, man” • “Cavities are preventable, so let’s just fund preventive dental care” • “Dental screening and referral is enough” • “Give a man a fish…”