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 MedicineDepartment of Population Health

Medical College of WisconsinMilwaukee, WI

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Confessions

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Introduction/overview

• Biases

• Limitations

• Formal Objectives

1. Review oral health pathophysiology2. Become familiar with oral health epidemiology3. Understand the implications of poor oral health on

general health and primary care practice4. Discuss potential solutions

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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.

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Dentistry in 3 5 minutes or less

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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)

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Plaque

Plaque revealed by “disclosing solution”

Plaque revealed by electron microscopy

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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

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Dental caries

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Caries Abscess

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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.)

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Periodontal disease

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Epidemiology

• National data

• Wisconsin data

• Local data

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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.

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Burden of poor oral health on children

– Concentration of disease• 80% of caries in permanent teeth of

children is found in 25% of population

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.

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

attainment

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

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

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Untreated caries in children by age group and insurance status: Medicaid and uninsured much worse, but differ

little from each other

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Rates of caries by insurance status over time: Medicaid getting worse (NHANES)

1988 to 1994

vs. 1999 to

2004

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Accessed dental care in past year, by insurance status (MEPS)

Gradient of access

depending on insurance

status:

Private >

Medicaid >

Uninsured

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Percentage of children with urgent dental need, by insurance status (NHANES):

private insurance < Medicaid and uninsured

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Unable to access needed care by insurance status (MEPS)

Gradient of poor access: Uninsured > Medicaid > Private

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Reasons for inability to access needed care, by insurance status

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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.

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Treatment urgency, Wisconsin 3rd graders

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

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Socioeconomic disparities in oral health status of Wisconsin children

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Sobering numbers: oral health in Wisconsin children

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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

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Implications of poor oral health

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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)

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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.

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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.

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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.

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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

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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

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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.

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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.

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Cardiovascular Disease

• CORADONT study, Spahr et al. 2006– observational design– statistically significant association between CAD and:

1. 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.

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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

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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.

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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.

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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 diabetesKuo, 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.

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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

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Potential Solutions

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Potential Solutions

• 1. community-based

• 2. practice-based

• 3. policy-based

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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

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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

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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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Potential solutions: practice-based

• What can the practicing physician do to improve oral health of children?– Improve your oral health knowledge/skills

• Smiles for Life curriculum of Society of Teachers of Family Medicine

– http://www.smilesforlife2.org/home.html– Modules on acute dental problems, adult and child oral health,

pregnancy and oral health, etc. – Even includes how to apply fluoride varnish!

– Get involved (see community-based, policy-based solutions)

– Engage/implore dental colleagues to improve access

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Potential solutions: Policy-based

• Supply/demand issues– WI doesn’t produce/keep enough dentists

• Improve state loan repayment programs for underserved areas• Increase size of Marquette class vs. UW dental school

• Federal HPSA-dental designation• Is your community designated?• Can lead to funding for federally qualified dental clinics; federal loan

repayment recipient sites• Cost-based reimbursement

• Need changes in Title 19 dental program• Low reimbursements are major obstacle to access• Need more than 3 dentists in Waukesha county to participate

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Conclusions

1. Too many Wisconsin children have poor oral health

--particularly minorities and low-income

2. Access to basic oral health services for low-income children is inadequate

3. Major downstream health consequences of (1) and (2) include increased cardiovascular risk, poor birth outcomes

4. There are ways to make a difference

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