Rethinking Oral

Health Intervention:

Meeting Families

Where They Are

Christie Lumsden, PhD, MS, RD, CDN

A little background…

Rethinking Oral Health Intervention: Meeting Families Where They Are November 7, 2019

• Associate Research Scientist

• PhD and MPhil in Behavioral Nutrition (2013)

• Registered Dietitian and NYS Certified Dietitian-Nutritionist (2010)

• MS in Nutrition Education (2009)

• Engaged in behavioral intervention research to reduce oral health

disparities in children

Most prevalent chronic

disease of U.S. children

• 21.4% of 2-5 year olds

• 50.5% of 6-11 year olds

Second most prevalent

chronic oral disease

• 40-90% of the global

population

DENTAL CARIES

Oral diseases remain a persistent problem…

1. Fleming E, Afful J. Prevalence of total and untreated dental caries among youth: United States, 2015–2016. NCHS Data Brief, no 307.

Hyattsville, MD: National Center for Health Statistics. 2018

2.Najeeb, S., Zafar, M. S., Khurshid, Z., Zohaib, S., & Almas, K. (2016). The role of nutrition in periodontal health: an

update. Nutrients, 8(9), 530.

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Caries disproportionately affects

low-income and minority children

• Low-income children are more than 2x as likely to have an untreated

dental cavity or pain.

• Children of recent immigrants have caries rates 3x higher and decay is

often more severe.

• Hispanic and African American children have worse overall oral health

and more severe decay, yet are half as likely to have a dental visit.

1. Nunn, M. E., Dietrich, T., Singh, H. K., Henshaw, M. M., and Kressin, N. R. (2009). Prevalence of early childhood caries among very

young urban Boston children compared with US children. J public health dent 69(3), 156-162. PMCID: PMC2814600

2. Rivara, F. P., Erwin, P. C., and Evans, C. (2011). Improving access to oral health care for vulnerable and underserved populations.

Washington, DC: The National Academies Press.

3. Edelstein, B. L., and Chinn, C. H. (2009). Update on disparities in oral health and access to dental care for America's children. Acad

Pediatr, 9(6), 415-419. doi: 10.1016/j.acap.2009.09.010. PMID: 19945076

4. Cruz, G. D., Chen, Y., Salazar, C. R., and Le Geros, R. Z. (2009). The association of immigration and acculturation attributes with oral

health among immigrants in New York City. Am J Public Health, 99 Suppl 2, S474-480. doi: 10.2105/ajph.2008.149799. PMID: 19443820

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Oral Health Disparities and Inequity

• These disparities are not simply differences between populations. They

represent inequities in health.

• Affect groups marginalized because of racial, ethnic, sociocultural

characteristics, including:

- socioeconomic status - disability status

- race/ethnicity - geographic location

- sexual orientation - gender

Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help

Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and

Human Services, Centers for Disease Control and Prevention; 2008.

Health Equity as Social Justice in Health

Oral health is Essential for Overall Health

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Poor oral health is associated with:

• Increased use of medical services

• Increased risk for chronic conditions, including heart disease

and diabetes

• Lost work/school time and lost wages

• Reduced quality of life

• Limited employment opportunities

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Drivers of Oral Health Inequities

• Limited access to dental care providers

• Health Professional Shortage Areas (HPSAs)

• Lack of culturally and linguistically competent providers

• High cost of dental insurance and services

• Poor oral health literacy, limited knowledge of disease and prevention

• Limited access to transportation, childcare, paid time off

• Unhealthy food environments

• Abundance of high-fat/sugar foods; limited fresh fruits/vegetables

• Competing demands – health, housing, social, legal challenges, etc.

• … and others

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Fisher-Owens, S. A., Gansky, S. A., Platt, L. J., Weintraub, J. A., Soobader,

M. J., Bramlett, M. D., & Newacheck, P. W. (2007). Influences on children's

oral health: a conceptual model. Pediatrics, 120(3), e510-e520.

Traditional dental care plays an essential role in health

promotion and maintenance

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

…but it isn’t the only, or even the best, approach for all

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Determinants of

Health

Source: “Lots to Lose: How America’s Health and Obesity Crisis Threatens our

Economic Future,” Bipartisan Policy Center (June 2012); Derived from information

from the Boston Foundation (June 2007)

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Determinants of

Health

Health

Biology & Genetics

Education

Physical Environment

Social Networks

Health Services

Income & Employment

Culture

Individual Behaviors

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Alternative, innovative intervention approaches are needed

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where

They Are

Health begins long before we visit a doctor…

Robert Wood Johnson Foundation Social Determinants of Health:

https://www.rwjf.org/en/our-focus-areas/topics/social-determinants-of-health.html

Rethinking Oral Health Intervention

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

• Dentists

• Physicians

• Allied Health Professionals

• Brick & Mortar Clinics

• Mobile Units

• Teledentistry

• Mobile Technology

• Community-based Organizations

• Community Health Workers

• Community Dental Health Coordinators

• Dental Health Aid Therapists

• Health Disparities

• Social Justice

• Reaching Underserved Communities and Vulnerable Populations

Health Equity

Community-based

Initiatives

Clinical Workforce

Care Delivery Models

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where

They Are

Rethinking Oral Health Intervention

to address Childhood Caries

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where

They Are

Typical Treatment for Early Childhood Tooth Decay

• Fillings

• Stainless Steel Crowns

• Surgical Extractions

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Surgical treatment does not address the underlying disease process…

and results in a high failure rate

Did you know?

Photograph: Stuart Isett for The New York Times (March 6, 2012)

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

53%21%

26%

Relapse Rates53-79%

Children Relapse

After Dental

Repair in the OR

Current dental care alone is only a Band-Aid solution

Dentists , Payers, & Parents are all seeking a

lower cost alternative with better health outcomes

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Effectively Combating Caries

Need to address the two key mediators:

Daily Diet- & Fluoride-related Behaviors

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Fisher-Owens, S. A., Gansky, S. A., Platt, L. J., Weintraub, J. A., Soobader,

M. J., Bramlett, M. D., & Newacheck, P. W. (2007). Influences on children's

oral health: a conceptual model. Pediatrics, 120(3), e510-e520.

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Tooth decay can be stopped by

fostering effective partnerships to increase

understanding of the disease process and

support action to reduce risk through

daily diet and fluoride behaviors

Shifting from dental care to oral health

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

The CHW Connection

Community Health Workers (CHWs) extend the reach of healthcare

providers.

• Are seen as peers, sharing cultural, linguistic, racial/ethnic backgrounds

• Meet people where they are, in home and community settings

• Provide health education

• Help families navigate complex health systems

• Provide an essential link to social services (housing, food, legal,

insurance, etc.)

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Better Health Outcomes

Lower Costs

Improved Patient

Experience

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Overarching Aim

To stop caries progression in affected children and

reduce their risk of future decay

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

An iPad-based family-level intervention that:

Seeks to eradicate early childhood caries

Targets two primary disease mediators: Diet and Oral Hygiene

Designed to be delivered by lay health workers in the community

https://vimeo.com/114512516

Password: smile

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

MySmileBuddy supports engagement between lay

health workers and families through:

1. Parent Engagement, Education, and Training

2. ECC risk assessment (including dietary risk)

3. Individualized risk score analysis

4. Family-specific goal setting

5. Family-designed action planning

6. Wrap-around support

About MySmileBuddy

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

• Innovation in mobile technology moves fast!

• Medicaid claims data for hospital-based dental care are often incomplete

• Clinical charting across sites is difficult to standardize

• Hiring, managing and retaining CHWs poses unique challenges

• CBOs are unique in management and structure

• Turnover is fairly common

• Difficult-to-reach target population

• Misconceptions about oral health and caries

• Oral health vs. dental care

• Sense of immediacy and concern often lower than other diseases

A few highlights from our experience…

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

• Providers’ acceptance of disease management approaches

• Many families are interested and motivated!

• High acceptance in clinics and Head Start centers

• Over 1,200 children enrolled

• CHWs/CBOs are eager and ready for engagement!

• Training was an eye opening experience

• CHW feedback and input are invaluable!

• Interest in scalability and ability to reach more families

• Project team collaboration, cooperation and communication

• Effective problem solving

• Creative solutions

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

“The mouth is the window to all

the diseases of the body”

Oral Health in America: A Report of the Surgeon General

… but it’s not the only target for oral health intervention

United States Department of Health and Human Services (DHHS). (2000). Oral

Health in America: A Report of the Surgeon General Rockville, MD. Retrieved from

http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf. PMID:11324049

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Christie Lumsden, PhD, MS, RD, CDN

phone: 212.342.0137

email: clc2123@cumc.columbia.edu

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Healthy People 2020 Definition

“…a particular type of health difference that is closely linked with

economic, social, or environmental disadvantage.

Health disparities adversely affect groups of people who have

systematically experienced greater social or economic obstacles

to health based on their racial or ethnic group, religion, socioeconomic

status, gender, age, or mental health; cognitive, sensory, or physical

disability; sexual orientation or gender identity; geographic location; or

other characteristics

historically linked to discrimination or exclusion.”

November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are

Everyone gets the same thing vs. everyone gets the same opportunity

http://www.maine.gov/dhhs/mecdc/health-equity/