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


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Title: Access to dental care for kids: implications for health and primary care 2008 Wisconsin Primary Care Research and Quality Improvement Conference

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

  • 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


February 28, 2007

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
Dentistry in 3 5 minutes or less
Dental Plaque
  • Definition
  • Colorless bacterial matrix on teeth
  • Mechanism
  • Buildup of bacterial biofilm
  • Deep layers convert to anaerobic

  • Acid production
  • Gingivitis
  • Demineralization
  • Periodontitis

  • Caries
  • Bacterial pathogensanaerobic or facultatively
  • anaerobic (Strep mutans, lactobacilli,

Plaque revealed by disclosing solution
Plaque revealed by electron microscopy
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
  • Tooth

Dental caries
Caries Abscess
  • 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.)

Periodontal disease
  • National data
  • Wisconsin data
  • Local data

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,
19881994. Hyattsville, MD Centers for Disease
Control and Prevention (CDC), unpublished data.
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, 19881991.
Journal of Dental Research 75631-641, 1996.
Untreated caries in kids 6-8, by race/ethnicity
and parental educational attainment
Increasing caries rates across many groups,
school age children (NHANES)
Increasing caries rates across all groups, young
children (NHANES)
Untreated caries in children by age group and
insurance status Medicaid and uninsured much
worse, but differ little from each other
Rates of caries by insurance status over time
Medicaid getting worse (NHANES)
1988 to 1994 vs. 1999 to 2004
Accessed dental care in past year, by insurance
status (MEPS)
Gradient of access depending on insurance
status Private gt Medicaid gt Uninsured
Percentage of children with urgent dental need,
by insurance status (NHANES) private insurance lt
Medicaid and uninsured
Unable to access needed care by insurance status
Gradient of poor access Uninsured gt Medicaid gt
Reasons for inability to access needed care, by
insurance status
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.
Treatment urgency, Wisconsin 3rd graders
Racial/ethnic disparities in oral health status
of Wisconsin 3rd graders
Socioeconomic disparities in oral health status
of Wisconsin children
Sobering numbers oral health in Wisconsin
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

Implications of poor oral health
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
  • Cardiovascular disease and periodontitis
  • preterm/LBW and periodontitis (hopefully
  • Diabetes (now and downstream)

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.
Poor oral healthfunctional/nutritional
  • Missing teeth/poor dentition correlated with poor
  • 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.
Poor oral healthfunctional/nutritional
  • 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 childs self-esteem

From Oral Health in America A Report of the
Surgeon General. Office of the Surgeon General of
the United States, 2000.
Poor oral health Pathophysiologic Model of
Systemic Effects
  • Chronic Inflammatory mediator cascade
  • Anaerobic oral infection local toxin
  • Local inflammatory cellular response
  • Local release of inflammatory mediators
  • (TNF? , interleukins, et al.)
  • Chronic release into systemic circulation

Systemic consequences
Cardiovascular Disease
  • Increasing evidence of association between
    periodontal disease and poor cardiovascular
  • No causality determined yetobservational data
  • Important downstream implications for managing
    cardiovascular risk in primary care

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 lt/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.
Cardiovascular Disease
  • Arbes et al., analysis of population-based NHANES
  • 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
  • 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.
Cardiovascular Disease
  • CORADONT study, Spahr et al. 2006
  • observational design
  • statistically significant association between CAD
  • overall periodontal pathogen burden
  • odds ratio 1.92 95 CI, 1.34-2.74 Plt.001)
  • 2. Actinomyces burden in periodontal pockets
  • odds ratio 2.70 95 CI, 1.79-4.07

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

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 lt .0001) for women
    with periodontal disease
  • Cautionhigher quality studies showed weaker

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

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

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

Potential solutions--community
  • Community-academic partnerships
  • Blues conversion-funded endowments
  • Wisconsin Partnership ProgramUW
  • Healthier Wisconsin Partnership ProgramMCW
  • 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
  • Making Milwaukee Smile
  • 3yr grant to establish in-school oral health
    promotion program

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

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//
  • 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
  • Engage/implore dental colleagues to improve access

Potential solutions Policy-based
  • Supply/demand issues
  • WI doesnt produce/keep enough dentists
  • Improve state loan repayment programs for
    underserved areas
  • Increase size of Marquette class vs. UW dental
  • Federal HPSA-dental designation
  • Is your community designated?
  • Can lead to funding for federally qualified
    dental clinics federal loan repayment recipient
  • 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

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  • Too many Wisconsin children have poor oral health
  • --particularly minorities and low-income
  • Access to basic oral health services for
    low-income children is inadequate
  • Major downstream health consequences of (1) and
    (2) include increased cardiovascular risk, poor
    birth outcomes
  • There are ways to make a difference

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