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Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,“Opening the Mouth”,Continuing MCH Education in Oral Health,Columbia University,School of Dental and Oral Surgery,Division of Community Health,Learning Objectives,Understand the connection between oral health and overall health,Understand that dental caries is an infectious, transmissible, communicable disease,Understand the prevalence, acuity and consequence of dental disease,Understand dental care finance, delivery and workforce issues,Be able to list general action steps that can be taken to decrease oral health disparities,Describe action steps specific to Title V Maternal and Child Health Federal Block Grant programs that can be taken to decrease oral health disparities,Oral Health and Health Care,Introduction:,Despite great strides in improving oral health, disparities still exist across all population groups. Those suffering the worst oral health are the poor of all ages, particularly children and older Americans. Racial and ethnic minority groups also experience a disproportionate level of oral health problems. Medically compromised individuals or those with disabilities, are at an increased risk for oral diseases, which in turn, further jeopardizes their overall health (1).,Tooth decay remains the single most common, chronic disease of childhood; 5x more prevalent than asthma (1). Children suffering the highest rates and most severe dental disease tend to be preschool-aged and disadvantaged by poverty, minority status or social conditions. Approximately 25% of children under age 19, account for 80% of the dental disease. Dental disease, untreated, results in pain, and infection, and may inhibit general growth and development (2).,Oral Health and Health Care,Periodontal disease and chronic oral infections are considered a risk factor for heart disease, inadequate glycemic control in diabetics and more recently, poor pregnancy and birth outcomes.,“Oral diseases and conditions may have a significant impact on general health.Oral health care is an important, but often neglected, component of total health care. Regular dental visits provide an opportunity for the early diagnosis, prevention, and treatment of oral and craniofacial diseases and conditions for persons of all ages, as well as for the assessment of self-care practices”. (3),To help reduce oral health disparities, there needs to be an increased understanding and awareness among the community, health care providers, and policy makers at the local state and federal level. Oral health must be integrated into overall health, and barriers to care need to be eliminated.,Part I: Conception to Birth,Meet Mrs. Perez. She is a 32-year-old, Hispanic mother of 2 children, under the age of 6 years, and pregnant for her third.,She presents to the dental clinic at her local community health care center, complaining of “bleeding gums and loose teeth”.,Her dental pain has progressed to the point that eating has become difficult.,Mrs. Perez was unable to attend the clinic prior to today, as she could not afford to pay for the dental treatment, not to mention child-care for her 2 children and the cost for public transportation.,The private dentist located “relatively” close to her inner-city home, informed her that he “does not accept Medicaid”.,After her examination, the dentist informs Mrs. Perez that she has periodontal or “gum” disease.,Periodontal Disease,The case of Mrs. Perez is unfortunate, but commonplace in community health center dental clinics.,The reality of this case?,Hispanic and African American populations have higher rates of oral disease and tooth loss than the white, non-Hispanic majority population,Approximately 26% of adults aged 18-34 years, do not have health insurance (1),72% of adults not obtaining dental care state that the major reason is financial (4),Few dentists participate in the Medicaid program (approx 1/3 of dentists provide at least one dental appt under medicaid, & only 14% are active medicaid providers, i.e. billing $10,000 as a percentage of total active patients) (5),There is a decline in the number of dentists per 100,000 people and it is anticipated this shortage will increase over time. As of June 2003, 2112 dental health professional shortage areas have been identified. It would take 8481 additional dentists to achieve a target dentist-to-population ratio of 1:3,000. (6),Periodontal Disease,The number of underrepresented minorities in the dental profession is significantly low compared to their proportion in the overall population (5.7% of graduate dentists are African American and 5.3% are Hispanic; These percentages are far below the percentage of African American (12%) and Hispanics (11%) in the general population) (7). Thus, patients may be faced with language barriers and/or cultural incompetence.,Safety net facilities (e.g. dental schools, community health centers, hospital clinics and mobile vans) are few in number compared to the medical safety net (primarily because community hospital emergency rooms comprise a major component of the medical safety net, whereas emergency rooms typically only offer palliation with medication for dental complaints. In addition, there are 4x as many medical schools than dental schools.,Although only 1% of Medicaid expenditures is related to dentistry (0.5% for children)(8), fiscal demands have led to reductions in, or elimination of dental benefits for adults and the disabled. In 2003, only 8 States had comprehensive adult dental coverage under Medicaid, while 43 States had no coverage or limited coverage (53),Periodontal Disease:Poor Birth Outcomes,Despite pain and discomfort, some women never present for care (Fact: less than two thirds of adults reported having a dental visit in the last year1).,What happens if Mrs. Perez does not receive the necessary dental treatment for her periodontal disease? The most obvious consequence will be continued mouth pain, disease progression and eventual tooth loss.,But what about the systemic effects of her periodontal disease? How will her oral disease affect her pregnancy or her unborn child?,Learning Objectives:,What is the association between periodontal disease and poor birth outcomes,What is the putative biologic pathway,What is the effectiveness & evidence for intervention,Periodontal Disease:Poor Birth Outcomes,Periodontal Disease:,Periodontal disease (periodontitis or “gum disease”) is a chronic infection caused by bacteria existing at the gum line in the form of plaque and calculus (“tarter”). (,Picture of periodontitis Papos Papapanou- waiting for picture),Periodontal disease causes inflammation and bleeding gums and, if not treated, leads to tissue destruction, tooth mobility and eventually tooth loss.,Growing body of research supports an association between periodontal disease and,Pre-term low birth-weight (,PLBW) (link to studies further on in module),Periodontal Disease:Poor Birth Outcomes,Preterm Low Birth-weight:,PLBW pregnancy outcomes in the U.S. remain a concern because of the significant consequences to maternal and child health, high costs, long-term disease burden, and individual suffering.,Economic consequences exceed $5 billion annually,Accounts for 6-9 percent of all births (9),Centers for Disease Control maintains that the second leading cause of infant mortality is premature/low birth-weight (10),Accounts for 70% of all perinatal deaths and 50% of long-term neurologic morbidity (9),NIH reports that “as many as 18% of the 250,000 premature low-weight infants born in the United States each year may be attributed to infectious oral disease” (call out box?)(11),Periodontal Disease:Poor Birth Outcomes,State of the Science:,Known causes of PLBW, that may be medically managed, include asthma, cigarette smoking, bacterial vaginosis and diabetes,However, much of its incidence remains unexplained,Classic measures for association between periodontal disease and poor birth outcomes, are being explored and show likely causality,Based on this emerging science, there is hope that the severe developmental, behavioural, health and economic consequences of PLBW may be minimized by improving oral health during pregnancy,Periodontal Disease:Poor Birth Outcomes,State of the Science:,Animal Studies,Inducing experimental periodontitis in animals, leads to significantly smaller litter weights (12).,These animals show higher levels of blood-borne chemical mediators that are responsible for causing uterine contraction, cervical dilation, labour and abortion (13).,Periodontal Disease:Poor Birth Outcomes,State of the Science:,Humans studies:,The association was first identified by secondary analysis of NHANES III (13),One case-controlled study, after adjusting for all other risk factors (e.g. tobacco use and maternal age) found that women with periodontal disease had 7 times the risk of delivering a PLBW baby (13).,More recent human studies following women through pregnancy, compares favourable and unfavourable birth outcomes. Preliminary results indicate that mothers with advanced periodontitis have a higher risk of delivering a PLBW infant. (14,15),NIH supported, multicenter, RCT studies are currently underway,Periodontal Disease:Poor Birth Outcomes,Effectiveness and Evidence for Intervention:,Can treating periodontal disease in pregnancy reduce poor birth outcomes?,Two studies have shown an association between treating periodontal disease during pregnancy and improved birth outcomes (16, 17),For the mother, there are no known negative consequences associated with improving the oral health of pregnant women. The positive is that it may reduce poor birth outcomes, which is a considerable benefit for the child. Thus, there is great enthusiasm in promoting optimal oral health during pregnancy.,Dental Care for Pregnant Women,The National Healthy Mothers, Healthy Babies Coalition (HMHB):,Issued a statement of position that “oral health care during pregnancy is crucial and should be available to all women, regardless of income level”. They are committed to “working with dental and other health care providers to increase awareness of, and support research on, the possible link between periodontal,disease and pre-term, low birth-weight babies” (18),See The National Healthy Mothers, Healthy Babies Coalition Position Statement on Oral Health and Pregnancy at,American Academy of Periodontology:,Has recently developed a draft policy statement that recommends pregnant women have a periodontal examination performed and appropriate preventive and/or therapeutic services provided,as there is immerging evidence that,women with periodontal disease may be more at risk to deliver a preterm low birth weight baby,(August 2003),See the AAP website ,Dental Care for Pregnant Women,Clinical guidelines suggest that routine plaque and calculus removal via polishing, scaling and curettage, can be performed safely during pregnancy, regardless of trimester (19).,Dentists and obstetricians agree that routine dental care should be maintained throughout pregnancy. (20,21),Despite the growing evidence and literature to support the association between periodontal disease and PLBW, it has not been widely translated into clinical or public policies.,Oral Health Programs for Pregnant Women,Medicaid programs, administered by the states within federal guidelines, are required to provide certain populations with specified (“mandatory”) benefits. Dental is only mandated under Early and Periodic, Screening, Diagnostic, and Treatment Services Program ( EPSDT).,Dental coverage for pregnant women (+ 21 years) currently is not a “mandatory” benefit (see note),Pregnant young women ( 21 years) that are covered by Medicaid, must be enrolled under the EPSDT to receive comprehensive dental benefits (22),Centers for Medicare and Medicaid Services (HCFA),Medicaid Services State by State, October 1, 1996,. HCFA Publication 02155-97.,California: first in the nation to extend dental benefits to pregnant women,Adult women and minors who are pregnant become eligible for either adult dental coverage (if over the age of 21) which includes periodontal treatment or the full range of EPSDT dental services, which also include periodontal treatment (23),Note: Louisiana and Utah have recently added benefits Waiting for info from Ann DeBiasi at CDHP,(Insert this in a “popup” box ?),Oral Health Programs for Pregnant Women,In California, with the addition of preventive periodontal to the scope of Medi-Cal benefits for women in the pregnancy services only and pregnancy and emergency services only aid categories, the estimated savings for fiscal year 2004-2005 is $24,427,000 (23),.,(Based on the estimate that in FY 2003-2004, the number of Medi-Cal low birth-weight babies attributable to periodontal disease is estimated at 2,655. The average neonatal savings per child is $22,000. Approx. 50% of women will complete sufficient preventive periodontal care to bear a normal birth-weight infant,Mrs. Perez was unable to undergo periodontal treatment as she could not afford to pay for the service. Six months after her visit to the health center dental clinic, she delivers a preterm low birth-weight baby girl, named Maria.,Fortunately, with advances in neonatal care, survival rates of pre-term, low-birth-weight babies have dramatically improved.,Unfortunately, studies indicate that pre-term children suffer from a multitude of acute and long-term problems, including significant delays in physical and psychological growth and development of all structures, including the craniofacial complex and teeth,Oral structures, like other tissues, are affected by prematurity and low birth- weight,(24),Part II: Early Childhood Tooth Decay,Learning Objectives:,Understand the goal of early intervention and importance of the “dental home”,Define dental caries (tooth decay),Differentiate between dental caries and early childhood tooth decay,Describe the transmission and colonization of bacteria associated with early childhood tooth decay,Understand the prevalence and consequence of early childhood tooth decay,Describe conventional treatment (restorative dentistry),Describe emerging treatment (Prevention and disease management),Early Childhood Tooth Decay,Now meet 12 month-old Maria Perez.,During Marias well-baby exam at her primary care physicians office, Mrs. Perez states that Marias front teeth “didnt look right” when they erupted. The health history indicates that Maria was a pre-term infant (i.e. 37 weeks gestation) with a low birth weight (i.e. 2500gm).,Her physician takes a brief look, reassures Mrs. Perez that it may be a “developmental problem” and suggests if she has further dental concerns, that she should see a dentist. He does not write a referral letter.,Early Childhood Tooth Decay,As young as Maria is, both developmental and acquired disease are already evident on examination.,Active Disease:,Maria was noted to have thick plaque and decalcification (mineral loss) on her primary teeth (,red arrow,). The gingival tissue appeared shiny and full (,blue arrow,), indicating inflammation.,Developmental Findings:,Notching of incisors (,yellow arrows,), eruption hematoma (,purple arrow,), atypical eruption sequence (,pink arrow,), and an anatomical variant of the labial frenum (,green arrow,),Early Childhood Tooth Decay,What is the most important clinical finding during Marias oral exam?,It is the abundant plaque on her front teeth.,Visible plaque on the front teeth, is positively correlated with caries development by age 3,(28),(Call out box?),The primary components of dental plaque are bacteria. Acid, produced by these bacterial species (mainly Streptococcus mutans) is considered the most important activity in the production of tooth decay.,Maria,being a low birth-weight infant, is at risk for enamel hypoplasia, as 20% of low birth-weight children are affected.,Enamel hypoplasia is defined as a deficiency in enamel formation, that manifests clinically as grooves or pits, or a lack of surface enamel (29). These surface irregularities act as “plaque traps” allow for an increased colonization of harmful bacteria and increase Marias risk for developing cavities.,Early Childhood Tooth Decay,Why should Marias physician refer her to a dentist?,The goal of an early dental assessment is primary prevention (see slide 36). This may be accomplished with the timely delivery of oral health information, including the conditions that create caries and its prevention (Anticipatory Guidance see slide 37), and the identification of populations at high risk for tooth decay,The traditional approach of treating the effects of tooth decay (i.e. “drilling and filling”) is being replaced by disease prevention and disease management.,Prevention focuses on the establishment and maintenance of good oral hygiene,optimizing systemic and topical fluoride exposure, and eliminating,prolonged exposure to simple sugars in the diet. Prevention is the foundation for the establishment of a “dental home” by 1 year of age.,The concept of the dental home is derived from the American,Academy of Pediatrics concept of the medical home. This concept states that “the primary health care of infants,children, and adolescents should be accessible, continuous,comprehensive, family centered, coordinated, compassionate,and culturally effective. It should be delivered or directed,by well-trained child health specialists who provide primary care and help,to manage and facilitate essentially all aspects of pediatric,care” (25).,Early Childhood Tooth Decay,Advances in the understanding of dietary influences and fluoride on dental disease become instrumental in supporting early intervention,Every child should have an examination and oral health risk assessment,by 12 months of age by a dentist or qualified pediatric health care professional. (26),The Caries Risk Assessment,Tool (CAT), provided by the American Academy,of Pediatric Dentistry (27), was designed to assist both dental and nondental health professionals in assessing the risk of tooth decay in infants, children and adolescents.,The CAT can be used to determine the relative risk of caries of the,patient,Questions directed,at dietary practices, fluoride exposure, oral hygiene, utilization,of dental services, socioeconomic status and general level of health can help determine if a child is at low, moderate or high risk for dental disease.,Using the CAT ( ), and Marias history (low socioeconomic status and no usual source of dental care) and exam findings (thick plaque, areas of demineralization and gingivitis), Maria would be considered at high risk for dental disease.,Early Childhood Tooth Decay,It is too late for Maria to gain the advantage of primary prevention and some aspects of anticipatory guidance, as she already exhibits signs of dental disease.,Maria is not too late for disease suppression (see slide 39). With proper diet control and the application of topical fluoride, Maria may have avoided surgical intervention. Unfortunately, without a timely dental referral, disease progression is inevitable.,The referral was never made from Marias physician to a dentist and Mrs. Perez fails to seek care on her own.,Early Childhood Tooth Decay,Maria is now 33 months old.,She has presented with her mother to the local health center dental clinic, because, according to Mrs. Perez, Maria has “been up all night, crying about her teeth”.,Dental History- in the last 2 months, Maria has become increasingly irritable at mealtimes. It began as whining with cold or sweet foods, and has progressed to crying when biting with the front teeth. For the last 3 nights Maria has a
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