3/3/2018 Support and Disclaimer The Forgotten Need: • Supported by the National Institute for Dental Oral Care in Underserved Patients and Craniofacial Research – RO3DE165701 – R21 DEO18523 – U54 DE142501 ( CAN-DO I) Susan A. Fisher-Owens, MD, MPH, FAAP – 2 UH2/3 • Other research funding from Western Dental UCSF Care of the Vulnerable and Underserved • No financial relationships to disclose regarding March 2, 2018 this topic Off-Label Discussion Objectives • Review the importance of oral care to overall • Fluoride varnish is licensed for treatment health and the role of primary care in promoting of tooth sensitivity oral care through the ages • Detail at least 3 examples of the impact that poor oral health has on a person’s overall health • Describe the role of medical providers in oral health assessments and the prevention of oral disease • Name at least 4 risk factors for dental caries
3/3/2018 Why should you Listen to a …About Oral health??? Pediatrician? • Big issue in children… • Dental caries--the most common chronic • Why a pediatrician? disease of childhood – Pt BR, or EM, or… – Frequency of dental vs medical visits • Seeing a pediatrician/FP for an “annual exam” • Seeing a dentist • Patients see PCP 9-11 times before dentist – 99% who saw medical and dental saw medical first – Already in 2-5 yo, 23% have caries Gift, 1992; Surgeon General’s Report 2000; Brown 1996; Macek 2004; Pew 2014; NCHS 1996, CDC Summary Statistics, NHIS 2015; Kranz 2014; Dye 2015 NHANES III …About Oral health??? …About Oral Health? • Increasing prevalence with age--bigger • Huge area of disparities—great test case issue in adults • By end of life, nearly every American has had complications with his/her teeth • Greatest risk factor for dental caries/disease in adulthood is dental caries in childhood
3/3/2018 Why should you care? …As people with hearts Not just pretty teeth Would you miss: Being free of chronic oral-facial pain Eating salad? conditions, oral and pharyngeal (throat) Crunching on an apple? cancers, oral soft tissue lesions, birth Being allowed to play outside? defects such as cleft lip and palate, and Going to school? scores of other diseases and disorders that Being able to get a job? affect the oral, dental, and craniofacial Photos courtesy of Operation Smile tissues What would it be like, seeing yourself SGR, 2000 for the first time? Why should you care? …As people who pay taxes In the Emergency Department • 2.5% of all visits for adults 18 to 44--for • The nation’s yearly dental bill, 2014: >$113.5 billion nontraumatic dental pain – Tens of billions of dollars in direct medical care and indirect costs of chronic craniofacial pain conditions such as temporomandibular disorders, trigeminal neuralgia, shingles, or • Increasing at 3 times the rate of other burning mouth syndrome reasons for ED visits – $100,000 minimum individual lifetime costs of treating craniofacial birth defects such as cleft lip and palate • In 2012, 2.18 million visits (0-18 10%) – Costs of oral and pharyngeal cancers and autoimmune diseases – Costs associated with the unintentional and intentional injuries – Cost $1.6 billion, averaging ~$750 per visit that so often affect the head and face – Social and psychological consequences and costs… – Mostly self-pay or government insurance • California’s National Guard; DoD Reserve – Almost 80% could be diverted, but 70% outside regular dentists’ hours Sun et al, AJPH 2015; Lee et al, AJPH 2012; Wall, Vujicic 2015 Wall, 2015; Health Care Financing Administration 2000; Surgeon General’s Report 2000; Belt, 2005
3/3/2018 Inequities in Oral and Systemic Health • Before ACA, over 46 million Americans lacked health insurance, 108 million lacked dental insurance Disparities – Essential benefit vs. mandatory • Adults, especially those with chronic conditions, often cite oral health as their top unmet health need SGR, 2000; Davidoff, 2005; Belt, 2005 Why should you care? Disparities Inequities Race/Ethnic Disparities • Greatest area of health care disparities-- • Concentrated race/ethnic – ~80% of disease in 25% of children – For children 2-5 years, 75% of caries occurred in 8% – 18% in low-risk group of population (non-Hispanic blacks or Mexican Americans) Brown, 1996; Vargas, 1998; Kaste, 1999; Healthy People 2010, 2000; NCCP , 2006 Brown, 1996; Vargas, 1998; Kaste, 1999; Healthy People 2010, 2000; NCCP , 2006
3/3/2018 Disparities Disparities Socioeconomic Disparities Race/Ethnic Disparities, cont’d •Rates 4.4 times • Greatest area of health care disparities--race/ethnic higher in 12-23 – Mexican-American mo for children < • Ages 2-19 years--almost 2x rate of untreated dental caries as 125% FPL white or black non-Hispanic children •All cases in kids <200% FPL • Even as young as 12-23 months old, Mexican-American •12 times as many children 3.5-4.6x more likely to have caries than children of restricted activity other racial/ethnic backgrounds days – American Indian and Alaska Natives ages 2-4 years: 5x the national average for caries, increasing to ages 15-19 years, when 91% of the population has caries (Indian Health Service, 2002) • 1/4 th report not smiling for fear of teeth appearance • 1/3 rd miss school because of tooth pain Health People 2010, 2000; US GAO, 2000 Brown, 1996; Vargas, 1998; Kaste, 1999; Healthy People 2010, 2000; NCCP , 2006 Why should you care? Children in some Overlap of Race/Ethnicity and SF Poverty neighborhoods have experienced 2-3x more caries Chinatown North Beach Nob Hill/Russian Hill/Polk Tenderloin South of Market Bayview/Hunter’s Point Visitation Valley Excelsior Portola Slide courtesy of CavityFreeSF
3/3/2018 Children of color are 2-3x more likely to have untreated decay as white children % of SFUSD Kindergarten Children with Untreated Caries 30 by Race/Ethnicity, 2012-2013 % of Children With Untreated Caries 23 20 17 16 10 8 0 White Black Chinese Hispanic SFUSD, 2013 ADA 2016 ADA 2016 ADA 2016
3/3/2018 Attitudes Consistent Across Except… Income Levels and Age Groups… ADA 2016 ADA 2016 Why should you care? Disparities in Services • Socioeconomic – Children near Federal Poverty Level (FPL) are 50% as likely to have sealants as those >200% of the FPL • Race/ethnic – Rates for sealants for black and Mexican-American children are 33% lower than those for white children Dye 2007 Pew, 2016
3/3/2018 Association of Race/Ethnicity and Oral Health Outcomes Fisher-Owens et al, JPHD 2012 Assn of Race/Ethnicity and Oral Assn of Race/Ethnicity and Oral Health Outcomes-- Model 1 Health Outcomes— Models 1--> 5 Fisher-Owens et al, JPHD 2012 Fisher-Owens et al, JPHD 2012
3/3/2018 CHRONIC CARIES EFFECT Impact of Oral Disease-- Increased Costs Children and Families • Cost to the health care system – Direct – Indirect • Learning and school performance – Impact on child – Impact on schools • Additional costs—eg, parents time lost to work 34 References: Vujicic 2013, Taylor 2009, Casamassimo 2009 Oral-Systemic Disease School Impact Connections • Children and poor school performance • 117,000 hours of school lost per 100,000 – Increased 1.4 times with poor oral OR poor school-age children, with an additional 17,000 general health activity days beyond school time restricted per – Increased 2.3 times with poor oral AND 100,000 individuals general health • ~52 million school hours annually • 874,000 days in CA last year References: Blumenshine 2008; Taylor 2009 Blumenshine , SGR, 2000
3/3/2018 Why should you care? Oral-Systemic Connections • Eg, ADHD – Medications – Self-medication – Higher dental anxiety – Higher caries rates (12x) – Higher traumatic injury rates – Lower executive function – Different dietary habits – Worse homecare habits Picture taken from Huffington Post Why should you care? Mouth’s Role in Body • Integral to systemic health – Productivity – Quality of life • Portal/Pros – Entryway of nutrition – Source of communication, pleasure, social interaction, and cultural facial and dental esthetics Linda Davidson / The Washington Post Hollister, 1993; SGR, 2000 http://digestive.niddk.nih.gov/ddiseases/pubs/barretts/
3/3/2018 Mouth’s Role in Body, cont’d Impact of Disease on Adults • Oral-systemic disease connections • Portal/Cons – Heart and lung diseases – Infection or – Stroke inflammation portal – Low-birth-weight, premature births – Diabetes – Dementia Health Care Financing Administration 2000; JADA 2016 SGR, 2000; Sheiham, 2000 http://digestive.niddk.nih.gov/ddiseases/pubs/barretts/ Adults with Heart Disease Adults with History of Stroke • Routine periodontal treatment decreased • Routine periodontal treatment decreased cost of dental care cost of dental care • AND overall medical care—by 25% • AND overall medical care—by 35% Taylor, 2009 Taylor, 2009
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