2/23/2017 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 new UH2/3 • Other research funding from Western Dental UCSF Care of the Vulnerable and Underserved • No financial relationships to disclose regarding February 23, 2017 this topic 1 2 Why should you listen to a Objectives Pediatrician? • Review the importance of oral care to overall • Why a pediatrician? health and the role of primary care in promoting – Greatest risk factor for dental caries/disease oral care through the ages in adulthood is dental caries in childhood • Detail at least 3 examples of the impact that – Pt BR, or EM, or… poor oral health has on a person’s overall health – 1 year olds • Describe the role of medical providers in oral health assessments and the prevention of oral • 89% seen a pediatrician/FP for an “annual exam” disease • 1.5% seen a dentist • 6-8% have caries • Name at least 4 risk factors for dental caries – Patients see PCP 9+ times before dentist MEPS, 2000-2005 3 4 1
2/23/2017 …About oral health??? …About Oral Health? • Big issue in children… • Dental caries--the most common chronic • Increasing prevalence with age--bigger disease of childhood issue in adults • By end of life, nearly every American has had complications with his/her teeth Gift, 1992; Surgeon General’s Report 2000; Brown 1996; Macek 2004; Pew 2014; NCHS 1996, 5 6 NHANES III …About oral health??? Not just pretty teeth • Huge area of disparities—great test case Being free of chronic oral-facial pain conditions, oral and pharyngeal (throat) cancers, oral soft tissue lesions, birth defects such as cleft lip and palate, and scores of other diseases and disorders that affect the oral, dental, and craniofacial tissues 7 8 SGR, 2000 2
2/23/2017 Why should you care? Why should you care? …As people with hearts …As people who pay taxes • The nation’s yearly dental bill, 2014: >$113.5 billion Would you miss: – Tens of billions of dollars in direct medical care and indirect Eating salad? costs of chronic craniofacial pain conditions such as temporomandibular disorders, trigeminal neuralgia, shingles, or Crunching on an apple? burning mouth syndrome Being allowed to play – $100,000 minimum individual lifetime costs of treating outside? craniofacial birth defects such as cleft lip and palate Going to school? – Costs of oral and pharyngeal cancers and autoimmune diseases Being able to get a job? – Costs associated with the unintentional and intentional injuries that so often affect the head and face Photos courtesy of Operation Smile – Social and psychological consequences and costs… • California’s National Guard What would it be like, seeing yourself 9 10 Wall, 2015; Health Care Financing Administration 2000; Surgeon General’s Report 2000; Belt, 2005 for the first time? The Emergency Department • 2.5% of all visits for adults 18 to 44--for nontraumatic dental pain • Increasing at 3 times the rate of other Disparities reasons for ED visits • In 2012, 2.18 million visits (0-18 10%) – Cost $1.6 billion, averaging ~$750 per visit – Mostly self-pay or government insurance – Almost 80% could be diverted, but 70% outside regular dentists’ hours Sun et al, AJPH 2015; 11 12 Lee et al, AJPH 2012; Wall, Vujicic 2015 3
2/23/2017 Why should you care? Inequities in Oral and Systemic Inequities Health • Concentrated • Before ACA, over 46 million Americans – ~80% of disease in 25% of children lacked health insurance, 108 million – 18% in low-risk group lacked dental insurance – 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 13 14 Brown, 1996; Vargas, 1998; Kaste, 1999; Healthy People 2010, 2000; NCCP, 2006 Disparities Disparities Race/Ethnic Disparities Race/Ethnic Disparities, cont’d • Greatest area of health care disparities-- • Greatest area of health care disparities--race/ethnic race/ethnic – Mexican-American – For children 2-5 years, 75% of caries occurred in 8% • Ages 2-19 years--almost 2x rate of untreated dental caries as white or black non-Hispanic children of population (non-Hispanic blacks, or Mexican Americans) • Even as young as 12-23 months old, Mexican-American children 3.5-4.6x more likely to have caries than children of other racial/ethnic backgrounds – 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 15 16 Brown, 1996; Vargas, 1998; Kaste, 1999; Healthy People 2010, 2000; NCCP, 2006 Brown, 1996; Vargas, 1998; Kaste, 1999; Healthy People 2010, 2000; NCCP, 2006 4
2/23/2017 Disparities Children of color are 2-3x more likely to have Socioeconomic Disparities untreated decay as white children •Rates 4.4 times higher in 12-23 % of SFUSD Kindergarten Children with Untreated Caries mo for children < 30 by Race/Ethnicity, 2012-2013 125% FPL % of Children With Untreated Caries •All cases in kids 23 <200% FPL 20 •12 times as many 17 16 restricted activity days 10 8 0 White Black Chinese Hispanic Health People 2010, 2000; 17 18 SFUSD, 2013 US GAO, 2000 19 20 ADA 2016 ADA 2016 5
2/23/2017 Attitudes Consistent Across Income Levels and Age Groups… 21 22 ADA 2016 ADA 2016 Why should you care? Overlap of Race/Ethnicity and Except… Poverty 23 24 ADA 2016 6
2/23/2017 Why should you care? Children in some Disparities in Services SF neighborhoods • Socioeconomic have – Children near Federal Poverty Level (FPL) are 50% experienced 2-3x as likely to have sealants as those >200% of the FPL • Race/ethnic more caries – Rates for sealants for black and Mexican-American Chinatown children are 33% lower than those for white children North Beach Nob Hill/Russian Hill/Polk Tenderloin South of Market Bayview/Hunter’s Point Visitation Valley Excelsior Portola 25 26 Dye 2007 27 28 Pew, 2016 7
2/23/2017 Association of Race/Ethnicity Assn of Race/Ethnicity and Oral and Oral Health Outcomes Health Outcomes-- Model 1 29 30 Fisher-Owens et al, JPHD 2012 Fisher-Owens et al, JPHD 2012 Assn of Race/Ethnicity and Oral Impact of Oral Disease-- Health Outcomes— Models 1--> 5 Children and Families 31 32 Fisher-Owens et al, JPHD 2012 8
2/23/2017 CHRONIC CARIES EFFECT Increased Costs School Impact • 117,000 hours of school lost per 100,000 • Cost to the health care system school-age children, with an additional 17,000 – Direct activity days beyond school time restricted per – Indirect 100,000 individuals • ~52 million school hours annually • Learning and school performance • 874,000 days in CA last year – Impact on child – Impact on schools • Additional costs—eg, parents time lost to work 33 34 References: Vujicic 2013, Taylor 2009, Casamassimo 2009 Oral-Systemic Disease Oral-Systemic Connections Connections • Children and poor school performance • Eg, ADHD – Increased 1.4 times with poor oral OR poor – Medications general health – Self-medication – Increased 2.3 times with poor oral AND general health – Higher dental anxiety – Higher caries rates (12x) – Higher traumatic injury rates – Lower executive function – Different dietary habits – Worse homecare habits 35 36 References: Blumenshine 2008; Taylor 2009 Blumenshine , SGR, 2000 9
2/23/2017 Why should you care? Why should you care? 37 38 Picture taken from Huffington Post Linda Davidson / The Washington Post Mouth’s Role in Body Mouth’s Role in Body, cont’d • Integral to systemic • Portal/Cons health – Infection or – Productivity inflammation portal – Quality of life • Portal/Pros – Entryway of nutrition – Source of communication, pleasure, social interaction, and cultural facial and dental esthetics 39 40 Hollister, 1993; SGR, 2000 http://digestive.niddk.nih.gov/ddiseases/pubs/barretts/ http://digestive.niddk.nih.gov/ddiseases/pubs/barretts/ SGR, 2000; Sheiham, 2000 10
2/23/2017 Impact of Disease on Adults Adults with Heart Disease • Oral-systemic disease connections • Routine periodontal treatment decreased – Heart and lung diseases cost of dental care – Stroke • AND overall medical care—by 25% – Low-birth-weight, premature births – Diabetes – Dementia 41 42 Health Care Financing Administration 2000; JADA 2016 Taylor, 2009 Adults with History of Stroke Adults with Diabetes • Routine periodontal treatment decreased • Routine periodontal treatment decreased cost of dental care cost of dental care • AND overall medical care—by 35% • AND overall medical care—by 28% 43 44 Taylor, 2009 Taylor, 2009 11
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