Access to dental care for kids: implications for health and primary care 2008 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
59
Embed
Access to dental care for kids: implications for health and primary care 2008 Wisconsin Primary Care Research and Quality Improvement Conference Kenneth.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Access to dental care for kids: implications for health and primary
care
2008 Wisconsin Primary Care Research and Quality Improvement Conference
Kenneth G. Schellhase, MD MPH
Department of Family & Community MedicineDepartment of Population Health
Medical College of WisconsinMilwaukee, WI
2
Confessions
3
Introduction/overview
• Biases
• Limitations
• Formal Objectives
1. Review oral health pathophysiology2. Become familiar with oral health epidemiology3. Understand the implications of poor oral health on
general health and primary care practice4. Discuss potential solutions
4
February 28, 2007 Page 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 died.
– 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.)
12
Periodontal disease
13
Epidemiology
• National data
• Wisconsin data
• Local data
14
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, 1988–1994. Hyattsville, MD: Centers for Disease Control and Prevention (CDC), unpublished data.
15
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, 1988–1991. Journal of Dental Research 75:631-641, 1996.
16
Untreated caries in kids 6-8, by race/ethnicity and parental educational
attainment
17
Increasing caries rates across many groups, school age children (NHANES)
18
Increasing caries rates across all groups, young children (NHANES)
19
Untreated caries in children by age group and insurance status: Medicaid and uninsured much worse, but differ
little from each other
20
Rates of caries by insurance status over time: Medicaid getting worse (NHANES)
1988 to 1994
vs. 1999 to
2004
21
Accessed dental care in past year, by insurance status (MEPS)
Gradient of access
depending on insurance
status:
Private >
Medicaid >
Uninsured
22
Percentage of children with urgent dental need, by insurance status (NHANES):
private insurance < Medicaid and uninsured
23
Unable to access needed care by insurance status (MEPS)
Gradient of poor access: Uninsured > Medicaid > Private
24
Reasons for inability to access needed care, by insurance status
25
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. 2001-2002.
26
Treatment urgency, Wisconsin 3rd graders
27
Racial/ethnic disparities in oral health status of Wisconsin 3rd graders
28
Socioeconomic disparities in oral health status of Wisconsin children
29
Sobering numbers: oral health in Wisconsin children
30
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
31
Implications of poor oral health
32
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 care– Cardiovascular disease and periodontitis (…
downstream)– preterm/LBW and periodontitis (…hopefully
downstream)– Diabetes (…now and downstream)
33
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.
From: Oral Health in America: A Report of the Surgeon General. Office of the Surgeon General of the United States, 2000.
36
Poor oral health: Pathophysiologic Model of Systemic Effects
Chronic Inflammatory mediator cascade
Anaerobic oral infection local toxin release
Local inflammatory cellular response
Local release of inflammatory mediators
(TNFά , interleukins, et al.)
Chronic release into systemic circulation
Systemic consequences
37
Cardiovascular Disease
• Increasing evidence of association between periodontal disease and poor cardiovascular outcomes
• No causality determined yet—observational data only
• Important downstream implications for managing cardiovascular risk in primary care
38
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 </=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.
39
Cardiovascular Disease• Arbes et al., analysis of population-based NHANES data
– 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 significant
– 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.
40
Cardiovascular Disease
• CORADONT study, Spahr et al. 2006– observational design– statistically significant association between CAD and:
1. overall periodontal pathogen burden
odds ratio = 1.92 95% CI, 1.34-2.74; P<.001)
2. Actinomyces burden in periodontal pockets
odds ratio = 2.70 95% CI, 1.79-4.07; P<.001)
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.
41
Preterm delivery/low birth weight
• Increasing body of evidence showing association between periodontal disease and poor birth outcomes
• Evidence is largely observational– Recent experimental studies
• Implications for anyone providing obstetric or newborn care
42
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 < .0001) for women with periodontal disease
• Caution—higher quality studies showed weaker association
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.
43
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.
44
Diabetes
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 infection
• Relevant for primary care of diabetesKuo, 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.
45
Poor Oral Health:Effects on primary care practice
• Increased cardiovascular events
• Increased high-risk deliveries
• Diabetic glycemic control more difficult to maintain
• System effects:– High frequency of dental problems presenting
in primary care office settings and in the ED
46
Potential Solutions
47
Potential Solutions
• 1. community-based
• 2. practice-based
• 3. policy-based
48
Potential solutions--community
• Community coalitions– Example: Waukesha County Dental Coalition
• Driving force: school nurse and a family medicine educator
• Involvement of diverse group of concerned individuals, plus support of a couple key dentists
• Product: Waukesha County Community Dental Clinic opened May 2008
– Has served > 1300 low-income patients, 75% children
• Need changes in Title 19 dental program• Low reimbursements are major obstacle to access• Need more than 3 dentists in Waukesha county to participate
53
54
Conclusions
1. Too many Wisconsin children have poor oral health
--particularly minorities and low-income
2. Access to basic oral health services for low-income children is inadequate
3. Major downstream health consequences of (1) and (2) include increased cardiovascular risk, poor birth outcomes