Post on 19-Jun-2015
transcript
Public Oral Health Public Oral Health Interventions for Mothers Interventions for Mothers
and Children: and Children: What WorksWhat Works
Mark D. Siegal, DDS, MPH
Ohio Department of Health
?
It’s not as easy as this It’s not as easy as this anymoreanymore
For every complex For every complex problem, there is a problem, there is a
solution that is:solution that is:QuickEasyCheap, and
Wrong!Wrong!!!
Now we look for an Now we look for an Evidence BaseEvidence Base
And the process often is not pretty
Levels of EvidenceLevels of EvidenceI: evidence from at least one properly randomized
controlled trial.II-1: evidence from well-designed control trials without
randomization.II-2: evidence from well-designed cohort or case-control
analytic studies, preferably from more than one center or research group.
II-3: evidence from multiple time series with or without intervention.
III: opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees.
Adapted from: U.S. Preventive Services Task Force.
““Tell Them What You’re Tell Them What You’re Going to Tell Them”Going to Tell Them”
Current evidence on oral-systemic health links (e.g., pre-term low birth weight) does not justify major intervention efforts at this time
Unfortunately, pregnant women tend not to get dental care
Evidence supports water fluoridation and school dental sealant programs for community-based prevention of dental caries
““Tell Them What You’re Tell Them What You’re Going to Tell Them”Going to Tell Them”
Nationally, there are some demonstration projects in place for preventing and/or arresting (Early Childhood Caries) with fluoride varnish
Access to dental care remains a problem for vulnerable populations
Stand on soapbox
1. Current evidence on 1. Current evidence on oral-systemic health links oral-systemic health links (e.g., pre-term low birth (e.g., pre-term low birth weight) does not justify weight) does not justify major intervention efforts major intervention efforts at this timeat this time
It’s Not “Just Teeth It’s Not “Just Teeth and Gums”:and Gums”:
The Oral Health-General The Oral Health-General Health ConnectionHealth Connection
A. Isabel Garcia, DDS, MPHNational Institute of Dental and Craniofacial Research
Presented at the Ohio Summit on Access to Dental CareNovember 14-15, 2001
Some of the serious parts of this presentation were taken from:
Possible Mechanism of Possible Mechanism of ActionAction
Evidence supports the role of infections in preterm birth low birth weight (PLBW)
Transient bacteremia of oral origin (provoked by chewing, brushing, flossing, etc.) increase with severity of gingival inflammation
Maternal immune response to infection produces substances that may interfere w/ growth and delivery (cytokines, prostaglandins)
Gums
Good Really bad
Periodontal Disease 101-Macro Level
Loss of Clinical Attachment Level
The PD conspiracy The PD conspiracy theories are at the theories are at the
micro(be) levelmicro(be) level Infections by gram-negative bacteria Gingival inflammation, pockets,
ulceration of epithelium, destruction of collagen, ligament and bone
Chronic inflammatory process Multifactorial – host response important
contributor to susceptibility
Periodontal Disease and Periodontal Disease and PLBW: SummaryPLBW: Summary
Periodontal disease may have the potential to affect pregnancy outcomes
Findings from animal studies and case-control studies are intriguing and promising
More studies, including longitudinal, intervention trials, and research on mechanisms are needed
No evidence yet that treatment for PD will reduce the risk of preterm birth
Periodontal Disease and Periodontal Disease and DiabetesDiabetes: Summary: Summary
Diabetics have increased prevalence, extent, and severity of periodontal disease– Assumed that this is due to compromised
ability to respond to infection Insufficient evidence of a causal
association Unclear whether periodontal treatment
can affect diabetic control
Oral Health - General HealthOral Health - General HealthThe bottom lines at this time:The bottom lines at this time:
Insufficient evidence on whether PD is an independent risk factor for CVD, stroke, adverse pregnancy outcomes
Relationship of periodontal diseases and diabetes has the strongest evidence
Effect of periodontal disease on glycemic control is less clear
Some folks are Some folks are overshooting the markovershooting the mark
Rhetoric exceeding evidence?
Microbes that Bite
“Cigarette smoking, hypertension, hypercholesterolemia, and periodontal disease have been established as major risk factors for cardiovascular disease.”
Periodontology Vol 23, 2000, 136-141
11 May 2000
GUM DISEASE IN PREGNANCY LINKED TO PREMATURE BIRTH
GUM disease in pregnancy could be a significant risk factor in whether your baby is born pre-term, according to US researchers.
A new study of 2000 pregnant women in the US confirms previous findings that women with gum disease and decay may be up to seven times more likely to deliver before full term, and for the babies to be of a low birth weight. The more decay and disease you have in your mouth, the bigger your risk.
2. Unfortunately, 2. Unfortunately, pregnant women tend not pregnant women tend not
to get dental careto get dental care
PRAMS for 4 states that PRAMS for 4 states that collected oral health data in collected oral health data in
19981998 (AR, IL, LA, NM)(AR, IL, LA, NM)
23-35% received dental care during pregnancy
12-25% (data from 3 states) reported having a dental problem– only 45-55% went for care
Oral considerations during Oral considerations during pregnancypregnancy
American Dental Association recommends avoiding dental care during 1st trimester and last half of 3rd trimester
Lack of formal policies Lack of studies examining relationship
between dental care during pregnancy and pregnancy outcomes
Limiting factorsLimiting factors
Professional recommendations (ADA)
Lack of insuranceAttitudes and beliefs about dental
treatment during pregnancy– women– obstetricians– dentists
Common Sense ApproachCommon Sense Approach
Pregnancy is an opportune time for health education and overall health/oral health promotion
In the absence of dental care-pregnancy outcomes research and formal guidelines from professional organizations, use of the ADA recommendations and consultation with a given patient’s obstetrician, as necessary, makes sense
3. Evidence supports 3. Evidence supports water fluoridation and water fluoridation and school dental sealant school dental sealant programs for community-programs for community-based prevention of based prevention of dental cariesdental caries
Promoting Oral Health: Promoting Oral Health: Interventions for Preventing Interventions for Preventing
Dental Caries, Oral and Dental Caries, Oral and Pharyngeal Cancers, and Pharyngeal Cancers, and
Sports-Related Craniofacial Sports-Related Craniofacial InjuriesInjuries
A Report on Recommendations of the Task Force on Community Preventive
ServicesMMWR 50(RR-21)
November 30, 2001http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5021a1.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5021a1.htm
SSchool-Based Dental
Sealant Programs
Title V-funded
Pit and fissure surfaces account for at least 83% of permanent tooth surfaces affected by dental caries (1988-91)
Dental Sealants:
Prevention that Works
Dental SealantDental Sealant
Ohio School-based Dental Ohio School-based Dental Sealant Programs, 2002Sealant Programs, 2002
ATHENS
BELMONT
CARROLL
COLUMBIANA
COSHOCTONDELAWARE
GALLIA
HARRISON
HOCKING
JACKSON
LAWRENCE
MEIGS
MONROE
MORGAN
MUSKINGUM
NOBLE
PERRY
PIKE
ROSS
SCIOTO
TUSCA-RAWAS
VINTON
WASHINGTON
MONT
JEFFER-SON
ADAMSBROWN
FAYETTE
HIGHLAND
HOLMES
GUERNSEY
OTTAWAWILLIAMS FULTON LUCAS
ASHLAND
ASHTABULA
CRAWFORD
CUYAHOGA
HURON
LAKE
MAHONING
MEDINAPORTAGE
RICHLAND
SENECA
STARK
SUMMIT
TRUMBULL
WAYNEWYANDOT
HANCOCKPAULDING
PUTNAM
WOODGEAUGA
DEFIANCE ERIE LORAINLORAINSANDUSKYHENRY
FAIRFIELD
FRANKLIN
HARDIN
KNOX
LICKING
MARION MORROW
PICKAWAYMONTGOMERY
ALLEN AUGLAIZE
BUTLER
CHAMPAIGN
CLARK
CLINTON
DARKE
GREENE
HAMILTON
LOGAN
MERCER
MIAMI
PREBLE
SHELBYUNION
VAN WERT
WARREN
CLER-
MADISON
School-Based Dental Sealant Programs: 2002
Ohio Health Priorities Trust Fund (Tobacco
Settlement) (1)
Locally Funded (2)
ODH Funded (Title V) (18)
Programs travel to these counties
21 Program
s
Serving
44 Counties
Serving
>28,000 children
(2000-01)
2/3 of high-risk elementary schools
Impact of Targeted School-Based Dental Impact of Targeted School-Based Dental Sealant Programs in Reducing Racial and Sealant Programs in Reducing Racial and
Economic Disparities in Sealant Economic Disparities in Sealant Prevalence Among Schoolchildren--Ohio, Prevalence Among Schoolchildren--Ohio,
1998-99 MMWR 1998-99 MMWR 8/31/018/31/01
010203040506070
Whit
e
Bla
ck
F/R
M E
lig.
No
F/R
M
Ohio
Sealant Program
No Program
3rd Graders
4. Nationally, there are 4. Nationally, there are some demonstration some demonstration projects in place for projects in place for preventing (Early preventing (Early Childhood) caries with Childhood) caries with fluoride varnishfluoride varnish
Fluoride VarnishFluoride VarnishFirst introduced in Germany in 1964 under
the trade name DuraphatOver 30 years of clinical study“Reports of 25-45% caries reduction”You may have heard about itApproach for “pre-cooperative” kidsThere’s a big “But”
N=1
Iowa Fluoride Varnish
Program in Head Start Preschool
Classrooms
But...But...Off-label useEvidence on caries-inhibiting effect in
primary teethprimary teeth is “insufficient” to recommend for or against varnish use in preschool-age children at this time
Mixed findings on cost-effectiveness Programs experimenting with application by
dental and by medical staff– CA, NC, IA, WA
5. Access to dental care 5. Access to dental care remains a problem for remains a problem for vulnerable populationsvulnerable populations
““When all you do is When all you do is what you’ve what you’ve
done…”done…”“…“…then all you’ll then all you’ll
get is what you’ve get is what you’ve got.”got.”
-Jackie “Moms” Mabley
Dental Disease
Haves
Have nots
Haves
Have nots
Access to Dental Care
What We’ve Got isWhat We’ve Got is Dental Disease &
Disparity
……and it isn’t prettyand it isn’t pretty
0%
10%
20%
30%
40%
50%
60%
F/RM+ (<185% FPL*) F/RM-(>185% FPL*)
Figure 3: Dental Disease and Access to Care for Ohio 6-8 Year Olds, According to Family Income,
1998-99.
Ever had decay
Untreateddecay
Couldn't getneeded care
No dental visitw/in 12 mos.
6. Standing on Soapbox6. Standing on Soapbox
Some policymakers’ Some policymakers’ misguided misguided
ways of thinking about state ways of thinking about state and local dental programs:and local dental programs:
“They’re just teeth”“It’s not my job, man”“Cavities are preventable, so let’s just
fund preventive dental care”“Dental screening and referral is enough”“Give a man a fish…”
RRaannggee
Some Title V-funded Some Title V-funded ApproachesApproaches
Full-blown oral health program– Dental director and staff
Partially-blown oral health program– Nondental administrator (e.g., RN)/supervisor +
some dental staffWork oral health into MCH programs
– WIC and well child clinics (anticipatory guidance)Be a catalyst for community actionIgnore dental, maybe it will go away
It won’t!!
““Tell Them What Tell Them What You’ve Told Them”You’ve Told Them”
Current evidence on oral-systemic health links (e.g., pre-term low birth weight) does not justify major intervention efforts at this time
Unfortunately, pregnant women tend not to get dental care
Evidence supports water fluoridation and school dental sealant programs for community-based prevention of dental caries
““Tell Them What Tell Them What You’ve Told Them”You’ve Told Them”
Nationally, there are some demonstration projects in place for preventing and/or reversing (Early Childhood Caries) with fluoride varnish
Access to dental care remains a problem for vulnerable populations
Oral health is an integral part of health, mothers, children and everyone else
Time