Childhood Adversity Correlates With Young Adult Health Dental Patient Behaviors

Kenneth J Glenn, BS; Christina Light, BS; Todd Franke, MSW, PhD; and Shane N. White, BDentSc, MS, MA, PhD

ABSTRACT

Background: This study related childhood adversity to current health behaviors in a young adult Los Angeles dental population presenting for wisdom tooth extraction.

Methods: Routine health questions relating to smoking, alcoholism, use of street drugs and addiction to drugs were correlated to childhood adversity.

Conclusions: People who suffer from high levels of childhood adversity are known to have unfavorable adult health trajectories.

Practical implications: Interpretation of routine health behavior questions can help to identify vulnerable and at-risk adults.

Keywords: Dental patient, vulnerability, adverse childhood exposure, health behavior

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AUTHORS

Kenneth J Glenn, BS, is a dental student at the University of California, Los Angeles, School of Dentistry. Conflict of Interest Disclosure: None reported.

Christina Light, BS, is a dental student at the University of California, Los Angeles, School of Dentistry. Conflict of Interest Disclosure: None reported.

Todd Franke, MSW, PhD, is a professor in the department of social welfare at the University of California, Los Angeles. Conflict of Interest Disclosure: None reported.

Shane N. White, BDentSc, MS, MA, PhD, is a professor at the University of California, Los Angeles, School of Dentistry. Conflict of Interest Disclosure: None reported.

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Early life stress exposure and experience, including socioeconomic status and harsh or chaotic or nonnutritive environments, are known to lead to vulnerability and unfavorable adult health trajectories. Stress, or cumulative allostatic load, influences neural, physiological and physical development and long-term health. Allostatic load is the concept that cumulative stress, wear and tear on physiological regulatory systems over a lifetime, may predispose to disease and other vulnerabilities. 1

The effects of childhood stress or adversity may not be visible or known to health care providers. However, childhood adversity has been linked to increased risks of infection, multiple chronic conditions and cardiovascular disease in adulthood as well as earlier death. 2–5

Adverse childhood experiences are associated with negative health behaviors in adults, including excessive alcohol use. 6–8 However, to date, there is little knowledge of dental patients’ health trajectories. 9

Only rarely has attention been directed to the impact of adverse childhood experience on oral health in adult life. 10,11 However, associations have been found between childhood adversity and inadequate dental care, caries, tooth loss, restoration placement and periodontal disease in later life. 10,12–14 Exposure to childhood adversity could be an important predictive factor for poor general and dental health. 10 Given the growing role that dental professionals have in identifying vulnerable individuals, as well as victims of violence, abuse and neglect, awareness of the potential for individuals to have suffered adverse childhood experiences should be raised. Additionally, the mechanisms linking childhood adversity to poor dental and systemic health should be understood. 10

Successive reports from the surgeon general and the Institute of Medicine (IOM) have highlighted the connections among overall health, oral health and vulnerability. 15–17 Not much has changed since 2009 when IOM President Harvey V. Fineberg, MD, PhD, enjoined: Can you imagine a time when we fully incorporate mental and dental health into our thinking about health? What is it about problems above the neck that seems to exclude them so often from policy about health care? But this is a two-way street; dentistry must also embrace the challenges of overall, mental and behavioral health.

Identifying those patients who are broadly vulnerable and/or at risk of unhealthful behaviors would allow interventions that are capable of modifying maladaptive responses to adverse childhood experiences, such as drinking and smoking and substance abuse. 18 Dentists have the opportunity to identify patients who may be at risk due to unhealthful behaviors. Are such adverse trajectories evident in dental populations, and how long does it take for childhood adversity to impact adult health behaviors?

The purpose of this study was to determine if childhood exposure to adverse experiences in a Los Angeles dental population was related to current young adult tobacco, alcohol and drug behaviors.

Materials and Methods

Patients presenting for extraction of lower wisdom teeth were recruited at the UCLA School of Dentistry Oral and Maxillofacial Surgery Clinic, a convenience sample. 9,19 All consenting patients requiring third molar extractions between June 2011 and September 2013 and who completed questionnaires were included, whether or not they completed wisdom tooth extraction.

The mechanisms linking childhood adversity to poor dental and systemic health should be understood.

This clinic has a socioeconomically diverse patient population because it provides specialty services to patients covered by Medi-Cal and is located in an extremely affluent part of Los Angeles. According to patient registration data, the UCLA School of Dentistry patient population for the 2012-13 financial year was: 50% male/female; < 1% transgender; and < 1% other. For the same year, patients described their race as Asian, 10%; African American, 11%; Caucasian, 50%; Hispanic, 20%; undescribed, 5%; Native American < 1%; other, 3%; Persian, 3%; and Pacific Islander, < 1%. Spanish speakers represent a significant part of the patient pool. This population was known to have spread among childhood experiences and current young adult health behaviors, so it was amenable to the purpose of this study. 9

A sample size of 131 was attained. 19 Subjects were aged 18 years or older and able to provide informed consent; most wisdom teeth are extracted from adults aged 18 and older. Some selection biases may have occurred.

Institutional Review Board approval was obtained (UCLA IRB #10-001874). Subjects were recruited using a posted flyer; interested patients contacted the clinic receptionist. Next, recruiters used a short eligibility screening, according to a standardized script, to determine eligibility. Finally, completion of informed consent occurred in a private room. Subjects were given a $20 gift card upon consent, whether or not they completed the questionnaire or treatment.

In order to ensure absolute patient confidentiality, no personal identifiers were collected, so the questionnaires could never be related to an individual participant even if subpoenaed. The questionnaires were catalogued by unique random bar codes.

Questionnaires were used to identify and quantify childhood stressors. The questionnaire first directed subjects to the period of ages 8-11 years during their childhood and included questions adapted to these years. Five questions were used to create an overall composite index of childhood adversity on a scale that ranged from 0 to 37. The questions used were previously established for such purposes; they rated emotional and physical abuse, parental disharmony; parental educational attainment, childhood financial comparison and childhood parental income. 20–22 The questions were derived from those developed in the ACE Study, a collaboration between Kaiser Permanente’s Health Appraisal Center (HAC) in San Diego and the U.S. Centers for Disease Control and Prevention, designed to assess the impact of numerous, interrelated, adverse childhood experiences on a wide variety of health behaviors and outcomes and on health care utilization. 23 These questions have repeatedly demonstrated a strong, graded, dose-response relationship to numerous health and social outcomes. 24

Four routine questions from the standard UCLA School of Dentistry Health Questionnaire were used to measure current young adult health behaviors related to smoking, alcohol and drug use. These were: Do you smoke? Have you ever considered yourself an alcoholic? Have you ever used street drugs? and Have you ever been addicted to drugs? All four measures were dichotomous, with zero indicating “no” and one indicating “yes.”

The questionnaires were administered immediately after completion of the standard UCLA School of Dentistry Health Questionnaire, with a trained clinic staff member in attendance to assist subjects as needed, in a closed private room.

Bivariate Pearson correlations were calculated between the childhood adversity index for each of the four young adult health behavior questions. Additionally, a full multiple regression model was used to assess the combined effect for the four young adult behavior questions as independent variables. Regression assumptions were checked including normality and heterogeneity of variance.

Results

Correlations were found between the childhood adversity index score, describing the 8-11 age period and smoking, alcoholism, use of street drugs and addiction to drugs as young adults (TABLE 1). The correlations with smoking, alcoholism and use of street drugs were moderate; the correlation with addiction to drugs was weak. But all were highly statistically significant (TABLE 1).

Multiple regression using the four independent variables significantly predicted the childhood adversity index score, F (4,91) = 12.9. The R-squared value for this model was 0.36. In comparing the bivariate results (TABLE 1) to the full model results (TABLE 2), three of the four independent variables remain significant in the full model. While the answer to the question “Have you ever been addicted to drugs?” was significantly correlated with the childhood adversity index in the bivariate in the model described above (TABLE 1), it was not a significant predictor in the regression analysis (TABLE 2). This is due to the fact that the other three variables in the model explained all of the variability that the question “Have you ever been addicted to drugs?” explained when alone in the bivariate model, making it a nonsignificant predictor in the presence of the other measures. This may be largely due to the relationship between having ever used street drugs and having been addicted to drugs. The observed range of scores on the childhood adversity index was 0 to 28. All three of the other independent variables seem to have a substantial impact on the change in the adversity index. For example, with a 1-point change on the response to “Have you ever considered yourself an alcoholic?” the model would predict over a 5-point change on the childhood adversity index. Likewise, a 1-point change in these measures accounted for a 4-point and 3.4-point change in the childhood adversity index with the questions “Have you ever used street drugs?” and Do you smoke?

Discussion

While signs of childhood adversity may be invisible to dentists and other care providers, questions in a routine dental health questionnaire correlated with childhood adversity and predicted the adversity experienced. Responses to such questions not only tell us about current health behaviors, but the results of this study demonstrate that they also inform the care provider to the general likelihood of childhood adversity and overall negative adult health trajectories. Given the known relationships between childhood adversity and adult diseases, such routine questions may help to recognize the potentially vulnerable who are at heightened risk of a variety of adverse trajectories, from respiratory and cardiovascular disease to mental disease, periodontal disease and caries.

These routine health behavior questions may be a surrogate for the very personal questions needed to directly measure childhood adversity. Measuring childhood adversity is difficult because the patient may be unaware of the context of adverse childhood experiences, feel uncomfortable answering such questions, be embarrassed, afraid for themselves, protective of an abuser or scared of the legal implications of an answer. Self-report is the usual practice for identifying patients with exposure to adversity. However, the use of markers such as these health behavior questions may provide a more objective identification. Consideration by a caregiver to the broader context of questions relating to health behaviors could be useful and important.

However, it is important to remember that although the results of this study were moderately predictive of a population, they are not necessarily predictive of every individual within the population. The answers to the questions are not diagnostic of childhood adversity; instead, they suggest a significantly heightened risk of an individual having experienced childhood adversity. 24

Although the impact of childhood adversity may take decades to manifest as respiratory or cardiovascular disease in middle age or late adulthood, the data in this study indicate that childhood adversity very quickly impacted young adult health behaviors, with this trajectory being manifested in less than a decade.

The correlations identified in this study were moderate. However, this should not be viewed as if childhood adversity is unimportant, but as a manifestation of the multifactorial etiologies of smoking, alcohol and drug abuse.

Some selection bias may have occurred in that it is possible that those who were most disadvantaged as children did not or were not able to access the dental school clinic for wisdom tooth extractions.

Diseases that may appear completely unrelated, such as periodontal disease and ischemic heart disease, have been found to be similarly associated with the same indicators of allostatic load, suggesting a possible common stress pathway linking socioeconomic position to both conditions. 11

Measuring childhood adversity is difficult because the patient may be unaware of the context.

In consideration of the questions relating to current health behaviors, Rossow has explained that people with drug use disorders have an elevated prevalence of oral diseases, in particular caries, periodontal disease and xerostomia. 25 She adds that the other main drivers of oral diseases and their progression, poor oral hygiene, frequent sugar intake and infrequent dental visits, can be ascribed to the irregular lifestyle, fiscal disadvantages and mental health problems that often accompany drug use. However, it is possible that all these drivers of oral disease flow from childhood adversity.

In a similar vein, Friedlander et al. noted that the prevalence of dental disease in alcoholics is usually extensive because of a disinterest in performing appropriate oral hygiene techniques and diminished salivary flow. 26 They explained that concurrent abuse of tobacco worsens dental disease and heightens the risk of developing oral cancer. Thus, identification of the alcohol-abusing patient, a cancerscreening examination, preventive dental education and use of saliva substitutes and anticaries agents are indicated. They added that special precautions must be taken when performing surgery and when prescribing or administering analgesics, antibiotics or sedative agents that are likely to have an adverse interaction with alcohol or psychiatric medications. Again, it is more than possible that disinterest in personal health may be a consequence of childhood adversity.

Holistic dental care recognizes the need to address behavioral, systemic and oral issues. To these things, we now add the need to consider allostatic load and early life adversity. The dental profession must identify, understand and support the vulnerable and guide patients to appropriate intercession by our health care partners. Dentists may not routinely probe for adverse childhood experiences or unhealthy behavior issues beyond the questions on a routine medical history form. However, the widely used routine questions “Do you smoke?” “Have you ever considered yourself an alcoholic?” and “Have you ever used street drugs?” can provide broader insight and direction to dentists than previously realized.

Recognizing, advising and referring to an appropriate caregiver are important for the success of current treatment, maintenance of oral health and overall health.

A dentist can implement the process of recognition and intervention to address health behaviors, such as reducing cigarette, alcohol or drug consumption, by including recommendation and referral in a treatment plan. This would allow the dentist to present the change in an objective nonjudgmental manner. An awareness and expectation would be recorded, and the behavioral change would be framed in terms of the patients own presenting complaint and the overall treatment plan.

Conclusions

Answers to several routine health behavior questions from a dental clinic health questionnaire “Do you smoke?” “Have you ever considered yourself an alcoholic?” and “Have you ever used street drugs?” correlated with childhood adversity experienced by a group of young adult dental patients. Childhood adversity is known to be linked to a wide variety of adverse adult health trajectories. Broader interpretation of answers to routine adult health behavior questions can better inform care providers as to the possibility of patients’ vulnerability associated with childhood adversity. Dentists must identify, understand and consider vulnerabilities created by adverse childhood experiences when they provide comprehensive adult patient care. n

ACKNOWLEDGMENTS

The authors are very grateful for support from NIH NIDA grant R21 DA031571. We are most appreciative of the efforts of all the faculty, staff and residents of the UCLA Oral and Maxillofacial Surgery Clinic in their gracious and invaluable support of this study.