Smiles Across America Webinar Series
Oral Health and Poverty: Addressing Racial and Socioeconomic Disparities in Pediatric Dental Caries
December 12, 2016
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Oral Health & Poverty
December 12, 2016 December 21, 2016
ORAL HEALTH AND POVERTY: ADDRESSING RACIAL AND SOCIOECONOMIC DISPARITIES IN PEDIATRIC DENTAL CARIES Qadira Ali Huff, MD, MPH
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Contributor Biography Qadira Ali Huff, MD, MPH is a pediatrician at a primary care health center owned and operated by Children’s National Health System in Washington, DC. Her clinic serves a majority Medicaideligible patient population. She completed her medical education at the University Of Maryland School of Medicine and her Master of Public Health at Johns Hopkins Bloomberg School of Public Health. She is a graduate of pediatrics residency at Children’s National Health System. Dr. Huff recently completed her two-year term as the American Academy of Pediatrics (AAP) Section on Pediatric Trainees (SOPT) Liaison to AAP Section on Oral Health. She is passionate about health disparities research and action, particularly surrounding the issues of oral health, early childhood education, and nutrition. She functions as an oral health champion at her clinic, helping to expand oral health services. 12
Learning Objectives
1. Describe the multiple layers of disparities within pediatric dental caries disease burden. 2. Explain the pattern of differential utilization of dental care among children and explore the contributing factors. 3. Conceptualize the social determinants of oral health and implications for disparities elimination. 4. Explore connection between adverse childhood experiences and oral health. 5. Review effective interventions and advocate action steps to reduce pediatric oral health disparities.
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Defining Early Childhood Caries
• Defined as the presence of one or more decayed, missing, or filled tooth surfaces in any primary tooth in a child 71 months of age or younger (AAPD Definition 2004)
• In the US, almost 25% of children 2-5 years of age have had at least one caries experience and almost 20% have untreated decay (Vargas et al. 1998)
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Defining Health Disparities
According to Healthy People 2020, a health disparity is: “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.�
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Burden of Childhood Caries
• Most common chronic disease of childhood: • 5 times as prevalent as asthma • 7 times as prevalent as allergic rhinitis
• About 80% of untreated caries occur in 25% of children ages 5-17 years (Dye et al. 2012).
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Burden of Childhood Caries
– Children living in poverty have 5 times more untreated caries than children from higher income families (GAO Report 2000). – In addition to children living at or near poverty, other high risk groups include: • Racial and ethnic minority communities – Recent immigrants
• Homeless population • Special needs children
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Disparities in Childhood Oral Health
• Significant disparities exist within the burden of caries disease, preventive oral health care utilization, and dental care utilization for decay.
• Disparities fall sharply along socioeconomic and racial-ethnic lines. • Dental care represents one of the greatest areas of unmet health need among US children.
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Racial Disparities in Untreated Caries Source: Burton L. Edelstein, Courtney H. Chinn. Update on Disparities in Oral Health and Access to Dental Care for America's Children. Academic Pediatrics, Volume 9, Issue 6, 2009, 415–419
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Racial Disparities in Untreated Caries
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Racial and Socioeconomic Disparities in Untreated Dental Caries
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Dental Care Access
• Insurance status is important, but not the sole factor in determining level of access.
• Even with Medicaid/CHIP dental coverage, children have irregular preventive dental visits and experience delays in care for acute dental complaints. • Families grapple with confusing insurance systems, geographically distant dental offices, and difficulty identifying dentists that accept Medicaid.
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Income-Based Disparity in Dental Care Utilization
Source: Burton L. Edelstein, Courtney H. Chinn. Update on Disparities in Oral Health and Access to Dental Care for America's Children. Academic Pediatrics, Volume 9, Issue 6, 2009, 415–419
Percentage of US children aged at birth to 21 years with a dental visit in 1996 and 2004, by family income level.9 Poor = children in families with income under 100% of the federal poverty level (FPL); low income = children in families with incomes between 101% to 200% of FPL; middle income = children in families with incomes between 201% to 400% of FPL; high-income = children in families with incomes in excess of 400% FPL. 23
Medicaid Dental Care Utilization
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Racial Disparity in Dental Care Utilization Source: Burton L. Edelstein, Courtney H. Chinn. Update on Disparities in Oral Health and Access to Dental Care for America's Children. Academic Pediatrics, Volume 9, Issue 6, 2009, 415–419
Figure 3. Percentage of US children aged at birth to 21 years with a dental visit in 1996 and 2004, by race and ethnicity.9
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Social Determinants of Oral Health Source: Adapted from Watt and Fuller: Watt R and Fuller S. 2007. Practical aspects of oral health promotion. Community Oral Health, (C Pine, R Harris Eds.), United Kingdom, Quintessence. 357-375
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Food Insecurity and Oral Health
• Food security requires both adequate quality and quantity of nutritious food. • One in five US children live in food insecure homes (Coleman-Jensen 2014). • Food options available due to cost and proximity are often both cariogenic and obesogenic. • Social-structural factors contributing to poor oral health and obesity overlap significantly.
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Adverse Childhood Experiences
– Adverse childhood experiences (ACEs) include: • • • • •
Parental incarceration Neighborhood violence Drug/alcohol abuse Poverty Divorce
– Children living in poverty tend to have more additional ACEs than those from higher income families.
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Implications of Adverse Childhood Experiences on Oral Health Disparities • Bright et al. (2015) found increased likelihood of poor dental health in the setting of just one adverse childhood experience (ACE), and a worsening cumulative effect on dental health as number of ACEs increased. • Traumatic experiences/stress in childhood are associated with downstream biological outcomes. • Mitigating oral health disparities necessitates more comprehensive approach. • Preventive dental care may benefit from screening for ACEs as a way to identify children at higher risk of poor oral health and to coordinate referral to appropriate social services.
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Hidden Toll of Untreated Caries
• • • • • • • •
Missed activity and school days Missed caregiver work days Chronic dental pain Poor school concentration Speech difficulties Eating difficulties Increased risk of poor oral health in adulthood Risk of infection
Source: Vargas and Ronzio 2006.
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Barriers that Build Disparities
• • • • • • • •
Lack of dental insurance Limited access to and availability of child-friendly dental services Lack of awareness of the need for preventive dental care Cost of dental procedures Fear of dental procedures Nutrition practices Parental education and health literacy Intergenerational cycles of poor oral health
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Healthy People 2020
• The federal Healthy People initiative provides science-based, 10-year national objectives for improving the health of all Americans.
• The updated 2020 goals focus on health equity, elimination of disparities, and optimizing health for all groups. • An oral health indicator selected as 1 of 12 national health indicator priorities: • To Increase the proportion of children, adolescents, and adults who used the oral health care system in past year
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Healthy People 2020
• Broad oral health goal of preventing and controlling oral and craniofacial diseases, conditions, and injuries, and improving access to preventive services and dental care. • Several objectives relate to pediatric oral health, including: • Reduce the proportion of children aged 3 to 5 years with dental caries experience in their primary teeth • Reduce the proportion of children aged 3 to 5 years with untreated dental decay in their primary teeth
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Oral Health Promotion Strategies
1. Advocate for increased dental care access for families. 2. Advocate for expanded community water fluoridation. 3. Advocate for school-based dental sealant programs.
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Community Water Fluoridation
• Community water fluoridation (CWF) is the single most effective public health intervention to prevent caries. • Shown to prevent decay by up 40%
• Communities save big through fluoridation. • In most cities, every $1 invested in CWF saves up to $38 in dental treatment
• Currently, only 62% of U.S. community water supplies are fluoridated.
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Community Water Fluoridation
• Fluoridation benefits entire population, but especially beneficial to those without regular dental care or at increased risk of caries. • Expanded CWF functions as an evidence-based and cost-effective means of reducing racial and socio-economic disparities in pediatric oral health disparities. • Healthy People 2020 goal for CFW is to expand reach to 79.6% of Americans.
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School-Based Dental Sealant Programs
• Effective caries prevention through physical barrier that blocks microorganisms and food from collecting in the pits and fissures of teeth. • Healthy People 2020 aims to increase number of children and teens with sealants • Sealants may reduce decay by up to 70 percent in school age children (US Surgeon General’s Report on Oral Health 2000). • School-based sealant programs are especially important for reaching children from low-income families who are less likely to receive private dental care.
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Dental Sealant Utilization
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School-Based Dental Sealant Programs
• Successful programs follow this road map: • • • • •
Define a target population within a school district Verify unmet need for sealants Get financial, material, and policy support Apply rules for selecting schools and students Apply sealants at school or offsite in clinics
• Despite evidence, dental sealants remain underutilized with unfulfilled potential to close gap in access to this critical preventive dental service. • Most states lagging in policies that provide sealants to low income and at-risk children in the school setting (PEW 2015).
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Future Directions
• Ongoing research on effect of adverse childhood experiences on oral health and overall wellbeing.
• Evolving towards more comprehensive models of medical and dental health care for children: • Less cumbersome to address psychosocial issues • Preventive dental care and education easier
• Targeted programs for Hispanic and immigrant children, among whom disparities are highest.
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Call to Action
• Educate!
– Ensure parents know timing of preventive dental services – Nutrition tips for good oral and overall health • Advocate!
– – – –
Financial support for school based dental sealant programs Interventions to expand dental care access to the underserved Ongoing research on health disparities in oral health Antipoverty advocacy supports child health
• Fluoridate!
– Encourage patients & families to drink fluoridated water – Know how to answer questions on CWF – Be a proponent of fluoridated water in your local community 41
Resources
HHS Insure Kids Now: • •
www.insurekidsnow.gov/ Search by state & insurance for local dentists
Campaign for Dental Health: • •
www.ilikemyteeth.org/ Resource for child oral health advocates
HealthyChildren.org: • •
www.healthychildren.org/English/healthy-living/oral-health/Pages/default.aspx Educational resource directed towards parents
CDC Public Health Grand Rounds on Community Water Fluoridation: •
www.cdc.gov/cdcgrandrounds/archives/2013/december-17-2013.htm 42
References
Bright MA, Alford SM, Hinojosa MS, Knapp C, Fernandez-Baca DE. Adverse childhood experiences and dental health in children and adolescents. Community Dent Oral Epidemiol 2015; 43: 193–199. Coleman-Jensen A, Gregory C, & Singh A. (2014). Household Food Security in the United States in 2013. USDA ERS. Dye BA, Li X, Beltran-Aguilar ED. Selected oral health indicators in the United States, 2005-2008. NCHS Data Brief. 2012;(96):1–8. Galvez MP, Morland K, Raines C, Kobil J, Siskind J, Godbold J, Brenner B. Race and food store availability in an inner city neighbourhood. Public Health Nutr. 2008;11(6):624– 631. Guide to Community Preventive Services. Improving oral health: dental caries .www.thecommunityguide.org/oral/caries.html. Holt K, Barzel R. 2013. Oral Health and Learning: When Children’s Health Suffers, So Does Their Ability to Learn (3rd ed.). Washington, DC: National Maternal and Child Oral Health Resource Center. http://mchoralhealth.org/PDFs/learningfactsheet.pdf Isong I, Dantas L, Gerard M, Kuhlthau K. Oral Health Disparities and Unmet Dental Needs among Preschool Children in Chelsea, MA: Exploring Mechanisms, Defining Solutions. Journal of oral hygiene & health. 2014;2:1000138. Mobley C, Marshall TA, Milgrom P, et al. The Contribution of Dietary Factors to Dental Caries and Disparities in Caries. Academic Pediatrics (2009) 9:6; 410-414. Moynihan P, Petersen PE. Diet, nutrition and the prevention of dental diseases. Public Health Nutrition (2004) 7(1A): 201-226. Accessed at http://www.who.int/nutrition/publications/public_health_nut7.pdf. Muirhead V, Quinonez C, Figueiredo R, et al. Oral health disparities and food insecurity in working poor Canadians. Community Dentistry and Oral Epidemiology (2009) 37(4): 294-304.
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References
Oral Health: Dental Disease is a chronic problem among Low-income populations. United States General Accounting Office. Report to Congressional Requesters: April 2000. Accessed at: http://www.gao.gov/new.items/he00072.pdf. Seal America: The Prevention Invention, school-based dental sealant program manual, 2012, National Maternal & Child Oral Health Resource Center. Sheiham A. Oral health, general health, and quality of life. Bulletin of the World Health Organization (2005) 83 (9) 644-645. Accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2626333/pdf/16211151.pdf. Singh GK, Siahpush M, Kogan MD. (2010a). Rising social inequalities in US childhood obesity, 2003-2007. Annals of Epidemiology, 20(1), 40-52. Selwitz RH. Winn DM, Kingman A, Zion GR. The prevalence of dental sealants in the U.S. population: findings from NHAN. US Department of Health and Human Services, Public Health Service, Office of the Surgeon General. Oral health in America: A report of the Surgeon General. Rockville, MD: National Institutes of Health, National Institute of Dental and Craniofacial Research; 2000. US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention. A national call to action to promote oral health, Rockville (MD): National Institutes of Health, National Institute of Dental and Craniofacial Research; May 2003, p. 1 -53. US Government Accountability Office (GAO). Medicaid: Extent of dental disease in children has not decreased and millions are estimated to have untreated tooth decay. 2008 Sep. 46 p. (GAO-08-1211)
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