Oral Health and Local Disparities

Hugh Silk, MD, MPH Vanessa Villamarin, BS

Waking up with a right-sided headache every day made getting ready for seventh grade a taxing chore. The bursts of pain shooting down my jaw throughout the day and night made simple tasks difficult and made concentrating almost impossible. I was having my first dental complication while experiencing a lack of access to care. No child should go through that experience. -Vanessa Villamarin

Why is oral health important?

Caries are the most common chronic childhood illness in the United States according to the Centers for Disease Control and Prevention (CDC). Children ages 5 to 19 from low-income households are over twice as likely (25%) to have caries compared to children from higher-income households (11%). Furthermore, among children aged 3 to 5 years, the largest racial and ethnic disparity in oral health is seen in Mexican-American and non-Hispanic Black children.

Complications from untreated dental caries include infections and pain which can affect speaking, eating and concentrating. Children with poor dental health have more school absences and receive lower grades than those with good dental health. (1) These racial disparities continue into adulthood; CDC data shows that non-Hispanic Blacks and Mexican-Americans aged 35 to 44 years experience untreated tooth decay at twice the rate of non-Hispanic whites and 1 in 4 women of childbearing age have untreated caries. Notably, children of mothers who have high levels of untreated caries are greater than three times as likely to also have caries. (2) Only a third of Black, Hispanic, or Asian women see a dentist during pregnancy. Compare this to their white counterparts where 50% see the dentist. What is contributing to these disparities?

To be clear, there is no biological reason for Black or Hispanic Americans to have more dental pathology; this occurs due to systemic and institutional racism and bias. This is not an indictment of individuals but instead, a reflection of the flaws of our healthcare, health education system and society. These issues impact a large percentage of our population, as Worcester’s population is 21% Hispanic/Latino, 13% Black or African American and 21% persons in poverty. (3)

Access to dental care in Worcester

The MassHealth database reports 33 dental practices in the city of Worcester accepting MassHealth and four practices accepting Health Safety Net. However, of these 33 practices, only 18 are currently accepting new patients and eight are English speaking only. According to the American Dental Association (ADA), dentists in Massachusetts are predominantly white/non-Hispanic (65-70%), with <4% being Black and <5% Hispanic/Latino. This data highlights the need for a more diverse provider population and more dentists in Worcester to accept MassHealth.

Dental health in the time of COVID-19

The populations at higher risk of experiencing disparities in oral health care (Black and Hispanic/Latinx) are the same populations who are disproportionately affected by COVID-19. Due to the risk of viral transmission through aerosol-generating procedures, the ADA recommended postponement of elective dental services in March 2020 and advised offices to remain closed with the exception of emergency care until April 30th. As dental offices opened, working down the backlog of preventive services for those with no dental issues leaves the vulnerable with more serious issues waiting in long lines for care.

Future steps

The most common oral pathologies (dental caries and periodontal disease) are preventable. There are several strategies that we should implore locally to reduce the inherent disparities.

Pregnancy

Children born to mothers with caries are more likely to have caries. In addition, periodontitis has been associated with an increased risk of preterm birth, low birth weight and preeclampsia. (4-6) Pregnancy is a teachable moment. Potential initiatives could include more dental offices designating chair times for pregnant patients to ensure that they are seen by a dentist at least once during their pregnancy. In addition, prenatal oral health education should be incorporated into local health schools and residency programs to reinforce the importance of oral health during pregnancy. The American Academy of Pediatrics’ Tiny Teeth campaign includes a robust tool kit (available in multiple languages at AAP.org/tinyteeth) for healthcare professionals that contains educational and outreach materials.

Childhood

Dental sealants (a coating applied to molars) are an effective preventative measure; they are easily applied and protect against cavities for up to four years. They are most effective when applied soon after the permanent molars erupt (between the ages of 6 and 12). Less than half of children between the ages of 6 and 11 receive dental sealants. If dental sealants were applied in schools nationally, it could prevent three million cavities and save up to $300 million in dental costs. (7) Furthermore, if this preventative approach was offered to all, this would reduce disparities in access to care.

Uninsured populations

The Worcester Free Clinic Coalition has some free dental services. Future initiatives could expand to providing dental cleaning services at all Worcester Free Clinics as well as oral hygiene education, free oral hygiene tools and fluoride varnish applications.

Fluoride

It is well-known that fluoride is beneficial for oral health. According to the CDC, community water fluoridation (CWF) is an important component of preventing tooth decay. CWF is economically beneficial for families, saves our U.S. healthcare system $38 in dental treatment costs for every $1 spent and reduces caries in both children and adults by 25%. Of the 132 water systems of Worcester County, 103 are not fluoridated. Ensuring that all public water systems provide fluoridation would greatly benefit our Worcester population providing inexpensive and safe prevention for all.

Education

Half of the population sees a medical provider in any given year but do not visit a dental provider; medical providers must be able to offer advice, examine the mouth and make timely dental referrals. Residents, students and faculty should learn the basics of oral hygiene, proper nutrition and importance of dental visits. Other health professionals should also be encouraged to study the subject. Lastly, we must continue to strengthen pipeline programs for Black and Latinx students into medical, nursing and dental programs. Societal norms must greatly evolve to increase the number of underrepresented minorities in health professions.

References

1. Jackson SL, Vann WF, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children’s school attendance and performance. Am J Public Health 2011;101:1900–6.

2. Dye BA, Vargas CM, Lee JJ, Magder L, Tinanoff N. Assessing the Relationship Between Children’s Oral Health Status and That of Their Mothers. J Am Dent Assoc. 2011;142(2), 173-183.

3. “U.S. Census Bureau QuickFacts: Worcester City, Massachusetts.” Census Bureau QuickFacts, www.census.gov/quickfacts/ worcestercitymassachusetts.

4. Corbella S, Taschieri S, Del Fabbro M, Francetti L, Weinstein R, Ferrazzi E. Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association. Quintessence Int. 2016 Mar;47(3):193-204.

5. Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for preeclampsia. ObstetGynecol 2003;101:227- 231.

6. Goepfert AR, Jeffcoat MK, Andrews WW, et al. Periodontal disease and upper genital tract inflammation in early spontaneous preterm birth. Obstet Gynecol 2004;104:777-783.

7. “School Sealant Programs.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 10 Sept. 2019, www.cdc.gov/oralhealth/dental_ sealant_program/index.htm.

Vanessa Villamarin, B.S. M.D. Candidate Class of 2021 University of Massachusetts Medical School

Hugh Silk, MD, MPH Professor, University of Massachusetts Medical School, Department of Family Medicine and Community Health and Instructor, Harvard School of Dental Medicine and Harvard Medical School