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