Primary Oral Health Care and

Coalition Building

ORAL HEALTHORAL HEALTH

•Tooth decay•Gum diseases•Oral cancer

Many health problems begin with poor oral hygiene

By Karen UhlenhuthKnight Ridder Newspapers

January 4, 2004

Dr. Marjorie Jeffcoat,

Dean of the University of Pennsylvania School of

Dental Medicine

Editor Journal of the American Dental

Association

GUM DISEASEGUM DISEASEa Chronic Infectiona Chronic Infection

• Increase the risk of heart attack and stroke. • Increase the incidence of premature, low-

birthweight babies. • Exacerbate diabetes, which now affects 17

million Americans. • Possibly contribute to grave lung disorders

such as pneumonia and emphysema.

Gum DiseaseGum Disease

• 25% to 35% of people 35 to 60 years old have the disease

• Among people older than 60, that rate escalates to 60 - 75%

Risk FactorsRisk Factors

• Poor dental hygiene. You should brush and floss daily to maintain healthy gums.

• Cigarette smoking. It's been identified as one of the leading causes of periodontal disease.

• Genes. About 30 percent of people have an inherited susceptibility.

Risk FactorsRisk Factors

• Stress. It interferes with the body's ability to fight periodontitis and other infections.

• Diabetes. Diabetics are more susceptible to all infections, including those in the mouth.

• Some drugs. They include oral contraceptives, antidepressants and some heart medications

Gum Disease and Fetal HealthGum Disease and Fetal Health

• A pregnant woman with periodontal disease is more likely than a noninfected woman to give birth prematurely and to deliver a small baby

• In a severe case of periodontitis, she is about seven times more likely

Dr. JeffcoatDr. Jeffcoat

It is time for us not to think of our mouths as somehow

disconnected from the rest of our bodies. The same blood

flows through them, the same nerves go to them. To have a

healthy body, you need a healthy mouth.

2020 vision: 2020 vision: What will you be treating in 20 What will you be treating in 20

years?years?

• There will be more older people and their oral health will be better than previous generations

• More and more of our patients will have complex medical conditions

Marjorie K. Jeffcoat, JADA 134: Dec 2003

What’s up with tooth decay in What’s up with tooth decay in the USAthe USA

• Caries is a transmissible infection that is diet dependent and saliva mediated

• Caries prevention has been effective with a large proportion of the population

Pathogenesis of Dental CariesPathogenesis of Dental Caries

• Caries is a transmissible infection– Mother to child (Berkowitz 1981)– Window of Infectivity, 12-30 months

(Caufield 1989)– 20% of 14 month old infants infected

(Mohan 1998)– Predentate infants infected (Milgrom

1998)

Essential Cause of Tooth DecayEssential Cause of Tooth Decay

• Susceptible tooth• Bacteria• Fermentable carbohydrate• Time

White SpotsWhite Spots

Subsurfacedemineralization

Why do some people get Why do some people get more cavities than more cavities than

others?others? • Caries is a transmissible infection that is

diet dependent and saliva mediated• Biofilms, complex communities of

microorganisms, where acid production occurs

• All biofilms are not alike

Joel Berg DDS, MS-Professor & Chair of Pediatric Dentistry, Univ. of Washington, Scientific American, Feb. 2003, p.93

Nature of the ProblemNature of the Problem• High risk group – 25% experience

80% of decay• Traditional treatment is

inaccessible and expensive• Effective preventive measures are

feasible

Access to dental care for children Access to dental care for children in the United Statesin the United States

A survey of general A survey of general practitionerspractitioners

N. Sue Seale, DDS, MSDPaul Casamassimo, DDS, MS

JADA Dec 2003, 134:1630-1640

ResultsResults

•The good news!–91% of the general dentists treated children

ResultsResults

• The bad news!– Few children younger than 4

years received treatment – Children funded by Medicaid

were represented in very low numbers

– Few children with high decay rates were treated

ResultsResults• Only 15% of the respondents identified

the age of 1 year as the appropriate age for the first dental visit

• There was a significant association of types of child patients in practice and

with the intensity of the respondents’ educational experiences

ResultsResults

• Practitioners in rural locations were significantly more likely to treat Medicaid-covered patients

• More than 40% indicated further education in oral sedation, nitrous oxide sedation and atraumatic restorative technique

Pete’s ConclusionsPete’s Conclusions

• General practitioners provide 90% of the dental care for children

• Expansion of access to oral health care by general dentists for young children, Medicaid-funded children, and high-risk for decay children will begin to turn the tide

The ProblemThe Problem•Poverty•Social and cultural isolation•Fear•Outdated concepts

An Example of Coalition Building

ABCD Counties 1995-2004ABCD Counties 1995-2004

18 of 39 counties>200,000 eligible for ABCD

• Started in Spokane in 1995• 17 counties currently participating• >200,000 children, 5 and under,

eligible

Spokane ABCDSpokane ABCD• Begun in 1995 and still going strong• 43% of children enrolled in the ABCD program

visited a dentist in the past year• 12% of Medicaid-enrolled children not in the

ABCD program visited a dentist in the past year

• An ABCD child was 5.3 times more likely to have had at least one dental visit than a child not enrolled in the ABCD program

• An ABCD child was 6 times more likely to have received preventive services

Four ComponentsFour Components• Outreach• Training and certification of

dental professionals• New and enhanced dental

benefits• Enhanced dental fees

• Three fluoride varnish treatments• Family Oral Hygiene Instruction• Other new Medicaid procedures• Enhanced fees

Reimbursement

Qualitative Research Qualitative Research ResultsResults

• Increased awareness of the need for early prevention and/or intervention in pre-school children

•The program reduced dental fear and increased parent satisfaction

The Efficacy and Cost-Effectiveness of the The Efficacy and Cost-Effectiveness of the ABCD ProgramABCD Program

M. KOBAYSHIM. KOBAYSHID. CHI, S. COLDWELL, P. DOMOTO and P. MILGROMD. CHI, S. COLDWELL, P. DOMOTO and P. MILGROM

Submitted Submitted

ResultsResults

• Children in ABCD county were healthier than the non-ABCD county

• ABCD expenditures were $33 per child for each cavity averted

• Expenditures for alternatives ranged from $59 to $273

ConclusionsConclusions

ABCD improves the health of preschoolers and has the

potential to save up to $1.3 million per year in Spokane and Pierce counties alone

Whatcom County PartnershipsWhatcom County Partnerships

• Mt. Baker District Dental Society• Whatcom County Health Department• St. Joseph Hospital• Opportunity Council• Madrona Pediatrics• Interfaith Coalition • Washington Medicaid/CSO• Washington Dental Service Foundation• University of Washington

Whatcom County Whatcom County Health DepartmentHealth Department

• Enrolls patients in ABCD• Sends more infants and toddlers to

dentists• Provides orientation for families• Assists in problem solving-please

call

GoalsGoals•Establishing a therapeutic

alliance with families•Getting children and

parents to return•Providing continuity of care

• Reducing the extent of disparities in oral health

• Increasing access to preventive dental care among preschool children from birth up to 5 years of age served by the Medicaid program

• Joint programs by dentists, health departments and Medicaid in counties all over the State.

AAPD Filling Gaps 2001AAPD Filling Gaps 2001

MAA billing data 48

]Increase in Service to Young ]Increase in Service to Young Children w/ MedicaidChildren w/ Medicaid

• Between 2000 and 2002, the number of children under 6 that were seen by private practice dentists more than doubled

• Children under 2 years of age that were seen jumped from 10% to 18%

Diane Lowry, MPH, MSW