Oral Health Research: A Social Disparities...

Oral Health Research: A Social Disparities Perspective Benjamin Chaffee Lisa Chung Stuart Gansky UCSF Center to Address Disparities in Children’s Oral Health Center on Social Disparities in Health Seminar Series November 5, 2014

UCSF Center to Address Disparities in Children’s Oral Health

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Oral Health & Oral Health Disparities: A Global Overview

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Oral Health & Oral Health Disparities

Oral Health is Health Medicine and Dentistry have professional boundaries The biological and social determinants of what makes us healthy or sick affect the entire body

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Determinants of Poor Oral Health

Oral Health is Health

Tobacco Alcohol Sugar Low Fruit/Vegetable Intake Oxidative Stress Low Health Literacy Limited Access to Care Inadequate Social Support

Poverty Lack of Preventive Behaviors Stigma Bacterial/Viral Infections Genetic Predisposition Poor Parental/Family Health Physical Inactivity Limited Education/Opportunity

Determinants of Poor Oral Health

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Oral Health: More Than Cavities

Periodontal disease Tooth loss Oral cancer Noma (cancrum oris) Oral infections Salivary dysfunction Caries: children and adults

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Poor general health can be reflected in the oral cavity:

Diabetes is major contributor to periodontal disease

HIV/AIDS can lead to oral infections/complications

Image credit: Dr Augustin Zerón (left); public domain files from Wikimedia Commons

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Oral health affects general health and quality of life: Pain and infection Nutritional intake Self-confidence and appearance Lost time from work or school

First-person perspective: <http://aeon.co/magazine/health/the-shame-of-poor-teeth-in-a-rich-world/>

Poor oral health perpetuates over the life-course and across generations

https://mail.ucsf.edu/owa/redir.aspx?C=_Fy9nr4_20KE4jfatxIiK2WyXpPcxdEI0vjrJuxHjEAFt8OT_DjswELew08IhPZQQzZz1SRNof0.&URL=http://aeon.co/magazine/health/the-shame-of-poor-teeth-in-a-rich-world/

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Impact of Poor Oral Health on Society

>4 million Emergency Department visits for dental conditions in US, 2008-2010. ~1% of all ED visits, $2.7 billion in charges ($760/visit) 101 deaths

Sources: Allareddy, Rampa, Lee, et al. JADA 2014; 45:331-337. http://www.washingtonpost.com/wp-dyn/content/article/2007/02/27/AR2007022702116.html

Deamonte Driver, 12-year-old boy near Washington DC, died from complications of dental infection in 2007 after his family unable to access timely dental care

Oral conditions affect nearly 60% of people worldwide:

>3.9 billion individuals

Marcenes, et al. (2013) J Dent Res 92(7):592-7 Vos, et al. (2012) Lancet 380(9859):2163-96

Pop

ulat

ion

(thou

sand

s)

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The Global Burden of Oral Conditions

Marcenes, et al. (2013) J Dent Res 92(7):592-7 Vos, et al. (2012) Lancet 380(9859):2163-96

Pop

ulat

ion

(thou

sand

s)

untreated dental caries, adult teeth

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The Global Burden of Oral Conditions

11 Source: http://viz.healthmetricsandevaluation.org/gbd-compare/

DALYs per 100,000 population attributable to dental caries

http://viz.healthmetricsandevaluation.org/gbd-compare/


DALYs per 100,000 population attributable to periodontal disease






DALYs per 100,000 population attributable to tooth loss





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The Daily Telegraph (London) mapped the prevalence of tooth decay among 3-year-olds from all English local authorities that provided data. (Sept 30, 2014)

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= 75% - 100% = 50% - 75% = 25 % - 50% = < 25%

source: http://www.cdc.gov/fluoridation/statistics/2012stats.htm

Water Fluoridation Status in in Pennsylvania, by County

http://www.cdc.gov/fluoridation/statistics/2012stats.htm

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Trends in Children’s Oral Health Disparities: an Example from Brazil

modified map; original by Raphael Lorenzeto de Abreu

Canoas

BRAZIL

Canoas, Brazil State: Rio Grande do Sul

Suburb of Porto Alegre Population (2010): 324,000 31st largest GDP in Brazil 553rd by Human Development Index HDI increasing: 0.665 in 2000 0.750 in 2010

Source: Brazilian Institute of Geography and Statistics

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Reference: Kramer, Chaffee, Bertelli, et al. (2014) Int J Paediatr Dent [in press]

Two Survey Waves, Ten Years Apart:

Oral Health Canoas 2000 1487 children in 28 preschools Oral Health Canoas 2010 1306 children in 31 preschools Recorded dental health status and indicators of family socio-economic position for children age < 6 years

2000 2010 2000 2010 0

10

20

30

40

50 Caries Prevalence (%)

39.6 1.53

0

0.5

1.0

1.5

2.0 Caries Severity (dmft)

25.9 1.13

Substantial Dental Health Improvements: Canoas, Brazil (2000 to 2010)

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NOT Distributed Equally

LOW MATERNAL EDU.

HIGH MATERNAL EDU.

0

10

20

30

40

50

Car

ies

Pre

vale

nce

(%)

2000 2010 2000 2010

43.3

33.4 35.1

21.0

Relative Change: -22.8% Absolute Change: -9.9 per100

Relative Change: -40.1% Absolute Change: -14.1 per100

0

0.5

1.0

1.5

2.0

Car

ies

Seve

rity

(dm

ft)

1st (lowest) 2nd 3rd 4th 5th (highest) HOUSEHOLD INCOME QUINTILE

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NOT Distributed Equally

2000

2010

Slope Index Inequality: - 0.73

Slope Index Inequality: - 0.82

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Brazilian primary health care system reorganized in 1990s and significantly expanded in 2000s “Oral health teams” were incorporated into public health centers, with emphasis on service utilization (Navarro, 2012) Major expansion in number of dentists; >100 new dental schools opened 1995-2008 (Saliba, 2009) Striking inequalities in access/utilization of dental services and in perceived treatment needs (Peres, 2013)

Reducing Oral Health Disparities CAN DO Multidisciplinary Research

UCSF Center to Address Disparities in Oral Health

Support: US DHHS NIH/NIDCR U54 DE 014251, R03 DE 018116, R21 DE 018650, R21 DE 019210, U54 DE 019285, P30 DE 020752

CreativeCommons.org attribution, non-commercial, cite alike

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A Public Health Problem

• International, National, California and local San Francisco data reveal oral health disparities.

• Higher caries prevalence among young children of color and low socioeconomic status families than white children and those from higher SES families.

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• To reduce oral health disparities among children and their caregivers through research, training, and dissemination with community partners

• Focus: preventing and reducing

early childhood caries

CAN DO Mission

.

Interdisciplinary Research

• Cariology • Medical

Anthropology • Epidemiology • Biostatistics • Microbiology • Pediatric Dentistry • Public Health

Dentistry

• Health Services Research

• Clinical Trials • Linguistics • Adolescent Medicine • Nursing • Molecular Biology • Health Literacy

Multidisciplinary Research Transdisciplinary Research

Summary of Study Populations • Low-income Hispanic, Chinese, Filipino,

African-American families • Preschool children • Parents/caregivers • Pregnant women • Agricultural worker families • English language learners • Dentists, Primary medical care providers

CANDO’s Partners in California

DAVIS

San Francisco Mendota

San Ysidro SAN DIEGO

San Jose

SACRAMENTO Albany/Berkeley

Oakland

Salinas

LOS ANGELES

Conceptual Framework of Children’s Oral Health Child, family, & community influences on child oral health outcomes

Microflora

Substrate (diet)

Host & Teeth

Oral Health

Child Level Influences

Development

Use of Dental Care

Dental Insurance Biologic and

Genetic Endowments

Physical Attributes

Health Behaviors and Practices

Family Level Influences Socioeconomic Status

Social Support

Health Status of Parents

Family Composition

Family Function

Health Behaviors, Practices, and Coping Skills of Family

Social Environment

Community Level Influences

Dental Care System Characteristics

Health Care System Characteristics

Physical Environment

Culture Social Capital Physical Safety

Community Oral Health Environment

Time

Fisher-Owens et al. Pediatrics 2007 NIH/NIDCR R03DE016571

Fisher-Owens, Gansky et al. 2007

Glass Ionomer & Fluoride Varnish Trial (GIFVT) Stuart Gansky, UCSF PI; Francisco Ramos-Gomez, UCLA PI

Metagenomics (Metagene) Ling Zhan, PI

CenteringPregnancy® Oral Health Promotion Extension (CPOPE) – Lisa Chung, PI

Salt Fluoridation Feasibility Judith Barker, PI

FV REACH Peggy Walsh, PI

Mediation Model Jing Cheng, PI

Data Coordinating Center – Steve Gregorich, PI

52 MDs and 298 nurses and WIC staff trained to apply FV in Contra Costa, El Dorado, Fresno, Lake, San Mateo, & Sonoma Counties

Hoeft et al. 2011

Caregiver: " I think it’s good because you don’t have to go anywhere, I mean, and especially people who don’t have transportation like that, it’s very good to just to be able to pick up the phone and be able to call and get your questions answered versus having to schedule a doctor’s appointment or go through all that. It’s not time consuming. It’s not costly and it’s just right there at your fingertips.”

Answered Caregiver Automated Telephone Education Call (N=56)






Mediation Model Jing Cheng, PI

CaMBRA Intervention

(CHX rinse, F rinse)

Mediator caries risk (high/low)

Dental Outcome: DMFS Increment direct effect

indirect effect

Cheng et al. In Press

RAP R21 Nancy Burke

RAP DentaQuest URM Willamette Dental Kellogg Beth Mertz

F31 Kristin Hoeft

RAP fundable KL2 Benjamin Chaffee

RAP Hellman Fdn Scholar R03 resubmission Ann Lazar

R34 resubmission Hellman Fdn Grant RAP submission Sally Adams & Lisa Chung

K23 Liliam Pinzón

Fostering New Research Projects and Junior Faculty

SFHIP Bahar Amanzadeh

caries health disparities in California school-children:

1993-94 to 2004-05 Stuart A. Gansky, DrPH

Gloria C. Mejia, DDS, MPH, PhD Estefania Guerreros

Pamela Z. Han, BS, MPH Nancy F. Cheng, MS, MS Sally H. Adams, RN, PhD

University of California, San Francisco Center to Address Disparities in Children’s Oral Health

US DHHS/NIH/NIDCR R03 DE 018116 & NDDK R25 DK78382-04

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measuring health disparities • define reference group • use healthier group as reference • absolute & relative differences • report adverse health effects • compare all groups with ref • use summary measures • but also report each group • use weights if justified • consider population size • use ordered summary measures • report confidence intervals Keppel et al. 2005

US DHHS Monograph

11 guidelines

health disparity indices Absolute • Range (rate) difference (RD) • Between group variance (BGV) • Absolute concentration index (ACI) • Slope index of inequality (SII)

Relative • Range (rate) ratio (RR) • Index of disparity (ID) • Mean log deviation (MLD) • Theil index (T) • Relative concentration index (RCI) • Relative index of inequality (RII(mean)) • Kunst-Mackenbach relative index (KMI)=RII(ratio) 40

Harper&Lynch 2005

US DHHS Monograph

NCI SEER HD*Calc

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HD*Calc summary

11 HDIs: estimates & 95% CIs nominal or ordinal groupings graphs (basic) import cross-classified means, SEs, counts

from survey data estimation program (somewhat peculiar data structure) good documentation

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2004-05

1993-94

0

25

50

75

100

0255075100

% U

ntre

ated

Den

tal C

arie

s

% School FRL Participation

Trends in % Untreated Caries by % FRL in 1993-94 AND 2004-05 CA Elementary schools

FRL = Free / Reduced cost Lunch program

Slope Index of Inequality (SII)

Lower SES Higher SES

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0 1 2 3 4

Prev

alen

ce

Year

Group D

Group C

Overall

Group B

Group A

D v A Odds Ratio: 2.25 2.33 2.67 3.86

Prevalence Differences: D -A = 0.200

Schematic Constant Decrease: Prevalence Difference Constant, Odds Ratio Increasing

Absolute HDI Measures

Relative HDI Measures ?

Absolute & Relative HD Indices differ In most scenarios, Absolute HDIs assess public health and policy targets

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Absolute Concentration Index (ACI) untreated caries

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low %FRL = high SES

high %FRL = low SES

1993-4

2004-5 Line of Equality

Higher SES Lower SES

Overall Prevalence ACI = Area Under the Curve (AUC)

Absolute Concentration Index (ACI) No Sealant

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3rd graders

Higher SES Lower SES

50

2004-5 California Oral Health Needs Assessment of Children (Smile Survey)

Socioeconomic Status & Language

Individual child level: free/reduced price lunch participation NS language other than English spoken at home p<0.05

N=10,450 Third Graders in 182 schools

R03 DE 018116 Dental Health Fdn, HRSA, CDA Fdn, ASTDD, CA First 5, CA Endowment

Mejia et al. CDOE 2010

Oral health interventions that address social determinants of health

Oral health in prenatal care Oral health in middle schools

UCSF-Elev8 Healthy Students & Families

• The Atlantic Philanthropies’ national initiative: struggling middle schools thriving places of learning and wellness

1. Enhanced learning 2. School based health centers 3. Family support services 4. Family engagement and advocacy

Awarded by Atlantic Philanthropies 6/11-6/14

School based health centers • Provides on-site primary

and mental health services, oral health sometimes included

• Promotes school and community health partnerships

• Strategically targets underserved populations

• Increases student success

Health starts where we live, learn, work and play

Educational attainment Health

SBHCs

Implementing CAMBRA in a School Setting: a pilot study

University of California San Francisco advancing health worldwide

Caries Management By Risk Assessment

MANAGEMENT ASSESSMENT

CAMBRA implementation

• Summer 2012 • Risk assessment and counseling

in the school health center • Tailored daily management

– 1 month in-class toothbrushing, rinsing plus supplies for home care

– 2 months at-home

At-Home Management

3-month Assessment

• Questionnaire • CAMBRA exam

Baseline Assessment


Fluoride varnish, sealants

1-month Assessment


In-Class Management

Summer School (n=54)

Supervise At-Home

Management

Post-study questionnaire

June 2012 July 2012 September 2012

Measures Baseline 1 mo 3 mo

Child Feasibility: Compliance Acceptability

Calendars Questionnaires

✔ ✔

✔ ✔

Parent and Teacher: Feasibility Acceptability

Questionnaire Questionnaire

✔ ✔

CAMBRA effectiveness: Oral Bacteria Oral Hygiene Caries Risk Level Child Knowledge Child Behaviors

ATP Bioluminescence Plaque Index CAMBRA screening Questionnaire Questionnaire

✔ ✔ ✔ ✔ ✔

✔ ✔ ✔ ✔ ✔

✔ ✔ ✔ ✔ ✔

Outcome Measures

Total Number (n=51) % Grade level 7th

8th

65 35

Race/Ethnicity Latino Black Asian/Pacific Islander

84 6 10

Language Preferred English Spanish Other

84 8 8

Sample Description

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Feasibility and Acceptability

• Compliance with daily management: 94% (1 mo) and 50% (3 mo)

• 100% liked all/some of the products; felt information received was important

• 88% found it easy to follow daily management • Parent and teacher ratings “extremely high”:

– Perceived importance of program – Ease of implementation; time required for daily

management – Satisfaction with information provided – Satisfaction with level of parent involvement

Effectiveness

Baseline (n=51)

1 month (n=48)

3 month (n=44) ΔBL-1mo ΔBL-3mo

Retention - 94% 86% - -

Bacterial ATP

5617 3754 6736 -1840 (p=0.0007) 1184

Plaque Index

0.80

0.77 0.73 -0.03 -0.04

Caries Risk Level

Low: 6% Mod: 16% High: 78%

Low: 10% Mod: 13% High: 77%

Low: 34% Mod: 16% High: 50%

-

38% from High to

Mod/Low (p=0.0001)

69%

30%

91%

37%

76%

24%

0%

20%

40%

60%

80%

100%

Brush 2x/day Floss once/day

%

Baseline1 month3 month

Oral health behaviors

p=0.002

• Well received by the teacher and families • High feasibility and acceptability • In-class daily management was effective in

lowering bacteria levels • Implications

– Inform the roll out of CAMBRA at other Elev8 schools

– use data for future grant applications.

Conclusion

CenteringPregnancy Oral Health Promotion (CPOP) Project

PI’s: Sally Adams & Lisa Chung

Why Maternal Oral Health? OH problems

common during

pregnancy

Cariogenic bacterial

transmission to infants

Periodontal disease and

adverse pregnancy outcomes?

7 months pregnant

•pre-chewing food •sharing utensils •cleaning pacifier in mouth

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Low dental care utilization during pregnancy

96%

35%

0

20

40

60

80

100

Dental visit Prenatal visit

2006 CA Maternal and Infant Health Assessment

CenteringPregnancy® Centering: a model for group health care Empowerment through knowledge & building skills

Over 300 sites across U.S.

CP® model of care Assessment

Self-assess BP, weight, gestational age Provider assesses maternal/fetal health

Education Ten 2-hour sessions of 8-12 women Circle led by a facilitator Facilitative, interactive, fun

Support Confidentiality, group stability Sharing and learning from each other Social time

no consistent oral health curriculum

Assessment

Education Support

CenteringPregnancy® Oral Health Promotion (CPOP)

Study aim: To develop and pilot test an oral health intervention for CP group prenatal care

I. Development & Training Phase Meetings with CP facilitators Focus groups with CP women

II. Pilot test & Evaluation Phase 4 CP sites: 2 intervention sites, 2 control sites

Behaviors

Personal factors

Environmental factors

Intervention Development

Social Cognitive Theory

Intervention Development CP® Care Components Social Cognitive Theory Assessment

Behaviors

Education Personal factors

Support Environmental

factors

2 session curriculum: Maternal & Infant oral health

Intervention Development

Precede Proceed Planning model Social Cognitive Theory

Community engaged -CP collaborators

-CP facilitators -CP women

Two 15 minute modules

Two CP sessions

Facilitator led Interactive

Discussion-based

Educational Skills-building

Brief Low-cost

Sustainable

CPOP Intervention

CPOP Evaluation

CPOP intervention during pregnancy Pre-post assessments during pregnancy,

6 months, 12 months postpartum: Maternal

- gingival health, plaque (dental exams) - knowledge, attitudes, behaviors (questionnaires)

Infants - cariogenic bacteria (salivary assays) - Knowledge, attitudes, behaviors (questionnaire)

Sample characteristics (N=99)

Hispanic 65%

White 20%

Other 15%

Race/Ethnicity

< High School

23%

High School

25%

> High School

52%

Highest Education

Public 56%

Private 29%

None 15%

Dental Insurance

< 20K 54% 20-59K

22%

60-99K 9%

≥ 100K 15%

Income

Baseline findings: OH disparities

45% untreated caries Higher burden of caries and gingival disease:

Hispanic Public dental insurance No dental visit in past 6 months

Mediation analysis:

Chung LH, Gregorich SE, Armitage GC, Gonzalez-Vargas J, Adams SH. Sociodemographic disparities and behavioral factors in clinical oral health status during pregnancy. Community Dent Oral Epidemiol. 2014 Apr;42(2):151-9

Hispanic, low-income

Oral Health Status • Gingival disease • plaque • untreated caries

Dental visit in past 6 months

Direct effects

Indirect effects

% Change in Plaque Levels by Group

-60

-40

-20

0

20

40

60

80

Improved No Change Worsened

% women

Intervention

Control

p= 0.0138

% Change in Probing Depths

-80

-60

-40

-20

0

20

40

60

Improved No Change Worsened

% women

InterventionControl

p= 0.0018

% Change in # of Bleeding on Probing Sites

p= 0.0001

% Infants with MS and LB at 12 months

23.9

15.2

10.5

5.3

27.4

17.8

0

5

10

15

20

25

30

MS LB

TotalCPOP interventionControls

Conclusions

A brief education and skills- based intervention delivered by non-dental providers in prenatal care may be effective in improving women and children’s oral health.

What’s next…

Further analysis NIH R34 planning grant for U01 clinical trial RAP grant to pilot test text message

intervention during post-partum period Future directions

Expand into other group care settings CenteringParenting

Acknowledgements

CPOP CP® partners: facilitators, women, Sharon Rising NIH/National Institute of Dental and Craniofacial Research

(NIDCR) Award #R21DE019211 UCSF Center to Address Disparities in Oral Health (CAN DO)

NIH/NIDCR Award #U54 DE019285 Dental Trade Alliance Foundation

CAMBRA in Schools Elev8 partners: Native American Health Center Oakland,

United for Success Academy, UCSF School of Nursing Atlantic Philanthropies American Association for Dental Research

Oral Health Research: A Social Disparities...

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