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Rethinking Oral
Health Intervention:
Meeting Families
Where They Are
Christie Lumsden, PhD, MS, RD, CDN
A little background…
Rethinking Oral Health Intervention: Meeting Families Where They Are November 7, 2019
• Associate Research Scientist
• PhD and MPhil in Behavioral Nutrition (2013)
• Registered Dietitian and NYS Certified Dietitian-Nutritionist (2010)
• MS in Nutrition Education (2009)
• Engaged in behavioral intervention research to reduce oral health
disparities in children
Most prevalent chronic
disease of U.S. children
• 21.4% of 2-5 year olds
• 50.5% of 6-11 year olds
Second most prevalent
chronic oral disease
• 40-90% of the global
population
DENTAL CARIES
Oral diseases remain a persistent problem…
1. Fleming E, Afful J. Prevalence of total and untreated dental caries among youth: United States, 2015–2016. NCHS Data Brief, no 307.
Hyattsville, MD: National Center for Health Statistics. 2018
2.Najeeb, S., Zafar, M. S., Khurshid, Z., Zohaib, S., & Almas, K. (2016). The role of nutrition in periodontal health: an
update. Nutrients, 8(9), 530.
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Caries disproportionately affects
low-income and minority children
• Low-income children are more than 2x as likely to have an untreated
dental cavity or pain.
• Children of recent immigrants have caries rates 3x higher and decay is
often more severe.
• Hispanic and African American children have worse overall oral health
and more severe decay, yet are half as likely to have a dental visit.
1. Nunn, M. E., Dietrich, T., Singh, H. K., Henshaw, M. M., and Kressin, N. R. (2009). Prevalence of early childhood caries among very
young urban Boston children compared with US children. J public health dent 69(3), 156-162. PMCID: PMC2814600
2. Rivara, F. P., Erwin, P. C., and Evans, C. (2011). Improving access to oral health care for vulnerable and underserved populations.
Washington, DC: The National Academies Press.
3. Edelstein, B. L., and Chinn, C. H. (2009). Update on disparities in oral health and access to dental care for America's children. Acad
Pediatr, 9(6), 415-419. doi: 10.1016/j.acap.2009.09.010. PMID: 19945076
4. Cruz, G. D., Chen, Y., Salazar, C. R., and Le Geros, R. Z. (2009). The association of immigration and acculturation attributes with oral
health among immigrants in New York City. Am J Public Health, 99 Suppl 2, S474-480. doi: 10.2105/ajph.2008.149799. PMID: 19443820
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Oral Health Disparities and Inequity
• These disparities are not simply differences between populations. They
represent inequities in health.
• Affect groups marginalized because of racial, ethnic, sociocultural
characteristics, including:
- socioeconomic status - disability status
- race/ethnicity - geographic location
- sexual orientation - gender
Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help
Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention; 2008.
Health Equity as Social Justice in Health
Oral health is Essential for Overall Health
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Poor oral health is associated with:
• Increased use of medical services
• Increased risk for chronic conditions, including heart disease
and diabetes
• Lost work/school time and lost wages
• Reduced quality of life
• Limited employment opportunities
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Drivers of Oral Health Inequities
• Limited access to dental care providers
• Health Professional Shortage Areas (HPSAs)
• Lack of culturally and linguistically competent providers
• High cost of dental insurance and services
• Poor oral health literacy, limited knowledge of disease and prevention
• Limited access to transportation, childcare, paid time off
• Unhealthy food environments
• Abundance of high-fat/sugar foods; limited fresh fruits/vegetables
• Competing demands – health, housing, social, legal challenges, etc.
• … and others
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Fisher-Owens, S. A., Gansky, S. A., Platt, L. J., Weintraub, J. A., Soobader,
M. J., Bramlett, M. D., & Newacheck, P. W. (2007). Influences on children's
oral health: a conceptual model. Pediatrics, 120(3), e510-e520.
Traditional dental care plays an essential role in health
promotion and maintenance
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
…but it isn’t the only, or even the best, approach for all
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Determinants of
Health
Source: “Lots to Lose: How America’s Health and Obesity Crisis Threatens our
Economic Future,” Bipartisan Policy Center (June 2012); Derived from information
from the Boston Foundation (June 2007)
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Determinants of
Health
Health
Biology & Genetics
Education
Physical Environment
Social Networks
Health Services
Income & Employment
Culture
Individual Behaviors
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Alternative, innovative intervention approaches are needed
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where
They Are
Health begins long before we visit a doctor…
Robert Wood Johnson Foundation Social Determinants of Health:
https://www.rwjf.org/en/our-focus-areas/topics/social-determinants-of-health.html
Rethinking Oral Health Intervention
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
• Dentists
• Physicians
• Allied Health Professionals
• Brick & Mortar Clinics
• Mobile Units
• Teledentistry
• Mobile Technology
• Community-based Organizations
• Community Health Workers
• Community Dental Health Coordinators
• Dental Health Aid Therapists
• Health Disparities
• Social Justice
• Reaching Underserved Communities and Vulnerable Populations
Health Equity
Community-based
Initiatives
Clinical Workforce
Care Delivery Models
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where
They Are
Rethinking Oral Health Intervention
to address Childhood Caries
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where
They Are
Typical Treatment for Early Childhood Tooth Decay
• Fillings
• Stainless Steel Crowns
• Surgical Extractions
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Surgical treatment does not address the underlying disease process…
and results in a high failure rate
Did you know?
Photograph: Stuart Isett for The New York Times (March 6, 2012)
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
53%21%
26%
Relapse Rates53-79%
Children Relapse
After Dental
Repair in the OR
Current dental care alone is only a Band-Aid solution
Dentists , Payers, & Parents are all seeking a
lower cost alternative with better health outcomes
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Effectively Combating Caries
Need to address the two key mediators:
Daily Diet- & Fluoride-related Behaviors
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Fisher-Owens, S. A., Gansky, S. A., Platt, L. J., Weintraub, J. A., Soobader,
M. J., Bramlett, M. D., & Newacheck, P. W. (2007). Influences on children's
oral health: a conceptual model. Pediatrics, 120(3), e510-e520.
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Tooth decay can be stopped by
fostering effective partnerships to increase
understanding of the disease process and
support action to reduce risk through
daily diet and fluoride behaviors
Shifting from dental care to oral health
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
The CHW Connection
Community Health Workers (CHWs) extend the reach of healthcare
providers.
• Are seen as peers, sharing cultural, linguistic, racial/ethnic backgrounds
• Meet people where they are, in home and community settings
• Provide health education
• Help families navigate complex health systems
• Provide an essential link to social services (housing, food, legal,
insurance, etc.)
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Better Health Outcomes
Lower Costs
Improved Patient
Experience
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Overarching Aim
To stop caries progression in affected children and
reduce their risk of future decay
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
An iPad-based family-level intervention that:
Seeks to eradicate early childhood caries
Targets two primary disease mediators: Diet and Oral Hygiene
Designed to be delivered by lay health workers in the community
https://vimeo.com/114512516
Password: smile
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
MySmileBuddy supports engagement between lay
health workers and families through:
1. Parent Engagement, Education, and Training
2. ECC risk assessment (including dietary risk)
3. Individualized risk score analysis
4. Family-specific goal setting
5. Family-designed action planning
6. Wrap-around support
About MySmileBuddy
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
• Innovation in mobile technology moves fast!
• Medicaid claims data for hospital-based dental care are often incomplete
• Clinical charting across sites is difficult to standardize
• Hiring, managing and retaining CHWs poses unique challenges
• CBOs are unique in management and structure
• Turnover is fairly common
• Difficult-to-reach target population
• Misconceptions about oral health and caries
• Oral health vs. dental care
• Sense of immediacy and concern often lower than other diseases
A few highlights from our experience…
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
• Providers’ acceptance of disease management approaches
• Many families are interested and motivated!
• High acceptance in clinics and Head Start centers
• Over 1,200 children enrolled
• CHWs/CBOs are eager and ready for engagement!
• Training was an eye opening experience
• CHW feedback and input are invaluable!
• Interest in scalability and ability to reach more families
• Project team collaboration, cooperation and communication
• Effective problem solving
• Creative solutions
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
“The mouth is the window to all
the diseases of the body”
Oral Health in America: A Report of the Surgeon General
… but it’s not the only target for oral health intervention
United States Department of Health and Human Services (DHHS). (2000). Oral
Health in America: A Report of the Surgeon General Rockville, MD. Retrieved from
http://silk.nih.gov/public/[email protected]. PMID:11324049
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Christie Lumsden, PhD, MS, RD, CDN
phone: 212.342.0137
email: [email protected]
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Healthy People 2020 Definition
“…a particular type of health difference that is closely linked with
economic, social, or environmental disadvantage.
Health disparities adversely affect groups of people who have
systematically experienced greater social or economic obstacles
to health based on their racial or ethnic group, religion, socioeconomic
status, gender, age, or mental health; cognitive, sensory, or physical
disability; sexual orientation or gender identity; geographic location; or
other characteristics
historically linked to discrimination or exclusion.”
November 7, 2019Rethinking Oral Health Intervention: Meeting Families Where They Are
Everyone gets the same thing vs. everyone gets the same opportunity
http://www.maine.gov/dhhs/mecdc/health-equity/