News
Tooth or consequences: The costs of poor dental fitness
The traditional divide between dentistry and medicine is shrinking as data accumulate linking oral health with overall health.
A few years ago, an extremely sick, 2½-year-old boy came to the Houston office of pediatrician Ray Wagner, MD, with a 105-degree temperature. The illness, which required five days of hospitalization and a course of intravenous antibiotics, got its start in an infected tooth; which, in turn, resulted from poor dental hygiene and a lack of dental care. Dr. Wagner, who was then an assistant professor at the University of Texas Medical School, decided to use this case as a hook for an educational session on oral health.
"We discovered that early childhood caries [tooth decay] was the most common chronic disease of children," he said. "We were all shocked."
Now a staff physician at El Rio Community Health Center in Tucson, Ariz., he is one of more and more physicians who are looking at patients' mouths and teeth before moving on to their throats. These doctors are motivated by both firsthand experiences and the scientific literature documenting that health in this area makes a difference to the whole body.
An increasing number of physicians are educating patients on cleaning teeth and gums and advising parents on reducing the risk of transmitting cavity-causing bacteria from their own mouths to their children's. Fluoride varnishes are being applied to teeth in doctor's offices, and dentists are being added to the list of specialists consulted as needed.
"The mouth is part of the body," said Wanda Gonsalves, MD, associate professor of family medicine at the Medical University of South Carolina in Charleston. She began her career as a dental hygienist. "I'd really like dentists and physicians to co-ordinate more and not have the mouth treated as a totally separate entity."
The American Medical Association and other medical organizations have supported water fluoridation, but a movement is now emerging to have physicians more involved in mouth health. This interest had its start with the release of the surgeon general's 2000 report, "Oral Health in America." It pushed the message that oral health means more than teeth, is an integral part of wellness, and nondentists need to be involved.
"You can't be healthy if you don't have good oral health," said David Satcher, MD, PhD, who was surgeon general at the time of the report's release and is now director of the Center of Excellence on Health Disparities and the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta.
Children's health
Physicians have since taken this report and applied it in various ways. The American Academy of Pediatrics published policy in the May 2003 Pediatrics urging pediatricians to start evaluating oral health at six months of age. Revised guidelines are expected before the end of this year. Also, a major educational session on the subject is being planned for the organization's annual meeting in October.
"We have to help physicians make [oral health] doable and make it easy, so it becomes second nature and no different than when you check the fingernails or the eyes or the ears," said Martha Ann Keels, DDS, PhD, chair of AAP's section on pediatric dentistry and head of pediatric dentistry at Duke University in Durham, N.C.
The U.S. Preventive Services Task Force recommended in April 2004 that primary care physicians prescribe fluoride supplements to preschoolers who primarily drink unfluoridated water. The Society of Teachers of Family Medicine launched "Smiles for Life," a curriculum designed to educate medical students and residents on oral health, in October 2005. A second edition will come out this summer. The New York Academy of Sciences hosted a symposium on this subject in January.
"Because of the historical separation of medicine and dentistry, there is a framework of thinking which separates dental care and oral health from medical care and general health. [The NYAS meeting] was one of many efforts to reconnect the mouth to the body," said Burton Edelstein, DDS, MPH, professor of clinical dentistry, health policy and management at Columbia University and a member of the event's planning committee.
These actions also were taken because, although overall dental health has improved, statistics related to children suggest the future may not be so bright. Dental caries is five times more common in children than asthma. An estimated 51 million school hours are missed annually because of health problems affecting the mouth. Data released by the Centers for Disease Control and Prevention's National Center for Health Statistics in April 2007 indicated that tooth decay in ages 2 to 5 increased for the first time in years.
"We as pediatricians haven't done a very good job of preventing disease in those youngest children," said David Krol, MD, MPH, chair of the pediatrics department at the University of Toledo's College of Medicine in Ohio and a member of the AAP's Oral Health Initiative Steering Committee. "Our previous policy in pediatrics was that we don't need to send a child to the dentist until they're age 3. By default, we were taking responsibility for those children's oral health."
Experts are particularly concerned because having bad teeth is a problem that goes far beyond the aesthetic and can become more serious as a child grows into adulthood.
"We are understanding more and more that having early childhood caries invariably sets you up to develop tooth decay of the permanent teeth," said Dr. Wagner. "Once the bacteria are well established in your mouth, they persist, and they're very hard to get rid of. Early oral disease predicts lifelong oral disease."
The mouth-body connection
And this circumstance can have implications beyond the mouth. The first signs of some diseases such as osteoporosis or HIV infection can show up in the mouth, but poor oral health can also cause damage to the rest of the body. Over the past decade, published studies have linked tooth loss to dementia and associated it with poor pregnancy outcomes. Dental plaque can be a source of ventilator-associated pneumonia among intensive care patients. Tooth decay may increase the risk of heart disease. Diabetes can increase the risk of gum disease, and, conversely, leaving this problem untreated can make blood sugar control next to impossible.
While significant data has tied such conditions to periodontal disease, attempts to improve them by going for the teeth have had mixed results. A study in the Nov. 2, 2006, New England Journal of Medicine reported that treating periodontal disease in pregnant women had no impact on the risk of preterm birth, although related research is continuing.
Other studies have been more positive. One in the March 1, 2007, issue of the same journal found that treating periodontitis could improve endothelial function. Others also documented that caring for the teeth can improve glycemic control in diabetics.
"In general the field is comfortable with the finding that treating periodontal disease in a diabetic will contribute to their glycemic control," said Robert Genco, DDS, PhD, distinguished professor of oral biology and microbiology at the State University of New York at Buffalo, who has authored numerous studies on this subject. "It probably wouldn't hurt [for physicians] to say this is a possible complication and you should see your dentist. People see their dentist anyway, but we have found that if the primary care physician makes a recommendation like that, the patients oftentimes will listen to that carefully and act on it."
Although physicians are getting more involved in oral health because of the science, the lack of access to dental care faced by so many patients -- in part because there are far fewer dentists than physicians -- also is an important factor driving their interest and involvement.
"There aren't enough dentists in this country. We really do need primary care physicians jumping on board," said Catherine Hayes, DMD, DMSc, chair of the Dept. of Public Health and Community Service in the School of Dental Medicine at Tufts University in Boston, who is investigating the impact of poor oral health on children's growth.
Patients also have more difficulty financing dental care. Far more lack dental than medical insurance. Medicare does not cover most dentistry. Medicaid dental coverage for adults is optional, although quite a few states do provide this benefit to some degree. Children on Medicaid have coverage, but because of low reimbursement rates and other issues associated with the program or with living in poverty, they can have a very difficult time finding a dentist who will see them. These realities mean disparities in oral health generally run directly along economic lines. According to data from the Agency for Healthcare Research and Quality, released in September 2007, 26.5% of those in poor families saw a dentist annually, while 57.9% of those from high-income families did.
"This is a problem that doctors have to grab hold of if we're really going to make inroads here," said Alan Douglass, MD, associate director of the family medicine residency program at Middlesex Hospital in Middletown, Conn., and co-chair of the STFM's oral health workgroup. "This can't just be relegated to dentists. There are just too many linkages to overall health, and the reality is that while most patients in the United States have access to some form of medical care, many fewer have access to dental care."
And the consequences of not being able to access care can be catastrophic. Last year, newspapers were filled with stories of 12-year-old Deamonte Driver of Prince George's County, Md., a Washington, D.C., suburb, who died of a brain infection caused by untreated dental disease. On and off Medicaid and occasionally homeless, he was not able to get care.
"Deamonte Driver's inability to obtain timely oral health care treatment underscores the significant chronic deficiencies in our country's dental Medicaid program," said Kathleen Roth, DDS, during a March 27, 2007, congressional hearing held in response to the incident. She was president of the American Dental Assn. at the time. "Fundamental changes to that program are long overdue, not simply to minimize the possibility of future tragedies, but to ensure that all low-income children have the same access to oral health care services enjoyed by the majority of Americans."
A bill was subsequently introduced in the U.S. House calling for increased funding of federally qualified health centers for dental services and training of more pediatric dentists. The proposal is currently in committee.
- reprinted from the AMA News
Oral Health Survey Finds Significant Oral Health Disparities in Massachusetts Children
A statewide survey of Massachusetts children, conducted by Dr. Michelle Henshaw in collaboration with the New England Research Institutes and the Catalyst Institute, found significant disparities in children’s oral health status and oral healthcare among racial, ethnic and socioeconomic groups.
The survey results showed that one out of ten Black, Hispanic and low-income children in the third grade are suffering from pain in their teeth and mouth. 58 percent of Hispanic third graders and 51 percent of Black third graders suffer from dental decay versus 36 percent of white third grade children. In addition, 60 percent of third grade children from low-income families suffer from dental decay compared to 33 percent of children from higher income families.
More detailed results of this survey can be found in the executive summary and the full report.
NIDCR Funds Practice-Based Research Networks
In March 2005, NIDCR awarded three seven-year grants, totaling $75 million, to establish practice-based research networks that investigate with greater scientific rigor everyday issues in the delivery of oral healthcare. The impetus behind the networks is the frequent lack of research data to guide treatment decisions in the dentist’s office.
Each regional network will conduct approximately 15 to 20 short-term clinical studies over the next seven years, comparing the benefits of different dental procedures, dental materials, and prevention strategies under a range of patient and clinical conditions. The networks also will perform anonymous chart reviews, as allowed by the Health Insurance Portability and Accountability Act (HIPAA), to generate data on disease, treatment trends, and the prevalence of less common oral conditions. Links to the networks that were funded are:
BUSDM Receives $4 Million Grant from Delta Dental of Massachusetts
With the goals of increasing diversity within the dental profession while increasing the number of dentists practicing in underserved areas in the state, DSM (d.b.a. Delta Dental of Massachusetts) has awarded a $4 million grant to Boston University School of Dental Medicine (BUSDM) to create the “Delta Dental of Massachusetts Scholars Program.” The gift establishes the largest endowment in the nation for dental scholarships for low income and minority students.
“Massachusetts does not have a public dental school and average tuition at the three Boston-based private dental schools is $38,500 annually,” said Dr. Ana Karina Mascarenhas, director of the Dental Public Health Program at BUSDM. “Dental school is financially out of reach for many of the state's disadvantaged students. Less than 2% of applicants to dental schools nationwide are from Massachusetts, indicating that many Massachusetts young adults, particularly low income and minority students, do not view dentistry as a viable educational path.”
To increase the number of Massachusetts low income and minority residents entering dental school, the endowment will provide scholarships to students in two new programs: the Early Dental School Selection Program and the Master of Arts in Medical Sciences Program. The Early Dental School Selection Program will identify potentially successful low-income and minority candidates in their second year of college and conditionally accept them to Boston University School of Dental Medicine. Provided they maintain an acceptable grade point average they will matriculate at BUSDM once they receive their bachelor's degree. Students will take courses during the summer and spend their entire senior year at Boston University. The second program, the Master of Arts in Medical Sciences Program, is for low income and minority students who had applied, but were not accepted into dental school. One-third of Massachusetts applicants are not accepted to dental schools each year. This program will provide these students with the opportunity to enhance their academic preparation and increase the likelihood of acceptance to dental school. The ultimate goal of the Delta Dental of Massachusetts Scholars Program is to improve access to dental care in underserved Massachusetts communities. Scholarship recipients will agree to practice in these underserved communities after graduation from dental school.“For each year students receive a scholarship they agree to practice for one year in an underserved community,” said Dr. Michelle Henshaw, director of Community Health Programs at BUSDM.
The average expected participation time for each student is four years.
“The mission of Delta Dental of Massachusetts is to improve oral health,” says Dr. Kathy O'Loughlin, President and CEO of Delta Dental of Massachusetts. “In one of the wealthiest nations on earth, the documented and increasing disparity in oral health status due to income or race is a serious public health dilemma. Delta Dental of Massachusetts' partnership with Boston University is one step toward achieving a sustainable, long-term solution to correcting inadequate access to basic health services for our neediest citizens. This is an exciting opportunity -- all Massachusetts residents deserve access to optimum oral health, and I believe through partnerships such as this that it is achievable in our lifetime.”
“Data consistently demonstrate that people living in poverty are disproportionately affected by poor oral health,” says Dr. Spencer N. Frankl, dean of Boston University School of Dental Medicine. “The Delta Dental endowment will allow Boston University to improve this situation by increasing the number of dentists who care for the state's poorest residents. An important aspect of the mission of BUSDM is to improve our community's health, and this endowment is a critical step towards achieving oral health parity across all Massachusetts populations.”
Clinical Research to Improve Oral Health of Special Needs Populations and the Elderly
The purpose of this initiative is to encourage the submission of applications focused on the oral health of special needs populations, including those who are mentally retarded, have developmental disabilities, people living with HIV/AIDS and the elderly. Clinical research projects will be solicited that include: 1) epidemiologic studies that document the prevalence, incidence and determinants of oral and craniofacial diseases and conditions, 2) behavioral and social sciences research and, 3) patient oriented research. Investigators will be encouraged to consider the submission of oral health research projects that capitalize on ongoing, funded research that address these populations.
