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Understanding, Preventing and Reducing Early Childhood Caries Jane A. Weintraub, DDS, MPH UCSF School of Dentistry Center to Address Disparities In Children’s.

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Presentation on theme: "Understanding, Preventing and Reducing Early Childhood Caries Jane A. Weintraub, DDS, MPH UCSF School of Dentistry Center to Address Disparities In Children’s."— Presentation transcript:

1 Understanding, Preventing and Reducing Early Childhood Caries Jane A. Weintraub, DDS, MPH UCSF School of Dentistry Center to Address Disparities In Children’s Oral Health (CAN DO) USPHS Symposium May 25, 2010; San Diego, CA

2 Presentation Outline 1. Terminology and Concepts 2. Examples of Oral Health Disparities 3. Research Findings from “CAN DO” -Understanding Factors Associated with ECC 4. Translating research findings into clinical practice and health policy 5. Information about new CAN DO studies 2

3 Life Expectancy at Birth by Country World Health Report, 2006 Swaziland – 36 years Sierra Leone – 37 Mexico - 72 USA, Cuba – 75 Japan, Iceland – 79 years 43 year GAP!

4 4 4 A Public Health Problem §National, State and local data reveal oral health disparities. §Higher caries prevalence among young children of color from low-income families than white children from less disadvantaged families.

5 5 5 Early Childhood Caries (ECC) Can be painful for young child; difficult and expensive to treat.

6 TERMINOLOGY §Disparity §Inequality §Inequity

7 What are Health Disparities (Health Inequalities)? HRSA Definition “ Population-specific differences in the presence of disease, health outcomes, or access to health care” From: Carter-Pokras and Baquet, Public Health Reports, 2002

8 AHRQ Definition of Health Disparities §Any differences among populations that are statistically significant and differ from the reference group by at least 10 percent. 8 Herbert, Sisk and Howell, Health Affairs, 2008

9 9 What are Oral Health Disparities? NIDCR Definition “ …the diminished oral health status of population subgroups defined by demographic factors such as age and socioeconomic status, geography, disability status, behavioral lifestyles, gender, racial or ethnic identity.”

10 §Some types of disparities are considered unavoidable differences: l Natural biologic variation l Freely chosen health damaging behavior –M. Whitehead, 1992 l But need to consider context.

11 Health Inequities WHO Definition §The WHO defines health inequities as "differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.” –Whitehead, 1992 §Not all health disparities are unfair, unjust, inequitable. Judgment call. 11

12 How do disparities arise? §“Differences in the quality of care received within the health care system § Differences in access to health care, including preventive and curative services § Differences in life opportunities, exposures, and stresses that result in differences in underlying health status” –Camara Phyllis Jones, MD, MPH, PhD

13 “ Cliff Analogy” to explain H.D. To Help People Falling off the Cliff of Good Health 13 Jones, CP et al. J Health Care Poor Underserved, 2009

14 “Cliff Analogy” 14 Jones, CP et al. J Health Care Poor Underserved, 2009

15 Examples of Childhood Oral Health Disparities National State & Local Data 15

16 Income/SES Disparities Overall Oral Health Status Children Age 1-17 by Household Income Level (% FPL) National Survey of Children’s Health, 2007 2007 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website.

17 Children with >1 Preventive Dental Care Visits During Past 12 Months by Household Income Level National Survey of Children’s Health, 2007 2007 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website.

18 18 Dye et al., 2004; NHANES III

19 19 Prevalence of Untreated Caries in primary teeth among 2-11 year olds by Race/ethnicity and Poverty Status, (NHANES, U.S, 1999-2004) Race/ethnicityFederal poverty level AI/AN 2-5 yr olds, 68%

20 20 State-level Disparities: Untreated Caries Prevalence by State From: The Cost of Delay: State Dental Policies Fail One in Five Children. PEW Center on the States, 2010

21 Geographic Disparities in Access to Community Water Fluoridation CDC/ASTDD Synopses

22 Neighborhood Factors: Access to Healthy Food §On average, how many more supermarkets are there in predominantly white neighborhoods compared to predominantly Black and Latino neighborhoods? A. about the same B. 1.5 times as many C. 2 times as many D. 4 times as many E. 6 times as many Source: Mari Gallagher Research & Consulting Group. (2006) Good Food: Examining the Impact of Food Deserts on Public Health in Chicago. Report commissioned by LaSalle Bank. ( From Unnatural Causes Health Equity Quiz

23 23 Percent of Kindergarteners in San Francisco with Caries Experience by Race/Ethnicity 2004-2005 55% 32%

24 24 Goal: Eliminate health disparities in oral, dental and craniofacial diseases and conditions among underserved populations and groups. NIDCR, 2001

25 .25 NIDCR 2009-2013 Strategic Plan §GOAL IV apply rigorous, multidisciplinary research approaches to eliminate disparities in oral, dental and craniofacial health StrategicPlan/

26 26 NIDCR Early Childhood Caries Collaborating Centers NIDCR Cooperative Agreements with: §University of California, San Francisco Center to Address Disparities in Children’s Oral Health (CAN DO) & Data Coordinating Center (DCC) l Jane Weintraub, PI, Stuart Gansky, DCC Director U54 DE019285 §Boston University Goldman School of Dental Medicine Northeast Center for Research to Evaluate and Eliminate Dental Disparities (CREEDD) l Raul Garcia and Michelle Henshaw, Co-PIs U54 DE019275 §University of Colorado Denver Center for Native Oral Health Research (CNOHR) l Judith Albino, PI U54DE019259 26

27 27 Center to Address Disparities in Children’s Oral Health (CAN DO) Supported by the NIH/NIDCR U54 DE 14251, U54 DE 019285

28 28 CAN DO Mission §Our mission is to reduce oral health disparities among children and their caregivers through research, training, and dissemination with community partners. §Current focus is on preventing and reducing early childhood caries.

29 29 “CAN DO 1” Experience §Work with communities in several parts of California §Conduct multidisciplinary, collaborative research l Qualitative and quantitative research, Randomized clinical trials §Disseminate findings and translate them into policy recommendations §Involve students at many levels

30 30 Keyes: Multifactorial Model for Dental Caries, 1962 Micro-flora Substrate (diet) Host & Teeth Oral Health Focus on individual

31 31 Copyright ©2007 American Academy of Pediatrics Fisher-Owens, S. A. et al. Pediatrics 2007;120:e510-e520. CONCEPTUAL MODEL OF CHILDREN’S ORAL HEALTH Child, family, and community influences on oral health outcomes of children

32 32 Caregivers’ Beliefs §Focus groups conducted with low-income parents of young children in African- American, Chinese, Filipino and Hispanic communities. §Qualitative, ethnographic studies conducted with low-income Hispanic families in rural and urban communities. §Cultural and generational differences found in beliefs and attitudes about dental care, especially preventive practices. Hilton et al., CDOE, 2007 Butani et al, BMC Oral Health, 2008

33 33 Oral Health Knowledge Misunderstanding: Caregivers of young children in many cultures do not recognize importance of “baby teeth.” “Baby teeth are not important. They will fall out anyway.” Hilton et al., CDOE, 2007 Butani et al, BMC Oral Health, 2008

34 34 Oral Hygiene Misunderstandings about tooth brushing §Time to start brushing child’s teeth is when child has all his/her teeth or is eating adult food. §Mean age children started tooth brushing was 1.8 years; only 13% at recommended 12 months §“Supervising” tooth brushing usually means “reminding” children to brush their teeth Hoeft, Barker & Masterson, Ped. Dent 2009.

35 35 Caries Etiology, Bottle feeding and Sugar consumption Misunderstood: §Not aware that dental caries is infectious, bacterial disease. §Not all realized that juice, soda, or night-time bottle feeding with milk were bad for teeth, especially among non-US born caregivers §Some thought bottle’s nipple rather than its fluid content was damaging to child’s teeth. Horton & Barker JPHD, 2008

36 36 Misconceptions about when to bring child to dentist Parents seek dental care for their child: §When child complains of pain §When there is a noticeable problem - teeth described as dark in color and structurally damaged §Tooth discolorations or “stains” interpreted as need for dental cleaning rather than dental problem. Horton and Barker, Comm Dental Health 2009..

37 37 Favorable Contexts Identified to Promote a Child’s Dental Visit §Recommendation from pediatrician, family doctor or WIC §School requirement §Older sibling already going to a dentist §However, many of these circumstances lead to visit at older age. Hoeft, Barker & Masterson, Ped Dent 2009

38 38 Intersection of Individual Factors & Dental Care System and Environment Children with publicly funded dental insurance: §Scarcity of dentists who accept Medicaid and treat children under age four. §More with extensive needs likely to be referred, resulting in delays for needed care. §Transportation and follow-up care can be problematic if referral is to distant location §Treatment delays can result in prolonged pain, lack of self-esteem and stigmatization. Barker and Horton, 2008

39 39 Interaction at the Dental Office §Communication can be difficult l Few dentists speak Spanish l Rely on busy bilingual staff or family members to convey information and educate caregivers l Professional translation and interpretation services rarely available  frequent miscommunication  missed opportunity for education Barker & Horton 2008

40 40 Intersection of Family and Societal Factors e.g., Family Dental Insurance Issues §Undocumented parents are hesitant to apply for Medicaid and other benefits, even if some children are US born and eligible. §“A public health policy that differentiates between citizen and non-citizen family members may have adverse effects on both.” l S. Horton, PhD, anthropologist

41 41 Some Consumers Need Resources to Improve Interactions with System §What to expect §How to ask questions about dental care §Participate in health care decision processes

42 What caries prevention education happens at the dental office? §Dental providers are instrumental in health education, but face many barriers (little compensation for time, little opportunity for follow-up, overwhelming treatment needs). §What really happens? 42

43 Exploratory, qualitative study §Main educational focus: Tooth brushing l Flossing and diet §Primary method used: Telling l Showing and Telling l Showing and Telling with Skill Building §Provider attitudes toward utility of oral health education varied: l pessimistic or hopeful 43 Tsai, C. et al. Presented at NOHC, 2010.

44 Relationship between Untreated Caries in Mothers and their Children §Population-based epidemiologic study of Hispanic agricultural worker families §Maternal untreated caries almost doubles the odds of children's untreated caries, even when controlling for demographic, behavioral and dental utilization factors. OR = 1.85 (95% CI: 1.12, 3.07) Weintraub et al. J Dental Research, in press. 44

45 Educational, Clinical and Policy Implications §A key message for parents is that their oral health can impact their child’s oral health. §Caries prevention and dental utilization needed for both mothers and their children. 45

46 Key Message for Dental Profession §Consider the whole family, not just the individual in the dental chair, as oral bacteria can be shared among family members. §If a parent or child has tooth decay, the dental providers should inquire about other family members and encourage dental care. 46

47 Preventing and Reducing Oral Health Disparities § Results from a randomized clinical trial and translation of findings into oral health policies. “The fluoride varnish story” 47

48 48 What is fluoride varnish? A high concentration of fluoride in a resin or synthetic base that is brushed onto the teeth and maintains prolonged contact with enamel. 5 % NaF (22,600 ppm F) Low cost, (~$1 /application) low tech procedure

49 49 The NIH / NIDCR Consensus Statement (2001) “The evidence for the benefit of applying fluoride varnish to permanent teeth is generally positive. In contrast, the evidence for the effectiveness of fluoride varnish applied to primary teeth is incomplete and inconsistent.”

50 50 Efficacy of fluoride varnish in preventing early childhood caries Supported by NIH P60 DE13058 and U54 DE14201

51 51 Study Design A 2-year dental-examiner masked, randomized clinical trial to determine the efficacy of FV applied 1x or 2x/year with parental counseling vs. counseling alone, in preventing ECC. Baseline 6 m 12m 18m Baseline 12m 1.Counseling + FV 2x/year 2. Counseling + FV 1x/year 3. Counseling only

52 52 Percent of Children with Caries Incidence at Last Follow-Up Exam by Treatment Arm (n=280) Both p < 0.001

53 53 Conclusions FV added to caregiver counseling is efficacious in reducing ECC incidence. No adverse health or safety events. Provides additional rationale for an early dental visit for children in high caries-risk groups. Supports conducting caries prevention clinical research in community health centers with vulnerable and minority populations.

54 54 Journal of Dental Research

55 55 Dissemination of Findings Linked to California First Five Initiative:

56 56 Simple Fluoride Treatment Fights Cavities In Kids By Carolyn Johnson Mar. 22 - KGO - New research out of UCSF shows a simple treatment for teeth can make a dramatic difference in fighting cavities in young children. In this Assignment 7 report, we look at fluoride varnish for toddlers.

57 57 Translating FV Research into Clinical Practice and Health Policy §San Francisco Dept Public Health dental programs began routinely applying FV to young children in their community clinics. §California Children’s Dental Disease Prevention Program began including FV in Pre-school and School-based programs

58 58 Parental Acceptability of Interventions Instrument developed to assess acceptability of 5 caries preventive methods to caregivers of young Hispanic children at Head Start Centers: Child: FV, Tooth brushing with F Toothpaste, Xylitol in food, Parent: Chlorhexidine mouthrinse, xylitol gum §All methods were acceptable. §Fluoride varnish and tooth brushing with fluoride toothpaste were the most preferred treatments by low-income, Hispanic families. Hyde et al., JPHD 2008 Adams et al. JPHD 2009.

59 59 Providing Evidence for FV Policies and Clinical Guidelines §Funding from CPAC led to FV policy brief for legislators; and was distributed to all FQHCs in CA. §American Dental Association: Evidence-based Clinical Recommendations for Professionally Applied Topical Fluoride includes FV (2006) §American Assoc of Public Health Dentistry: FV Policy for caries prevention (2008) Gansky et al., 2007

60 60 Policy Applications- Medicaid §The California Medicaid program now has a FV benefit for children younger than age 6, up to 3 times/year. §“Physicians, nurses and medical personnel are legally permitted to apply FV when the attending physician delegates the procedure and establishes protocol.”

61 61 CDC/ASTDD Synopses

62 62 Fluoride Varnish Programs §Now being implemented by many communities and states. §Programs vary by a wide range of characteristics. §What’s best?

63 63 2008-2015: “CAN DO 2” Dissemination Research and Clinical Trials Center PI:J. Weintraub Associate Director: J. Barker Data Coordinating Center Director: S. Gansky Study PIs: M. Walsh, F. Ramos-Gomez 20 Faculty 50 study locations 20,000 low-income families with preschool children

64 64 Project 1: Fluoride Varnish REACH FV Reach in EArly CHildhood P.I. Peggy Walsh, UCSF §To determine the best delivery system to disseminate FV and caregiver education to REACH the 1-3 year old children at caries-risk who are likely to benefit.

65 65 Delivery Systems: Stratum 1, FQHC UCSF Primary Care Collaborative Research Network in FQHCs serving primarily low-income, minority populations in CA. Health Centers randomized to 1 of 2 groups: 1.After receiving training from study staff, medical providers apply FV ON-SITE or 2.Medical providers REFER families to a dentist for FV

66 66 Stratum 2: WIC CA Special Supplemental Nutrition Programs for Women, Infant and Children (WIC) In CA, >60% of infants receive WIC services; 80% of WIC families are Medicaid-eligible. WIC Centers randomized to 1 of 2 groups: 1.Registered dental hygienists in alternative practice (RDHAP) provide FV ON-SITE and bill Medicaid, or 2.WIC staff will REFER families to a dentist for FV

67 67 FV REACH STUDY 24 Primary Care Clinics24 WIC sites Randomize On-site FV + Educ Referral to DDS+ Educ On-site FV + Educ Referral to DDS + Educ Pilot testing ways to deliver Caregiver Education

68 68 Pilot Testing 3 Ways to Deliver Caregiver Education Messages 1)Brochure Only 2) Brochure + Automated Telephone information: Parents receive a phone call. Brochures and telephone messages developed initially in English and Spanish. 3) Brochure + Automated Telephone Information: Parents call a toll-free number.

69 69 Project 2: GIFVT Glass Ionomer & Fluoride Varnish Trial P.I. Francisco Ramos-Gomez, UCLA A RCT conducted in dental and non-dental settings to compare the efficacy of 2 caries prevention strategies on 3-year caries incidence of 3-6 year olds. 596 Kids Randomized to 1 of 2 groups: 1)Fluoride Varnish (FV) every 6 months or 2)Fluoride Varnish (FV) every 6 months AND Fluoride releasing Glass Ionomer Sealant (GIS) applied annually to eligible primary molars

70 70 GIFVT San Ysidro Health Center (Dental Setting) Randomize FV FV+ GIS FV FV+ GIS Comprehensive Health Center (Non-dental Setting)

71 71 GC Fuji TRIAGE ™ Fluoride-releasing Glass Ionomer Pit & Fissure SEALANT Triturate Capsule 10 Seconds Apply mixed GI Sealant Pit and Fissures To Pit and Fissures Pictures from G.C. America

72 72 CAN DO 2 Community Partners FV REACH §UCSF Primary Care Collaborative Research Network §WIC §Dental Health Foundation §RDHAP §Provider and Community Advisory Boards GIFT §San Ysidro Health Center §Comprehensive Health Center §Community Advisory Board Academic Partners §UCLA, SFSU § UNC, SDSU

73 73 Key Messages Reducing oral health disparities requires §Team research – many disciplines §Effective community-based partnerships §Addressing individual, family, community and societal health determinants.

74 §Oral Health Disparities Collaborative Implementation Manual l Early childhood caries prevention and tx l Improving Perinatal Oral Health Hilton, Lampron, Anderson & Jacobs, 2008. 74 Resources:

75 IHS Early Childhood Caries Initiative 2010-2015 – IHS Oral Health Head Start toolkit – Toolkit.pdf 75 Resources:

76 76 Goal To improve the oral health of children. Please visit our website:

77 77 A sampling of UCSF CAN DOers

78 78 Credits Families who have participated in our projects and CAN DO 1 Colleagues. UC San Francisco §Sally Adams §Nancy Adler §Charles Alexander §Abbey Alkon §Pedro Arista §Christopher Barker §Judith Barker §Charla Baugh §Edwin Bringas §Laura Castro §Jason Celis §Nancy Cheng §Lisa Chung §Adriana Clark §Pam Den Besten §Marguerite Laccabue §Alma Loos §Francina Lozada-Nur §Rocio Madrigal §Erin Masterson §Rosalia Mendoza §Beth Mertz §Susan Millstein §Paul Newacheck §Susie Ordorica §Lilliam Pinzon §Preeti Prakash §Angie Phong San Ysidro Health Center §Natasha Brambila §Rocio Gonzalez-Beristain §Ed Martinez §Melina Lopez §Beverly Matinson §Laura Paniagua §Joachim Reiman §Ariel Rodriguez §Gregory Talavera §Karen Duderstadt §John Featherstone §Stuart Gansky §Judy Gonzalez §Steve Gregorich §Kevin Grumbach §Kristin Hoeft §Charles Hoover §Sarah Horton §Susan Fisher-Owens §Shelia Husting §Susan Hyde §Umo Isong §Bonnie Jue §Pui Kwok §Howard Pollick §Francisco Ramos-Gomez §Alicia Rodriquez §Corie Rowe §William Santo §Sara Shain §Caroline Shiboski §Terri Sonoda §Josaphine Stephenson §Bani Tamraz §Margaret Walsh §Ru-Fang Yeh §Ling Zhan SF Dept of Public Health §Irene Hilton §Samantha Stephen UC Davis - Mendota §Tamara Hennessy §Kathleen O'Conner §Marc Schenker §Maria Stoecklin UC San Diego §Tracy Finlayson

79 79 CAN DO 2 Faculty and Staff UCSF School of Dentistry Bill Bird Edwin Bringas Nancy Cheng Caroline Damsky John Featherstone Stuart Gansky Pamela Han Barbara Heckman Sarit Hellman Joanna Hill Kristin Hoeft Susan Hyde Bonnie Jue Catherine Kavanagh Gloria Mejia Beth Mertz Jana Murray Marcia Rapozo-Hilo Bill Santo Sara Shain Terri Sonoda Zenelia Roman Steve Silverstein Peggy Walsh Jane Weintraub UCSF School of Medicine §Judith Barker §Susan Fisher-Owens §Steven Gregorich §Margaret Handley §Rosalia Mendoza §Michael Potter §Dean Schillinger UCLA §Charles Alexander §Francisco Ramos-Gomez §Mario Orozco §Debra Tom-Salgado San Ysidro Health Center §Rocio Beristain §Ed Martinez §Beverly Matinson §Laura Paniagua §Olga Lopez San Diego State University §Tracy Finlayson San Francisco State University §Barry Rothman 79

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