A Systemic and Coordinated Approach to Offering Oral Health Care Services to Amish Population with High Incidence of Hemophilia Tamar Diamond D.M.D. Scenic Bluffs Community Health Center, Cashton, WI

Objective To highlight special concerns regarding oral care for the Amish patient.

Background of Clinic and Community

Staffing There are 52 staff members including: 1 physician 3 dentists 2 nurse practitioners 1 physician assistant 1 chiropractor 1 optometrist 2 pharmacists 4 dental hygienists

Economic Impact $4 million annual business Health Centers’ economic impact on local communities is $6.2 million on local communities Since 1994, Health Centers brought in $6.48 million in federal grant dollars for primary care in our communities Since 2001, Health Centers secured $1.10 million in state grant dollars specifically targeted at primary care access

Health Center Overview Section 330 funded Community Health Center - receive federal grant funds from US Department of Health and Human Services, Bureau of Primary Health Care Have a published sliding fee scale – Healthy Neighbor Plan Governed by a community based Board of Directors – currently 10 members Serve a federally designated medically underserved area

Patients and Encounters

Other Patient Data 90% of patients are white 6% are Hispanic 44% have Medicaid/BadgerCare insurance 26% uninsured 50% live at or below the federal poverty level

Old Order Amish Community Greater demand for emergency care Preventive care not as high a priority Obstacles in putting patients on recall schedule

Caries Triad 1. Bacteria a.Mother has poor oral health and bacterial composition in mouth is passed to child 2. Host a.Importance of brushing teeth is often not culturally transmitted from parent to child b.Brushing once a week is not uncommon c.Heavy plaque bio-film 3. Sugar a.Very high sugar diet b.Bakery goods, candy, and maple syrup are part of the livelihoods of families c.Mountain Dew and other sugary drinks are very popular

Early childhood caries Caries on newly erupted teeth Caries on 4 surfaces Common Incidence of Caries

1.Misgivings about the restoration of primary teeth leading to a. Pain b. Emergency appointments c. Space maintenance issues 2. Unwillingness to have dental cleanings a.Fear of harming the tooth ("Stripping the enamel") b.When asked to schedule cleaning, patient says that they will call clinic if desired c.Heavy gingival bleeding during operative procedures Cultural Barriers to Care

Extensive intermarriage leading to consanguinity Bottle neck population Recessive genetic diseases become more prominent Levels of clotting factor remain stable for life Degrees of severity run in the family Additional clotting factor needed for routine dental care Hemophilia in the Amish Population

Cashton Amish Population Tends toward mild to moderate hemophilia Moderate = % clotting factor of the normal range Spontaneous bleeding does not occur, but prolonged bleeding after injury does occur Given factor prior to treatment, a patient can receive the normal range of dental services Preventive factor improves the clinical prognosis

Hemophilia Screening Day Begun as a collaboration between the clinic and the area blood center in nearby La Crosse Goal is to identify needs of hemophiliac patients and decrease emergency care situations Patients register for 15 minute screenings to determine urgent care needs or potential problems At the end of the screening, both a medical appointment and dental appointment are made for the same day During the medical appointment, the patient receives factor During the dental appointment, the most pressing dental issues are addressed

Conclusion We are working to address the needs of this special population by Educating parents about the importance of primary teeth Encouraging dental cleanings Attempting to reduce reliance on emergency appointments Increasing awareness of the importance of oral hygiene in tooth retention and overall health