Members of APHA’s Oral Health Section contributed a series of posts today discussing opportunities and challenges in oral health on World Oral Health Day.

Reducing oral health disparities in the US — Pathway to a healthier nation

By Nayanjot K Rai, MPH, BDS, professional research assistant/data analyst, Department of Community Dentistry and Population Health, School of Dental Medicine, University of Colorado Anschutz Medical Campus

Oral health is an essential component of overall health and well-being. Inequalities in oral health exist throughout the United States affecting millions of people. These inequalities are seen to be more prevalent in racial and ethnic minority populations, people from low socioeconomic class and those living in areas with limited access to care. These inequalities result due to the interaction of distal and proximal factors with biological, social and cultural determinants of oral health.

logo, World Oral Health DayThe oral diseases range from dental caries to oral cancer, causing pain, discomfort and disability to millions of Americans, thereby affecting their oral health quality of life. According to “Health, United States, 2016,” a report by the Centers for Disease Control and Prevention, 19 percent of children aged 5-19 years and 32 percent of adults aged 20-44 years had untreated dental caries (2011-2014). More than 90 percent of U.S. adults have had a cavity and nearly 50 percent of adults 30 years or older have periodontal disease. Disparities in access to care are more evident in minority populations, families with low educational attainment and low socioeconomic background. In addition, CDC reports that 42 percent of adults ages 18-64 could not afford dental treatment and had no insurance.

Various U.S. agencies are working to implement programs and provide resources to prevent and reduce these disparities. For example, the U.S. Oral Health Alliance provides various measures to improve the oral health literacy of the population and discusses the importance of oral health within community leaders and policymakers. In addition, it engages oral health providers to motivate and encourage patients by providing science-based education about their oral health needs, at all levels, to alter their behavior towards maintaining good oral hygiene. Another example is the implementation of school dental sealant program by CDC, which provides sealants to children from low-income families who may have barriers in accessing care. Additionally, Oral Health 2020 has created some goals to reduce disparities in oral health and move towards a healthier nation. These goals include incorporation of oral health in the school system to provide school-based oral health education, screenings and preventive care to school children; expansion of adult dental benefit in Medicaid and Medicare, to increase access to care and ability to measure oral health data including disease trends in order to design preventive programs and provide oral health education in various communities.

Although some progress has been made in reducing oral health disparities, the continual initiation, development and implementation of these oral health interventions could be considered as a pathway towards accomplishing health equity and promotion, consequently leading to the development of a healthier nation.

Social injustice and achieving oral health equity

By Hamida Askaryar, MPH, RDH, CHES, CLE, program manager, UCLA School of Dentistry, Section of Pediatric Dentistry

Each year thousands of children miss school days, suffer from malnutrition and painful infections, all due to early childhood caries, or ECC, which is the most common chronic childhood disease and is entirely preventable. It is estimated that in California, 7 of every 10 children have history of tooth decay. Unfortunately, ECC disproportionately affects low-income, underserved populations and communities of Hispanic and African-American decent, a true social injustice of the 21st century.

Through our UCLA Strategic Partnership for Interprofessional Collaborative Education in Pediatric Dentistry program, or SPICE-PD, we seek to achieve social justice and health equity for children’s oral health through an inter-professional curriculum for pediatric dental residents, general practice dentists, nurses and physicians. SPICE-PD is designed to meet the growing needs of underserved and minority populations by training the future workforce. For example, pediatric dental residents receive extensive training in public health dentistry and policy and advocacy to understand the impact of social determinants on oral health. Each year our pediatric dental residents meet with members of Congress to discuss oral health issues and to help improve access to oral care.

SPICE-PD residents also participate in local community center rotations that provide preventive oral services, including free or low-cost dental exams, caries risk assessments, prophylaxis and fluoride varnish applications. More importantly, families receive anticipatory guidance and oral health education that provides them with the necessary tools to prevent tooth decay at home. Such an innovative model has over the past seven years helped hundreds of families avoid tooth decay.

If we want to reach oral health equity, we must take the necessary steps to educate families in disease prevention and utilization of available insurance benefits to obtain primary dental care before children miss school days, suffer unnecessary painful infections and are unable to have proper nutrition due to tooth decay.

Integrating physician assistants into the oral health workforce supports the opportunity for health

By Cynthia Booth Lord, MHS, PA-C, past chair, nccPA Health Foundation & PA program director, Case Western Reserve University; and Dawn Morton-Rias, EdD, PA-C, president and CEO, nccPA Health Foundation

In the United States, millions of people lack access to dental care, which contributes to preventable disease that adversely impacts chronic and other conditions, self-esteem and confidence. With growing health inequities, physician assistants, or PAs, have embraced a movement that integrates oral health as part of quality care for everyone.

More than 123,000 certified PAs practice in all settings and specialties, and approximately 8,000 graduates join the workforce annually. PAs are qualified to integrate oral health as screening, risk assessment, coordination of care and behavior change counseling are fundamental to practice. Engaging patients about oral health habits and hygiene during a history and looking in the mouth during a comprehensive physical are essential, and PAs strive to follow a HEENOT model — head, ears, eyes, nose, oral cavity and throat — initiated by Oral Health Nursing Education and Practice, to ensure the oral cavity is not overlooked.

PA organizations leverage collective impact, including mutually reinforcing activities and shared goals, to support this movement. For example, the National Commission on Certification of Physician Assistants Health Foundation provides grants for PAs, educators and students that support education, research and outreach as strategies to integrate oral health into practice.

Evaluative studies demonstrate impact. In 2014, 78 percent of responding PA programs (n=125) included oral health, a significant uptick from 2008 work that found 33 percent (n=98) included content. A 2016 study linked educational experience with practice transformation and found that PAs who received oral health education were approximately 2.79 times more likely to provide oral health services in their practice, compared to those who did not receive education. Finally, a 2015 study found that across disciplines, 32 percent of PAs reported encountering oral health at least weekly with larger percentages reporting encounters in primary care and emergency settings.

PAs are committed to sharing a mantle of responsibility for a culture of health that increases access, fosters prevention and promotes the opportunity for oral and overall health for all.

Community Water Fluoridation, a Public Health Issue

By John P. Fisher, DDS, chair, Better Oral Health for Massachusetts Coalition

Community water fluoridation is a public health issue. What does that mean? Occasionally, it’s worthwhile to think about what a public health issue is. Closing the beaches in a seaside community when there’s red tide. That’s a public health issue. Prevention and treatment are both public health concerns, but emphasis on prevention has begun to take a more prominent role, and has given us a different perspective on what the phrase “public health issue” means.

Community water fluoridation has recently come under attack in some communities. Individuals refer to this as a legal issue or a personal rights issue. But what they seem to ignore is that community water fluoridation has never lost in a court of last resort; defining a public health issue is not a democratic process. It is not left to the general public nor should it be, to decide what is in the best interest of the majority of the population. Community water fluoridation has been shown over and over in credible, current, peer-reviewed studies to be efficient, affordable and effective in the reduction of tooth decay, the most common form of disease in children, throughout the lifetime of everyone.

It becomes incumbent upon all health professionals, not just oral health providers, to be vigilant in their communities and pay attention to this issue as it arises. It also becomes incumbent upon us to educate ourselves more fully on community water fluoridation so that we not only understand it as a public health issue, but that we are sufficiently well founded in the topic that we can support our local and state governments in defense of this common sense preventive initiative. APHA’s community water fluoridation webpage has credible information and links to excellent resources.

Healthier nation with less sugar

By Jaana Gold, DDS, PhD, MPH, CPH, associate professor, College of Dentistry, University of Florida

Heart disease, diabetes, obesity and dental caries are the most common and costly health conditions. These diseases are associated with poor lifestyle behaviors, which affect and are affected by multiple levels of influence, including intrapersonal, interpersonal, organizational, community and public policy factors. A link between health disparities and poorer health outcomes with increased morbidity and mortality is well established.

The relationship between sugar and health is a complex one, due to these multiple interrelated factors. Added sugars contribute to an energy dense poor diet and are associated with increased cardiovascular disease risk in children. Sugars are also the most important dietary risk factor in the development of dental caries. Reducing added sugars at a population level may result in a decrease of these costly diseases.

USDA Dietary Guidelines recommend reducing added sugars consumption to less than 10 percent of calories per day and to choose drinks with no added sugars. During 2011–2014, 63 percent of children aged 2-19 consumed at least one sugary drink a day and this consumption increased with age. One-half of U.S. adults consumed at least one sugar-sweetened beverage a day. American Heart Association recommends that children consume ≤25 g (100 cal or ≈6 teaspoons) of added sugars per day and to avoid added sugars for children <2 years of age. However, most children exceed the daily limits, making this an important public health mission.

Reducing sugary drink consumption requires collaborative actions on several levels — from researchers to policymakers at state and federal level and to the sugar industry; and from consumers and families to schools and communities. We need to act on behalf of policy efforts to support healthy food choices and to support taxing sugary and artificially sweetened drinks to reduce consumption of sugary drinks. We must commit to reduce and eliminate disparities in health and its determinants and pursue Health Equity for all, even if it’s just one sugary drink at a time.

Data-oriented dental medicine – An opportunity to enhance access to high-quality oral health care for all

By Pierre M. Cartier, DMD, MPH, dentist, Arlington Free Clinic

Oral health care has historically focused on tertiary care to address conditions, such as dental caries, also known as tooth decay. However, there is an increasing emphasis on managing oral conditions through secondary prevention, employing techniques such as resin infiltration for early caries lesions. This paradigm shift from “dental surgery” toward “dental medicine” provides opportunities for both clinicians and public health professionals to ensure that high-quality oral health care reaches all Americans.

One of the key challenges that we face in furthering the implementation secondary prevention is the nature of “data collection” in oral health care. Clinical organizations predominately focus on Current Dental Terminology, or CDT, codes to facilitate compensation for services. While CDT coding is integral to the sustainability of most dental organizations, these codes provide limited opportunities to track diagnoses and analyze population health outcomes.

To further demonstrate the value of preventive efforts in dental medicine, we need to facilitate an enhanced, inter-professional focus on epidemiologic data collection and analysis. Quality assessment metrics, such as those related to dental urgency classification and caries risk, allow us to monitor the end results of our efforts. Further, information present within medical records, such as health histories, may support the longitudinal examination of relationships between oral diseases and chronic health conditions.

Enhanced support for clinical data collection and analysis in practice management software will allow clinicians and public health professionals to demonstrate best practices, further reinforcing the value of primary and secondary prevention to federal agencies, third-party payers and other funders of oral health care. Additionally, it will provide additional avenues for epidemiologic research, advancing efforts to demonstrate the relationship between oral and systemic health.

Healthier food for healthier teeth: Promoting healthy diet among pediatric dental patients

By Irene Tami-Maury, DMD, MSc, DrPH, assistant professor, Department of Behavioral Science, University of Texas MD Anderson Cancer Center; and Karen Basen-Engquist, PhD, professor and director of the Center for Energy Balance, University of Texas MD Anderson Cancer Center

The number of children and adolescents affected by obesity has dramatically increased over the past 40 years in the United States. Compared with 1 in 25 children in 1970, 1 in 6 children ages 2-19 today are obese increasing their chances of suffering early heart disease, hypertension, diabetes, some cancers and even premature death in adulthood.

Poor eating practices and unhealthy food choices can lead to both increased weight and tooth decay among children and adolescents, negatively impacting quality of life. While more research needs to be conducted to determine the nature of any relationship existing between dental cavities and overweight/obesity among children and youth, it is evident that these conditions share common, modifiable lifestyle risk factors.

Dietary and behavioral interventions targeting pediatric patients and their caregivers in dental environments can not only reduce the development of tooth decay but also contribute to preventing or reducing childhood obesity. Further, this approach may encourage the adoption and maintenance of lifestyles that can prevent the long-term complications of obesity in adulthood. Dental professionals, including dentists, dental hygienists, dental assistants and dental educators have regular access to a large proportion of pediatric patients and could play a unique role in promoting healthier eating practices during regular dental visits. Because of the negative impact of a poor diet on oral health — decay and gum diseases — dental environments may also be effective for engaging parents in child obesity prevention. Many parents may not be aware of the possible oral manifestations associated with a poor diet, and educating them about healthy eating could encourage them to implement changes at home that will be conducive to healthy lifestyles.

The role of the oral health team in addressing the HIV continuum of care

By Helene Bednarsh, RDH, MPH, director, HIV Dental Program, Boston Public Health Commission; and Anthony J. Santella, DrPH, MCHES, associate professor, Hofstra University

The evolving association between oral health and systemic health reinforces the importance of oral health and interprofessional collaboration. Oral health provides a window to overall health as stated by former Surgeon General C. Everett Koop in year 2000 report “Oral Health in America,” which stated, “You are not healthy without good oral health.” Moreover, in 2011, the National Academies of Science, Engineering and Medicine, formerly the Institute of Medicine, called for an emphasis on disease prevention and oral health promotion as well as reducing oral health disparities in their 2011 report, “Advancing Oral Health in America.”

Although not discussed very often, the oral health team can help curb the HIV pandemic. The Centers for Disease Control and Prevention reports an estimated 37,600 new HIV infections in 2014 with approximately 12 percent of people living with HIV, or PLWH, unaware of their HIV status. The HIV Care Continuum outlines the steps a PLWH experiences from initial diagnosis to achieving viral suppression. The oral health team, including dentists and hygienists, can help move PLWH through each stage of the continuum, whether it be by providing HIV screening in the dental setting, connecting and retaining people living with HIV to medical care, providing those on anti-retroviral therapy, or ART, adherence support, and helping PLWH navigate and manage health systems with the goal of achieving viral suppression. This is especially promising as now we have strong evidence that undetectable = untransmittable (U=U). This means that the risk of HIV transmission from a PLWH who is on ART and has achieved an undetectable viral load in their blood for at least six months is non-existent.

Former Surgeon General Regina Benjamin said it best: “While good oral health is important to the well-being of all population groups, it is especially critical for PLWH. Inadequate oral health care can undermine HIV treatment and diminish quality of life, yet many individuals living with HIV are not receiving the necessary oral health care that would optimize their treatment.” Let’s remember during National Public Health Week that the oral health team is critical to our future success in creating the healthiest nation.