California Childrens Oral Health: Opportunities

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California Childrens Oral Health Opportunities
Hal Slavkin, Dean, School of Dentistry,
University of Southern California, Los Angeles,
California
5th Annual Community Forum on the Conditions of
Children in Orange County November 15th, 2006
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Todays Program

• The Changing Landscape of Oral Health in America
• Surgeon Generals Report Oral Health in
  America (2000)
• Healthy People 2010 (2000)
• Californias The Silent Epidemic (2000-2006)
• HRSA Report on Oral Health
• Improving the Oral Health in California
• A Call to Action
• Community-based programs (e.g. WomenAndCommunity)
• Fast Food Services vs Community Wellness
  Strategies

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A Changing Environment

• Changing patterns of morbidity/mortality
• Changing demographics
• Changing management of health care
• Changing paradigms for health and disease
• Golden era of biomedical research
• Changing societal expectations and quality of
  life
• Global information technology

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General Background

• Demographics
• 1980- - - 235.1 million people
• 2000- - - 277.8 million people
• 2006- - - 300.0 million people
• 2020 - - -332 million people
• Expenditures For Dental Services
• 1980 - - - 13 billion (30 dental insurance)
• 2000 - - - 60 billion (50 dental insurance)
• 2006 - - 109 billion
• Demand For Oral Health Services
• Demand increasing for prevention, periodontics,
  endodontics, orthodontics, implants, esthetic
  dentistry
• 110 million Americans do not have dental
  insurance (access issue)
• Oral Health Workforce
• 180,000 dentists in 140,000 dental practices
• 6,000 dentists retire each year and 4,200
  DDS/DMD graduate each year
• 5,000 dental hygienist graduate per year
• 4,900 dental assistant graduates per year
• 490 dental technician graduates per year
• Expanded Work Force

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A Case Study California

• The Neglected Epidemic (1993-1994)
• Halting A Neglected Epidemic (2000, 2006)
• HRSA Oral Health Survey, (2001-2006)
• USC Southern California Center Health (2001)
• California in the New Millennium, Mark Baldassare
  (2000)

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California in 2006

• Approximately 224 languages/dialects spoken
• The under-18 population grew gt20 from 1990-2000
• State Asian-Americans grew by 38 versus 35 for
  Latinos (1990-2000)
• Fifth largest economy in the world
• Major issues include education, health, energy,
  water air quality, transportation

• State population of 37.5 million project 50
  million by 2028
• Southern California 8 Counties (Santa Barbara,
  Ventura, Los Angeles, Orange, Riverside, San
  Bernardino, San Diego Imperial) 24.4 million
• Largest ethnic group is Latinos gt58 of State
  youth are Latino
• States growth primarily driven by immigration

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Californias Children

• Only 30 of Californians receive the benefits of
  fluoridated drinking water
• More than 20 of children are overweight
• More than 25 of preschool children without
  dental insurance
• More than 40 of high school students without
  dental insurance
• Between 50 and 75 of minority high school
  students need dental care

• Californias children have twice as much
  untreated tooth decay (dental caries) as the
  national average
• Children living in poverty have increased in
  number with attendant increases in disease
  especially minority children.
• The under-18 population increased gt20 across
  Southern California from 1990-2000

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Southern California Region

• 9 counties (Santa Barbara to San Diego)
• 24.4 million people
• 55 of all births in the state
• Nearly 10,000 cases of structural birth defects
  annually
• 32 speak Spanish at home
• 13 earn less than 15,000 annually

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Los Angeles County

• 11.5 million people
• 4,000 square miles
• 88 cities
• 23 are non-citizens
• 36.3 foreign-born
• Increases by 300,000 people per year
• 1/3 of all births in the State of California

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Language Spoken at Home Los Angeles County
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America and Poor Children

• By 2030, non-White children will constitute a
  majority
• From 1969-1997 the number of poor children grew
  by 46 (more than 4 million)
• In 2000, a child is born into poverty every 40
  seconds
• A child is reported abused or neglected every 11
  seconds
• A child runs away from home every 24 seconds
• A child bears a child every minute
• In 2000, gt30 of high school females smoked
  cigarettes (Surgeon Generals Report Women and
  Smoking, March 26, 2001) tobacco linked with
  chronic diseases and disorders
• 1 Chronic disease of children is tooth decay
• 1 Reason for school absenteeism is tooth decay

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California Opportunities

• Improve oral health and well-being in California
• Translate scientific and technology results into
  oral health promotion, disease prevention,
  standards of care, diagnosis treatments,
  clinical management of diseases and disorders,
  health services, health outcomes and health
  professional education
• Recruit retain cultural diversity in the oral
  health professions workforce
• Increase multi-center, multidisciplinary
  prospective and randomized clinical trials by
  linking 5 dental schools
• Create a coalition between five dental schools,
  organized dentistry, dental insurance sector,
  key medical programs such as pediatrics and
  primary care, and other public and private
  partners
• Promote student- and patient-centered,
  evidence-based, problem-based learning in dental
  education
• Create state-wide oral health coalition with
  communities, dentistry, medicine, nursing,
  pharmacy, industry, government and non-profit
  foundations--- Emphasize Health Promotion!

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Competencies for Oral Health Professionals

• Cultural competencies
• Clinical competencies skills required for
  primary care oral health/dentistry
• Health administration management
• Epidemiology
• Biostatistics
• Human behavior
• Cultural anthropology
• Nutrition
• Conflict resolution and mediation skills

• Critical thinking and life-long learner
• Communications
• Public health education
• Behavioral modifications
• Skills of fluoridation, dental sealants, oral
  hygiene, infection control
• Human genetics counseling
• Manage oral infections systemic diseases
• Information technology

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Oral Health in America A Report of the Surgeon
General (2000)
Department of Health and Human Service
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The Charge
Define, describe, and evaluate the interaction
between oral health and health and well-being
(quality of life), through the life span in the
context of changes in society. Secretary Donna
Shalala, 1996
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The SG Report Project Team

• Caswell A. Evans
• Asst Director, Los Angeles County Department of
  Health Services
• Dushanka V. Kleinman
• Deputy Director, NIDCR, NIH
• William R. Maas
• Chief Dental Officer, USPHS and Director,
  Division of Oral Health, CDC
• Harold C. Slavkin
• Director, NIDCR, NIH

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Organization of the SG Report

• What is Oral Health?
• What is the Status of Oral Health in America?
• What is the Relationship Between Oral Health and
  General Health and Well-Being?
• How is Oral Health Promoted and Maintained and
  How are Oral Diseases Prevented?
• What are the Needs and Opportunities to Enhance
  Oral Health?

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Surgeon Generals Report Oral Health in America

• Oral diseases affect health and well being
  throughout lifespan
• Safe and effective preventive measures do exist
• Lifestyle behaviors that affect general health
  such as tobacco alcohol use, and poor dietary
  choices, also affect oral health
• Major oral health disparities
• The mouth reflects general health and well being

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SG ORAL HEALTH MESSAGES

• Over 4.2 million live births each year
• A major complication is low birth weight,
  premature babies
• Most common birth defects being craniofacial,
  oral and dental deformities
• The most common chronic disease in children is
  dental caries
• Over 70 million children in US (26 US
  population)

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Tooth Decay The Most Common Chronic Disease of
Children
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Oral Health Disparities - Children

• Dental caries are caused by transmissible
  bacterial infections from caregiver to infant
• Inhibition of oral bacterial colonization into
  biofilms is a major target for caries prevention
  (antibodies? chemicals?)
• Dental sealants are proven to be 100 effective
  in preventing dental caries on chewing surfaces
  of teeth
• Fluoride varnish is an effective tool
• Fluoridation of community drinking water appears
  to be the major factor responsible for the
  decline of dental caries in the US
• More than 52 million school hours are lost due to
  dental pain and suffering in children

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Oral Infection Associated With Low Birth Weight
Premature Babies and Congenital Craniofacial
Birth Defects
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Craniosynostosis
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Cleft Lip Cleft Palate

• One of the most common birth defects
• Prevalence is one per hour in the United States
  1 per 500 live births in California
• Direct health costs are approximately 110,000
  per child

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Dental Caries is a Transmissible Bacterial
Infectious Disease
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SG ORAL HEALTH MESSAGES

• Unintentional injuries to head and neck in
  children is a major health issue
• Oral cancer is the sixth most common cancer
• One American dies every hour of oral cancer
• Periodontal diseases found in gt60 of adults
• Tobacco linked with all major chronic diseases
  in 2000, 30 of high school females smoked
  cigarettes
• Oral infections associated with systemic diseases
• Systemic diseases have oral complications

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In a recent survey of adults 40 yrs older, only
14 of respondents said they had ever been
examined for oral cancer

• Regular oral self-examination to inspect lips,
  gums, inside of cheeks, tongue, back of throat,
  and floor and roof of mouth
• Annual oral health professional examination

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Towards understanding oral neoplastic biological
processes

• Inherited and acquired gene mutations
• Multiple and sequential gene mutations
• Multiple gene-gene and gene-environment
  interactions
• Significant candidate gene mutations associated
  with transcription controls, mitosis, and
  apoptosis

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Genetic Factors in Oral Microbial Infections
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Oral Infection and Systemic Diseases

• Low birth weight, premature babies
• Cardiovascular disease
• Cerebrovascular disease
• Pulmonary diseases
• Osteoarthritis
• Diabetes complications with oral infection
• Cancer therapy (radiation, surgery, chemotherapy)
  and oral complications (e.g. dry mouth and
  rampant tooth decay)

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from your mouth to your heart?

• Cardiovascular plaques (atherosclerosis) are
  contaminated with oral bacterial pathogens
• In addition, cytomegalovirus and Chlamydia
  pneumoniae found in plaques
• Four different antibodies directed to oral
  pathogens cross-react with blood
• In animal studies, oral pathogens injected into
  blood are recovered in atherosclerotic plaques
• Oral infection also associated with diabetes,
  chronic respiratory disease, stroke and low birth
  weight, premature births
• Approximately 33 of adults over thirty years
  present periodontal diseases

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SG ORAL HEALTH MESSAGES

• 34 million adults report severe chronic facial
  pain (migraine, tension headaches, fibromyalgia,
  myofascial pain, TMD, trigeminal neuralgia,
  Bells palsy, atypical facial pain, phantom limb,
  postherpetic neuralgia)
• Unrelieved pain in 75 advanced cancer, 30-80
  HIV, 40 terminally ill, and 47 during cancer
  therapy
• Osteoarthritis, osteoporosis, diabetes and cancer
  therapy have significant oral complications
• Tooth loss, tooth pain, swallowing and facial
  pain are major complaints of poor elderly
• The fastest growing subpopulation in US are
  people over 80 years of age (15 over 65 years of
  age by 2020)

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The SG Report A Framework For Action

• Change perceptions regarding oral health and
  disease so that oral health becomes an accepted
  component of general health ( e.g. public
  perceptions, policymakers perceptions health
  providers perceptions)
• Accelerate the building of the science-base to
  improve oral health
• Build infrastructure that provides comprehensive
  oral health care for all Americans
• Remove known barriers between people and oral
  health care services
• Utilize public-private partnerships to improve
  the oral health of those who suffer
  disproportionately from oral diseases and
  disorders

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A CALL TO ACTION

• Integrate health promotion disease prevention
  in preschool K-12 education, social
  behavioral sciences education
• Promote prenatal care with diet, exercise,
  multivitamin supplements
• Integrate oral health- - -dentistry, medicine,
  nursing, pharmacy, speech therapy, physical
  therapy, social services

• California campaign for tobacco cessation,
  alcohol reduction, healthy food choices,
  exercise, fluoridation, calcium for child and
  adolescents
• Immunizations, oral hygiene, diet, sleep, exercise

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A CALL TO ACTION

• Preschool programs to include oral health
• All school-based programs should provide
  caregivers and children with tools to optimize
  health and well being and to reduce burdens of
  disease

• California standards for health promotion and
  disease prevention
• Clinical and cultural competencies for all health
  professionals
• Cross-disciplinary training programs between
  medicine, dentistry, dental hygiene, pharmacy,
  nursing, speech therapy, and social services

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A CALL TO ACTION

• Public/private coalitions to promote health and
  well being, risk assessment and disease
  prevention
• Increase outcomes and health services research
• Increase collaborations of health professions
  from prenatal through elderly stages of life
• Achieve student debt forgiveness as incentive to
  address oral health disparities

• Health needs of the California population,
  especially special needs and developmental
  disabilities, must be addressed by a continuum of
  biomedical,behavioral and health services
  research, and community-based prevention
  strategies

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The Future of Oral Health For All Californians?

• the future can be very bright if we seize the
  opportunities.

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Knowing is not enough we must apply. Willing is
not enough we must do. Goethe