Opportunities to Reduce Oral Health Disparities: Basic Sciences to Clinical Practice

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Opportunities to Reduce Oral Health Disparities
Basic Sciences to Clinical Practice Peter
Milgrom, DDS University of Southern California,
February 2003
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University of Washington Northwest/Alaska Center
for Research to Reduce Oral Health Disparities
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Beta-Defensins in Caries-Prone Children Goals

• This project is designed to study a biological
  marker that may influence susceptibility to tooth
  decay

Dental Health
Oral hygiene
Diet
Host Defense
The oral soft tissue and saliva make defenses
against bacteria. These defenses include
beta-defensins, natural antibiotics. We believe
that these beta-defensins help to prevent dental
caries.
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People

• Beverly A. Dale-Crunk, PhD
• Richard Jurevic, DDS
• Norma Wells, RDH, MPH
• Marjorie Tsutsui, Dental Stud
• Nancy Chino, Science Stud

• Peggy Chrisman, UW Res Tech
• Kimberly Matteiu, BS, RDH
• Oscar Suarez, DDS

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More People

• Eileen Beiersdorf, Superintendent, Toppenish
  School
• Leonor de Maldonado, Principal, Toppenish Middle
  School
• Susan Vlahakis, RN special education
• Pat Brown, DSHS Childrens Program Manager and
  Yakima County Childrens Oral Health Coalition

• James Falco, Dean, Arts Sciences, Heritage
  College
• Robert Ozuna, Director, UW-Yakima Valley Comm
  Partnerships, Heritage Center
• Barbara Owens, Director Dental Admin. Services,
  YVFWC
• Mark Koday, DDS, Dental Director, YVFWC
• Cheryl Vyhmeister, Mobile Unit Coordinator, YVFWC

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Defensins
Bacteria
Tooth Decay
Diet
Defensins are natural antibiotic peptides - and
we make them !!! They are inherited like hair
color and height.
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• Our study explores possible links between
  beta-defensins and dental caries in children.
• Is there a difference in children with low and
  high dental decay?

Measure the amount of beta-defensins in saliva
Look at genetic differences
Subject Population We chose Toppenish for our
study because of the history of the University of
Washington Dental School in promoting oral health
in the Yakima Valley area, because of the
location near Heritage College, a partner in
education and research, and because of the YVFWC.
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Time Line

• Hum subjects, fall 01
• Meet with Toppenish school and community group
  representatives 2/02
• Meet with parents and children - educational
  presentation 5/02

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SNPs are genetic differences that we can assay
We have found single base pair changes in the
genes for beta-defensins. These changes, called
single nucleotide polymorphisms (SNPs) are a very
common type of genetic variation. SNPs can be
silent, deleterious, or even advantageous.
Preliminary data shows a possible protective
effect of one SNP (-44).
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Demographics

• 149 subjects 88 females 61 males
• Mainly Hispanic (127), Native American (5),
  Caucasian (16), African Amer. (1)
• Age (range 11-15)
• Most had permanent dentition
• mixed dentition (20), missing teeth (6), loose
  teeth (11)

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hBD-1 SNP (-44) analysis and caries experience

• Caries 0 Lo Hi
• Number 50 47 47
• SNP -44 0.40 0.47 0.53
• There is not an association of this hBD-1 SNP
  with caries experience. Our findings did not
  support the trend of the pilot data.

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Additional Work in Progress

• hBD-1 and hBD-2 SNP analysis
• Bacterial load in saliva
• hBD-2, and hBD-3 assay in saliva
• Determine association of additional
  b-defensin SNPs with caries experience
• Determine association of salivary bacterial load
  with defensin expression and caries experience

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Sign up and Be part of the Solution
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Benefits

• The potential long-term benefit is
  that simple, non-invasive procedures
  may be developed to
  help predict susceptibility to dental caries.
• We hope to gain an understanding of the
  biological basis for susceptibility to caries.
• Subjects in this study with severe dental
  problems will be referred to the Yakima Valley
  Farm Workers Clinic or other local providers for
  treatment.

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Early Orthodontic Intervention Under Medicaid
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OBJECTIVE To examine the usefulness of early
orthodontic intervention as a means of increasing
access to orthodontic services for children of
low-income families
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Rationale

• Prevalent model for rationing orthodontic
  services for Medicaid patients
• Minimal participation by dentists
• Minimal access for clients
• Potential advantages of interceptive / limited
  treatment
• Potential for increased participation by dentists
  thereby increasing access
• Potential for psychosocial benefits during
  development
• Potential for reduced costs / client
• Demonstration project at Odessa Brown Childrens
  Clinic serving low-income children in urban inner
  Seattle

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Specific Aim 1

• To compare orthodontic outcomes, facial body
  image, and quality of life between Medicaid
  participants who receive early orthodontic TX and
  those who do not
• To compare the level of understanding,
  compliance, and orthodontic outcomes between
  subjects given information about goals, risks,
  and benefits by an orthodontist with those who
  also use an interactive CD-ROM.

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Specific Aim 2

• To compare orthodontic outcomes, facial body
  image, and quality of life between
  Medicaid-funded and private-pay patients who
  receive full orthodontic TX

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Specific Aim 3

• To compare orthodontic outcomes, facial body
  image, and quality of life between
  Medicaid-funded patients who receive early
  orthodontic treatment only and Medicaid funded
  patients who receive full orthodontic treatment
  at adolescence

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Why Do This?

• Develop community-based research that
  translates existing knowledge and new information
  about children and their caretakers into new
  technologies and interventions that will reduce
  disparities

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Study Design

• Component 1
• Randomized Clinical Trial
• Aim 1 - treatment vs no treatment in mixed
  dentition (ages 8-11)
• Aim 3 - same subjects, with those not receiving
  early treatment receiving comprehensive treatment
  (ages 12 - 14)
• Component 2
• Cohort Study
• Aim 2 - Medicaid-funded comprehensive treatment
  compared to private-pay comprehensive treatment

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Observation
Early TX (n75)
AIM 1
AIM 3
Medicaid Patients
Observation (n75)
Full TX
AIM 2

Matched Private-Pay Patients (n65)
Full TX
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Early TX (n75)
Medicaid Patients
Observation (n75)
Randomization
AIM 1
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Outcome Variables

• Dental Variables
• Peer Assessment Rating (PAR) Index
• Index of Complexity, Outcome, and Need (ICON)
• Attitude and Behavior
• Dental Background
• Body Image
• Quality of Life

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Timeline
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Early childhood caries prevention with xylitol
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Turku sugar studies
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Xylitol/clinical studies
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Xylitol/clinical studies
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Xylitol/clinical studies

• Xylitol is most effective in caries prevention of
  erupting teeth (Ylivieska 1988, Belize 1996,
  Estonia 2000)
• The therapeutic effects of xylitol appear only
  in habitual use and with high enough
  frequencies/doses
• Xylitol vehicles chewing gum, lozenges,
  toothpaste (?)

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Mechanisms of action of xylitol

• No acid production
• Reduces plaque by suppressing formation of
  adhesive macromolecules, especially glucans
• Selects for less adhesive mutans streptococci

XylitolC5
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Xylitol reduces plaque formation
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Xylitol makes mutans streptococci to shed more
easily to the saliva