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Tooth decay: Disease of disparity

Students from the College of Dentistry provided free screenings and flouride treatments for young patients in two area Wal-Mart stores in March. Students in the college's chapter of the American Student Dental Association came up with the idea as a project for this year's national Give Kids a Smile Day, and hope the idea becomes a new tradition in the college, which this year celebrates a 125-year legacy of education, research, and care. Photo by Michael Kanellis.

Early one Saturday morning last month, two groups of students from the UI College of Dentistry set out for Wal-Mart stores in the nearby towns of Coralville and Washington.

Their visits lent a new dimension to the dental college’s efforts to reach out to those who have trouble finding oral health care. During their project for the national Give Kids a Smile Day, 25 UI dental students saw more than 200 children in the two stores, where they provided free dental screenings, fluoride varnishes, and referrals for follow-up care.

The American Dental Association stresses that Give Kids a Smile Day “isn't a cure-all; it's a wake-up call.” It is meant to provide education and preventive and restorative care to low-income children who do not have access to care, according to Michael Kanellis, professor of pediatric dentistry and assistant dean of patient care in the College of Dentistry.

Reaching children at risk

The Iowa dental students thought about where they might provide the most care to the most children in the shortest time, according to third-year student Kristine Cody.
She and second-year student Jill Sholka, philanthropy cochairs of the college’s chapter of the American Student Dental Association, realized they could use Wal-Mart’s busy shopping Saturday to reach children at risk.

“Parents did not have to make a special trip to find dental care for their children, or even take their children out of their strollers or carts,” Cody says.

Cody and the other dental students treated children as old as 8 who never had been to a dentist.

American Academy of Pediatric Dentistry guidelines recommend that children have their first dental visit within six months of getting their first primary tooth and no later than their first birthday.

“I think the greatest impact we made was increasing awareness among parents about the importance of early dental care for their children,” says Cody, who hopes the free screenings become a tradition for the college on Give Kids a Smile Day.

But children are not the only ones

Children from poor families are not the only ones who have trouble finding adequate dental care, according to Kanellis. Over the years, the College of Dentistry, which celebrates its 125th anniversary this spring, has brought care to other hard-to-reach populations, such as the elderly and adults with special needs.

As Kanellis tells fyi in this interview, barriers to care have made dental caries (tooth decay) a “disease of disparity” and a concern of priority as the college begins its next 25 years of care, research, and outreach.

fyi: What are the barriers to access to dental care?

Kanellis: The most pervasive barrier to care that we see is financial. Both low-income children and adults often have difficulty affording dental care. Government programs like Medicaid help, however low-income patients covered by Medicaid (Title XIX) often have a difficult time finding a dentist willing to see them.

The Medicaid program for adults does not cover many essential dental services, including root canals on back teeth and treatment of periodontal disease.

Many individuals and families with limited resources do not qualify for Medicaid and simply cannot afford dental care. This is especially true for elderly people living on fixed incomes.

A number of programs throughout the state help with access to care for children, including the Hawk-I program (Children's Health Insurance Program). But there are frequently loopholes, and kids fall through the cracks.

Other barriers to care include lack of understanding about the benefit of early preventive care, difficulty finding reliable transportation, language barriers, and cultural barriers, to name a few.

fyi: Who suffers the most from these barriers?

Kanellis: To a large extent, the problem of dental caries—more commonly called tooth decay—is a disease of disparity for children and adults.

For children, approximately 80 percent of tooth decay is found in 25 percent of children, and these children are overwhelmingly from low-income families.

Additionally, certain population groups and minorities—Hispanic and Native American children, for example—experience more decay than other groups. Elderly adults often are either low-income or living on a fixed income, and therefore these individuals also face financial barriers. Patients with special health care needs, nonambulatory patients, and patients in nursing homes also can experience difficulty accessing care.

fyi: How does the college reach those who have a hard time finding care?

Kanellis: The College of Dentistry helps with access to care through a variety of means. The cost of dental care in our student clinics is approximately half the cost in in private clinics, so many people seek care in the college because it is more affordable. This is one of the biggest ways we help.

The college also participates in a variety of outreach programs throughout the state. Each senior dental student spends approximately 10 weeks participating in community clinical experiences serving traditionally underserved populations. Some of these experiences take place in hospitals, such as Broadlawns Medical Center in Des Moines and St. Luke's Hospital in Cedar Rapids. Other sites include community health centers in Davenport, Des Moines, and Sioux City, as well as in private preceptorships in rural Iowa.
The college also has a Geriatric Mobile Unit that students take to care facilities in eastern in eastern Iowa.
These experiences give students the opportunity to provide clinical care in underserved communities and get involved in communities through presentations, oral health screening programs, and the like.

In addition to the senior clinical and community experiences associated with the college’s Department of Preventive and Community Dentistry, the pediatric dentistry department has an infant oral health clinic in the Johnson County Health Department, and an outreach clinic for low-income children in Muscatine and Louisa County.

fyi: What College of Dentistry research focuses on these hard-to-reach groups?

Kanellis: In a sense, all of our research is aimed at improving oral health for everyone, young or old, rich or poor. But in particular, we have at least a couple of researchers focusing on specific concerns about access to care.

Peter Damiano [UI professor of preventive and community dentistry, and director of the University’s Public Policy Center] evaluates state programs, such as the Hawk-I, or State Children’s Health Insurance Program, to formally document issues of care access, and to help state agencies evaluate and improve their programs.

David Drake [UI professor of microbiology in endodontics and the Dows Institute for Dental Research, and director of research for the UI endodontics department] is working on identifying risk factors for early childhood caries among Native American infants and toddlers. Native Americans have the highest caries rates in the United States. Drake is trying to determine if Streptococcus mutans, a strain of bacteria, either alone or in combination with environmental and behavioral factors, increases risk of caries in Native American infants and toddlers. Working closely with the Aberdeen Area Tribal Chairman's Health Board, he and his research team will work with the Oglala Sioux tribal community at Pine Ridge, S. Dak.

fyi: Dentists know that bacteria causes tooth decay. What is new about Drake's research, and how might it help Native Americans?

Kanellis: For decades we’ve known there’s bacteria associated with tooth decay, but that hasn’t necessarily led to effective preventive therapies, and only in the last 10 years have we started to understand that it’s actually a transmissible disease, that it spreads from person to person, and that one way to stop it is to stop the transmission.

Drake’s research project is exciting because early childhood caries—what we used to call baby-bottle tooth decay—continues to be a hard nut to crack, as far as figuring out how to prevent it. First of all, early childhood caries—when it’s bad, it’s really bad. For example, every week, we [faculty members in the pediatric dentistry department] admit kids to the operating room in University of Iowa Hospitals and Clinics to treat 2- or 3-year-olds whose teeth are so severely decayed that we can’t treat them in the regular clinic setting. Part of the problem has to do with early identification and prevention. Many families aren’t aware of early education, prevention, and intervention, so they don’t bring their kids to the dentist until it’s too late, and by then you have a very expensive and difficult problem, because the kids aren’t old enough to cooperate, and you have a lot of treatment needs.

There’s been a lot of research interest in the last 10 years in looking at the bacteria that cause childhood caries, and specifically the transmission of the bacteria from the caregiver to the child. Kids aren’t born with the bacteria, they get it somewhere, and typically that’s from their primary caregiver or their mother. Drake and his team will look at pairs of mothers and infants or toddlers to see if they can suppress the bacteria in the mother’s mouth, and find out if that will make their child less susceptible to decay. That’s a whole different way of looking at prevention—it’s not just, “Brush twice a day.” It’s more looking at it from a microbiological standpoint.

fyi: What needs to happen in the next 25 years in dentistry to help break down the barriers to care?

Kanellis: We need to make several things happen:

  • Reform health care to increase the number of people with insurance coverage.

You hear that with medical and dental. Nationwide, it just isn’t fair that some people go without treatment because they don’t have coverage or other means.

  • Improve the public programs we have.

For example, Title XIX, or Medicaid, for adults in Iowa doesn’t pay for periodontal treatment. Now we have a clear understanding that periodontal health can significantly affect outcomes of pregnancies. We know that low birth weight, preterm deliveries are more likely if the mother has untreated periodontal disease. So you look at low-income mothers who may be on Title XIX or Medicaid who cannot get their teeth cleaned adequately or their periodontal problems treated, and now we’ve got an outcome that is carried over to the next generation with an infant who is going to cost the state a whole lot more money than it would have taken to cover the simple prevention of taking care of the mother’s oral health.

  • Increase emphasis on prevention and management of caries using a medical model.

If you get a high-risk patient and you just drill out the decay and put in a filling, you can keep doing that every six months until there’s no more tooth to drill on. The medical model is to try equally hard to control the disease process and not just the symptoms of the disease. The symptom of caries is the decay, the hole in the tooth. Here in the College of Dentistry, for example, Sandra Guzman-Armstrong [clinical assistant professor of operative dentistry] runs a “rampant caries” control program that’s involved very heavily with the medical management of the disease process before she even launches into definitive restorative care. Otherwise you’re constantly fighting a losing battle. 

fyi: What encouraging signs are you seeing that this can happen?

Kanellis: With every year come new opportunities and new hope for improvement. Research breakthroughs are always a possibility. Legislation that addresses health care reform, access to care, and so on, also shows promise, especially in a time of changing governments.

Additionally, forming partnerships with others dedicated and interested in oral health—and willing to play a part in oral health—shows promise. In the American Academy of Pediatrics, for example, physicians are understanding more about the relationship between oral health and overall health, and pediatricians have a pretty good understanding that they are often the first to see high-risk infants who aren’t seeing a dentist. Pediatricians are now looking at teeth, and it should be in their curriculum to develop skills on how to examine the mouth of an infant. There have been some exciting pilot programs nationwide. For example, in North Carolina, pediatricians are participating in the state’s Into the Mouths of Babes program by screening for dental problems, educating parents about proper oral health for their children, and applying fluoride varnish, if the patients are on Medicaid, under the age of 3, and unlikely to see a dentist.                                                            

by Gary Kuhlmann



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