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  • I need to start out by saying that we used to be a lot smarter than we are now. When I was in dental school, the faculty seemed to know everything. Now it seems that we’ve got dumber, because “It’s not as easy as this anymore”
  • Caution. Need for scientific (evidence) base for programs.
  • Now we have a base in evidence as a standard. And it isn’t always pretty.
  • There is both clinical and laboratory evidence that subclinical infections can cause preterm birth especially those occuring before 30 weeks. For example amniotic fluid infection, infection of the outer fetal membranes (chorioammion), and lower genital tract infections are associated with preterm birth (SGROH). Toxins or other products generated by periodontal bacteria in the mother may reach the general circulation, cross the placenta and harm the fetus (SGROH) In addition the response of the maternal immune system to the periodontal infection elicits continued release of inflammatory mediators, growth factors, and other potent cytokines which may directly or indirectly interfere with fetal growth and delivery.
  • Multifactorial disease-
  • P. gingivalis in mice can increase proteins that enhance fatty deposits in the blood or on the walls of arteries Preliminary data: persons with PD are more likely to have thick arterial walls that those without PD (Beck et al) Attachment loss associated with increased odds of coronary artery disease in men, not women (OR’s 1.5 – 1.7)
  • Logic: 1st trimester=greatest risk of birth defects from teratogens. Highest rate of spontaneous abortion: avoid perception that dental care was causal Last 1/2 of 3rd=increased sensitivity of fetus to external stimuli increases risks associated with premature delivery.
  • While there is no evidence to support the notion that tx for PD during pregnancy will result in favorable pregnancy outcomes, during pregnancy a woman may be particularly open to advice and education to enhance her own as well as her infant’s health including oral health.
  • Evidence comment based on Rozier’s paper at NIDCR Consensus Conference J Dent Ed 65(10):1063-71
  • Don’t dwell on the numbers or all the categories. Flow into next slide.
  • Give a man a fish, feed him for a day Teach a man to fish, feed him for a lifetime
  • Whichever approach you take, what follows are some of the basics about what is available.
  • Summary States must be creative to be able to come up with meaningful performance measure data on oral health measure(s). States must commit to putting resources to oral health data collection. It doesn’t have to be large out-of-pocket (budget) expenditures -- unless you want it to be. Ohio’s Sentinel School approach is doable (once you have done a big survey from which to select your sentinel schools). The proof of the pudding will come in 4 years when we compare the sentinels to a full sample.
  • siegal.ppt

    1. 1. Public Oral Health Interventions for Mothers and Children: What Works Mark D. Siegal, DDS, MPH Ohio Department of Health ?
    2. 2. It’s not as easy as this anymore
    3. 3. For every complex problem, there is a solution that is: <ul><li>Quick </li></ul><ul><li>Easy </li></ul><ul><li>Cheap, and </li></ul>Wrong!!
    4. 4. Now we look for an Evidence Base And the process often is not pretty
    5. 5. Levels of Evidence <ul><li>I: evidence from at least one properly randomized controlled trial . </li></ul><ul><li>II-1: evidence from well-designed control trials without randomization. </li></ul><ul><li>II-2: evidence from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. </li></ul><ul><li>II-3: evidence from multiple time series with or without intervention. </li></ul><ul><li>III: opinions of respected authorities, based on clinical experience; descriptive studies and case reports ; or reports of expert committees. </li></ul><ul><li>Adapted from: U.S. Preventive Services Task Force. </li></ul>
    6. 6. “Tell Them What You’re Going to Tell Them” <ul><li>Current evidence on oral-systemic health links (e.g., pre-term low birth weight) does not justify major intervention efforts at this time </li></ul><ul><li>Unfortunately, pregnant women tend not to get dental care </li></ul><ul><li>Evidence supports water fluoridation and school dental sealant programs for community-based prevention of dental caries </li></ul>
    7. 7. “Tell Them What You’re Going to Tell Them” <ul><li>Nationally, there are some demonstration projects in place for preventing and/or arresting (Early Childhood Caries) with fluoride varnish </li></ul><ul><li>Access to dental care remains a problem for vulnerable populations </li></ul><ul><li>Stand on soapbox </li></ul>
    8. 8. 1. Current evidence on oral-systemic health links (e.g., pre-term low birth weight) does not justify major intervention efforts at this time
    9. 9. It’s Not “Just Teeth and Gums”: The Oral Health-General Health Connection A. Isabel Garcia, DDS, MPH National Institute of Dental and Craniofacial Research Presented at the Ohio Summit on Access to Dental Care November 14-15, 2001 Some of the serious parts of this presentation were taken from:
    10. 10. Possible Mechanism of Action <ul><li>Evidence supports the role of infections in preterm birth low birth weight (PLBW) </li></ul><ul><li>Transient bacteremia of oral origin (provoked by chewing, brushing, flossing, etc.) increase with severity of gingival inflammation </li></ul><ul><li>Maternal immune response to infection produces substances that may interfere w/ growth and delivery (cytokines, prostaglandins) </li></ul>
    11. 11. Good Periodontal Disease 101- Macro Level Gums Really bad Loss of Clinical Attachment Level
    12. 12. The PD conspiracy theories are at the micro(be) level <ul><li>Infections by gram-negative bacteria </li></ul><ul><li>Gingival inflammation, pockets, ulceration of epithelium, destruction of collagen, ligament and bone </li></ul><ul><li>Chronic inflammatory process </li></ul><ul><li>Multifactorial – host response important contributor to susceptibility </li></ul>
    13. 13. Periodontal Disease and PLBW: Summary <ul><li>Periodontal disease may have the potential to affect pregnancy outcomes </li></ul><ul><li>Findings from animal studies and case-control studies are intriguing and promising </li></ul><ul><li>More studies, including longitudinal, intervention trials , and research on mechanisms are needed </li></ul><ul><li>No evidence yet that treatment for PD will reduce the risk of preterm birth </li></ul>
    14. 14. Periodontal Disease and Diabetes : Summary <ul><li>Diabetics have increased prevalence, extent, and severity of periodontal disease </li></ul><ul><ul><li>Assumed that this is due to compromised ability to respond to infection </li></ul></ul><ul><li>Insufficient evidence of a causal association </li></ul><ul><li>Unclear whether periodontal treatment can affect diabetic control </li></ul>
    15. 15. Oral Health - General Health The bottom lines at this time: <ul><li>Insufficient evidence on whether PD is an independent risk factor for CVD, stroke, adverse pregnancy outcomes </li></ul><ul><li>Relationship of periodontal diseases and diabetes has the strongest evidence </li></ul><ul><li>Effect of periodontal disease on glycemic control is less clear </li></ul>
    16. 16. Some folks are overshooting the mark Rhetoric exceeding evidence?
    17. 17. Microbes that Bite
    18. 18. <ul><li>“ Cigarette smoking, hypertension, hypercholesterolemia, and periodontal disease have been established as major risk factors for cardiovascular disease.” </li></ul><ul><li>Periodontology Vol 23, 2000, 136-141 </li></ul>
    19. 19. 11 May 2000 GUM DISEASE IN PREGNANCY LINKED TO PREMATURE BIRTH GUM disease in pregnancy could be a significant risk factor in whether your baby is born pre-term, according to US researchers. A new study of 2000 pregnant women in the US confirms previous findings that women with gum disease and decay may be up to seven times more likely to deliver before full term, and for the babies to be of a low birth weight. The more decay and disease you have in your mouth, the bigger your risk.
    20. 20. 2. Unfortunately, pregnant women tend not to get dental care
    21. 21. PRAMS for 4 states that collected oral health data in 1998 (AR, IL, LA, NM) <ul><li>23-35% received dental care during pregnancy </li></ul><ul><li>12-25% (data from 3 states) reported having a dental problem </li></ul><ul><ul><li>only 45-55% went for care </li></ul></ul>
    22. 22. Oral considerations during pregnancy <ul><li>American Dental Association recommends avoiding dental care during 1st trimester and last half of 3rd trimester </li></ul><ul><li>Lack of formal policies </li></ul><ul><li>Lack of studies examining relationship between dental care during pregnancy and pregnancy outcomes </li></ul>
    23. 23. Limiting factors <ul><li>Professional recommendations (ADA) </li></ul><ul><li>Lack of insurance </li></ul><ul><li>Attitudes and beliefs about dental treatment during pregnancy </li></ul><ul><ul><li>women </li></ul></ul><ul><ul><li>obstetricians </li></ul></ul><ul><ul><li>dentists </li></ul></ul>
    24. 24. Common Sense Approach <ul><li>Pregnancy is an opportune time for health education and overall health/oral health promotion </li></ul><ul><li>In the absence of dental care-pregnancy outcomes research and formal guidelines from professional organizations, use of the ADA recommendations and consultation with a given patient’s obstetrician, as necessary, makes sense </li></ul>
    25. 25. 3. Evidence supports water fluoridation and school dental sealant programs for community-based prevention of dental caries
    26. 26. Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries A Report on Recommendations of the Task Force on Community Preventive Services MMWR 50(RR-21) November 30, 2001 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5021a1.htm
    27. 27. S School-Based Dental Sealant Programs Title V-funded
    28. 28. <ul><li>Pit and fissure surfaces account for at least 83% of permanent tooth surfaces affected by dental caries (1988-91) </li></ul>Dental Sealants: Prevention that Works
    29. 30. Dental Sealant
    30. 31. Ohio School-based Dental Sealant Programs, 2002
    31. 32. ATHENS BELMONT CARROLL COLUMBIANA COSHOCTON DELAWARE GALLIA HARRISON HOCKING JACKSON LAWRENCE MEIGS MONROE MORGAN MUSKINGUM NOBLE PERRY PIKE ROSS SCIOTO TUSCA-RAWAS VINTON WASHINGTON MONT JEFFER - SON ADAMS BROWN FAYETTE HIGHLAND HOLMES GUERNSEY OTTAWA WILLIAMS FULTON LUCAS ASHLAND ASHTABULA CRAWFORD CUYAHOGA HURON LAKE MAHONING MEDINA PORTAGE RICHLAND SENECA STARK SUMMIT TRUMBULL WAYNE WYANDOT HANCOCK PAULDING PUTNAM WOOD GEAUGA DEFIANCE ERIE LORAIN SANDUSKY HENRY FAIRFIELD FRANKLIN HARDIN KNOX LICKING MARION MORROW PICKAWAY MONTGOMERY ALLEN  AUGLAIZE BUTLER CHAMPAIGN CLARK CLINTON DARKE GREENE HAMILTON LOGAN MERCER MIAMI PREBLE SHELBY UNION VAN WERT WARREN CLER - MADISON            School-Based Dental Sealant Programs: 2002         Ohio Health Priorities Trust Fund (Tobacco Settlement) (1) Locally Funded (2) ODH Funded (Title V) (18) Programs travel to these counties 21 Programs Serving 44 Counties Serving >28,000 children (2000-01) 2/3 of high-risk elementary schools  
    32. 33. Impact of Targeted School-Based Dental Sealant Programs in Reducing Racial and Economic Disparities in Sealant Prevalence Among Schoolchildren--Ohio, 1998-99 MMWR 8/31/01 3rd Graders
    33. 35. 4. Nationally, there are some demonstration projects in place for preventing (Early Childhood) caries with fluoride varnish
    34. 37. Fluoride Varnish <ul><li>First introduced in Germany in 1964 under the trade name Duraphat </li></ul><ul><li>Over 30 years of clinical study </li></ul><ul><li>“Reports of 25-45% caries reduction” </li></ul><ul><li>You may have heard about it </li></ul><ul><li>Approach for “pre-cooperative” kids </li></ul><ul><li>There’s a big “But” </li></ul>
    35. 41. N=1
    36. 42. Iowa Fluoride Varnish Program in Head Start Preschool Classrooms
    37. 43. But... <ul><li>Off-label use </li></ul><ul><li>Evidence on caries-inhibiting effect in primary teeth is “insufficient” to recommend for or against varnish use in preschool-age children at this time </li></ul><ul><li>Mixed findings on cost-effectiveness </li></ul><ul><li>Programs experimenting with application by dental and by medical staff </li></ul><ul><ul><li>CA, NC, IA, WA </li></ul></ul>
    38. 44. 5. Access to dental care remains a problem for vulnerable populations
    39. 45. “ When all you do is what you’ve done…” “… then all you’ll get is what you’ve got.” -Jackie “Moms” Mabley
    40. 46. What We’ve Got is Dental Disease & Disparity Dental Disease Haves Have nots Haves Have nots Access to Dental Care
    41. 47. … and it isn’t pretty
    42. 49. 6. Standing on Soapbox
    43. 50. Some policymakers’ misguided ways of thinking about state and local dental programs: <ul><li>“They’re just teeth” </li></ul><ul><li>“It’s not my job, man” </li></ul><ul><li>“Cavities are preventable, so let’s just fund preventive dental care” </li></ul><ul><li>“Dental screening and referral is enough” </li></ul><ul><li>“Give a man a fish…” </li></ul>
    44. 51. R a n g e
    45. 52. Some Title V-funded Approaches <ul><li>Full-blown oral health program </li></ul><ul><ul><li>Dental director and staff </li></ul></ul><ul><li>Partially-blown oral health program </li></ul><ul><ul><li>Nondental administrator (e.g., RN)/supervisor + some dental staff </li></ul></ul><ul><li>Work oral health into MCH programs </li></ul><ul><ul><li>WIC and well child clinics (anticipatory guidance) </li></ul></ul><ul><li>Be a catalyst for community action </li></ul><ul><li>Ignore dental, maybe it will go away </li></ul>It won’t!!
    46. 53. “Tell Them What You’ve Told Them” <ul><li>Current evidence on oral-systemic health links (e.g., pre-term low birth weight) does not justify major intervention efforts at this time </li></ul><ul><li>Unfortunately, pregnant women tend not to get dental care </li></ul><ul><li>Evidence supports water fluoridation and school dental sealant programs for community-based prevention of dental caries </li></ul>
    47. 54. “Tell Them What You’ve Told Them” <ul><li>Nationally, there are some demonstration projects in place for preventing and/or reversing (Early Childhood Caries) with fluoride varnish </li></ul><ul><li>Access to dental care remains a problem for vulnerable populations </li></ul><ul><li>Oral health is an integral part of health, mothers, children and everyone else </li></ul>
    48. 55. Time

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