Oral Health Disparities and the Future Face of America

Abstract

The 4th Annual AADR Fall Focused Symposium (FFS), “Oral Health Disparities Research and the Future Face of America”, took place on November 3-4, 2011 in Washington, DC. The FFS strategy was developed by the AADR to help provide additional opportunities for members to engage in research discussions during the year by identifying specific research topics of interest among the 21 Scientific Groups and 4 Networks of the IADR and targeting a focused topic area for the FFS. The conference attracted an international group of approximately 120 registrants, including participants from Canada, India, Mexico, and China; 4 oral sessions and 32 poster presentations were offered.

Keywords

access to care caries detection/diagnosis/prevention community dentistry dental public health economic evaluation geriatric dentistry

Introduction

As has been reported, oral diseases in America can be considered a “silent epidemic” (Evans and Kleinman, 2000). Tooth decay affects 78% of the population by age 17 and 98% by age 44. Nearly 25% of adults aged 35 through 44 yrs have destructive periodontal disease. Of note, the prevalence of chronic oral diseases such as periodontal disease and their associated adverse outcomes increases with age, affecting approximately 45% of adults over 50 yrs of age in the US, and these diseases are disproportionately borne by persons with low socio-economic status (Dye and Thornton-Evans, 2007; Demmer et al., 2008; Sabbah et al., 2008; Fernandes et al., 2009; Jin et al., 2011). Oral health means much more than healthy teeth. In adults and children, a lack of dental care often results in severe or persistent pain, inability to eat, swollen faces, and increased susceptibility to other medical conditions. Self-reported impacts of oral conditions on social function include limitations in verbal and non-verbal communication, social interaction, and intimacy. The major message of the Surgeon General’s report on Oral Health in America (USDHHS, 2000) is that “oral health is essential to the general health and well-being of all Americans and can be achieved by all Americans.” Dental disease or visits for treatment result in annual loss of more than 164 million hours of work among adults and more than 51 million school hours among children (US Department of Health and Human Services, 2000). For example, only approximately 68% of adults 18 yrs or older have visited the dentist in the preceding 12 mos (Centers for Disease Control and Prevention, 2010), with both Healthy People 2010 and 2020 metrics targeting increasing this proportion to emphasize that dental care improves oral health. Poor adults are much more likely to have lost 6 or more teeth to decay and gum disease than are higher income adults (Kenney et al., 2000). National surveys have shown little improvement in the use of dental care services among low-income populations over the past 2 decades, which suggests that barriers other than access to insurance coverage contribute to the problems faced by low-income populations. Oral health disparities are unacceptable, although, national, state, and regional data are limited or non-existent for many oral and craniofacial diseases/conditions within specific population groups, including rural, agrarian areas (Chattopadhyay, 2008). Importantly, progress must be made in moving from national, state, and regional surveillance data toward research studies that are designed to identify the factors that are the underlying causes of oral health disparities, as reported at this conference.

More broadly, oral diseases constitute a major health burden on a global scale, and the health community recognizes the importance of addressing the global burden of non-communicable diseases, including periodontal disease. Furthermore, non-communicable diseases can arise from exposures throughout the lifespan, starting in utero (Williams, 2011). As reported by Beaglehole et al. (2009), the World Health Organization estimates that, in global terms, oral diseases are the fourth most expensive to treat, with estimates for dental services accounting for 3 to 12.5% of overall health expenditures in industrialized countries. In some industrialized countries, the mouth is the most expensive part of the body to treat (Williams, 2011). The burden of oral disease for individuals in terms of pain and suffering, school attendance, and work absence is considerable, but the economic impact of oral disease on governments is enormous (Casamassimo et al., 2009). Expenditures on dental services in the US in 2010 were $104.8 billion, which represents 4.0% of total health care expenses (Centers for Medicare & Medicaid Services, 2009). Research is needed to influence care utilization, focusing on broad access to preventive care that will substantively affect overall health expenditures in the US. This change can be accomplished only by changing community oral health norms and expanding community-based prevention efforts that lower barriers to personal oral health care for disadvantaged populations.

The Institute of Medicine (IOM) report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations (IOM and NRC, 2011), represents a product of a 2009 request from the Health Resources Services Administration (HRSA) for the IOM to assess the current oral health care system and to recommend strategic actions for Department of Health and Human Services (HHS) agencies to improve oral health and oral health care in America, to develop a vision for how to improve oral health care for these populations, and to recommend ways to achieve this vision. The report conveyed a range of crucial issues that need to be addressed to improve oral health in these vulnerable populations:

(1) “Access to oral health care across the life cycle is critical to overall health, and it will take flexibility and ingenuity among multiple stakeholders—including government leaders, oral health professionals, and others—to make this access available.”

(2) “Good health requires good oral health, yet millions of Americans lack access to basic oral health care. Various factors create barriers, preventing access to care for vulnerable and underserved populations, such as children and Medicaid beneficiaries.”

(3) “To improve provider participation in public programs, states should increase Medicaid and Children’s Health Insurance Program reimbursement rates.”

(4) “With proper training, nondental health care professionals can acquire the skills to perform oral disease screenings and provide other preventive services.”

(5) “Dental schools should expand opportunities for dental students to care for patients with complex oral health care needs in community-based settings in order to improve the students’ comfort levels in caring for vulnerable and underserved populations.”

(6) “. . .states should examine and amend state practice laws to allow healthcare professionals to practice to their highest level of competence.”

This roadmap, provided by the IOM’s deliberations and review of the “state of the nation” with regard to oral health in the population, delivers a range of “important and necessary next steps to improve access to oral health care, reduce oral health disparities, and improve the oral health of the nation’s vulnerable and underserved populations.”

This was preceded by another IOM report, Advancing Oral Health in America (IOM, 2011). This report noted that “tooth decay is a common chronic disease in the United States and one of the most common diseases worldwide. Evidence shows that decay and other oral health complications may be associated with adverse pregnancy outcomes, respiratory disease, cardiovascular disease, and diabetes. While tooth decay is a highly preventable disease, individuals and many healthcare professionals remain unaware of the risk factors and preventive approaches for many oral diseases, and they do not fully appreciate how oral health affects overall health and well-being.” Furthermore, the IOM recommended that HHS design an oral health initiative focusing on the areas in greatest need of attention and on the approaches that have the most potential for creating improvements. The report also stressed “three key areas needed for successfully maintaining oral health as a priority issue: strong leadership, sustained interest, and the involvement of multiple stakeholders.”

In the context of these national and global considerations, this AADR FFS conference was organized to bring together the range of constituencies addressing oral health disparities, both in the US and internationally, to share concepts on experimental designs, infrastructure needs, partnership requirements, and some lessons learned.

Session I: Overview of Health Disparities Research Initiatives was designed to provide an immediate interface between the funding stakeholders and the AADR researchers engaged in oral health disparities research. This session was stratified into 3 emphasis areas. Dr. Joyce A. Hunter, Deputy Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, provided a presentation, “Perspectives from the NIMHHD”. Dr. Martha Somerman, recently appointed the 8^th Director of the National Institute of Dental and Craniofacial Research (NIDCR), provided a presentation titled “Perspectives from the NIDCR Health Disparities Research Program.” These presenters emphasized the expanding recognition of the importance of oral health for the population, as reflected by commitments of the HHS program. Additionally, they described the broad list of opportunities available from the NIH for investigators focusing on oral health inequalities, particularly in mothers and children, as well as numerous programs targeted toward the training and development of young faculty, and students at all levels. Also described was the wide array of FOAs in disparities research that remains a focus of the NIDCR, providing opportunities to move forward in these health challenges. The second emphasis area integrated presentations from Drs. Melissa W. Riddle (Chief) and David B. Clark, from the Behavioral and Social Sciences Research Branch, NIDCR/NIH, who presented a talk on “Building Programs of Behavioral and Social Research with the NIDCR” and Dr. Ruth Nowjack-Raymer (Director, Health Disparities Research Program, Center for Clinical Research, NIDCR). These presentations emphasized the need to move research in the behavioral and social sciences of oral health away from observational studies to those critically evaluating models of health change. They presented the context of a recent supplement to the Journal of Public Health Dentistry (Riddle and Clark, 2011), which they co-edited, that presented a range of invited papers focusing on model constructs for studies of behavioral and social science strategies to effect changes in oral health norms for the population. Dr. Nowjack-Raymer provided some insights into some of these models, including the “Life Course Theory” (http://mchb.hrsa.gov/lifecourseapproach.html; see Fig. 1), focusing on the health of mothers and children and recognizing that the interplay of risk and protective factors, such as socio-economic status, toxic environmental exposures, health behaviors, stress, and nutrition, influences health throughout one’s lifetime. She also referenced a paper by Fisher-Owens and colleagues (Fisher-Owens et al., 2007), delineating a conceptual model to influence children’s oral health (Fig 2.). This model emphasizes multilevel, holistic approaches to analyses of the complex and interactive causes of children’s health problems, by including a broad array of genetic, social, and environmental risk factors and the complex of interactions among these. The last area was presented by Dr. Glen P. Mays (F. Douglas Scutchfield Endowed Professor in Public Health Services and Systems Research, University of Kentucky College of Public Health), who spoke on the topic of “Disparities Research in Public Health PBRNs”. This exciting presentation provided an overview of strategies that are evolving in the effective use of the various programs and systems within public health departments and community health centers to implement practice-based network research activities that do target vulnerable populations that may not generally be included in classic private-practice-based research networks in dentistry and medicine.

Session II: Oral Health Disparities: Programmatic Targets focused attention on the range of existing disparities center programs funded by the NIDCR. A goal was to highlight similarities and unique features of the programs, as well as to provide a venue for sharing in the identification of barriers across populations and delivery of information on “best practices” that may have been determined through the successes of these various programs. Dr. Raul I. Garcia (Boston University, Northeast Center for Research to Evaluate and Eliminate Dental Disparities) spoke on “Community Engagement and Oral Health Disparities Research”, Dr. Stuart A. Gansky (UCSF) summarized the history and activities of the “Center to Address Disparities in Children’s Oral Health: CAN DO” project, and Dr. Judith Albino [President Emerita/Interim Dean/Clinical Professor, Colorado School of Public Health/Centers for American Indian and Alaska Native Health (CAIANH)] delivered a presentation on "Disparities Research in Indian Country: Challenges and Rewards". Dr. Donald Chi (University of Washington Northwest Center to Reduce Oral Health Disparities) delivered an impassioned address describing the Center’s activities and focusing on “A Multi-disciplinary Approach to Reduce Children’s Oral Health Disparities”. Dr. Woosung Sohn (former Deputy Director, Detroit Center for Research on Oral Health Disparities, University of Michigan) spoke on “Oral Health Disparities Research in an Inner-city African American Population”, and Dr. Henrietta Logan (Southeast Center for Research to Reduce Disparities in Oral Health) provided a presentation on “Theoretically Grounded Community-based Research”, which helped to provide a bit of historical perspective and a current roadmap of these programs across the US. Some central themes of these presentations included: (i) the need to transition from “observation to intervention” and the various challenges associated with this process through community participatory research; (ii) opportunities for oral health promotion and disease prevention that are delivered in “non-dental care” settings; (iii) the importance of clearly enunciating the “rules of engagement” when committed community participation is needed to accomplish the goals of research and service; (iv) methods and models such as “Elaboration Likelihood Model”, “Theory of Planned Behavior”, and “Extended Parallel Process Model (EPPM)” to understand and prevent oral disease, and provide evidence for health policy changes; (v) the stark realities of both oral and general health needs in minority populations and the challenges of developing and nurturing trusting relationships with target communities to help them successfully change oral health expectations for these populations; (vi) the crucial need to clarify social determinants of health with a goal of illuminating causal pathways in health disparities in these populations; (vii) an understanding of how far we have fallen behind in attaining US Department of Health and Human Services goals as outlined in “Healthy People 2010” (http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf); (viii) the need for broad conceptual models of influences on oral health and oral health disparities that include community, interpersonal, individual, and population requirements to improve oral health, all of which require a multidisciplinary approach; and (ix) the importance of supporting interventional research that would have a clinically meaningful impact, and influence clinical practice, health policy, and community and/or individual actions to eliminate disparities in vulnerable subgroups.

Session III: Oral Health Disparities: Focused Approaches attempted initially to identify disparities research activities more broadly and included individual investigators who targeted specific topics and strategies to alter oral health disparities. Dr. Jessica Y. Lee (University of North Carolina) reported on the “Contribution of Oral Health Literacy to Disparities in Oral Health Status and Health Behaviors”. She provided a construct put forward by Kilbourne et al. (2006) that addressed phases of disparities research and attempted to identify a range of key determinants for the origins of health care disparities. Her project assessed oral health literacy levels in low-income, high-risk populations, examined caregivers’ roles in oral health literacy related to both health behaviors and children’s health status, and determined the relationship between oral health literacy and cumulative treatment and costs of Medicaid dental services. Dr. Robert J. Weyant (University of Pittsburgh) presented “Genetic Factors Contributing to Oral Health Disparities in Appalachia: Focus on Dental Caries”. This report described the COHRA study (Center for Oral Health Research in Appalachia) focusing on overwhelming oral health disparities in Northern Appalachia. This talk focused on Genome Wide Association Studies (GWAS) to identify heritability estimates of caries. The results described several genes related to caries susceptibility/resistance and included genes for tooth development and resistance to infectious agents, supporting the likely importance of environment-gene interactions in dental caries severity. Dr. Sara A. Quandt (Wake Forest School of Medicine) delivered a presentation on “Oral Health Disparities among Older Rural Adults: Implications for Dietary Quality”. She first emphasized that this was the first generation of older adults retaining their teeth into old age, although their condition reflects both life-course experience and access to dental and medical care. Her research design focused on the concept that “elderly well-being depends on location, location, location” with regard to general demographics and overall health. Dr. Ralph V. Katz (New York University) provided his views on “Oral Cancer: Health Disparities Findings and Future Issues in the US and Globally”. His presentation initially summarized the results from the NYU Oral Cancer RAAHP (Research on Adolescent and Adult Health Promotion) Center. One major finding from these studies supported the contention that African American individuals are just as willing to participate in research studies, but are less trusting, thus establishing one basis for greater difficulty in enlisting minorities into research studies. He finished his presentation by “crystal ball gazing” for the future of oral cancer research, and, as an epidemiologist, suggested that epi-genetic, epi-behavioral, and health services research should be a major part of the future of this field.

The final three speakers for this session described and discussed issues on the infrastructure that is required to conduct and sustain an effective program in disparities research and care. Dr. Susan Reisine (University of Connecticut) described her group’s activities in “Building Collaborative Research Infrastructure to Reduce Oral Health Disparities among Older Urban Adults”. She emphasized the importance of oral health disparities as individuals age, and described a multilevel approach to building research infrastructure to conduct collaborative research and fostering their project to change oral health norms and practices among vulnerable older adults. Dr. Mary McNally (Dalhousie University) presented “Oral Care in Continuing Care Settings: Collaborating to Improve Policies & Practices”. The emphasis of this project was oral health for nursing home elderly. The design and questions asked were how to integrate oral health care for frail and dependent older adults in rural continuing-care settings. She emphasized the range of programmatic strategies and organizational culture that was required to fully engage all of the stakeholders in these venues. The importance of this challenge was a continuous theme throughout the conference. Last, Dr. Gary Slade (UNC) reviewed some underlying assumptions on oral health disparities in a presentation titled “Is It Low-income or High-income Inequality that Contributes to Poor Oral Health?: Evidence from National Surveys”. He presented concepts relating income inequality to both health and oral health in these populations. In summarizing the implications of the county, state, and country data derived from these studies, he suggested that income inequality is a lower hazard for tooth loss than is low household income, and that state-level and not county-level income inequality is associated with tooth loss. With regard to his data and the International Association for Dental Research program to address global oral health inequalities, he emphasized the need to “Think globally. . .act locally.”

Session IV: Lessons Learned and Wrap-up closed with Dr. David Williams (University of London), a Past President of the IADR, providing an update on “Global Oral Health Inequalities: the Research Agenda (GOHI:RA) – an IADR Initiative”. This provided a direct link between the primarily US-oriented topics and the recognition of similar broader global problems and goals. His presentation focused on the major oral health maladies of mankind and provided summary data regarding the cost of dental care globally, as well as the relationship of health care costs for dental disease vs. other major diseases in the population. His presentation continued by describing concepts of the social determinants of health and how the economic and social conditions provide certain societal risk conditions coupled with individual risk factors to alter disease expression, prevalence, and severity. Dr. Williams emphasized that the GOHI:RA agenda is attempting to advocate for global oral health and oral health equity, which should be everyone’s business.

Summary

In summary, the 2011 FFS engaged a broad array of individuals from within the dental research and service sectors to provide a substantive overview of the range of activities that are occurring, nationally and globally, to address oral health disparities and inequalities. It is clear that the NIDCR is committed to this effort and continues to identify creative ways to use limited resources to extend this aspect of its research portfolio. The Institute remains engaged with a collection of researchers at multiple institutions fostering community-based studies to improve oral health in children, adults, and the elderly. The overall emphasis of the panel of presenters and participants focused on the magnitude of oral health disparities in the US population across the lifespan, and the disproportionate impact on minorities and other historically vulnerable populations (e.g., rural, elderly). An additional common theme of the presenters was the absolute requirement for the community to be fully engaged as a true partner in the development, implementation, and assessment of any interventions to improve oral health. Last, a take-home message was the sometimes-daunting challenge of coordinating these studies to affect the targeted populations and the existing limitations of current funding and study implementation to small segments of the disadvantaged child and adult populations relative to the total oral health improvement needs of the nation. This FFS represents the AADR’s, as part of the IADR, mission to help improve global oral health through supporting our dental research community, providing opportunities for scientific discourse and communication, and advocating at all levels for the importance of oral health for the population.

Footnotes

Acknowledgements

We gratefully acknowledge the Procter & Gamble Co., the Oral Health Institute, and the American Association for Dental Research for support of this conference. Importantly, this document and the success of the conference would not have been possible without the crucial contributions and time provided by the presenters. We thank Drs. Hunter, Riddle, Clark, Nowjack-Raymer, Somerman, Mays, Garcia, Gansky, Albino, Chi, Sohn, Logan, Lee, Weyant, Quandt, Katz, Reisine, McNally, Slade, and Williams for providing their insights into helping to effect change in oral health disparities for the future. Dr. Christopher Fox serves as Executive Director of the AADR.

The authors received no financial support and declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

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