California Children’s 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

Today’s Program Today’s Program The Changing Landscape of Oral Health in AmericaThe Changing Landscape of Oral Health in America Surgeon General’s Report “Oral Health in Surgeon General’s Report “Oral Health in

America” (2000)America” (2000) Healthy People 2010 (2000)Healthy People 2010 (2000) California’s “The Silent Epidemic” (2000-2006)California’s “The Silent Epidemic” (2000-2006) HRSA Report on Oral HealthHRSA Report on Oral Health

Improving the Oral Health in CaliforniaImproving the Oral Health in California A Call to ActionA Call to Action

Community-based programs (e.g. WomenAndCommunity)Community-based programs (e.g. WomenAndCommunity) Fast Food Services vs Community Wellness StrategiesFast Food Services vs Community Wellness Strategies

A Changing EnvironmentA Changing Environment Changing patterns of Changing patterns of

morbidity/mortalitymorbidity/mortality Changing demographicsChanging demographics Changing management of Changing management of

health carehealth care Changing paradigms for Changing paradigms for

health and diseasehealth and disease ““Golden era of biomedical Golden era of biomedical

research”research” Changing societal Changing societal

expectations and “quality expectations and “quality of life”of life”

Global information Global information technologytechnology

General BackgroundGeneral BackgroundDemographicsDemographics

1980- - - 235.1 million people1980- - - 235.1 million people2000- - - 277.8 million people2000- - - 277.8 million people2006- - - 300.0 million people2006- - - 300.0 million people2020 - - -332 million people2020 - - -332 million people

Expenditures For Dental ServicesExpenditures For Dental Services1980 - - - $13 billion (30% dental insurance)1980 - - - $13 billion (30% dental insurance)2000 - - - $60 billion (50% dental insurance)2000 - - - $60 billion (50% dental insurance)2006 - - $109 billion2006 - - $109 billion

Demand For Oral Health ServicesDemand For Oral Health ServicesDemand increasing for prevention, periodontics, endodontics, orthodontics, implants, Demand increasing for prevention, periodontics, endodontics, orthodontics, implants, esthetic dentistryesthetic dentistry110 million Americans do not have dental insurance (“access issue”)110 million Americans do not have dental insurance (“access issue”)

Oral Health WorkforceOral Health Workforce180,000 dentists in 140,000 dental practices180,000 dentists in 140,000 dental practices6,000 dentists retire each year and 4,200 DDS/DMD graduate each year6,000 dentists retire each year and 4,200 DDS/DMD graduate each year 5,000 dental hygienist graduate per year5,000 dental hygienist graduate per year4,900 dental assistant graduates per year4,900 dental assistant graduates per year490 dental technician graduates per year490 dental technician graduates per year

Expanded Work ForceExpanded Work ForceFamiles and CommunitiesFamiles and CommunitiesPreschool and K-12 EducatorsPreschool and K-12 EducatorsPediatricians, Nurses, Pharmacists, Social ServicesPediatricians, Nurses, Pharmacists, Social ServicesFood and drink servicesFood and drink services

A Case Study: CaliforniaA Case Study: California

The Neglected The Neglected EpidemicEpidemic (1993-1994) (1993-1994)

Halting A Neglected Halting A Neglected EpidemicEpidemic (2000, 2006) (2000, 2006)

HRSA Oral Health HRSA Oral Health SurveySurvey,, (2001-2006) (2001-2006)

USC Southern USC Southern California Center: California Center: HealthHealth (2001) (2001)

California in the New California in the New MillenniumMillennium, Mark , Mark Baldassare (2000)Baldassare (2000)

California in 2006California in 2006 State population of 37.5 State population of 37.5

million; project 50 million million; project 50 million by 2028by 2028

Southern California 8 Southern California 8 Counties (Santa Barbara, Counties (Santa Barbara, Ventura, Los Angeles, Ventura, Los Angeles, Orange, Riverside, San Orange, Riverside, San Bernardino, San Diego & Bernardino, San Diego & Imperial) 24.4 millionImperial) 24.4 million

Largest ethnic group is Largest ethnic group is Latinos; >58% of State Latinos; >58% of State youth are Latinoyouth are Latino

State’s growth primarily State’s growth primarily driven by immigrationdriven by immigration

Approximately 224 Approximately 224 languages/dialects languages/dialects spokenspoken

The under-18 population The under-18 population grew >20% from 1990-grew >20% from 1990-20002000

State Asian-Americans State Asian-Americans grew by 38% versus 35% grew by 38% versus 35% for Latinos (1990-2000)for Latinos (1990-2000)

Fifth largest economy in Fifth largest economy in the worldthe world

Major issues include Major issues include education, health, education, health, energy, water & air energy, water & air quality, transportationquality, transportation

California’s ChildrenCalifornia’s Children Only 30% of Californians Only 30% of Californians

receive the benefits of receive the benefits of fluoridated drinking waterfluoridated drinking water

More than 20% of children More than 20% of children are overweightare overweight

More than 25% of preschool More than 25% of preschool children without dental children without dental insuranceinsurance

More than 40% of high More than 40% of high school students without school students without dental insurancedental insurance

Between 50% and 75% of Between 50% and 75% of “minority high school “minority high school students” need dental carestudents” need dental care

California’s children have California’s children have twice as much untreated twice as much untreated tooth decay (dental caries) tooth decay (dental caries) as the national averageas the national average

Children living in poverty Children living in poverty have increased in number have increased in number with attendant increases with attendant increases in disease; especially in disease; especially “minority children.”“minority children.”

The under-18 population The under-18 population increased >20% across increased >20% across Southern California from Southern California from 1990-20001990-2000

Southern California RegionSouthern California Region 9 counties (Santa Barbara to San 9 counties (Santa Barbara to San

Diego)Diego) 24.4 million people24.4 million people 55% of all births in the state55% of all births in the state Nearly 10,000 cases of structural birth Nearly 10,000 cases of structural birth

defects annuallydefects annually 32% speak Spanish at home32% speak Spanish at home 13% earn less than $15,000 annually13% earn less than $15,000 annually

Los Angeles CountyLos Angeles County

11.5 million people11.5 million people 4,000 square miles4,000 square miles 88 cities 88 cities 23% are non-citizens23% are non-citizens 36.3% foreign-born36.3% foreign-born Increases by 300,000 people per yearIncreases by 300,000 people per year 1/3 of all births in the State of California1/3 of all births in the State of California

Language Spoken at Home

Los Angeles County

[

  

      

  Los Los Angeles Angeles County County

CaliforniaCaliforniaStateState

English English 4,032,6144,032,614))

46%46% 19,014,87319,014,873

 61%  61% 

Spanish Spanish 3,330,9353,330,935

38%38% 8,105,5058,105,505

 26%  26% 

Asian Pacific Asian Pacific Islander Islander

875,515875,51510%10%

2,709,1792,709,179  9%   9% 

Other Other 552,032552,032

6%6% 1,587,0721,587,072

  6%   6% 

America and Poor ChildrenAmerica and Poor Children By 2030, non-White children will constitute a majorityBy 2030, non-White children will constitute a majority From 1969-1997 the number of poor children grew by From 1969-1997 the number of poor children grew by

46% (more than 4 million)46% (more than 4 million) In 2000, a child is born into poverty every 40 secondsIn 2000, a child is born into poverty every 40 seconds A child is reported abused or neglected every 11 A child is reported abused or neglected every 11

secondsseconds A child runs away from home every 24 secondsA child runs away from home every 24 seconds A child bears a child every minuteA child bears a child every minute In 2000, >30% of high school females smoked cigarettes In 2000, >30% of high school females smoked cigarettes

(Surgeon General’s Report (Surgeon General’s Report Women and SmokingWomen and Smoking, March , March 26, 2001); tobacco linked with chronic diseases and 26, 2001); tobacco linked with chronic diseases and disordersdisorders

#1 Chronic disease of children is tooth decay#1 Chronic disease of children is tooth decay #1 Reason for school absenteeism is tooth decay#1 Reason for school absenteeism is tooth decay

California OpportunitiesCalifornia Opportunities Improve oral health and well-being in CaliforniaImprove oral health and well-being in California Translate scientific and technology results into oral health promotion, Translate scientific and technology results into oral health promotion,

disease prevention, standards of care, diagnosis & treatments, clinical disease prevention, standards of care, diagnosis & treatments, clinical management of diseases and disorders, health services, health management of diseases and disorders, health services, health outcomes and health professional educationoutcomes and health professional education

Recruit & retain cultural diversity in the oral health professions Recruit & retain cultural diversity in the oral health professions workforceworkforce

Increase multi-center, multidisciplinary prospective and randomized Increase multi-center, multidisciplinary prospective and randomized clinical trials by linking 5 dental schoolsclinical trials by linking 5 dental schools

Create a coalition between five dental schools, organized dentistry, Create a coalition between five dental schools, organized dentistry, dental insurance sector, “key” medical programs such as pediatrics dental insurance sector, “key” medical programs such as pediatrics and primary care, and other public and private partnersand primary care, and other public and private partners

Promote student- and patient-centered, evidence-based, problem-Promote student- and patient-centered, evidence-based, problem-based learning in dental educationbased learning in dental education

Create state-wide oral health coalition with communities, dentistry, Create state-wide oral health coalition with communities, dentistry, medicine, nursing, pharmacy, industry, government and non-profit medicine, nursing, pharmacy, industry, government and non-profit foundations--- Emphasize Health Promotion!foundations--- Emphasize Health Promotion!

Competencies for Oral Health Competencies for Oral Health ProfessionalsProfessionals

Cultural competenciesCultural competencies Clinical competencies & Clinical competencies &

skills required for primary skills required for primary care oral health/dentistrycare oral health/dentistry

Health administration & Health administration & managementmanagement

EpidemiologyEpidemiology BiostatisticsBiostatistics Human behaviorHuman behavior Cultural anthropologyCultural anthropology NutritionNutrition Conflict resolution and Conflict resolution and

mediation skillsmediation skills

Critical thinking and life-Critical thinking and life-long learnerlong learner

CommunicationsCommunications Public health educationPublic health education Behavioral modificationsBehavioral modifications Skills of fluoridation, Skills of fluoridation,

dental sealants, oral dental sealants, oral hygiene, infection controlhygiene, infection control

Human genetics & Human genetics & counselingcounseling

Manage oral infections & Manage oral infections & systemic diseasessystemic diseases

Information technologyInformation technology

Oral Health in America: A Report of the Surgeon General (2000)

Department of Health and Human Service

The ChargeThe 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

The SG Report Project TeamThe SG Report Project Team

Caswell A. EvansCaswell A. Evans Asst Director, Los Angeles County Asst Director, Los Angeles County

Department of Health ServicesDepartment of Health Services Dushanka V. KleinmanDushanka V. Kleinman

Deputy Director, NIDCR, NIHDeputy Director, NIDCR, NIH William R. MaasWilliam R. Maas

Chief Dental Officer, USPHS and Director, Chief Dental Officer, USPHS and Director, Division of Oral Health, CDCDivision of Oral Health, CDC

Harold C. SlavkinHarold C. Slavkin Director, NIDCR, NIHDirector, NIDCR, NIH

Organization of the SG ReportOrganization of the SG Report What is Oral Health?What is Oral Health? What is the Status of Oral Health in America?What is the Status of Oral Health in America? What is the Relationship Between Oral Health What is the Relationship Between Oral Health

and General Health and Well-Being?and General Health and Well-Being? How is Oral Health Promoted and Maintained How is Oral Health Promoted and Maintained

and How are Oral Diseases Prevented?and How are Oral Diseases Prevented? What are the Needs and Opportunities to What are the Needs and Opportunities to

Enhance Oral Health?Enhance Oral Health?

Surgeon General’s ReportSurgeon General’s Report Oral Health in AmericaOral Health in America

Oral diseases affect health Oral diseases affect health and well being throughout and well being throughout lifespanlifespan

Safe and effective Safe and effective preventive measures do preventive measures do existexist

Lifestyle behaviors that Lifestyle behaviors that affect general health such affect general health such as tobacco & alcohol use, as tobacco & alcohol use, and poor dietary choices, and poor dietary choices, also affect oral healthalso affect oral health

Major oral health disparitiesMajor oral health disparities The mouth reflects general The mouth reflects general

health and well beinghealth and well being

SG ORAL HEALTH SG ORAL HEALTH MESSAGESMESSAGES

Over 4.2 million live births each yearOver 4.2 million live births each year A major complication is low birth weight, A major complication is low birth weight,

premature babiespremature babies Most common birth defects being Most common birth defects being

craniofacial, oral and dental deformitiescraniofacial, oral and dental deformities The most common chronic disease in The most common chronic disease in

children is dental carieschildren is dental caries Over 70 million children in US (26% US Over 70 million children in US (26% US

population)population)

Tooth Decay: The Most Common Tooth Decay: The Most Common Chronic Disease of ChildrenChronic Disease of Children

Oral Health Disparities - ChildrenOral Health Disparities - Children

Dental caries are caused by transmissible bacterial Dental caries are caused by transmissible bacterial infections from caregiver to infantinfections from caregiver to infant

Inhibition of oral bacterial colonization into biofilms is a Inhibition of oral bacterial colonization into biofilms is a major target for caries prevention (antibodies? chemicals?)major target for caries prevention (antibodies? chemicals?)

Dental sealants are proven to be 100% effective in Dental sealants are proven to be 100% effective in preventing dental caries on chewing surfaces of teethpreventing dental caries on chewing surfaces of teeth

Fluoride varnish is an effective “tool”Fluoride varnish is an effective “tool” Fluoridation of community drinking water appears to be the Fluoridation of community drinking water appears to be the

major factor responsible for the decline of dental caries in major factor responsible for the decline of dental caries in the USthe US

More than 52 million school hours are lost due to dental More than 52 million school hours are lost due to dental pain and suffering in children pain and suffering in children

Oral Infection Associated With Low Birth Weight Premature Babies and Congenital Craniofacial Birth Defects

Craniosynostosis

Cleft Lip & Cleft PalateCleft Lip & Cleft Palate

One of the most One of the most common birth defectscommon birth defects

Prevalence is one per Prevalence is one per hour in the United hour in the United States; 1 per 500 live States; 1 per 500 live births in Californiabirths in California

Direct health costs Direct health costs are approximately are approximately $110,000 per child$110,000 per child

Dental Caries is a Transmissible Bacterial Infectious Disease

SG ORAL HEALTH SG ORAL HEALTH MESSAGESMESSAGES

Unintentional injuries to head and neck in Unintentional injuries to head and neck in children is a major health issuechildren is a major health issue

Oral cancer is the sixth most common cancerOral cancer is the sixth most common cancer One American dies every hour of oral cancerOne American dies every hour of oral cancer Periodontal diseases found in >60% of adultsPeriodontal diseases found in >60% of adults Tobacco linked with all major chronic diseases; in Tobacco linked with all major chronic diseases; in

2000, 30% of high school females smoked 2000, 30% of high school females smoked cigarettescigarettes

Oral infections associated with systemic diseasesOral infections associated with systemic diseases Systemic diseases have oral complicationsSystemic diseases have oral complications

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

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

Annual oral health Annual oral health professional professional examinationexamination

Towards understanding oral Towards understanding oral neoplastic biological neoplastic biological

processesprocesses Inherited and acquired Inherited and acquired gene mutationsgene mutations

Multiple and sequential Multiple and sequential gene mutationsgene mutations

Multiple gene-gene and Multiple gene-gene and gene-environment gene-environment interactionsinteractions

Significant candidate Significant candidate gene mutations gene mutations associated with associated with transcription controls, transcription controls, mitosis, and apoptosismitosis, and apoptosis

Genetic Factors in Oral Microbial InfectionsGenetic Factors in Oral Microbial Infections

Genetic Modifiers

ClinicalClinicalDiseaseDiseaseSeveritySeverity

InflammationInflammation in in

OralOralTissuesTissues

MicrobesMicrobes in Biofilmsin Biofilms

Environmental Modifiers

Oral Infection and Systemic Oral Infection and Systemic DiseasesDiseases

Low birth weight, premature babiesLow birth weight, premature babies Cardiovascular diseaseCardiovascular disease Cerebrovascular diseaseCerebrovascular disease Pulmonary diseasesPulmonary diseases OsteoarthritisOsteoarthritis Diabetes complications with oral infectionDiabetes complications with oral infection Cancer therapy (radiation, surgery, Cancer therapy (radiation, surgery,

chemotherapy) and oral complications (e.g. chemotherapy) and oral complications (e.g. “dry mouth” and rampant tooth decay)“dry mouth” and rampant tooth decay)

……from your mouth to your from your mouth to your heart?heart?

Cardiovascular plaques (atherosclerosis) are Cardiovascular plaques (atherosclerosis) are contaminated with oral bacterial pathogenscontaminated with oral bacterial pathogens

In addition, cytomegalovirus and In addition, cytomegalovirus and Chlamydia pneumoniaeChlamydia pneumoniae found in plaquesfound in plaques

Four different antibodies directed to oral pathogens cross-Four different antibodies directed to oral pathogens cross-react with bloodreact with blood

In animal studies, oral pathogens injected into blood are In animal studies, oral pathogens injected into blood are recovered in atherosclerotic plaquesrecovered in atherosclerotic plaques

Oral infection also associated with diabetes, chronic Oral infection also associated with diabetes, chronic respiratory disease, stroke and low birth weight, premature respiratory disease, stroke and low birth weight, premature birthsbirths

Approximately 33% of adults over thirty years present Approximately 33% of adults over thirty years present periodontal diseasesperiodontal diseases

SG ORAL HEALTH SG ORAL HEALTH MESSAGESMESSAGES

34 million adults report severe chronic facial pain 34 million adults report severe chronic facial pain (migraine, tension headaches, fibromyalgia, (migraine, tension headaches, fibromyalgia, myofascial pain, TMD, trigeminal neuralgia, Bell’s myofascial pain, TMD, trigeminal neuralgia, Bell’s palsy, atypical facial pain, phantom limb, postherpetic palsy, atypical facial pain, phantom limb, postherpetic neuralgia)neuralgia)

Unrelieved pain in 75% advanced cancer, 30-80% HIV, Unrelieved pain in 75% advanced cancer, 30-80% HIV, 40% terminally ill, and 47% during cancer therapy 40% terminally ill, and 47% during cancer therapy

Osteoarthritis, osteoporosis, diabetes and cancer Osteoarthritis, osteoporosis, diabetes and cancer therapy have significant oral complicationstherapy have significant oral complications

Tooth loss, tooth pain, swallowing and facial pain are Tooth loss, tooth pain, swallowing and facial pain are major complaints of poor elderlymajor complaints of poor elderly

The fastest growing subpopulation in US are people The fastest growing subpopulation in US are people over 80 years of age (1:5 over 65 years of age by 2020)over 80 years of age (1:5 over 65 years of age by 2020)

The SG Report: A Framework For The SG Report: A Framework For ActionAction

Change perceptions regarding oral health and Change perceptions regarding oral health and disease so that oral health becomes an accepted disease so that oral health becomes an accepted component of general health ( e.g. public component of general health ( e.g. public perceptions, policymaker’s perceptions & health perceptions, policymaker’s perceptions & health provider’s perceptions)provider’s perceptions)

Accelerate the building of the science-base to Accelerate the building of the science-base to improve oral healthimprove oral health

Build infrastructure that provides comprehensive Build infrastructure that provides comprehensive oral health care for all Americansoral health care for all Americans

Remove known barriers between people and oral Remove known barriers between people and oral health care serviceshealth care services

Utilize public-private partnerships to improve the Utilize public-private partnerships to improve the oral health of those who suffer disproportionately oral health of those who suffer disproportionately from oral diseases and disordersfrom oral diseases and disorders

A CALL TO ACTIONA CALL TO ACTION Integrate health promotion Integrate health promotion

& disease prevention in & disease prevention in preschool & K-12 preschool & K-12 education, social & education, social & behavioral sciences behavioral sciences educationeducation

Promote prenatal care with Promote prenatal care with diet, exercise, & diet, exercise, & multivitamin supplementsmultivitamin supplements

Integrate oral health- - -Integrate oral health- - -dentistry, medicine, dentistry, medicine, nursing, pharmacy, nursing, pharmacy, speech therapy, physical speech therapy, physical therapy, & social servicestherapy, & social services

California campaign California campaign for tobacco cessation, for tobacco cessation, alcohol reduction, alcohol reduction, healthy food choices, healthy food choices, exercise, fluoridation, exercise, fluoridation, calcium for child and calcium for child and adolescentsadolescents

Immunizations, oral Immunizations, oral hygiene, diet, sleep, hygiene, diet, sleep, exerciseexercise

A CALL TO ACTIONA CALL TO ACTION

Preschool programs Preschool programs to include oral healthto include oral health

All school-based All school-based programs should programs should provide caregivers provide caregivers and children with and children with “tools” to optimize “tools” to optimize health and well being health and well being and to reduce and to reduce burdens of diseaseburdens of disease

California standards for California standards for health promotion and health promotion and disease preventiondisease prevention

Clinical and cultural Clinical and cultural competencies for all competencies for all health professionalshealth professionals

Cross-disciplinary training Cross-disciplinary training programs between programs between medicine, dentistry, medicine, dentistry, dental hygiene, dental hygiene, pharmacy, nursing, pharmacy, nursing, speech therapy, and speech therapy, and social servicessocial services

A CALL TO ACTIONA CALL TO ACTION Public/private coalitions to Public/private coalitions to

promote health and well promote health and well being, risk assessment and being, risk assessment and disease preventiondisease prevention

Increase outcomes and Increase outcomes and health services researchhealth services research

Increase collaborations of Increase collaborations of health professions from health professions from prenatal through elderly prenatal through elderly stages of lifestages of life

Achieve student debt Achieve student debt forgiveness as incentive to forgiveness as incentive to address oral health address oral health disparitiesdisparities

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

The Future of Oral Health The Future of Oral Health For All Californians?For All Californians?

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

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

Goethe