More U.S. Kids Getting Government Dental Insurance

About 30 percent of U.S. children and adolescents were covered by government-sponsored dental insurance in 2006, a significant increase from the 18 percent covered in 1996, according to the latest News and Numbers from the Agency for Healthcare Research and Quality. Private dental insurance enrollment remained relatively unchanged during the period.

Much of the increase resulted from the State Children's Health Insurance Program, which began in 1997, and extensions of Medicaid coverage for dental services.

AHRQ's analysis also found that between 1996 and 2006:

• Enrollment in government dental insurance rose sharply among Hispanic and black adolescents and children, 48 percent and 35 percent, respectively
• White children and adolescents were less likely than blacks and Hispanics to have public dental insurance, but their enrollment doubled, climbing from 10 percent to 20 percent.
• Largely due to expanded government coverage, only 19 percent of U.S. children had no dental insurance in 2006 compared with 29 percent in 1996.

AHRQ, which is part of the U.S. Department of Health and Human Services, works to enhance the quality, safety, efficiency, and effectiveness of health care in the United States. The data in this AHRQ News and Numbers summary are taken from the Medical Expenditure Panel Survey, a detailed source of information on the health services used by Americans, the frequency with which they are used, the cost of those services, and how they are paid. For more information, go to Dental Coverage of Children and Young Adults under Age 21, United States, 1996 and 2006 (http://www.meps.ahrq.gov/mepsweb/data_files/publications/st221/stat221.pdf).

Does Treating Periodontitis Help Control Diabetes?

Researchers at Stony Brook University’s (SBU) School of Dental Medicine and School of Medicine received a $12.5 million five-year grant from the National Institute of Dental and Craniofacial Research (NIDCR), an arm of the National Institutes of Health, to conduct a multi-center clinical trial to evaluate whether treatment of chronic periodontitis may help to improve diabetes control. The study will be the largest clinical trial of diabetes and periodontitis to date and may lead to potential improvements in diabetes patient care. This collaborative effort, led by the SBU team, includes researchers from the University of Alabama, University of Minnesota, and the University of Texas.

The 2000 Surgeon General’s Report on Oral Health identified the relationship between improvement in periodontal health and glycemic control as an area in need of further investigation. Thus, SBU researchers were prompted to design a large scale clinical trial to meet this research need and to address the important public health goal of improving the standard of care for patients with diabetes. They will test whether non-surgical periodontal therapy helps to improve glycemic control in patients with Type 2 diabetes.

According to the American Diabetes Association, Type 2 diabetes is the fifth leading cause of death in the U.S. and affects an estimated 23.6 million Americans (7.8% of the population). The American Academy of Periodontology estimates that chronic periodontitis affects about half of Americans over the age of 55 but is 2 to 4 times more likely to occur among people with diabetes.

“Research clearly shows an association between chronic periodontitis and Type 2 diabetes, and there is early evidence that treating periodontal infection and inflammation can improve glycemic control,” says Steven Engebretson, D.M.D., M.S., M.S., Principal Investigator for the study and Assistant Professor of Peridontics and Implantology at the Stony Brook University School of Dental Medicine. “Previous studies in this area have been encouraging but are too small to be conclusive. This will be the first large multi-center study to determine whether periodontal treatment can improve glycemic control.”

Dr. Engebretson says that scientifically the exact connection between periodontitis and diabetes or blood sugar control has not been fully defined. He adds that researchers suspect the association is related to inflammatory molecules caused by the periodontal infection that reach the circulation and disrupt the insulin pathway.

“Inflammation anywhere in the body can lead to glucose management problems, and keeping glucose levels as close to normal as possible is the key to managing diabetes,” says Dr. Ralph DeFronzo, Deputy Director of the Texas Diabetes Institute and Co-Investigator of the study. “If treating chronic periodontitis can help reduce blood glucose, the implications could be very significant to patient care.”

“Our study will address limitations of prior studies and will follow the highest standards for clinical trial design and conduct,” says Leslie Hyman, Ph.D., Director of the Coordinating Center for the study, and Professor, SBU Department of Preventive Medicine. “The multi-disciplinary study team includes leading researchers from the fields of periodontics, diabetology, clinical trials, and biostatistics who will provide their different expertise to ensure that the study can provide a clear answer to this important question.”

Drs. Engebretson and Hyman’s colleagues from SBU include Elinor Schoenfeld, Ph.D., and Li Ming Dong, Ph.D. The Clinical Centers are led by Dr. Michael Reddy and Dr. Beth Lewis of the University of Alabama, Dr. Bryan Michalowicz, Dr. Michael Tsai, and Dr. Betsy Seaquist of the University of Minnesota, and Dr. Thomas Oates and Dr. Ralph DeFronzo of the University of Texas. Dr. Mohammed Saad and Dr. Kevin A. Peterson are consultants for the study.

Participant enrollment in the trial is slated to begin during spring/summer 2009.

Dentist Says OK To Eat Lots Of Haloween Candy

Halloween can present a very scary time of year for any parent concerned about their child’s oral health. Megan Chiplock says that when her daughters go trick or treating, they come back with a pretty big haul – but she lets them enjoy as much as they want.

“We let them go at it, gorge themselves, and maybe for a few days after if they want a piece here and there,” she says. “But they really get their fill on Halloween night, and [then] it’s sort of out of their system.”

Temple University pediatric dentist Mark Helpin says that might not be such a bad idea.

“The frequency of eating candy, and other refined carbohydrates, and their stickiness, are big factors in creating the risk of caries (cavities),” he said.

Eating carbohydrates can change the pH balance of the mouth, making it more acidic, which can increase the risk of cavities. Each time candy is eaten, the acid environment in the mouth can take up to an hour to dissipate.

“So, if I eat a piece of candy now, the pH in my mouth will become acidic, and it will take 30-60 minutes for it to become normal,” said Helpin. “If I keep eating candy throughout the day, there is acid in my mouth for a much longer period of time. The longer teeth are in an acid environment, the greater the risk they will become decayed.”

Helpin, the acting chair of Pediatric Dentistry at Temple’s Maurice H. Kornberg School of Dentistry, says that there are a number of ways parents can minimize this risk while still letting their children enjoy the holiday.

“Parents can let kids eat a bunch [of candy] now and a bunch later. But don’t let them have one piece now, then an hour later let them have another piece,” he said, adding that candy can also be dispensed as a dessert or snack.

Meals are a good time at which to have treats as dessert because the production of saliva increases, which helps to wash away acidity in the mouth. Helpin also recommends that parents have their children brush their teeth after eating candy, or if that's not possible, tell their children to rinse their mouth with water 3 or 4 times after eating, which will help reduce acidity in the mouth.

Helpin warns that substituting small bags of chips or pretzels for candy doesn't solve the cavity problem, either.

“Chips and pretzels are also carbohydrates and they also will create an acid environment that can create cavities,” he says. “These treats and snacks get stuck on your teeth, and that’s the stickiness factor,” he said.

When trick-or-treaters come to his door, Helpin likes to give out sugar-free candies, and avoids the sticky, gummy candies. Megan says her kids don’t really go for those sticky treats either.

“My three-year-old doesn’t enjoy the chewy candies,” she said. “She’s tried them but they just get stuck in her teeth.”

Ultimately, “it's not realistic to think you can tell your child you can't have candy, cookies, cakes, or other treats,” says Helpin. “Those are the things most people enjoy—and we want our kids to enjoy life.”

Bleeding gums linked to heart disease

Bad teeth, bleeding gums and poor dental hygiene can end up causing heart disease, scientists heard today (Thursday 11 September 2008) at the Society for General Microbiology's Autumn meeting being held this week at Trinity College, Dublin.

People with poor dental hygiene and those who don't brush their teeth regularly end up with bleeding gums, which provide an entry to the bloodstream for up to 700 different types of bacteria found in our mouths. This increases the risk of having a heart attack, according to microbiologists from the University of Bristol and the Royal College of Surgeons in Ireland.

"The mouth is probably the dirtiest place in the human body," said Dr Steve Kerrigan from the Royal College of Surgeons in Dublin, Ireland. "If you have an open blood vessel from bleeding gums, bacteria will gain entry to your bloodstream. When bacteria get into the bloodstream they encounter tiny fragments called platelets that clot blood when you get a cut. By sticking to the platelets bacteria cause them to clot inside the blood vessel, partially blocking it. This prevents the blood flow back to the heart and we run the risk of suffering a heart attack."

The only treatment for this type of disease is aggressive antibiotic therapy, but with the increasing problem of multiple drug resistant bacteria, this option is becoming short lived.

"Cardiovascular disease is currently the biggest killer in the western world. Oral bacteria such as Streptococcus gordonii and Streptococcus sanguinis are common infecting agents, and we now recognise that bacterial infections are an independent risk factor for heart diseases," said Professor Howard Jenkinson from the University of Bristol. "In other words it doesn't matter how fit, slim or healthy you are, you're adding to your chances of getting heart disease by having bad teeth."

Researchers at Bristol have been investigating the ways in which the bacteria interact with platelets in order to develop new and improved therapies.

"Most of the studies that have looked at how bacteria interact with platelets were carried out under conditions that do not resemble those in the human circulatory system. We mimicked the pressure inside the blood vessels and in the heart", said Professor Jenkinson. "Using this technique we demonstrated that bacteria use different mechanisms to cause platelets to clump together, allowing them to completely encase the bacteria. This shields the bacteria from the cells of our immune systems, which would normally kill bacteria, and most importantly also protects them from antibiotics."

These findings suggest why antibiotics do not always work in the treatment of infectious heart disease and also highlight the need to develop new drugs to treat this disease. "We are currently in the process of identifying the exact site at which the bacteria stick to the platelets," said Professor Jenkinson. "Once this is identified we will design a new drug to prevent this interaction."

"We also identified several proteins on the bacteria that lead to platelet clumping," said Dr Kerrigan. "Genetic deletion of these proteins from the bacteria prevented the platelets from clumping which shows that these proteins play an essential role and may be candidate proteins for new drug development or producing vaccines."

Study Shows High Gum Disease Rates

Research on 445 families centered in two Pennsylvania towns and two West Virginia counties shows that 80 percent of adults suffer from more severe forms of periodontal disease, according to Richard Crout, D.M.D., Ph.D., an expert on gum disease and associate dean for research in the West Virginia University School of Dentistry.

“Leaving periodontal disease untreated is a major public health problem,” Crout says. “Not only do we see cases where the inflammatory process has eaten down around the bone, ultimately causing tooth loss in many patients, but also more important the inflammation likely has traveled throughout the body. A person with periodontitis may be twice as likely to have a heart attack and almost three times more likely to have a stroke.”

He added, “If a woman is pregnant, she is four to seven times more likely to have a preterm, low birth-weight baby compared to someone who does not have gum disease.”

Unlike gingivitis, an inflammation of the gums that is reversible, periodontitis can create infections below the gum line leading to bone destruction and tooth loss if not treated. Bleeding of the gums can signal gingivitis. But in periodontitis, no pain or symptoms may accompany the infection spreading into the bone.

Eighty-five percent of adults in the study showed signs of bone loss.

The study focusing on rural areas of Appalachia is a WVU-University of Pittsburgh collaboration, yielding a gold mine of dental data. Crout, who is directing the West Virginia portion of the collaboration, is sharing some of the more significant findings at the 94th Annual Meeting of the American Academy of Periodontology in Seattle Sept. 8. (The academy’s annual meeting runs Sept. 6 through 9.)

“This is the largest oral health study ever done in Appalachia,” Crout says.

In addition to dramatic rates of periodontal disease, discovery of high bacterial counts and the virulence of the disease-causing organisms in the mouth surprised the researchers, Crout says.

“These findings are significant in a state that leads the nation in all those who have lost all their teeth over the age of 65,” Crout says. “The national average is 20 percent, but in West Virginia, it’s 43 percent.”

The West Virginia families in the study live in Webster and Nicholas Counties. The Pennsylvania families are from the towns of Burgettstown and Bradford.

WVU’s portion of the National Institutes of Health grant is approximately $3.12 million. WVU researchers have followed the West Virginia families since 2002, studying genetic as well as environmental factors including attitudes, behaviors and beliefs. They are also examining microbial samples.

The study is part of COHRA – the Center for Oral Health Research in Appalachia. Originally involving only WVU and the University of Pittsburgh, the study has expanded to include the University of Michigan and the University of Iowa.

The researchers say parents and grandparents who have already lost their teeth are likely to transmit attitudes to the next generation. “Too often the attitude is, ‘Don’t worry, you’re going to lose them anyway,’ ” Crout says.

When Crout travels throughout West Virginia giving presentations to students on the importance of oral health, he sometimes meets schoolchildren who come up after the talk and say, “Hey, Mister, what’s this bump?” The child will crook a finger inside his cheek to offer a look, and Crout will observe a large, untreated abscess of the tooth.

A large abscess sometimes means the mouth can’t be numbed. So the child’s first visit to the dentist may end up being painful. Fear of pain may lead to a lifelong reluctance to visit the dentist.

“We have found that dental fear is highest in the very young. It may be one of the reasons that, by the age of 8, one-third of children have untreated dental decay in West Virginia,” Crout says. “One-third of West Virginians under age 35 have lost at least six permanent teeth. Our research has found that more than 25 percent of people would rather have a tooth out than have treatment done that might preserve the tooth. Fear was one of the main factors.”

Crout would like the study to lead to interventions such as introducing children to the dentist and the dentist’s chair at age 1 or when the first tooth comes in.

“It’s likely that at this age, treatment will be more preventive and provide a more positive first dental visit experience. This would go a long way in reducing fear and be very helpful in getting larger numbers of people to go to the dentist,” Crout says.

“It is also critically important to get the word out to our people in the state of the importance of oral health. Not only will it keep their teeth, but it will also be very important for good systemic health. Brushing, flossing and routine dental visits have never been more important,” Crout says.

Dental fillings without gaps

Tooth cavities are usually closed with plastic fillings. However, the initially soft plastic shrinks as it hardens. The tension can cause gaps to appear between the tooth and the filling, encouraging more caries to form. For the first time, researchers have simulated this process.

The patient’s hands are clasped firmly around the armrests as the dentist drills away the caries-stricken sections of the tooth. Once the drilling is over, most toothache sufferers can begin to relax. All the doctor now has to do is to slightly etch the cavity, apply an adhesive film, and fill it with a special type of plastic. The plastic is soft at first, so that the doctor can easily press it into the cavity. It only solidifies afterwards under the light of a small lamp. However, the material tends to shrink slightly as it hardens, occasionally producing tension that can cause tiny gaps to form between the plastic filling and the tooth. Bits of food can get caught in these gaps and lead to more caries. Manufacturers of filling materials therefore offer a variety of plastics to choose from. But which filling is best suited to which shape of cavity? This is where dentists have to draw on their experience. “Until now, it has not been possible to establish a theoretical model of the hardening process. The tension occurring in the material always depends on the shape of the cavity, and can vary widely by a factor of up to ten, particularly at the edges,” says Dr.-Ing. Christof Koplin, research assistant at the Fraunhofer Institute for Mechanics of Materials IWM in Freiburg. Measurements do not help either, as tension can only be measured selectively. Its precise course of development has never yet been observed.

A new method of simulation now enables tension in dental fillings to be accurately predicted, helping doctors to choose the least tension-prone plastic for each shape of cavity. Dentists can now draw on the results of the IWM to select the best material, and manufacturers can use the simulations to optimize their products. “We theoretically subdivide the dental filling into thousands of small parcels and calculate how each element affects its neighbor. Experimental parameters are incorporated in the individual elements. We started our laboratory tests by using a standard geometry to find out how each material reacts to the stresses that occur when the volume shrinks, and how the flow capability of the material changes as it hardens,” explains Koplin. The IWM researchers have now successfully simulated the development of tension in dental fillings for various cavity shapes and materials, and more will follow.

Diabetes and Obesity Linked to Periodontitis?

The University of Illinois at Chicago has received a two-year federal grant to continue a study on how periodontitis, an inflammatory disease of the tissues surrounding teeth, is linked to type 2 diabetes and obesity.

Dr. Keiko Watanabe of the UIC College of Dentistry has found that periodontitis accelerates the onset of insulin resistance in rats fed a high-fat diet. Her new research will determine how periodontitis affects diabetic complications in the retina, aorta and pancreas.

"The prevalence of type 2 diabetes has risen dramatically as the result of an increase in obesity caused by a high-fat diet, junk food and a sedentary lifestyle," said Watanabe, associate professor of periodontics. Although the association between obesity, type 2 diabetes and periodontitis is recognized, she said, the underlying causes remain poorly understood.

Watanabe said the goal of the new study is to identify the causes by which periodontitis influences insulin resistance, type 2 diabetes and organ damage, so clinicians will be able to screen prediabetic individuals at risk of developing the disease. A plan to treat periodontal inflammation will also be developed so that insulin resistance will not accelerate to diabetes.

A key challenge is to determine whether the relationship between diabetes, obesity and periodontitis is causal, Watanabe said. Most of the data linking the conditions are based on epidemiologic or cross-sectional studies, she said.

Watanabe uses female diabetic fatty rats in her research, a model that closely resembles humans who consume a high-fat diet and subsequently develop insulin resistance and type 2 diabetes. Human subjects, she said, cannot be used to study the direct effect of periodontitis because it is not ethical to induce the disease.

"Several prospective studies using human subjects demonstrated that the treatment of periodontitis led to improvement of glycemic control in subjects with type 2 diabetes," she said. "However, confounding factors, such as medications used to treat type 2 diabetes, body mass index, the stage and duration of diabetes, and the onset and severity of periodontitis are difficult to assess or are broadly controlled in such studies.

"Thus, the causal nature between periodontitis, diabetes and obesity remains unclear."

Diabetes is a disease in which the body fails to produce -- or responds poorly to -- insulin, a hormone needed to control the level of blood sugar. It is estimated that 300 million people worldwide will suffer from type 2 diabetes by the year 2025, nearly double the number of people affected in the year 2000. Most Americans diagnosed with diabetes have type 2, according to the American Diabetes Association.

Watanabe's initial study was published in the July issue of the Journal of Periodontology. The study was funded by a UIC College of Dentistry Research Seed Grant.

The new study, totaling $432,000, is being funded by the National Institute of Dental and Craniofacial Research, one of the National Institutes of Health. Dr. Terry Unterman, professor of medicine, physiology and biophysics, and Haohua Qian, associate professor of ophthalmology, will collaborate on the project.