Children's oral health disparities persist despite equal dental care access

Oral health of children who receive dental care through Medicaid lags behind their privately insured peers, even though the children receive the same amount of dental care, according to a study from the Columbia University College of Dental Medicine.

The study was released in Health Affairs' December issue, and was discussed by Jaffer A Shariff, DDS, MPH, at a Washington, D.C., health policy briefing on December 7. 

"If poor and low-income children now enjoy equal access to dental care but do not have equal oral health, then the remedy should focus more tightly on the day-to-day factors that put them at higher risk for dental problems," said lead author Burton L. Edelstein, DDS, MPH, chair of the Section of Population Oral Health, professor of dental medicine at the College of Dental Medicine (CDM), and professor of health policy and management at Columbia's Mailman School of Public Health. "Low-income families often face income, housing, employment, and food insecurities that constrain their ability to engage in healthy eating and oral hygiene practices," he noted. 

The study considered data from the 2011-2012 National Survey of Children's Health, which included parent reports of oral health and use of dental care for 79,815 children and adolescents (age 1 to 17 years) of all social strata. No differences were found between Medicaid-insured and commercially-insured children in the odds of their having a dental visit, preventive or otherwise. However, parents of children enrolled in Medicaid were 25 percent more likely to report that their child did not have an "excellent or very good" dental condition and were 21 percent more likely to report that their child had a dental problem within the last year than were parents of commercially insured children.

"Because we found that low-income kids are seeing dentists at similar rates as privately insured children, we believe that other issues may negatively impact low income children's oral health. Addressing this would require attention from those currently outside the dental profession, such as social workers, health educators, nutritionists, and community health workers," said Jaffer A. Shariff, DDS, MPH, a research associate in the Section of Population Oral Health, a periodontal resident at CDM, and co-author of the study. "We need to develop an oral health promotion system that complements traditional dental care."

Medicaid's Equal Access Provision mandates that Medicaid beneficiaries have access to equivalent health services as the general population. While the study confirms that the mandate is being followed, it also shows that, "equal access to dental care does not ensure that low-income children obtain and maintain oral health at the same levels as other children," Dr. Edelstein said. 

Dentists need to "rethink the nature of oral health care by seeing it as part of a child's total health care and by treating tooth decay as the chronic disease that it is. We can't segregate oral health from overall health," Dr. Edelstein cautioned. "Evolving health systems that bring teams of providers together to promote healthy behaviors can address common risk factors that benefit a child's overall and oral health. But if you segregate dentistry, especially for Medicaid kids, then you lose that opportunity."

Periodontitis therapeutic vaccine trials could start in 2017

A world-first vaccine developed by Melbourne scientists, which could eliminate or at least reduce the need for surgery and antibiotics for severe gum disease, has been validated by research published this weekend in a leading international journal.

A team of dental scientists at the Oral Health CRC at the University of Melbourne has been working on a vaccine for chronic periodontitis for the past 15 years with industry partner CSL. Clinical trials on periodontitis patients could potentially begin in 2018.

Moderate to severe periodontitis affects one in three adults and more than 50 per cent of Australians over the age of 65. It is associated with diabetes, heart disease, rheumatoid arthritis, dementia and certain cancers. It is a chronic disease that destroys gum tissue and bone supporting teeth, leading to tooth loss.

The findings published in the journal NPJ Vaccines (part of the Nature series) represent analysis of the vaccine's effectiveness by collaborating groups based in Melbourne and at Cambridge, USA.

The vaccine targets enzymes produced by the bacterium Porphyromonas gingivalis, to trigger an immune response. This response produces antibodies that neutralise the pathogen's destructive toxins.

P. gingivalis is known as a keystone pathogen, which means it has the potential to distort the balance of microorganisms in dental plaque, causing disease.

CEO of the Oral Health CRC, Melbourne Laureate Professor Eric Reynolds AO, said it was hoped the vaccine would substantially reduce tissue destruction in patients harbouring P. gingivalis.

"We currently treat periodontitis with professional cleaning sometimes involving surgery and antibiotic regimes," Professor Reynolds said.

"These methods are helpful, but in many cases the bacterium re-establishes in the dental plaque causing a microbiological imbalance so the disease continues."

"Periodontitis is widespread and destructive. We hold high hopes for this vaccine to improve quality of life for millions of people.

Few older Americans have dental insurance

Only 12 percent of older Americans have some form of dental insurance and fewer than half visited a dentist in the previous year, suggests new Johns Hopkins Bloomberg School of Public Health research on Medicare beneficiaries.

Insurance status appeared to be the biggest predictor of whether a person received oral health care: For those with incomes just over the federal poverty level, 27 percent of those without dental insurance had a dental visit in the previous year, compared to 65 percent with dental insurance, according to an analysis of 2012 Medicare data.

Income also played a role: High-income beneficiaries were almost three times as likely to have received dental care in the previous 12 months as compared to low-income beneficiaries, 74 percent of whom reported receiving no dental care. Many high-income beneficiaries - even those with dental insurance - paid a sizable portion of their bills out of pocket.

The findings, published in the December issue of the journal Health Affairs, suggest an enormous unmet need for dental insurance among those 65 and older in the United States, putting older adults at risk for oral health problems that could be prevented or treated with timely dental care, including tooth decay, gum disease and loss of teeth. It also highlights the financial burden associated with dental visits, among both the insured and uninsured.

"Medicare is focused specifically on physical health needs and not oral health needs and, as a result, a staggering 49 million Medicare beneficiaries in this country do not have dental insurance," says study author Amber Willink, PhD, an assistant scientist in the Department of Health Policy and Management at the Bloomberg School. "With fewer and fewer retiree health plans covering dental benefits, we are ushering in a population of people with less coverage and who are less likely to routinely see a dentist. We need to think about cost-effective solutions to this problem."

Eighty percent of Americans under the age of 65 are covered by employer-sponsored programs that offer dental insurance, which covers routine cleanings and cost-sharing on fillings and other dental work. Many of them lose that coverage when they retire or go on Medicare. The vast majority of Medicare beneficiaries who have dental insurance are those who are still covered by employer-sponsored insurance, either because they are still working or because they are part of an ever-dwindling group of people with very generous retiree medical and dental benefits.

For the new study, the researchers analyzed data provided by 11,299 respondents to the 2012 Cost and Use Files of the Medicare Current Beneficiary Survey. The data included information collected on income, dental insurance status, dental health access and out-of-pocket expenditures.

Among the findings: On average, Medicare beneficiaries reported spending $427 on dental care over the previous year, 77 percent of which was out-of-pocket spending. An estimated seven percent reported spending more than $1,500. Dental expenses, on average, accounted for 14 percent of Medicare beneficiaries' out-of-pocket health spending.

Poor dental hygiene not only contributes to gum disease, but the same bacteria linked to gum disease has also been linked to pneumonia, a serious illness that increases the risk of hospitalization and death. It can also contribute to difficulty eating, swallowing or speaking, all of which bring their own health challenges. Nearly one in five Medicare beneficiaries doesn't have any of his or her original teeth left, according to the Centers for Disease Control and Prevention.

The researchers took the research a step further. They analyzed two separate proposals for adding dental benefits to Medicare, estimating how much each would cost. One was similar to the premium-financed, voluntary Medicare Part D benefit that was added to Medicare a decade ago to help cover prescription drugs for seniors. The other was similar to a proposal that has been introduced in Congress that would embed dental care into Medicare as a core benefit for all of the program's 56 million beneficiaries, which is not expected to pass before Congress recesses.

The first proposal, which would cost an average premium of $29-a-month and would come with a subsidy for low-income seniors who couldn't afford that, would run an estimated $4.4 to $5.9 billion annually depending on the number of low-income beneficiaries who participate. The second, with a $7 monthly premium and subsidies for low-income people, would cost between $12.8 and $16.2 billion annually. The packages would cover the full cost of one preventive care visit a year and 50 percent of allowable costs for necessary care up to a $1,500 limit per year to cover additional preventive care and treatment of acute gum disease or tooth decay.

First-ever study shows e-cigarettes cause damage to gum tissue

A University of Rochester Medical Center study suggests that electronic cigarettes are as equally damaging to gums and teeth as conventional cigarettes.

The study, published in Oncotarget, was led by Irfan Rahman, Ph.D. professor of Environmental Medicine at the UR School of Medicine and Dentistry, and is the first scientific study to address e-cigarettes and their detrimental effect on oral health on cellular and molecular levels.

Electronic cigarettes continue to grow in popularity among younger adults and current and former smokers because they are often perceived as a healthier alternative to conventional cigarettes. Previously, scientists thought that the chemicals found in cigarette smoke were the culprits behind adverse health effects, but a growing body of scientific data, including this study, suggests otherwise.

"We showed that when the vapors from an e-cigarette are burned, it causes cells to release inflammatory proteins, which in turn aggravate stress within cells, resulting in damage that could lead to various oral diseases," explained Rahman, who last year published a study about the damaging effects of e-cigarette vapors and flavorings on lung cells and an earlier study on the pollution effects. "How much and how often someone is smoking e-cigarettes will determine the extent of damage to the gums and oral cavity."

The study, which exposed 3-D human, non-smoker gum tissue to the vapors of e-cigarettes, also found that the flavoring chemicals play a role in damaging cells in the mouth.

"We learned that the flavorings-some more than others--made the damage to the cells even worse," added Fawad Javed, a post-doctoral resident at Eastman Institute for Oral Health, part of the UR Medical Center, who contributed to the study. "It's important to remember that e-cigarettes contain nicotine, which is known to contribute to gum disease."

Most e-cigarettes contain a battery, a heating device, and a cartridge to hold liquid, which typically contains nicotine, flavorings, and other chemicals. The battery-powered device heats the liquid in the cartridge into an aerosol that the user inhales.

"More research, including long term and comparative studies, are needed to better understand the health effects of e-cigarettes," added Rahman, who would like to see manufacturers disclose all the materials and chemicals used, so consumers can become more educated about potential dangers.

Cognitive Behavioral Therapy Resource for Children's Dental Anxiety

The International and American Associations for Dental Research (IADR/AADR) have published an article titled "Development and Testing of a Cognitive Behavioral Therapy Resource for Children's Dental Anxiety" in the OnlineFirst portion of JDR Clinical & Translational Research. In this study, Jenny Porritt, Department of Psychology, Sociology, and Politics, Sheffield Hallam University, UK, et al describe the development of a guided self-help cognitive behavioral therapy (CBT) resource for the management of children's dental anxiety and provide preliminary evidence for the feasibility and acceptability of this approach with children aged between nine and 16 years.

CBT is an evidence-based treatment for dental anxiety; however, access to therapy is limited. This study employed a mixed methods design where within phase one, a qualitative "person-based" approach informed the development of the self-help CBT resource. Guidelines for the development and evaluation of complex interventions were also used. Within phase two, children aged between nine and 16 years who had elevated self-reported dental anxiety and were attending a community dental service or dental hospital were invited to use the CBT resource. Children completed questionnaires, which assessed their dental anxiety and health-related quality of life prior to and following their use of the resource. Recruitment and completion rates were also recorded.

Acceptability of the CBT resource was explored using interviews and focus groups with children, parents/caregivers and dental professionals. A total of 85 children were invited to participate in the feasibility study and trial the CBT resource. The recruitment rate (proportion of children invited to take part in the study who agreed to participate) and completion rate (proportion of children who agreed to participate who completed the study) was 66 percent and 86 percent, respectively. A total of 48 patients completed the study.

At the conclusion of the study, the authors ascertained that there was a significant reduction in dental anxiety and an increase in health-related quality of life following the use of the guided self-help cognitive behavioral therapy resource. The results of this study will inform the design of a definitive trial to examine the treatment and cost-effectiveness of the resource for the reduction of children's dental anxiety.

"Having launched this year, JDR Clinical & Translational Research provides a unique opportunity for oral health research leaders to publish their research and effectively translate their findings to those who need the information to deliver evidence-based prevention and care. On behalf of the International Association for Dental Research, I am pleased that the authors of this study contributed their research to this publication," said IADR President Jukka Meurman.

Why some dental implants work and others don't

Each year, about 500,000 North Americans get dental implants. If you are one of them, and are preparing to have an implant, it might be a good idea to start taking beta blockers, medication that controls high blood pressure, for a while. And to stop taking heartburn pills.

A body of research from McGill led-teams indicates that in order to raise the odds that dental implants will attach properly, there are clear benefits to taking certain common medications and avoiding others.

Bone cell growth, healing and death

"The success of procedures like dental implants depends mainly on how the existing bone accepts the implants to create a connection between the living bone and the surface of the implant," says Prof. Faleh Tamimi, who teaches in the McGill Faculty of Dentistry, and is the senior author on a number of papers published on the subject in recent weeks. "Because some medications affect bone metabolism and the way that bone cells heal and multiply or die, they can have an important effect on the success of implants."

The McGill research team reviewed data about the integration of dental implants gathered from over 700 patients who were operated on at the East Coast Oral Surgery Clinic in Moncton, New Brunswick between 2007-2015. They then confirmed the results they saw in human patients through studies in rats.

Implications for hip and knee replacements

"We believe that this research may have implications for orthopedic interventions such as hip and knee replacements, because the same mechanisms of bone cell growth break down, and healing take place in all the bones in the body," says Tamimi. "Our work with implants in rats suggest that this is indeed the case, but further research will be needed to confirm it."

Drugs that aid integration of implants - Beta blockers

Conclusions are based on 1499 dental implants in 728 patients between Jan. 2007 -- Sept. 2013 at the East Coast Oral Surgery in Moncton, New Brunswick

• 327 implants were in 142 people who took beta blockers for hypertension
• 1172 implants were in 586 people who didn't take beta blockers
• Failure rates of implants for people using beta blockers was 0.6%
• Failure rates of implants in people who don't take beta blockers was 4.1%
• More than 640 million patients around the world take beta blockers to control hypertension.

"We carried out this study because we knew that beta blockers have been reported to increase bone formation," says Prof. Tamimi from McGill's Faculty of Dentistry. "So we thought it was possible that they would also decrease the risk of failure of dental implants. However we didn't expect that there would be such a clear difference in the failure rates for implants between users and non-users of beta blockers. Randomized clinical trials will need to be carried out as well as other studies of large numbers of patients to investigate this phenomenon in more depth."

Drugs that impede integration of dental implants - Heartburn treatment

Conclusions are based on 1773 dental implants in 799 patients between Jan. 2007 -- Sept. 2015 at the East Coast Oral Surgery in Moncton, New Brunswick

• 133 implants were in 58 people who took heartburn medication
• 1640 implants were in 741 people who don't take heartburn medication
• Failure rates of implants for people using heartburn medication were 6.8%
• Failure rates of implants for people not taking heartburn medication were 3.2%
• More than 20 million Americans, about one in 14 people, take heartburn medication.
• Heartburn medication is rapidly becoming the third most prescribed pharmaceutical product worldwide, especially for elderly people, who take it either on an occasional or long-term basis.

"Scientists already knew that drugs for heartburn reduce calcium absorption in bones and generally increase the risk of bone fractures," says Faleh Tamimi, of McGill's Faculty of Dentistry. "That is why we wanted to look at how it affects the integration of implants and bone healing after this type of surgery. But we didn't expect to find that the negative effects of these type of drugs would be as great as they are. Further work will need to be done to find the appropriate dosages and time periods that people should take or avoid these medications."

To read the full articles on effects of Beta blockers

In humans: "Antihypertensive medications and the survival rate of osseointegrated dental implants: A cohort study" by X. Wu et al in Clinical Implant Dentistry and Related Research: http://onlinelibrary.wiley.com/doi/10.1111/cid.12414/full

Regular dental visits may help prevent pneumonia

That twice-yearly trip to the dentist could do more than keep teeth and gums healthy: It may decrease the risk of pneumonia by reducing bacteria in the mouth, suggests research being presented at IDWeek 2016™.

Nearly one million Americans become ill with the infection every year and 50,000 die. While it is more common among older people and those with conditions such as AIDS or lung disease, anyone can get pneumonia. Based on an analysis of a national database of more than 26,000 people, the new research found that people who never get dental checkups had an 86 percent greater risk of pneumonia than to those who visit the dentist twice a year.

"There is a well-documented connection between oral health and pneumonia, and dental visits are important in maintaining good oral health," said Michelle Doll, MD, lead author of the study and assistant professor of internal medicine in the Division of Infectious Disease at Virginia Commonwealth University, Richmond. "We can never rid the mouth of bacteria altogether, but good oral hygiene can limit the quanitities of bacteria present."

Researchers analyzed data obtained from the 2013 Medical Expediture Panel Survey, which asks about healthcare utilization (including dental care), costs and patient satisfaction. They found 441 of 26,246 people in the database had bacterial pneumonia (1.68 percent) and that those who never had dental checkups had an 86 percent increased risk of pneumonia compared to those who had twice-yearly appointments.

The body contains 10 times as many microbes (bacteria, fungi and viruses) as human cells on or in the body, from the skin to the gastrontestinal system (including the mouth). Some microbes are good and some are bad, but even bad microbes only cause disease under certain circumstances. In some cases, bacteria can be accidentally inhaled or aspirated into the lungs and cause pneumonia. Bacteria that commonly cause pneumonia include streptococcus, haemophilus, staphylococcus, and anaerobic bacteria. Routine dental visits may reduce the amount of bacteria that can be aspirated, said Dr. Doll.

"Our study provides further evidence that oral health is linked to overall health, and suggests that it's important to incorporate dental care into routine preventive healthcare," said Dr. Doll.