Burton L. Edelstein

Disparities in Oral Health and Access to Care: Findings of National Surveys

In this background paper, sociodemographic variables, including age, race, family income, sex, parental education, and geographic location, have been used to characterize the dental status of US children and their access to dental services. Because tooth decay, or dental caries, remains the preeminent oral disease of childhood and national data is available on dental office visits, tooth decay has been used as the primary marker for childrens oral health, and visits to the dentist is the marker for care. In general, children from low-income families experience the greatest amount of oral disease, the most extensive disease, and the most frequent use of dental services for pain relief. Yet these children have the fewest overall dental visits. Paradoxically, children in poverty-those living in households with annual gross incomes under

Update on Disparities in Oral Health and Access to Dental Care for America's Children

16 500 for a family of 4-or near poverty-those in family households with incomes between

Bisphenol A and Related Compounds in Dental Materials

16 500 and

Oral Health in Women During Preconception and Pregnancy: Implications for Birth Outcomes and Infant Oral Health

33 000-also have the highest rates of dental insurance coverage, primarily through Medicaid and SCHIP. For those most affected, dental disease is consequential for their growth, function, behavior, and comfort. The twin disparities of poor oral health and lack of dental care are most evident among low-income preschool children, who are twice as likely to have cavities as are higher income children. Medicaid-eligible children who have cavities have twice the numbers of decayed teeth and twice the number of visits for pain relief but fewer total dental visits, compared to children coming from families with higher incomes. Fewer preventive visits for services such as sealants increase the burden of disease in low-income children. These disparities continue into adolescence and young adulthood, but to a lesser degree. Disparities in oral health status and access to dental care are also evident when comparing black, Hispanic, and Native American children to white children and when comparing children of parents with low educational attainment to children of parents with higher educational attainment. The fastest growing populations of children are those that currently have the highest disease rates and the lowest amount of dental care. If the strong correlation between these subpopulations and dental diseases continues, caries rates are likely to rebound after longstanding declines, and the stress on publicly financed dental care will likely increase.

MySmileBuddy: An iPad-Based Interactive Program to Assess Dietary Risk for Early Childhood Caries

This contribution updates federal survey findings on childrens oral health and dental care since release of Oral Health in America: A Report of the Surgeon General in 2000. Dental caries experience continued at high levels, impacting 40% of all children aged 2 to 11 years, with greater disease and untreated disease burden borne by poor and low-income children and racial/ethnic minorities. Caries rates increased for young children (to 28% of 2- to 5-year-olds in the period 1999-2004) and remained flat for most other ages. The total volume of caries and untreated caries increased as the numbers of children increased. The proportion of US children with a dental visit increased modestly (from 42% to 45% between 1996 and 2004), with the greatest increases occurring among children newly covered by the State Childrens Health Insurance Program (SCHIP). Disparities in dental visits continued to be evidenced by age, family income, race/ethnicity, and caregiver education. Parental reports of childrens oral health and dental care parallel these findings and also reveal higher unmet dental needs among children with special health care needs. Racial- and income-based disparities in both oral health and dental care continue into adolescence and young adulthood. These disparities can, as in the past, be expected to exacerbate under the forces of growing income disparities and demographic trends.

Putting Teeth in CHIP: 1997–2009 Retrospective of Congressional Action on Children's Oral Health

CONTEXT: Dental sealants and composite filling materials containing bisphenol A (BPA) derivatives are increasingly used in childhood dentistry. Evidence is accumulating that BPA and some BPA derivatives can pose health risks attributable to their endocrine-disrupting, estrogenic properties. OBJECTIVES: To systematically compile and critically evaluate the literature characterizing BPA content of dental materials; to assess BPA exposures from dental materials and potential health risks; and to develop evidence-based guidance for reducing BPA exposures while promoting oral health. METHODS: The extant toxicological literature and material safety data sheets were used as data sources. RESULTS: BPA is released from dental resins through salivary enzymatic hydrolysis of BPA derivatives, and BPA is detectable in saliva for up to 3 hours after resin placement. The quantity and duration of systemic BPA absorption is not clear from the available data. Dental products containing the bisphenol A derivative glycidyl dimethacrylate (bis-GMA) are less likely to be hydrolyzed to BPA and have less estrogenicity than those containing bisphenol A dimethacrylate (bis-DMA). Most other BPA derivatives used in dental materials have not been evaluated for estrogenicity. BPA exposure can be reduced by cleaning and rinsing surfaces of sealants and composites immediately after placement. CONCLUSIONS: On the basis of the proven benefits of resin-based dental materials and the brevity of BPA exposure, we recommend continued use with strict adherence to precautionary application techniques. Use of these materials should be minimized during pregnancy whenever possible. Manufacturers should be required to report complete information on the chemical composition of dental products and encouraged to develop materials with less estrogenic potential.

Changes in Children’s Oral Health Status and Receipt of Preventive Dental Visits, United States, 2003–2011/2012

The mouth is an obvious portal of entry to the body, and oral health reflects and influences general health and well being. Maternal oral health has significant implications for birth outcomes and infant oral health. Maternal periodontal disease, that is, a chronic infection of the gingiva and supporting tooth structures, has been associated with preterm birth, development of preeclampsia, and delivery of a small-for-gestational age infant. Maternal oral flora is transmitted to the newborn infant, and increased cariogenic flora in the mother predisposes the infant to the development of caries. It is intriguing to consider preconception, pregnancy, or intrapartum treatment of oral health conditions as a mechanism to improve womens oral and general health, pregnancy outcomes, and their childrens dental health. However, given the relationship between oral health and general health, oral health care should be a goal in its own right for all individuals. Regardless of the potential for improved oral health to improve pregnancy outcomes, public policies that support comprehensive dental services for vulnerable women of childbearing age should be expanded so that their own oral and general health is safeguarded and their childrens risk of caries is reduced. Oral health promotion should include education of women and their health care providers ways to prevent oral disease from occurring, and referral for dental services when disease is present.

Changes in state policies related to oral health in the United States, 2002‐2009

E ARLY CHILDHOOD CARIES (ECC), DEFINED AS THE occurrence of tooth decay in children younger than age 6 years, is a chronic, highly prevalent, and consequential disease of US children that is overwhelmingly diet-dependent. Although ECC is a multifactorial disease that is only partially explained by sugar intake, the importance of diet has long been established through laboratory, clinical, and epidemiologic studies. This knowledge has been translated into dietary recommendations for the prevention or suppression of caries activity in young children, often with only limited success. In an effort to reduce ECC prevalence and its consequences in a high-risk, economically stressed Latino population in Northern Manhattan, NY, a multidisciplinary team of Columbia University researchers—including experts from behavioral nutrition, pediatric medicine and dentistry, community health, social work, and information technology—has developed MySmileBuddy, a prototype Internet-based application for the iPad (Apple, Inc) that facilitates community health workers’ (CHWs) engagement of parents in dental caries prevention, with funding support from the National Institute on Minority Health and Health Disparities. The prototype was designed for the iPad but can be used by CHWs with parents on any laptop, desktop, tablet, or Internet-enabled telephone because this program operates in common Internet browsers. Central to its utility is its diet recall function (Figure 1), a subprogram designed to engage families in a modified 24-hour recall that contributes to a risk score for individual children. Here we describe the challenges confronted and approaches adopted in designing this diet recall function for initial dietary screening by nonprofessional peer counselors.

Perspectives on evolving dental care payment and delivery models

When Congress reenacted the Child Health Insurance Program (CHIP) in 2009, it incorporated a range of dental provisions that had not been considered when the program was initiated in 1997. This paper posits that this change evidences the establishment of pediatric oral health as a distinct policy issue within Congressional deliberations. During this period, the US Congress received impetus for action on behalf of childrens oral health from multiple streams of activity: the Surgeon Generals Report, Oral Health in America, policies enacted by states, advocacy by the professions, promotion by policy groups, attention by the press, and actions of federal agencies. The death of 12-year-old Deamonte Driver appears to have created a tipping point for action that dovetailed with Congressional need to reauthorize CHIP. Federal legislative policymaking is a complex process that frequently builds on an issue that has emerged as timely and relevant. Although much remains to be done, childrens oral health, cast as a public policy issue of import, is one such idea that appears to have gained traction among members of Congress.

Reducing early childhood caries in a Medicaid population: A systems model analysis

Introduction Oral health represents the largest unmet health care need for children, and geographic variations in children’s receipt of oral health services have been noted. However, children’s oral health outcomes have not been systematically evaluated over time and across states. This study examined changes in parent-reported children’s oral health status and receipt of preventive dental visits in 50 states and the District of Columbia. Methods We used data from the 2003 and the 2011/2012 National Survey of Children’s Health. National and state-level estimates of the adjusted prevalence of oral health status and preventive dental visits were calculated and changes over time examined. Multivariable logistic regression was used to compare outcomes across all states and the District of Columbia for each survey year. Results The percentage of parents who reported that their children had excellent or very good oral health increased from 67.7% in 2003 to 71.9% in 2011/2012. Parents who reported that their children had preventive dental visits increased from 71.5% in 2003 to 77.0% in 2011/2012. The prevalence of children with excellent or very good oral health status increased in 26 states, and the prevalence of children who received at least 1 preventive care dental visit increased in 45 states. In both years, there was more variation among states for preventive dental visits than for oral health status. Conclusions State variation in oral health status and receipt of preventive dental services remained after adjusting for demographic characteristics. Understanding these differences is critical to addressing the most common chronic disease of childhood and achieving the oral health objectives of Healthy People 2020.