Children’s Outcomes Research Projects Focus on Oral Health
Healthy People 2010 Oral Health Goal:
Prevent and control oral and craniofacial diseases, conditions, and injuries and improve access to related services
Improving oral health in children is important to researchers in the Children’s Outcomes Research (COR) program at Children's Hospital Colorado. Directed by Allison Kemple, COR has been developing collaborations with pediatricians, dentists and hygentists to improve screening and treatment for early childhood caries and periodontal diseases in children at high-risk for these oral infections.
Early Childhood Caries Prevention: The Dental Hygienist Co-Location Project
Dr. Matt Daley is directing a demonstration project to evaluate the integration of caries screening and preventive fluoride treatment with well child care visits occurring in primary care offices seeing low-income children. This study evaluates the clinical value of incorporating hygienists into pediatrician practices where access to early dental care is important given a higher incidence of early childhood caries.
Disparities in Oral Health Screening
The American Academy of Pediatric Dentistry (AAPD) recommends an oral health risk assessment between birth and 12 months of age. Nationally, an estimated 47 percent of children less than 18 years old do not receive the recommended number of dental visits per year. In addition, significant disparities exist with regard to the receipt of AAPD-recommended preventive dental care, with income, race/ethnicity, and insurance status all impacting receipt of appropriate dental care.
While the majority of children obtain routine well-child care, fewer children obtain routine preventive dental care. Although many factors contribute to this difference in utilization, difficulties in accessing preventive dental care clearly play a role. Nationally, public insurance programs suffer from a shortage of participating dentists, especially pediatric dentists, and therefore children with public health insurance, such as Medicaid, or with no insurance are more likely to have poor access to dental care than commercially insured children, and therefore have avoidable oral disease.
Linking Preventive Dental Care with Preventive Medical Care
There has been interest in the U.S. in exploring whether innovative dental hygiene practice models could expand access to preventive services and improve outcomes for high-risk populations. Because most infants, toddlers and preschoolers have more exposure to medical care than dental care, leveraging well-child visits may represent an opportunity to expand access to preventive dental services for children who are younger than school-age. One innovative approach would be to co-locate dental hygienists within primary health care offices. Such a model could maximize the opportunities created by the well-child visit.
Linking preventive dental care to preventive medical care has the potential to substantially improve the oral health of children, especially low-income children. Providing preventive dental care in the “medical home” has many possible benefits, such as:
Overcoming the barrier of not being able to find a Medicaid-accepting dentist
Allowing families to take care of preventive medical and dental needs at one visit
Facilitating the scheduling of preventive dental visits
Promoting the concept that oral health is an important part of overall health
Facilitating the screening of children for existing oral disease
Establishing a mechanism for referral of patients needing additional dental treatment
Colorado is uniquely positioned to test this innovative model of incorporating hygienists into well care visits because state regulations permit the unsupervised practice of dental hygienists. According to the American Dental Hygienists’ Association (ADHA), Colorado is one of 19 states that permit dental hygienists to practice independently, and one of just 10 states that allow dental hygienists to bill Medicaid directly for reimbursement.
This pilot project consists of co-locating dental hygienist services in medical primary care offices. Dental hygienists will work in close collaboration with the primary care offices, providing preventive dental care to young children either before or after scheduled well-child visits. The target population for this intervention will be children zero to three years of age because:
Early childhood caries starts at a very young age, before age one in some cases
Children this age are less likely to receive preventive dental care than older children
Children this age are less likely to have already established a dental home than older children. All children seen by the dental hygienist will be referred to a dentist for additional care as needed. Services will be provided twice per year for any individual child, typically when children are seen for well-child visits.
Children will be eligible for hygienist services regardless of health insurance or dental insurance status. However, for this pilot project, primary care practices with a high proportion of patients with public health insurance will be targeted for participation.
This project is funded by a generous donation from the Delta Dental Foundation of Colorado. The project has recruited several practices in western Colorado and several practices in the Front Range for participation. The first patients will be seen by the summer of 2008.
For more information about the Hygienist Co-Location Project contact Matt Daley, MD.
Study Looks at Possible Connection Between Periodontal Disease and Type 1 Diabetes in Children
Elaine Morrato, DrPH, MPH
Assistant Professor, University of Colorado Denver School of Medicine
Children’s Outcomes Research Program
Dr. Elaine Morrato is initiating a new study to investigate the prevalence of periodontal disease in adolescents with Type 1 diabetes. The study is a multidisciplinary collaboration between investigators from the University of Colorado Denver School of Dentistry (Dr. Lonnie Johnson, Ms. Valerie Orlando), the Barbara Davis Center for Childhood Diabetes (Drs. Paul Wadwa and David Maas and Ms. Franziska Bishop), and the Pediatric Dentistry Department at Children's Hospital Colorado (Dr. Anne Wilson). The study objective is to identify clinical and behavioral determinants of early periodontal disease in youth with diabetes so that the best preventive interventions can be identified.
Periodontal disease is a chronic infection caused by the long-term colonization of bacteria in dental plaque. Bacterial plaque triggers an inflammatory host reaction that leads to gum redness and bleeding (gingivitis) and ultimately to the destruction of both soft and hard tooth-supporting structures (periodontitis). Periodontal disease is the most common cause of tooth loss, which has physical, emotional and economic consequences including poor nutrition, speech problems, and negative self-image.
It is important to identify and treat periodontal disease early while it is still reversible with good brushing and flossing. Later stages of the disease have irreversible consequences, such as clinical attachment and bone loss. This stage of disease requires more aggressive therapeutic and surgical intervention to prevent further destruction of the supporting tissue and eventual tooth loss.
Not Just a Disease of Aging
Periodontal disease is commonly thought of as a disease of aging; however, inflammation and bleeding gums is almost universal in children and adolescents. More progressive periodontal disease is not uncommon in young adults, particularly surrounding third-molars (wisdom teeth). Children with diabetes are at particular risk. By some estimates, the average loss of clinical attachment around the teeth of children with diabetes is comparable to the average attachment loss seen in U.S. adults 50 to 64 years of age.
The Diabetes-Periodontal Disease Connection
People with diabetes are at higher risk for developing infections, including periodontal disease. These infections can impair their ability to process and/or utilize insulin, which may cause their diabetes to be more difficult to control and their periodontal infection to be more severe than for someone without diabetes. Periodontal disease may increase insulin resistance in a way similar to obesity through a hyperinflammatory mechanism.
Micro- and macro-vascular complications associated with diabetes are also correlated with periodontal disease. Periodontal disease is associated with high blood pressure, heart attacks and increased incidence of coronary heart disease. Periodontitis also predicts development of renal disease in individuals with Type 2 diabetes. It is hypothesized that periodontal bacteria results in a systemic inflammatory response that elevates systemic inflammatory biomarkers linked to micro- and macro-vascular changes.
The study’s goal is to assess the periodontal knowledge, behavior and clinical status of adolescents with Type 1 diabetes compared to non-diabetic controls. There are several unanswered questions related to periodontal disease risk in children with diabetes. For example, is bone loss already starting to occur? What is the rate of periodontal destruction over time? Are the markers of cardiovascular and renal disease risk seen in adults also present in children with diabetes? Which is a stronger predictor of less periodontal destruction in children with diabetes — better glycemic control or better oral hygiene behavior and frequency of dental visits?
Up to 300 adolescents with Type 1 diabetes and 100 non-diabetic control subjects will be enrolled in this study over a two-year period. Our study takes advantage of the unique opportunity to recruit patients from a study just initiating at the Barbara Davis Center for Childhood Diabetes, led by Dr. Wadwa, examining cardiovascular disease risk factors and the development of vascular changes. A two-year follow up examination will allow us to compare the rate of periodontal disease progression in children with diabetes versus children without the disease.
For more information, contact Elaine Morrato, DrPH, MPH.