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IHS looks at new ways of addressing oral health disparities

August 24, 2017

By Jennifer Garvin


Dr. Tinanoff
 
Dr. Horst

Rockville, Md. — Despite making progress in early childhood caries with prevention and improved access, American Indian and Alaska Native children continue to "suffer disproportionately from dental disease" across all age groups, according to the Indian Health Service Division of Oral Health.

During an Aug. 15-16 stakeholder meeting, the Indian Health Service said that American Indian and Alaska Native children ages 2-5 experience caries at four times the rate of U.S. white children and more than double of the next highest ethnic group, U.S. Hispanics. For American Indian and Alaska Native children ages 6-9 and 13-15, eight out of 10 have a history of caries.

With those statistics in mind, Indian Health Service gathered internal and external stakeholders from several tribal organizations, dental organizations, academic institutions and federal agencies to help collaborate and develop a strategic plan for addressing oral health disparities. The ADA was one of nine dental organizations invited to participate in the two-day event.

"The ADA is dedicated to lowering dental disease in the American Indian/Alaska Native population and was grateful to be included in this historic discussion," said ADA President Elect Joseph P. Crowley. 

Over the last two decades, Indian Health Service has embarked on several national initiatives — including the Early Childhood Caries Collaborative and Maternal Dental Access Project — designed to raise awareness of the problem. The agency also partnered with the Centers for Disease Control and Prevention, National Institute of Dental and Craniofacial Research and others to help eliminate disparities. Outreach efforts include working with providers to increase access for pregnant women and children 2 years old and younger.

These efforts have led to significant improvements, according to the agency. Overall, the caries rate in 6-9 year-olds decreased to 52 percent in 2017, down from 72 percent in 1999, and 13-15-year-olds dropped to 53 percent from 64 percent during that time. Since 2010, there also have been decreases in decay in 1- and 2-year-olds with the former's caries rates decreasing from 22 percent in 2010 to 15 percent in 2015 and the latter going from 45 percent to 38 percent. 

For Dr. Norman Tinanoff, professor of pediatric dentistry at the University of Maryland School of Dentistry and a member of the ADA Council on Scientific Affairs, the meeting was a chance for the experts to get together to propose innovative solutions to the problem.

"You can't get caries without sugar," said Dr. Tinanoff, who believes that reducing sugar can be an "upstream approach" especially if people don't have access to healthy foods. One solution he offered would be encouraging American Indians and Alaska Natives to adopt measures that reduce sugar availability on their lands. These measures could include optimizing food in convenience stores/trading posts; a sugar-sweetened beverage tax; and adjusting the government's juice recommendations for its programs.

"For children with a very high caries risk, as in many of the American Indian and Alaska Native communities, preventive measures are often overwhelmed by risk factors," he said. "The preventive approaches have to precede the risk factors."

During his presentation on Evidence for ECC Intervention, Dr. Tinanoff also offered these steps to succeeding in lowering the incidence of caries:

  • Optimizing preventive procedures such as fluoride varnish, silver diamine fluoride and fluoride toothpaste.
  • Conducting trials on sealants and interim therapeutic restorations.
  • Working collaboratively with health workers, physicians and nutritionists on community-based programs.

"I thought the meeting was productive, and may lead to more effective approaches to this highly prevalent problem," Dr. Tinanoff said.

Dr. Jeremy Horst, a pediatric dentist and postdoctoral fellow in infectious disease at the University of California San Francisco School of Medicine, looked at the evidence in favor of minimally invasive techniques for treating caries in children.

After reviewing multiple prevention methods — including the use of fluoride varnish, silver diamine fluoride and sealants — Dr. Horst concluded that combining treatments is essential to progress. For instance, while nine recent studies show minimal effects from fluoride varnish in children under 3, it could be effective when paired with the common antiseptic, povidone iodine (Betadine). Another fluoride combination is silver diamine fluoride, which costs less than a $1 per treatment and can be applied in less than six minutes.

This is true in medicine as well where difficult diseases such as HIV or certain cancers have become easier to treat by combining several therapies, he said.

These treatments — including targeting bacteria in the mouth and educating policy makers on the role sugar plays in health — are also part of the solution. So are simple, but proven tools such as giving patients regular access to fluoride toothpaste — even if it means going to a reservation and giving it away. He also liked the idea of inspiring older children to act as role models or oral health champions in their communities.

Dr. Horst also shared evidence of the success of the atraumatic restorative treatment (partial caries excavations with glass ionomer fillings) and the Hall Crown Technique, which seals off decay in a child's back molars by using stainless steel crowns.

"I was profoundly impressed with the way Indian Health Service was listening to everyone — no matter how simple or extravagant the ideas were," Dr. Horst said.

Following the meeting, Indian Health Service area dental officers and clinical and preventive support centers developed a draft strategic plan for the IHS Division of Oral Health to share with external and internal stakeholders. Once completed, the strategic plan will be used to help guide Indian Health Service prevention and intervention projects and initiatives for the next decade.