Running head: DENTAL DISEASE: IMPLICATIONS FOR EDUCATION

Dental Disease as a Chronic Health Issue: Implications for Education Maureen M. Harrington University of the Pacific

DENTAL DISEASE: IMPLICATIONS FOR EDUCATION

Dental Disease as a Chronic Health Issue: Implications for Education There are several important reasons to examine the connections among population oral health, chronic disease management strategies and their possible integration into educational systems. Dental disease affects all individuals and has a significant role in overall health. Current disease management strategies are focused on treatment of disease while future disease management mechanisms can integrate supportive strategies into educational systems with the end result improving the oral health of historically underserved communities. Leaders in oral health, policymakers, public health experts, physicians and health systems are increasingly integrating this understanding of oral health in more significant ways (IOM, 2011; Polverini, 2012). Globally, nearly 35% of children and adults have untreated caries cavities in permanent teeth (Marcenes, 2013). Strategies to impact the oral health of a population must address social determinants of health, including those factors related to sociocultural, family, and community environments (Finbar, 2012). With the development and integration of oral health promotion strategies into various types of educational institutions, such as preschools, elementary schools, high schools, universities and dental/dental hygiene schools, there is a significant opportunity to fundamentally alter the oral health of large numbers of traditionally underserved communities. This literature review will explore the connection among population oral health, chronic disease management strategies and their potential integration into educational systems.

Methodology and Definitions The literature search addressed dental disease as a chronic health issue; population oral health; oral health outcome measures; prospective dental education; oral health services; and,

DENTAL DISEASE: IMPLICATIONS FOR EDUCATION

health education in school settings. The literature is growing in the area of dental disease as a chronic health issue and there is significant literature related to educational and social services integrating oral health services. However, the intersection of dental disease as an epidemic in the United States and the ability to prevent dental disease by utilizing systems like educational settings is not well-developed. In this literature review, the definition of health determinants involves genetic and biological factors, the social environment, the physical environment, health behaviors, and dental and medical care (Fisher-Owens, 2007). Oral health is defined by the World Health Organization (2013) as a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects (e.g., cleft lip and palate), periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity. According to the National Academies, Institute of Medicine 2011 report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations, access to care is access to linguistically and culturally appropriate, quality oral health care throughout the life cycle. Chronic diseases are diseases of long duration and generally slow progression. The World Health Organizations World Health Survey indicates complete tooth loss affects approximately 30% of old-age people 65-74 years globally. Tooth loss is the ultimate consequence of tooth decay and severe gum disease (periodontitis), which are conditions caused by lifelong exposure to risk factors common to other chronic health issues (WHO, 2013). Background Oral health is becoming more prominent in the national healthcare discussion since the Affordable Care Act initial implementation in 2010 (US HHS, 2013). Dentistry, medicine, nursing, public health, education and social services are becoming more informed and aware of

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the impact of oral health on general health (IOM, 2011). The oral health status of a population and associated costs of neglect are much like that of other chronic health issues with costs increasing as untreated disease progresses (Watt, 2007). In fact, oral diseases share many of the same determinants and risk factors as the most significant chronic diseases, including heart disease, cancer, chronic obstructive pulmonary disease, diabetes, dementia and stroke (Williams, 2013). Of particular importance, oral disease is associated with socio-economic status, which links to family income, educational attainment, employment status, housing, risk of accidents, physical health, and mental health (Williams, 2013). Chronic disease management is defined as the use of various tools to reduce susceptibility to disease throughout ones lifetime and used extensively in general health services (IOM, 2011). Chronic disease management approaches have not been integrated into oral health, and even less so into educational systems. The potential to improve population oral health via these routes is tremendous. Social engagement occurs at higher levels when oral health is good, however, broken or missing teeth frequently contribute to lack of smiling and lower self-esteem (zhayat, 2013; Silva-Sanigorski, 2013). Oral health self-efficacy and knowledge are potentially modifiable risk factors of oral health outcomes, and these findings suggest that interventions could help foster positive dental health habits in families. Injury prevention is important as well. Bendo (2010) noted that untreated traumatic dental injury in children between 11-14 years of age, especially in the anterior teeth, produced a negative impact on social wellbeing. The main issues with social wellbeing related to avoidance of smiling or laughing and being concerned about what other people may think or say about the damaged teeth.

DENTAL DISEASE: IMPLICATIONS FOR EDUCATION

Employability is another component to the rationale for improving oral health. Bedos (2009) notes that individuals receiving social assistance: (a) define oral health in a social manner, placing tremendous value on dental appearance; (b) complain about the decline of their dental appearance and its devastating impact on self-esteem, social interaction, and employability; and (c) feel powerless to improve their oral health and therefore contemplate extractions and complete dentures. Our research demonstrates that perception of oral health strongly influences treatment preference and explains low and selective use of dental services in this disadvantaged population. (pg. 653.) Importantly, successful social engagement and employment can reduce poverty yet an unsatisfying dental appearance (Bedos, 2009) reduces the options for those living with limited income or utilizing social assistance. Barriers to Care Significant research has occurred in the area of access to oral health in the United States (Williams, 2013; Griffin, Jones, Brunson, Griffin & Bailey, 2012). Since many in the United States do not take advantage of the traditional dental care system, there are opportunities for innovative systems to serve historically underserved communities in creative ways (IOM, 2011; Bedos, 2009; Williams, 2013). People with incomes greater than 400% of the federal poverty line who account for only 36% of the population account for over 50% of dental spending (The Agency for Health Quality and Research (AHRQ MEPS Dental Services Expenses for General Dentist Visits - 2010). These are also the healthiest members of society and the least likely to need dental care. If oral health providers could engage members of the population who currently do not seek dental treatment in the traditional oral health delivery system, and who also

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have the majority of dental disease, many poor oral health trends could be reversed (IOM, 2011). The American Dental Association Health Policy Resources Center, in an August 2013 publication, A Profession in Transition: Key Forces Reshaping the Dental Landscape, described a declining utilization of dental care among adults and decreasing total dental spending in the U.S. These trends are reported as the new normal and not just fleeting abnormalities. This research indicates that a new approach to the practice of dentistry could be particularly relevant and timely. Research from the California Dental Association indicates that nearly 10 million Californians face barriers to accessing dental care (CDA, 2012). The barriers many underserved individuals experience are related to cost of care, insurance status, general health status, employment, education, disability status, transportation, hours of dental clinic operation and geography. Loignon (2012) provides interesting insight into dentists perspectives of poverty on accessing dental care which noted that in the individualistic-deficit perspective, dentists explained poverty by individual factors and emphasized individuals' negative attitudes toward work and lack of capabilities. This view is contrasted by dentists with a socio-lifecourse perspective who described poverty as a structural rather than an individual process. Fundamentally, dentists, who acknowledge individuals' distress and powerlessness, had greater empathy toward people receiving social assistance. The results suggest the individualistic-deficit perspective impedes the care relationship between dentists and poor patients, as well as highlighting the need to better prepare dentists for addressing issues of poverty and social inequities in clinical practice. The recognition of these issues is shaping professional education. A New System Requires New Tools

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The principles of accountable care adopted by the United States with adoption of the Affordable Care Act of 2010 are: 1) improved health outcomes, 2) better patient experience 3) at a lower cost. Oral health providers will likely be held to the same standards in the near future (USHSS, 2013). However, there is limited research in the movement of dentistry from a fee-forservice model of care to an accountable care system using a chronic disease management approach. The accountable care approach to health care uses different providers, patientcentered, innovative tools and behavior change supports to care provision. With the increased use of non-dentist oral health professionals providing care to underserved communities, the use of health outcomes as a measurement of acceptability of care has grown (Wright, 2013). This trend to use new measurements to gauge the impact of one type of provider (like a dental therapist) will lead to the use of the same metrics with traditional providers like a dentist. In this new accountable health world and in dental terms, a surgical procedure like a filling would be provided with significant education and supportive activities rather than patient education in a clinical setting alone (Cohen, 2013). The metrics of oral health outcomes are not a factor in most dental practices nationally and globally. The most common model for oral health services is to provide surgical treatment to the patients disease, which often has no real impact on the status of ongoing oral health. Very little attention is given to population oral health other than the fluoridation of community water sources (Watt, 2012). However, it is likely that these new expectations will guide oral health providers to contribute to policy and system changes designed to impact the population oral health, not just an individuals oral health, and the evolution of dentistry will mimic the evolution of health care (Watt, 2012). Dentistry will likely utilize new tools, methods and allied oral health providers to optimize interactions with patients (Grant, 2012).

DENTAL DISEASE: IMPLICATIONS FOR EDUCATION

Chronic Disease Prevention and Management Strategies Despite the Centers for Disease Control and Prevention, the World Health Organization and the Institutes of Medicine identify oral health as a significant and growing chronic health issue, research and literature are only beginning to introduce the idea of chronic disease prevention strategies into oral health. Research related to oral health chronic disease prevention and control strategies implemented through systems like K-12 education is lacking. There is extensive research addressing school-based health and oral health services. Identifying possible avenues to include health promotion begins with a scan of institutions surrounding people. For example, educational institutions and work places, as well as social services and community systems. Fundamentally, chronic diseases like diabetes and heart disease are fairly similar to the two primary dental diseases caries (cavities) and periodontal disease. The highest rates of dental disease can be found in those of low socioeconomic status, with the result being significant oral health disparities (Watt, 2012). Hayden (2013) notes that obesity management programs and oral health interventions, because of common risk factors, should be examined as potential avenues for health improvement. In a similar manner, Da Rosa (2011) reports that schools socioeconomic index is connected in a statistically significant manner to oral health outcomes. Lower socioeconomic index of a school is connected to poorer oral health outcomes with the presence of more dental disease. While Kwan (2005) indicates health promotion in schools is a valuable component to improving oral health. Social engagement occurs at higher levels when oral health is good, however, broken or missing teeth frequently contributes to lack of smiling and lower self-esteem (zhayat, 2013., Silva-Sanigorski, 2013). Oral health self-efficacy and knowledge are potentially modifiable risk

DENTAL DISEASE: IMPLICATIONS FOR EDUCATION

factors of oral health outcomes. Importantly, interventions increasing oral health self-efficacy and knowledge could help foster positive dental health habits in families. Injury prevention is important as well with Bendo (2010) supporting the idea that untreated traumatic dental injury in children between 11-14 years of age, especially in the anterior teeth, produced a negative impact on social wellbeing, mainly with regard to avoiding smiling or laughing and being concerned about what other people may think or say. Why should schools care about the oral health of their students? Research indicates that oral health affects students academic performance (Seirawan, 2012). The negative impact of poor oral health can be seen in attendance at school which Gift (1992) estimated that in 1992 more than 50 million school hours were lost in the US due to oral health problems. Yet, Seirwawan also states that additional studies are needed to unbundle the clinical, socioeconomic, and cultural challenges associated with this epidemic of dental disease in children. Da Rosa (2011) further explores the link between school socioeconomic status and higher reported rates of pain. Schools have various incentives to have children in school and healthy. These data provide evidence to support the integration of chronic disease management strategies into a population health approach to oral health. Larsen (2009) compared school- and community-based dental clinics in New York City which provide dental services to children in need. The results showed that when services are based in schools, barriers such as transportation issues, parent availability, and missed appointments are greatly reduced. Schools provide a natural location for preventive and responsive dental care. In many cases, the school-based clinics could increase support for immigrant families who face additional cultural, linguistic and educational barriers to accessing dental care (Mouradian, 2007, Juhee, 2013).

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Eaton (2007) discussed interventions to impact oral health, which can be embedded in educational institutions and workplaces. This research shows success in employee wellness programs in schools. More schools could implement comprehensive employee wellness programs to improve faculty and staff personal health behaviors and oral health status. Professional Education Different members of the health team contribute to effective chronic disease management. For example, interprofessional education was used successfully to improve health outcomes of patients with chronic diseases (Vanderbilt, 2013). The interprofessional education of health professionals and oral health professionals is becoming more common in dental schools but has not moved as successfully to implementation in practice settings (Polverini, 2012). Some new ways that the dental team is being prepared to care for historically underserved communities and those with the highest levels of disease involve community service-learning (CSL). This method has been proposed as one way to enrich medical and dental students' sense of social responsibility toward people who are marginalized in society. The outcome of Dharsamis research (2010) indicates that CSL can play an important role in nurturing a purposeful sense of social responsibility among future practitioners. However, the knowledge and skills related to social determinants of health and related disparities need to be more aggressively integrated into dental education (Dharsami, 2010). Tellez (2011) shows that U.S. dentists surveyed have not adopted evidence-based clinical recommendations regarding the sealing of permanent first molar and premolar, and that new educational and dissemination programs should be developed regarding these evidence-based caries management approaches. Recent research indicates that ingrained practice behavior based on personal clinical experience that diered substantially from evidence-based

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recommendations resulted in a rejection of these recommendations (ODonnell, 2013, p. 24). Some insurers have increased adherence to evidence-based practice standards through the use of claim reviews, professional in-service and incentive packages. It is likely these same strategies will be adopted by other insurers in the future. However, private payors may be less likely to adopt these measures as quickly as public funders like Medicaid. The implications on cost containment and the adoption of effective prevention strategies is significant for public entities feeling pinched by budget reductions (Compton, 2012). Another point, which integrates community health with professional education, is water fluoridation. Community water fluoridation (CWF) has historically been a community level prevention strategy which was widely accepted if municipal funding was available. More recently, CWF has emerged in a negative manner in some communities and has been discontinued despite evidence to support safety and efficacy of intervention. Melbye (2013) notes that Community water fluoridation is an important public health intervention that reduces oral health disparities and increases the health of the population. Promotion of its safety and effectiveness is critical to maintaining its widespread acceptance and ensuring its continued use. Dentists are a potentially important source of knowledge regarding the oral health benefits and safety of water fluoridation. The role of focused population health education at the community level to address misconceptions such as those related to CWF will be essential for dentists to master. The skills related to community oral health must be integrated into dental education (Polverini, 2012). Mouradian (2007) indicates that childrens health outcomes result from the complex interaction of biological determinants with sociocultural, family, and community variables.

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Dental professionals efforts to reduce oral health disparities often focus on improving access to dental care. However, this strategy alone cannot eliminate health disparities. The community oral health curriculum in dental education will need to inform students and future practitioners of the need to promote health, integrate oral health into other health and social programs, and empower communities. Mouradian (2007) further highlights that dental schools have a leadership role to play in expanding community partnerships and providing education to the health determinants which impact oral health status. Watt (2009) explores common risk factors health promotion. The risk factors associated with the caries patterns include: demographics (age, sex, birth year, race/ethnicity, and educational attainment), anthropometrics (height, body mass index, waist circumference), endogenous (saliva flow), and environmental (tooth brushing frequency, home water source, and home water fluoride). These areas should be brought into the education of dentists and dental hygienists as well. However, Melbye states (2013) current undergraduate dental curricula do not adequately prepare dentists for this role, and continuing dental education may be insufficient to change clinical practice. Conclusion The implications for addressing dental disease as a chronic health condition and its integration into the structures of educational systems are significant. It is clear that the traditional approach to improving oral health is ineffective. Roberts-Thomson (2012) indicates that those patients at highest risk are often those least able to make best use of any advice given,

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particularly in relation to behavior change and individual health education is ineffective in controlling caries disease process. Yet, comprehensive community health education increases knowledge and self-reported preventive practices (Macintosh, 2010) Can educational institutions become part of the solution to improved population oral health much like the issue of childhood obesity by supporting community health education? The chronic disease management paradigm with particular attention to the social determinants of health can build on the structure, tools and social connections of educational systems. The connections between social determinants linked to oral health and the role of chronic disease prevention tools in educational settings are especially important as health access, health disparities and the cost of health care in the US continue to be major issues. Future research in this area will likely yield interesting results that may translate into useful practice.

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