Opportunities to Reduce Oral Health Disparities Basic Sciences to Clinical Practice. Part I

Opportunities to Reduce Oral Health Disparities: Basic Sciences to Clinical Practice Peter Milgrom, DDS University of Southern California, February 2003 University of Washington Northwest/Alaska Center for Research to Reduce Oral Health Disparities Beta-Defensins in Caries-Prone Children Beta-Defensins in Caries-Prone Children Goals This project is designed to study a biological marker that may influence susceptibility to tooth decay Dental Health Diet Host Defense Oral hygiene The oral soft tissue and saliva make defenses against bacteria. These defenses include beta-defensins, natural antibiotics. We believe that these beta-defensins help to prevent dental caries. Beverly A. Dale-Crunk, PhD Richard Jurevic, DDS Norma Wells, RDH, MPH Marjorie Tsutsui, Dental Stud Nancy Chino, Science Stud People Peggy Chrisman, UW Res Tech Kimberly Matteiu, BS, RDH Oscar Suarez, DDS More People • Eileen Beiersdorf, Superintendent, Toppenish School • Leonor de Maldonado, Principal, Toppenish Middle School • Susan Vlahakis, RN special education • Pat Brown, DSHS Children’s Program Manager and Yakima County Children’s Oral Health Coalition • James Falco, Dean, Arts & Sciences, Heritage College • Robert Ozuna, Director, UW-Yakima Valley Comm Partnerships, Heritage Center • Barbara Owens, Director Dental Admin. Services, YVFWC • Mark Koday, DDS, Dental Director, YVFWC • Cheryl Vyhmeister, Mobile Unit Coordinator, YVFWC GM Bacteria Diet Oral hygiene Defensins JE Tooth Decay Defensins are natural antibiotic peptides - and we make them !!! They are inherited like hair color and height. Our study explores possible links between beta-defensins and dental caries in children. Measure the amount of beta-defensins in saliva Look at genetic differences Is there a difference in children with low and high dental decay? Subject Population We chose Toppenish for our study because of the history of the University of Washington Dental School in promoting oral health in the Yakima Valley area, because of the location near Heritage College, a partner in education and research, and because of the YVFWC. Time Line • Hum subjects, fall 01 • Meet with Toppenish school and community group representatives 2/02 • Meet with parents and children educational presentation 5/02 We have found single base pair changes in the genes for beta-defensins. These changes, called single nucleotide polymorphisms (SNPs) are a very common type of genetic variation. SNPs can be silent, Preliminary data shows a deleterious, or even possible protective effect advantageous. of one SNP (-44). SNPs are genetic differences that we can assay Demographics • 149 subjects; 88 females 61 males • Mainly Hispanic (127), Native American (5), Caucasian (16), African Amer. (1) • Age (range 11-15) • Most had permanent dentition – mixed dentition (20%), missing teeth (6%), loose teeth (11%) hBD-1 SNP (-44) analysis and caries experience Caries Number SNP -44 0 50 0.40 Lo 47 0.47 Hi 47 0.53 There is not an association of this hBD-1 SNP with caries experience. Our findings did not support the trend of the pilot data. Additional Work in Progress • hBD-1 and hBD-2 SNP analysis • Bacterial load in saliva • hBD-2, and hBD-3 assay in saliva Determine association of additional b-defensin SNPs with caries experience Determine association of salivary bacterial load with defensin expression and caries experience Benefits • The potential long-term benefit is that simple, non-invasive procedures may be developed to help predict susceptibility to dental caries. • We hope to gain an understanding of the biological basis for susceptibility to caries. • Subjects in this study with severe dental problems will be referred to the Yakima Valley Farm Workers Clinic or other local providers for treatment. Early Orthodontic Intervention Under Medicaid OBJECTIVE To examine the usefulness of early orthodontic intervention as a means of increasing access to orthodontic services for children of low-income families • Prevalent model for rationing orthodontic services for Medicaid patients – Minimal participation by dentists – Minimal access for clients Rationale • Potential advantages of interceptive / limited treatment – Potential for increased participation by dentists thereby increasing access – Potential for psychosocial benefits during development – Potential for reduced costs / client • Demonstration project at Odessa Brown Children’s Clinic serving low-income children in urban inner Seattle Specific Aim 1 • To compare orthodontic outcomes, facial body image, and quality of life between Medicaid participants who receive early orthodontic TX and those who do not • To compare the level of understanding, compliance, and orthodontic outcomes between subjects given information about goals, risks, and benefits by an orthodontist with those who also use an interactive CD-ROM. Specific Aim 2 • To compare orthodontic outcomes, facial body image, and quality of life between Medicaidfunded and private-pay patients who receive full orthodontic TX Specific Aim 3 • To compare orthodontic outcomes, facial body image, and quality of life between Medicaid-funded patients who receive early orthodontic treatment only and Medicaid funded patients who receive full orthodontic treatment at adolescence Why Do This? Develop community-based research that translates existing knowledge and new information about children and their caretakers into new technologies and interventions that will reduce disparities • Component 1 Study Design – Randomized Clinical Trial – Aim 1 - treatment vs no treatment in mixed dentition (ages 8-11) – Aim 3 - same subjects, with those not receiving early treatment receiving comprehensive treatment (ages 12 - 14) • Component 2 – Cohort Study – Aim 2 - Medicaid-funded comprehensive treatment compared to private-pay comprehensive treatment Medicaid Patients Early TX (n=75) Observation (n=75) A I M 1 Observation A I M Full TX 3 A I M 2 Matched Private-Pay Patients (n=65) Full TX Medicaid Patients Early TX (n=75) Observation Randomization (n=75) CD-ROM (n=30) Standard consult (n=30) AIM 1 AIM 1A Outcome Variables • Dental Variables –Peer Assessment Rating (PAR) Index –Index of Complexity, Outcome, and Need (ICON) • Attitude and Behavior –Dental Background –Body Image –Quality of Life Timeline Year 1 Aim 1 Recruitment Aim 1 Clinical Phase Aim 3 Clinical Phase Aim 2 Recruitment Aim 2 Clinical Phase Data Analysis and Reports 2 3 4 5 6 7 Early childhood caries prevention with xylitol Turku sugar studies 7 6 5 4 3 2 1 0 0 2 4 6 8 10 12 14 16 18 20 22 Sucrose Fructose Xylitol 24 Month 20 Xylitol/clinical studies… 36 18 Xylitol Control 16 36 30 14 36 30 30 29 12 10 36 0 Baseline 1 Years 2 3 Final 8 7 6 Xylitol/clinical studies… control 5 candy 4 3 2 1 10 11 12 Age (years) 13 gum Xylitol/clinical studies… • Xylitol is most effective in caries prevention of erupting teeth (Ylivieska 1988, Belize 1996, Estonia 2000) • The ”therapeutic” effects of xylitol appear only in habitual use and with high enough frequencies/doses • Xylitol vehicles: chewing gum, lozenges, toothpaste (?) Mechanisms of action of xylitol • No acid production • Reduces plaque by suppressing formation of adhesive macromolecules, especially glucans • Selects for less adhesive mutans streptococci Xylitol:C5 Xylitol reduces plaque formation 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 CHX XYLITOL SORBITOL Mean plaque scores following use of chlorhexidine-, xylitol-, and sorbitol-containing chewing gum in absence of mechanical plaque control measures for 6 days. Xylitol makes mutans streptococci to shed more easily to the saliva