study major threats to/needs of the health of a general population.
Research environment: in the field
Field studies - technique or intervention to be introduced or used must be: (1)(2), 7(3)
applied to entire population (accessible)
give some examples of disease states or conditions in which dentistry can have a major impact:
•Pregnancy and birth
The US SG (Satcher)'s report Oral Health in America pointed out two public health issues that exist in US they are:
there is a lack of awareness of the importance of oral health among the public; and
there is a marked disparity between racial and socioeconomic groups in relation to oral health and overall health issues.
according to US SG, "oral health is integral to ____ _____."
and Tobacco use and ____ ____ also effect oral health."
What is US Healthy People 2020?
a US governernment project, Healthy People provides science-based, 10-year national objectives for improving the health of all Americans.
Goals to : Encourage collaborations across communities and sectors.Empower individuals toward making informed health decisions.Measure the impact of prevention activities.
Healthy People 2020: how many oral health objectives covering children, adolescents, and or adults: #
give at least four examples:
•Access to Preventive Services
•Oral Health Interventions
•Monitoring, Surveillance Systems
•Public Health Infrastructure
•Elderly-Reduce rate of dentures, have good healthy teeth that they can eat with– rate has gone down- the one initiative they are happy about the progress
What is CDC? What part of govt is it? what is its oral health budget?
How much does TX get?
what is SCHIP?
Centers for Disease Control and Prevention
member of US Dept of Health and humand services
oral health budget is $14.4 M
TX receies btwn $235K to 355K per yr
SCHIP is Texas Children's Health Insurance Program covering about 732K children.
how many dental schools in TX?
what percent of public drinking water in TX is fluoridated?
is UTSD a partner of the TX Dept. of health state services?
3 dental schools
21 hygiene schools
78% of TX public drinking water is fluoridated
What are the three key challenges to the new millennium for oral healthcare?
1. Aging of the population
It will be different to manage an older population
how will retirees pay for care?
2. Modification of disease patterns
3. Changes in oral health coverage policies
What is the WHO and what does it do?
what are its target groups?
World Health Organization
It promotes and supports global health policies (including oral health promotion and disease prevention)
targets to help school children, youth and elderly
why are schools a good place for health promotion?
it is a good physical (safe) and educational environment where kids have access to adequate safe water and nutrition.
what is a culture?
The sum total of human behavior or
social characteristics peculiar to a specific group and passed from generation to generation or from one to another within the group.
the natural belief that one’s native country, culture, language, and modes of behavior are superior to all others.
•People who are ethnocentric use their own culture as the standard of excellence against which people from other cultures are judged.
•common but erroneous behavior assuming that people possess certain characteristics or traits because they are members of a particular group.
•Stereotypical behavior can be unlearned.
•Race – one of three classifications (White, Black, Mongoloid) of human beings based on physical characteristics, such as skin color, stature, eye color, hair color and texture, facial characteristics and general body characteristics, all of which are hereditary.
Ethnicity is derived fom the greek word ethnos, meaning ____________, and refers to people who have a common ____________ and ____________
ethnos is greek for NATION, and refers to people with common ancestry and culture.
the unique cultural and social heritage and traditions of groups that reflect distinct customs, language and social values.
•Ethnic groups share common factors such as language, dialect, nationality, music, folklore, religious beliefs, food preferences, geographical location, and a sense of uniqueness.•Examples of ethnic groups: Hispanic, Japanese, Polish, Haitian.
what is cultural diversity
what is a synonym?
•The differences in race, language, ethnicity, values systems, religion, and local cultures that make up various groups in a community also account for the diversity.
•It is also called multiculturalism.
define Cultural Assimilation
A process by which members of an ethnic minority group lose cultural characteristics that distinguish them from the dominant cultural group or take on the cultural characteristics of another group.
Minority groups are “absorbed” into
an established, larger community.
what is the MELTING POT theory of cultural assimilation?
•Melting Pot– old theory of cultural assimilation.
•People from other countries come to the US
and assimilate into the mainstream white Anglo-Saxon Protestant culture.
•Gave up their own cultural identity in
favor of the predominant culture of the society in which they found themselves.
•Thought to result in a blended culture with
liberty, equality and justice for all.
what is SALAD BOWL theory of Cultural Assimilation?
•Salad Bowl– current theory of cultural assimilation.•Recognizes cultural diversity as separate
and unique components that remain heterogeneous within society.
•Recognizes that culture influences the
health status, beliefs and behaviors of individuals and that healthcare providers must be prepared to accommodate these differences.
describe the INDIVIDUALIST type of culture:
•Goals, rights and needs of each person are considered important.
•Individual has a right to stand up for himself/herself.
•Individuals take risks independent of the group
•Feel comfortable revealing their feelings only to people whom they know well.
•More likely to hide emotions from outsiders.
describe collectivist type of culture:
Collectivist •Concerns of the group are more important than those of the individual.
•Group identity is emphasized.
•Harmony among the members of the group is prized.
•Assertive behavior seems rude and insensitive.
•All risk is shared.
•Discouragement of any negative emotions that might upset people in the group BUT frank about expressing negative emotion to outsiders.
compare individualism to collectivism
INDIVIDUALISM: Value is placed on self determination.
-Shows initiative and works independently.
-“I’ll make up my own mind.”
-“The self-made man/woman.”
COLLECTIVISM-Identifies with and works well with groups.
Protection in exchange for loyalty and compliance.
Emphasis is on the group identity.
describe "low context" language
Use language primarily to express thoughts, feelings and ideas as clearly and logically as possible.
Look for the meaning of a statement in the words that were used to express it.
“Say what you mean and mean what you say.”
Value being direct and literal. Gets right to the point.
May be viewed as insensitive and blunt.
Grow impatient with “beating around the bush.”
North Americans use low context language.
Describe "High Context" language
Value language as a way to maintain social harmony.
The listener or the interpreter of the message is expected to “read between the lines,” to accurately infer the implicit intent of the message.
discover meaning from the context the nonverbal behavior of the speaker (posture, tone of voice), the history of the relationship, and the general social rules that govern interaction between people.
Value harmony - speak in an indirect way to avoid threatening another person’s “face” (to avoid giving offense).
Use roundabout expressions. Example: In Japan, rather than saying “No,” a person may say “Let me think about it for a while.”
High context language is used in Asia and the Middle East.
If a patient says ‘let me think about that’ instead of ‘I cant afford that treatment right now.’
Compare the Cultural ways of using language: Elaborate vs. Succinct
Use language that is much more rich and expressive than most people who speak English.
Use strong assertions and exaggerations that don’t sound normal to English speakers.
Can lead to misunderstandings between people from different backgrounds.
Example: Arabic. If you just say “No” they will think you mean “Yes.” To really say “No,” you have to say it several times and add “By God” or “I swear to God.”
Most extreme in cultures where silence is valued, such as Native American.
Compare the Cultural ways of using language: Formal vs. Informal
Formal - not so much a matter of using correct grammar as of defining social position.
Example: Korean - there are special vocabularies for different sexes, levels of social status and different social occasions.
Asia and Africa
Informal - casual friendliness, even to strangers.
U.S., Canada, Australia, Scandinavia
What is meant by "culturally competent healthcare?"
The ability to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural and linguistic needs.
To become culturally competent, the health care provider must be aware of the impact of social and cultural factors on health beliefs and behaviors.
Increases access to care for all patient populations.
Attracts new patients to your practice.
What did Dr. Palmer Beasly MD do?
Research on Hepatitis B being easily transferred from mothers to infants during childbirth
Randomized blind controlled trial to test efficacy of
Hepatitis B vaccine in a high risk group
Helped persuade world health officials to
include a vaccine for the virus in
its global recommendations for immunizations
Oral Health Disparities - Define
“Systematic differences in health status that occur among population groups”
“Differences in health between socially defined groups assumed to be correctable”
A central goal of population health policy
how does life expectancy correlate with socioeconomic status?
it appears access to care, affording food and education increases life
may be due to random variation or chance, but this demonstrates social disparities
why is improvement of oral health disparities difficult?
US population is so diverse
no one size fits all solution
approaches need to be tailored and targeted to individual, community and socio-environmental factors to have positive impact
what was the conclusion from the August 20, 2012 conference of public health experts on oral healthcare in US?
There is no single solution that will fix the system, which currently leaves tens of millions of Americans without dental care.
what are recommended actions to address variations in the systems to promote and care for children’s oral health?
1. Several states would benefit from a stronger emphasis on oral health promotion in young children
2. Disparities from a young age suggest the need for better engagement of early childhood professionals in oral health promotion.
What is the role of the health professional in reducing disparities?
Advocate!!! - not only restorative, but we want to promote oral health.
At what stage of the life course would a public health practitioner seek to intervene to prevent the greatest amount of illness?
A: Early Childhood. One question is “have you had any carries experienced in the past three years? This is b/c if they have, they’ll have more bacteria in their oral cavity from the earlier carriers.
How do we identify problems and oral health disparities?
Identifying patterns of diseases
What is DMFT Study?
Disease, Missing, Filled, Treated survey (oldest and most used index in dentistry when studying populations).
WHAT did the DMFT study in rural Alaska demonstrate:
The studies showed positive impact of fluoridation in alaska.
Lack of water fluoridation and soda consumption (pH) were associated with dental caries severity- did not matter if the child brushed
No other risk factor, including infrequent brushing or lack of dental floss use, was associated with dental caries severity
Describe the oral health disparities in Houston TX:
Health of Houston 2010
Areas of high disadvantage also have the highest level of fair/poor health
Biggest reason for being uninsured: 1. I couldn't afford it 2. due to where I work I’m ineligible
50% of adults had no dental insurance last year. Another 8% had it only part of last year (as opposed to medical where only 34% do not have it)
What were the to main objectives of US Healthy people 2010?
Improving quality of life for all Americans
reducing health disparities
What Additional objectives were added to US Healthy People 2020?
1. Increase the proportion of adults who received information from a dentist or dental hygienist focusing on reducing tobacco usage or smoking cessation.
2. Increase the proportion of patients that receive oral health services at Federally Qualified Health Centers each year.
What has US Healthy People 2020 noted/done different from 2010?
Dental medicare coverage for the elderly is really bad right now
Healthy people 2010 must measure their results
Moved away from target of preventing caries in 2-8 year olds
Did great on objectives of decreasing adolescent caries and decreasing tooth loss in adults aged 35-44
___ million Americans lack dental health insurance
Health Care Reform Act has more benefits covering _______
Children…Poor children have Medicaid Access but few providers make it challenging
_______million Americans living in rural or poor areas with limited number of dental providers
Name the barriers causing oral health disparities in TX:
Note some facts about actions in TX to combat oral healthcare disparities:
Receives CDC funding to promote growth of school-based and school-linked dental sealant programs
Monitor and expansion of community water fluoridation program
Oral health program are in use
how did TX compare to the national average for oral health?
Compared to the national average:
Texas had lower proportions of children with teeth in excellent or very good condition
Texas had higher prevalence of caries experience, including untreated decay, among six-to-eight-year-old children
No difference was noted at the highest socio-economic status level
What are the oral healthcare based objectives of Healthy People 2020?
Increase awareness of the importance of oral health to overall health and well-being (example).
Increase acceptance and adoption of effective preventive interventions (examples).
Reduce disparities in access to effective preventive and dental treatment services.
what is NNIDCR strategic plan? and its objectives to combat oral health disparities?
National Institute of Dental and Craniofacial Research
National Institutes of Health (NIH)
GOAL FOUR: Apply rigorous, multidisciplinary research approaches to eliminate disparities in oral, dental and craniofacial health.
Goal FOUR works based on 4 objectives: identification of the problem; Support research; provide information to target audience and monitor the oral health status
What was Dr. Satcher, Surgeon General's report on oral health in America?
Office of the Surgeon General
First oral health report, published in 2000 (David Satcher, Surgeon General)
Interactions between oral health and general health and well-being
DISCUSSED HOW Water fluoridation – one of the 10 top health advances of the 20th century
Woke people up about oral health connection to systemic health
What are the four actions listed in the U.S. Department of Health and Human Services. National Call to Action to Promote Oral Health?
Action 1. Change perceptions of oral health.
Action 2. Overcome barriers by replicating effective programs and proven efforts.
Action 3. Build the science base and accelerate science transfer.
Action 4. Increase oral health workforce diversity, capacity, and flexibility.
Action 5. Increase collaborations.
what were the conclusions of the National Call to Action to Promote Oral Health?
The impact of oral disease disproportionately affected disadvantaged groups
Females and minorities experiencing higher rates of tooth loss than males or whites
Adequate oral health have the potential to address the major goal established by US Healthy People 2020
Remarkable progress has been made in improving oral health and addressing oral health disparities
The mortality due to smoking is estimated to be _________/year in the US, and ________/Year globally.
440,000/y in US, 5M/y globally
T/F More people die from AIDS per year than from smoking.
False: smoking deaths outnumber AIDS+alcohol+drugs+accidents+fire related deaths
what percent of general US pop. is smokers?
what percent of US substance abusers also smokes?
Smoking Prevalence has been consistently higher among _____ than _____, while _______ have lower smoking rates
Smoking Prevalence has been consistently higher among blacks than whites, while Hispanics have lower smoking rates
T/F:Nicotine is an addictive substance comparable to heroin, cocaine and alcohol
Nicotine dependence should be considered a ____________ ____________ disorder
It may take up to __ attempts for some smokers to achieve success, average 5 or 6
What is our role in smoking cessation?
Our job is to help improve the success rate for quitting and in fact good treatments are available which can raise the success 7-8 times. But we are far from having the ideal treatment, yet.
There are 8 "determinants of smoking" name them:
A. Nicotine addiction
B. Social behavior
C. Genetic susceptibility
D. Psycho-social susceptibility
E. Knowledge and ability to process it
G. Social environment
H. Laws, especially “environmental” rules
(Clean indoor air laws, Bars in California, etc….)
What are the 5 "A's" to follow in smoking intervention?
The Five A’s
Ask if they smoke
Advice to quit
Assess motivation x change
Assist if willing to
Arrange for follow-up
What are Prochaska and DiClemente's stages of change(quitting)?
4. Action (can skip straight to relapse)
then either (6.1) Permanent Exit, or (6.2) Relapse back to step 2 or 3.
what are the principles of MI (M? Intervention)
Roll with Resistance
Support Self Efficacy
How do you assist with smoking cessation is patient is willing?
Start Bupropion-SR or Chantix 1-2 w. before quit date
Fix a quite date (Most Important). Remove all tobacco products the night before quit date.
Follow-up on that date or next day. Provide Nicotine Patch, Nasal or Mouth Inhaler, Gum
Identify/Educate a support person (best if ex-smoker)
Educate about the high risk for relapse & and how to cope with it: “don’t quit quitting”.
Describe the "reward pathway" (and addiction)
The concept of reward: Humans, as well as other organisms engage in behaviors that are rewarding; the pleasurable feelings provide positive reinforcement so that the behavior is repeated. There are natural rewards as well as artificial rewards, such as drugs.
what are Natural rewards
Natural rewards such as FOOD, WATER, SEX and NURTURING allow the organism to feel pleasure when eating, drinking, procreating and being nurtured. Such pleasurable feelings reinforce the behavior so that it will be repeated. Each of these behaviors is required for the survival of the species. Remember, there is a pathway in the brain that is responsible for rewarding behaviors.
Briefly describe Brain regions and neuronal pathways
Certain parts of the brain govern specific functions. Such as the sensory, motor and visual cortex. The cerebellum for coordination and the hippocampus for memory. Nerve cells or neurons connect one area to another via pathways to send and integrate information. The distances that neurons extend can be short or long. For example: the reward pathway
What are the major brain structures/regions involved in REWARD PATHWAY?
the ventral tegmental area (VTA), the nucleus accumbens and the prefrontal cortex. The VTA is connected to both the nucleus accumbens and the prefrontal cortex via this pathway and it sends information to these structures via its neurons. The neurons of the VTA contain the neurotransmitter dopamine which is released in the nucleus accumbens and in the prefrontal cortex. This pathway is activated by a rewarding stimulus. [Note: the pathway shown here is not the only pathway activated by rewards, other structures are involved too, but only this part of the pathway is shown for simplicity.]
What areas of the brain are rich in dopamine? Which area of brain is the decision maker?
NA and VTA, the PC is the decision maker: the connection between NA VTA and PC is used in addiction.
T/F: substances you smoke go immediately to your brain (faster than any other delivery system)
What percent of Texas population will be over age 60 in year 2018, 2028, 2038?
in 2018, 5Million
in 2028, 7Million
in 2038, over 9Million
what percent of the US population is Elderly? what is the proportion of healthcare costs attributed to the elderly population?
Elderly constitute 13% of US population and 31% of healthcare costs.
What are some socioeconomic considerations for the elderly population? (who lives longer W/M? how many elderly by 2030?
Life expectancy is greater for women of all ages & Women outlive men 7-8 years
Number about 37 million by 2030.
What are the implications for dentistry as a result of increasing elderly population?
Nearly twice as many teeth are projected to be at risk for dental disease in 2030 as were in 1972.
More primary oral health and preventive services will be required.
Periodontal and prosthodontic needs will increase.
Higher levels of income and education in elderly pop. will result in:
the elderly seeking dental services throughout their lives.
More will retain their teeth.
Incidence of edentulism is declining in age 65+
T/F The demand for geriatric care will never exceed the number of dentists currently willing and able to provide such care.
False, the number of geriatric pop will far exceed the number of dentists willing...
List some major chronic diseases of the elderly:
Name some categories of circulatory disease:
High blood pressure – 73million
Coronary heart disease – 18 million
Stroke – 6.5 million
Heart failure – 6 million
Angina pectoris – 8 million reduces risk by 1/3rd
Peripheral Vascular Disease (PVD)
Deep Vein Thrombosis (DVT)
T/F Women are at a greater risk of circulatory disease after age 60.
False, Women are at a greater risk of circulatory disease after age 65.
Women are ___ times as likely as men to see a dentist in the past 6 mos.
2 times as likely
How many adults are estimated to have been a victim of cardiovascular disease in 2011?
80 Million people have some form of CVD
____ percent of adults in US have been affected by periodontal disease
What can a dentist do to reduce patient’s risk atherosclerotic cardiovascular disease?
CVD can be affected by moderate to severe periodontitis; they should receive evaluation and possible treatment for disease state and prevention. we should work in collaboration with physicians to reduce inflammation.
Stroke is the largest CVD related cerebral disorders facing the geriatric pop. how does it rank in leading causes of death in us?
Stroke is the third leading cause of death (7%) causing 160,000 deaths/year
what population is at greatest risk for stroke?
African American Women
what are some risk factors for stroke?
Elevated cholesterol & lipids *Alcohol Use
Name five of the many Stroke Impariments including ones affecting oral health:
Loss of Motor control and coordination
Dysphagia (difficulty swallowing)
Dysarthria (speech disorder)
Decrease in muscle tone of affected side
Cognitive deficits such as confusion
Visual disturbances or perceptions
Communication deficits (word-finding)
Changes in the facial muscles, movement or sensory problems due to dysphasia or numbness.
[… so, Dentures may no longer fit →discomfort, pain]
Reduced fluid intake → dry mouth may result
Reduced ability to chew or swallow→ poor nutrition→ poor health
Oxygen therapy → dry mouth
Medications → dry mouth is a side effect of 85% of drugs, some contain sugar=decay
Food remains in mouth → needs total oral care assistance
Diabetes affects ____ in ____ Americans age 60 and older
1 in 4
T/F diabetic patients with severe periodontal disease are much more likely to experience major cardiovascular disease than diabetics without periodontal disease.
What are collagenases?
(they break down collagen) They are are enzymes that break the peptide bonds in collagen.
They assist in destroying extracellular structures in pathogenesis of bacteria such as Clostridium. They are an exotoxin (a virulence factor) and help to facilitate the spread of gas gangrene. They normally target the connective tissue in muscle cells and other body organs.
In one sentence explain how periodontal disease can greatly impact diabetes:
Periodontal disease results in higher pro- inflammatory cytikine TNF-alpha that causes insulin resistance.
Name some Mental disorders that can affect patients:
* Avoid barbiturates, narcotics, antihistamines, and anticholinergics
* Steroid supplementation ???
* Drug interactions with COPD medication
What are some keys to managing a patient with Asthma?
* Avoid precipitating factors
* Bring inhaler for each appointment
* Avoid ASA, NSAIDs, barbiturates, and narcotics
* Drug interactions -asthmatic medications (ex. Theophylline vs. Antibiotics, Cimetidine)
* Steroid supplementation ???
* For sedation, nitrous oxide/oxygen and/or small doses of oral diazepam is recommended
Name some musculoskeletal diseases facing the elderly:
over 100 others
w/r/t musculoskeletal disorders, what protein is produced in the liver during acute inflammation/ infection?
What is the correlation between periodontal disease and Rheumatoid Arthritis?
Conclusions (based on data derived from self-reported health conditions) conclude that there is good evidence to suggest that individuals with moderate to severe periodontal disease are at higher risk of suffering from rheu. arthritis and vice versa.
What are some key factors to do or look for if treating a patient with osteoarthritis or rheumatoid arthritis?
Observe brushing – can the person maneuver toothbrush
*Toothbrush modifications – check finger grasp
*Arthritis medication – implications for treatmentespecially if they will have pain after appointment
*AB coverage if joint replacement – more prevalent
*Do better for afternoon appointment – will be more comfortable
If treating the elderly, what are the key points to focus on to help you provide quality dental care?
Assess each category of chronic condition
*Know effects for body and mouth
*Learn treatments and medications given
*Elderly are not dependable reporters of status, past disease, medications
*Collaborate with other health care professionals to know your patient’s past history
What question did the MacArthur Studies of Successful Aging ask? what did it examine?
What genetic, biomedical, behavioral, and social factors are crucial to maintaining health and functional capacities in the later years?”
They Examined longitudinally a large cohort of independent elders on several physical, cognitive, emotional, and social parameters.
What are the common predictors for healthy aging (from MacArthur Studies of aging)?
Common predictors have emerged, such as remaining active physically and cognitively, maintaining social contacts, and avoiding disease.
What are some issues geriatric patients face as they age (Cavity Prone Years)