During National Public Health Week, Public Health Newswire is featuring guest commentary from our members. Here are a collection of vignettes from APHA’s Oral Health Section.

Quality health care includes oral health care for all
by Jeanne M Chambers, RDH, MPH

Jeanne Chambers, RDH, MPH, is a member of APHA's Oral Health Section. Photo by APHA Oral Health Section

Jeanne Chambers, RDH, MPH, is a member of APHA’s Oral Health Section. Photo by APHA Oral Health Section

One of APHA’s goals is to advance quality health care for all. Too often, the mouth and the preventive oral care involved in keeping the mouth healthy are not part of the overall health picture. In fact, oral health is a key part in overall health and is necessary to keep us all healthy. Dental caries, periodontal disease and oral cancer all limit the ability to eat healthy foods such as raw fruits and vegetables and other fibrous foods necessary for good health.

Diabetes is a prevalent disease that has a two-way relationship with oral health. Those with this disease are more prone to periodontal disease and untreated periodontal disease makes glucose regulation harder. Diabetes disproportionately affects low-income communities and oral health care is also less available in these communities. Preventive care can reduce or even eliminate most dental disease.

The emphasis on dentists needed for low access areas overlooks the value of prevention, which is best provided by dental hygienists. These professionals historically have been the educators for oral health and prevention. Advancing fluoridation, sealants and topical fluoride applications — as well as teaching self-care models that are designed for the individual — have been the basis for dental hygiene practice.

A goal of public health needs to be advancing state dental practice acts to allow dental hygienists to reach those not served by the traditional private practice model. Some states have done so, but it needs to be a national effort because oral health matters!

Social injustice in Flint
by Brittany Seymour, DDS, MPH, with acknowledgements to Janice Cho and Brittanie Dillon

We may not have consensus on the definition of social justice, but we can certainly agree that what has transgressed in Flint, Michigan is social injustice.

Over a decade ago, financial crises paved the way for an historic violation of a basic human right: safe water. Flint, where 52 percent of citizens are African American and 40 percent live in poverty, could no longer afford its water contract with Detroit. Following a complex and undemocratic decision-making process, in 2014 the city switched to water from the Flint River. Poor management decisions at state and local levels and inadequate water treatment created the perfect storm for lead to leach into the public water system.   Adding to the injustice, authorities remained unresponsive to the months’ long outcries from the people of Flint.

In 2011, 81 percent of Flint children qualified for free and reduced lunch, a proxy metric for poverty. Due to preventable decay, over 60 percent of eligible third graders had teeth with fillings, untreated cavities, or loss of their permanent 1st molars. Compared to the state as a whole, the Flint region reports higher rates of oral pain, and African American children are at the highest risk for both developing tooth decay and not receiving necessary treatment. The presence of lead in the absence of fluoridation may compound this risk further. Now, when public trust in the water is at its lowest, the need for water fluoridation is at its highest.

To be healthy, children need healthy mouths. There is no public health measure more equitable than community water fluoridation and no better way to start building a nation of healthy communities.

Avoiding FUN (functionally unnecessary) Wisdom Tooth Extraction
by Jay Friedman, DDS, MPH

Each year, tens of thousands of mostly young people are injured and billions of dollars are wasted in the prophylactic removal of wisdom teeth. Prophylactic surgery such as the removal of the tonsils or the appendix to prevent tonsillitis or appendicitis, where the risk of future pathology is small, has long been discontinued in medicine. Yet it is common practice for dentists to recommend extraction of wisdom teeth, whether or not impacted, as if they were a special disease.

The American Public Health Association’s policy, Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth), is in keeping with its commitment to protect the public from needless and injurious health care, and as a means to educate the public, health practitioners and health insurance administrators on the need to avoid treatment that is not evidence-based.

Health plan administrators are in a unique position to educate their public ― health plan members ― as well as oral health care providers by developing and implementing evidence-based policies. With respect to wisdom teeth, such a policy might read: Removal of asymptomatic, non-pathologic third molars, whether fully erupted, partially erupted or impacted, is not a covered benefit.

Do you have canker sores? Try eliminating dairy?
by Anuradha Nayudu, Mimansa Cholera and Nita Chainani-Wu

Apthous ulcers, also referred to as canker sores, is a common oral mucosal condition, estimated to affect one-fifth of the human population at least once during their lives. Clinically, the condition presents as yellowish round or oval ulcers with a red halo. In most affected individuals, these lesions appear infrequently, are smaller than one cm in diameter, and heal within 1–2 weeks without treatment. However, a subset of affected individuals have a more severe presentation, with frequent occurrence of multiple or large ulcerations that are painful, particularly when eating and brushing. This can result in compromised nutrition and oral hygiene and negatively impact quality of life. Medications used for management have potential side-effects.

Local trauma, stress, and hormonal factors are common self-identified triggers for recurrent apthous ulcers by patients. Published case reports have described resolution of RAU after dairy elimination, and case-control studies have found elevated levels of circulating antibodies to cow’s milk protein in patients with RAU. However, awareness of this association is low among both patients and health care providers.

The proportion of patients in whom cow’s milk protein acts as a trigger for RAU is unknown. However, a dairy elimination trial is safe, easy and feasible and therefore should be tried prior to use of medications, particularly medications with a potential for side-effects. Cow’s milk protein has also been associated with other inflammatory conditions such as rheumatoid arthritis, lupus, ulcerative colitis and eczema, as well as with common childhood conditions such as asthma. Cow’s milk protein is present in all dairy products made from milk such as yoghurt, cheese, and butter, which are common ingredients in cooking and baking. Therefore, in addition to liquid cow’s milk, these milk products and any foods that contain these products as ingredients also need to be discontinued during a dairy elimination trial.

Fluoridation: because health equity matters
by Johnny Johnson, DMD, MS

APHA has challenged our nation to use equity values “to drive community health work.” When community water fluoridation began in 1945, its supporters didn’t talk much about health equity—perhaps because dental disease affected people of every racial, ethnic or income group. In recent decades, research has identified significant oral health disparities and the crucial role the fluoridation plays in addressing them.

Fluoride is a mineral that exists naturally in all public water supplies but usually at a concentration that is too low to protect teeth from cavities. Fluoridation is the process of adjusting this concentration (typically by adding more fluoride) to drinking water. Because fluoridated water reaches everyone in a community—regardless of age, race, ethnicity or income level—it has helped to advance the goal of oral health equity.

After examining various prevention strategies, a University of Michigan researcher concluded that to reduce dental disparities in the U.S., “the first obvious step is to fluoridate drinking water wherever feasible.” The research confirms fluoridation’s ability to improve the oral health of racial and ethnic minorities. For example, a 2016 New Zealand study showed that 5-year-old children in the nation’s largest ethnic minority group were 64 percent more likely to be cavity-free if they lived in fluoridated areas.

Despite the fact that this strategy is recommended by the leading health and medical authorities, fluoridation policies are under attack in a number of communities. When a community ceases fluoridation, it stands to worsen existing disparities. A study published this year revealed that dental disparities “occurred more frequently, across more outcome measures” after Canada’s third-largest city ceased fluoridation.

During National Public Health Week, let’s reaffirm our collective commitment to health equity by educating our friends, family and neighbors that tooth decay is a preventable disease. We also must raise awareness in our communities that the presence of fluoride toothpaste does not diminish the need for water fluoridation. As the Centers for Disease Control and Prevention explains, fluoride in toothpaste and water “provide important and complementary benefits.”

Given water fluoridation’s effectiveness, safety and low cost, any community that truly cares about social justice should initiate or maintain this proven health strategy.

The Minnesota Oral Health Project: Crush childhood caries at the community level
by Amos Deinard, MD, MPH

The Minnesota Oral Health Project (MNOHP) focuses on assuring preventive dental care for all children, including high-risk children who depend on Medical Assistance (Medicaid) or MNCare (Minnesota’s CHIP) for medical and dental care at the community level.

The essence of MNOHP is education about caries etiology and prevention and importance of a dental home so that the county’s community members (CM) will ask for caries prevention services (CPS) from their child’s primary care medical provider (PCMP) with the eruption of the first tooth or by age one.   The expectation is that CM will urge dentists and PCMP to collaborate with the latter offering CPS and the former providing all other oral healthcare services.

MNOHP promotes oral healthcare education for mothers-to-be and caregivers of children 0-5 via: WIC, engagement with Public Health Nurses, Early Head Start, Head Start, and Minnesota’s Early Childhood Family Education program.

PCMP (physician, nurse practitioner, physician assistant) are trained by MNOHP to provide CPS during well/ill child visits.  CPS includes an oral evaluation, risk assessment, quarterly application of fluoride varnish(fv), anticipatory guidance for the caregiver about caries and their role in prevention, all reimbursable services under C&TC (Minnesota’s name for EPSDT). Minnesota Medicaid will reimburse an extra fee for quarterly fv applications.  Minnesota’s Managed Care Organizations cover 90% of Medicaid eligible children.  PCMP s must heed the C&TC periodicity schedule.

Community leaders from the Kiwanis, Lions, and Rotary Clubs are educated about caries etiology and the role of the caregivers in prevention, supporting their “reason for being”, ie: children and community.  Together with CM, these leaders are best equipped to build upon their community’s strengths to coordinate affordable and accessible oral healthcare for each of the county’s high-risk children.

Caries is overwhelmingly preventable.  It is this reality that has led to the creation of MNOHP.

New workforce policies to address disparities in oral health
by Christine Wood, RDH

Although the improvement in the oral health of Americans is one of the major public health successes of this past century, these improvements have not been experienced uniformly. The availability of providers, restrictive state dental practice acts, insurance status, and lack of awareness of the importance of oral health all contribute to disparities.

Policymakers are trying to identify new solutions that address these disparities. These include regulatory changes in licensure for dental and allied dental professionals and expanding the scope of prac¬tice of allied dental and other healthcare professionals. New mod¬els of care include dental therapists, advanced practice dental hygienists, registered dental hygienists in alternative practice, community dental health coordinators, the virtual dental home (a model that incorporates tele-dentistry to facilitate access to care), and interprofessional education and practice whereby dental, medical and nursing providers integrate screening, referral, and other care as appropriate into their practices.

All of these models have strengths and limitations and ongoing evaluation will likely find that no “one size fits all.” Addressing access to care issues will require innovate workforce, licensing, and payment mechanisms to ensure that we ultimately have the “right people, with the right competencies, in the right places, at the right time.” For more information visit Improving oral healthcare delivery systems through workforce innovations.