Social Networks, Novel Approaches Can Lift Oral Health of Underserved

Innovation in healthcare delivery channels could help to improve oral health in underserved communities, researchers said during an Annual Meeting press briefing. | Ashley Gilleland/AAAS

BOSTON – The oral health of ethnic minorities and lower-income groups is much worse than that of the general population, but leveraging social networks and other innovative healthcare delivery channels may help close this troubling gap.

That was the conclusion of three researchers who shared the results of several recent clinical trials and studies at a press briefing at the 2017 AAAS Annual Meeting on 16 February.

Brenda Heaton, assistant professor at Boston University’s School of Dental Medicine, has studied residents of Boston public housing, where over half of all children are Hispanic and more than one third are African American.

“We know from national data that those are the populations that suffer the most from dental decay in the early years,” she said.

Through structured interviews, Heaton and her colleagues mapped the social networks of 200 women living in Boston public housing developments, in order to better understand how caregivers seek advice and make decisions about oral healthcare for their young children.

“These are tightly clustered, close-knit, multi-generational units,” Heaton said. She found that, though the networks tend to be small – about four or five people – the relationships within them are very strong and durable. These social networks can influence caregivers to embrace behavior changes to improve their children’s oral health.

“We found that these networks may be fertile ground to intervene and have more bang for buck in terms of outcomes,” Heaton said. “The hope is that any interventions that give credence to social networks will not only be more effective but more sustainable over time.”

“The key here is prevention,” she added. “If you can prevent [problems] by age two to five, you can set them up for a lot of success in terms of their dental health.”

In some other communities, the disparity in oral health outcomes is even starker.

“When we look at the disparities in ethnic minority populations, in populations that are living in poverty, we see extremes that most of us don’t come into contact with,” said Judith Albino, professor and director of the Center for Native Oral Health Research at the University of Colorado. “This is nowhere more striking than in the American Indian population.”

American Indian children have extremely high incidence of dental caries [cavities], she observed. Across all tribes, 62% of children have some dental decay, compared to just 22% in the general U.S. child population, she said. “We are seeing up to 98%, for five-year-old children in one southwestern tribe with which we’ve worked.”

The incidence of surface tooth decay in the groups she studied was “startling”, she said. “That has a big impact on children. Not only does it become a painful situation, it also affects quality of life. It affects eating patterns, affects sleep and affects learning.”

Albino discussed the results of two recent large-scale clinical trials that sought to determine if preventive programs could make a difference in the oral health of some American Indian children. The intervention was applying a fluoride varnish, using culturally tailored approaches.

While she and her colleagues found no major differences in outcomes between the control and intervention groups, a closer look at their data revealed that the oral health literacy of parents was an important factor in the small differences that they did measure.

“If parents attended any of the [oral health literacy] sessions we offered, even one session, then their children did better than the rest,” Albino said. “But only 35% attended any sessions. It takes a different kind of outreach and a different way of working with parents to get them connected with the issue.”

Jean Schensul, founder and senior scientist at the Institute for Community Research in Hartford, Connecticut, discussed some structural, systemic obstacles to accessing dental care for yet another vulnerable population: pregnant women on Medicaid.

In a recent study, she examined how much dental care pregnant women in Connecticut were receiving from small private dental offices. Of more than 70 offices that saw pregnant women, more than half reported that they were no longer taking pregnant patients on Medicaid, due to concerns about reimbursement.

“Under the conditions we can anticipate in the near future, there will be cuts in Medicaid and more private dentists’ offices will turn down pregnant women,” concluded Schensul. “So we will see, for low-income women, increasing disparities for dental care during pregnancy.”

All three researchers said they see promise in innovative approaches to providing preventive dental care to underserved populations. For example, dental therapists and hygienists can perform certain important services in areas with a dearth of access to licensed dentists.

“If we are thinking about prevention, dental hygienists are a phenomenal resource for community-based programs and other sorts of novel implementation of services,” Heaton said.

“Even a modest amount of preventive education, in terms of proper tooth brushing flossing and small diet changes, makes a huge difference,” said Schensul. “The problem is reimbursement. If hygienists could operate independently, they would need to be reimbursed.”

Under Colorado’s state licensing laws, Albino pointed out, dental hygienists are able to perform some procedures such as fluoride varnishing, which don’t involve drilling but are important for basic oral health and restoring tooth function.

“We need to look very carefully and think more aggressively about other models of care,” said Albino. She noted that Indian Health Service dental clinics, for example, are chronically understaffed and underfunded.

“Dental therapists practicing in Alaska have made a huge difference, particularly for Alaskan Native people living in remote villages, who do not have access to care on a regular basis,” Albino said. “This could make a difference not just for American Indian people on reservations, but for many of the rural and impoverished populations where the number of dentists is not adequate to meet people’s needs.”

[Associated image: Ashley Gilleland/AAAS]