Opportunities to Reduce Oral Opportunities to Reduce Oral Health Disparities: Basic Health Disparities: Basic

Sciences to Clinical PracticeSciences to Clinical Practice

Peter Milgrom, DDSUniversity 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

Diet Oral hygiene

Host Defense

Dental Health

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.

PeopleBeverly A. Dale-Crunk, PhD

Richard Jurevic, DDS

Norma Wells, RDH, MPH

Marjorie Tsutsui, Dental Stud

Nancy Chino, Science Stud

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

Defensins

Tooth Decay

Oral hygiene

Bacteria

Diet

Defensins are natural antibiotic peptides - and we make them !!!

They are inherited like hair color and height.

ToothGM

JE

Our study explores possible links between beta-defensins and dental caries in children.

Is there a difference in children with low and high dental decay?

Measure the amount of beta-defensins in saliva

Look at genetic differences

Subject PopulationWe 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

SNPs are genetic differences that we can assay

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, deleterious, or even advantageous.

Preliminary data shows a possible protective effect of one SNP (-44).

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 0 Lo Hi

Number 50 47 47

SNP -44 0.40 0.47 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 β-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

Rationale • Prevalent model for rationing orthodontic services

for Medicaid patients– Minimal participation by dentists– Minimal access for clients

• 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 Medicaid-funded 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

Study Design• Component 1

– 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

Early TX(n=75)

Observation(n=75)

Medicaid Patients

Observation

Full TX

Full TX

AIM

1

AIM

3AIM

2Matched Private-Pay

Patients(n=65)

Medicaid Patients

Early TX(n=75)

Observation(n=75)Randomization

AIM 1

CD-ROM(n=30)

Standard consult(n=30)

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

TimelineYear

1 2 3 4 5 6 7

Aim 1 Recruitment

Aim 1 Clinical Phase

Aim 3 Clinical Phase

Aim 2 Recruitment

Aim 2 Clinical Phase

Data Analysis and Reports

Early childhood caries prevention with xylitol

Turku sugar studies7

6

5

4

3

2

1

00 2 4 6 8 10 12 14 16 18 20 22 24

SucroseFructoseXylitol

Months

Xylitol/clinical studies…20

18

16

14

12

10

0 1 2 3Baseline Final

XylitolControl

30

36

36

29

36

30

36

30

Years

Xylitol/clinical studies…8

7

6

5

4

3

2

110 11 12 13

Age (years)

control

candy

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

Mean plaque scores following use of chlorhexidine-, xylitol-, and sorbitol-containingchewing gum in absence of mechanical plaque control measures for 6 days.

Tellefsen et al., 1996

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0CHX XYLITOL SORBITOL

Xylitol makes mutans streptococci to shed more easily to the saliva