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Promoting Oral Health Equity for Older Adults Mary E. Northridge, PhD, MPH Oral Health in the New Age of Aging OrOHC 2015 Fall Conference, Portland, OR, October 2, 2015 Slide 2 Learning objectives: 1. Identify existing social disparities in oral health status and oral health service access for older adults. 2. Discuss interventions to: (1) promote oral health and (2) address oral health disparities for older adults at the individual, interpersonal, community and societal levels. 3. Define implementation science and explain why it is useful in the study of oral health and health care. Slide 3 Social justice Social justice is the foundation of public health. Krieger N, Birn AE. A vision of social justice as the foundation of public health: commemorating 150 years of the Spirit of 1848. American Journal of Public Health. 1998;88(11):1603-1606, p. 1603. 3 Slide 4 If and when we are able to ensure respectful and accessible health care that includes comprehensive oral health care to everyone regardless of race/ethnicity, socioeconomic position, age, gender, sexuality, or immigration status, then the United States will have achieved the measure of a just society: oral health for all. Treadwell HM, Northridge ME. Oral health is the measure of a just society. Journal of Health Care for the Poor and Underserved. 2007;18(1):12-20, p. 20. Oral health equity 4 Slide 5 Dental justice Raising this question [of how many cannot get the dental care they need] in a systematic way requires understanding the social forces that may foster or impede the path to dental justice. Bayer R. The core mission of dental education. Journal of the Academy of Distinguished Educators. 2013;1(1):21-22, p. 22. 5 Slide 6 6 Oral health epidemiology Oral health epidemiology is the study of the distribution and determinants of oral health-related states or events in human populations, and the application of this study to the prevention and control of oral health problems. Slide 7 Harlem Household Survey Of more than 50 health complaints that were part of the Harlem Household Survey, problems with teeth or gums (30%) were the most frequently cited. The percentage of Harlem adults suffering from dental problems was greater than the percentage suffering from hypertension, asthma, or diabetes. Zabos GP, Northridge ME, Ro MJ, Trinh C, Vaughan R, Moon-Howard J, Lamster I, Bassett MT, Cohall AT. Lack of oral health care for adults in Harlem: a hidden crisis. American Journal of Public Health. 2002;92(1):49-52. 7 Slide 8 Whether due to rapid population shifts and the resulting larger numbers of older adults in both developed and developing nations, willful neglect, or ageism or a combination of all three there is no doubt that more resources need to be directed towards meeting the oral health care needs of our seniors. Northridge ME, Lamster IB. A life course approach to preventing and treating oral disease. Sozial- und Praventivmedizin. 2004;49(5):299-300, p. 300. Healthy aging 8 Slide 9 ElderSmile program Among ElderSmile participants with no previous diagnosis by a physician of diabetes or hypertension, 7.8% and 42.2% had hemoglobin A1c (HbA1c) levels in the diabetes range and prediabetes range, and 24.6% and 37.7% had blood pressure readings in the hypertension range and prehypertension range, respectively. Marshall SM, Cheng B, Northridge ME, Kunzel C, Huang C, Lamster IB. Integrating oral and general health screening at senior centers for minority elders. American Journal of Public Health. 2013;103(6):1022- 1025. 9 Slide 10 The overall goal of the proposed research is to provide critical new knowledge to facilitate the widespread implementation, dissemination, and sustained utilization of evidence-based primary care screening, monitoring, and care coordination guidelines, thereby increasing the impact of dental hygienists actions on patients oral and general health. Primary care coordination at chairside 10 Slide 11 Implementation science 11 Implementation science is the study of methods that influence the integration of evidence-based interventions into practice settings. Slide 12 Views of dental providers 12 Participating dental providers do not cite evidence- based guidelines in deciding what blood pressure reading is too high to perform dental treatment HYGIENIST: I guess no matter which reading I get, if I felt like anything was over like 140 over 90, I would have to ask my doctor, and she would let me know whether what she felt was okay to treat. In my own opinion? To be honest, I guess I would say like, I mean, 90 is pretty high. I would say like maybe 155 over like 95 or something or a hundred. Something like that would make me really nervous. No. DENTIST: Yeah. Yes. Yes, there is, and Ibut I must admit that I dont routinely screen for high blood pressure either. I would say Id be veryId be concerned about anything systolic of 160 and above. Northridge ME, Birenz S, Gomes G, Golembeski CA, Greenblatt AP, Shelley D, Russell SL. Views of dental providers on primary care coordination at chairside. Journal of Dental Hygiene (in press) Slide 13 Views of dental providers 13 Participating dental providers use their phones or other devices at chairside to obtain clinical information related to the care of their patients Northridge ME, Birenz S, Gomes G, Golembeski CA, Greenblatt AP, Shelley D, Russell SL. Views of dental providers on primary care coordination at chairside. Journal of Dental Hygiene (in press) HYGIENIST: WebMD. WebMD and PubMed...But honestly, I use a search engine, and then I go to like a couple different ones to get what I'm looking for. DENTIST: I have Hippocrates on my phone to look up drugs, but generally I dont use it much more [than] that. Slide 14 The CDSS is intended to combine the tenets of evidence-based medicine and dentistry, provider knowledge, existing research, and patient values and preferences into a tool to aid dental hygienists in selecting the appropriate course of action for each patient. Developing a clinical decision support system (CDSS) 14 Russell SL, Greenblatt AP, Gomes D, Birenz S, Golembeski CA, Shelley D, McGuirk M, Eisenberg E, Northridge ME. Toward implementing primary care at chairside: developing a clinical decision support system for dental hygienists. Journal of Evidence-Based Dental Practice (in press) Slide 15 The impact of Medicaid expansion on oral health equity for older adults: a systems perspective 15 Pathways toward improved oral health equity involve availability, affordability and quality of oral health care. Because oral health inequity is a salient indicator of fundamental socioeconomic disparities, making oral health care more accessible to vulnerable adults is an important avenue toward public health and social justice. Metcalf SS, Birenz SS, Kunzel C, Wang H, Schrimshaw EW, Marshall SE, Northridge ME. The impact of Medicaid expansion on oral health equity for older adults: a systems perspective. Journal of the California Dental Association. 2015;43(7):379-387. Slide 16 Evidence from ElderSmile for diabetes and hypertension screening in oral health programs 16 Linking primary care and oral health care together in accessible locations can identify seniors in need of better monitoring and treatment for both, and promote a more holistic view of their health and well- being. Marshall SE, Schrimshaw EW, Kunzel C, Metcalf SS, Greenblatt AP, De La Cruz LD, Northridge ME. Evidence from ElderSmile for diabetes and hypertension screening in oral health programs. Journal of the California Dental Association. 2015;43(7):379-387. Slide 17 At a time when the world is more messy, more crowded, more interconnected, more interdependent, and more rapidly changing than ever before, the more ways of seeing, the better. Systems thinking 17 Slide 18 Integrating Social and Systems Science to Promote Oral Health Equity 18 Slide 19 Dentists cause pain Moderator: Why do you think people dont go to the dentist? Participant 1: Painful. P2: Scared of the needle. [Several agree.]: Oh right, the needle! P3: They are also scared because of the work they are gonna do on you. You start thinking about it. Oh, what they gonna do? That starts getting you scared. The needle starts to get you. P2: The pliers they are going to use on you. You see all of these machines that they are going to use. All of the gadgets on you. P4: Thats it right there. You get in and seeing everything on the table. You start thinking and you start getting nervous. P3: Right. M: But thats when you are already there. What about people who havent gotten there yet? Why dont they go? P3: Because of that! [Several agree.] They are scared of that. - Group 20: Puerto Rican men, with dental care Slide 20 Need respect and caring P1: You have to be cordial. You have to show that you are really concerned about their health. So, listen. We adapt very well to people who show us respect. P2: Right. P1: Seniors like respect because weve paid our dues. We really have. Weve suffered some real indignities and now that weve gotten older, they got worse. [Group laughs.] P1: I mean they really have! We shouldnt have to have discussions about senior health. This should have been a foregone conclusion years ago. All thats been happening is that stuff has been taken away from us. Its made it more difficult for us to live like decent human beings. - Group 8: African American men, no dental care Slide 21 The oral public health approach responds to the Surgeon General's call to reconnect the mouth to the rest of the body in health policies and programs, and may thus be able to overcome certain barriers that far too many of the public face in obtaining dental care. Northridge ME. Reconnecting the mouth to the body of public health. American Journal of Public Health. 2002;92(1):9. Oral public health 21 Slide 22 Public health dentistry 22 Dentistry Slide 23 Oral public health 23 Dentistry Medicine Public Health Slide 24 Acknowledgments A special thanks to Eric Schrimshaw and Shirley Birenz for their assistance in creating this presentation, and to our funding agencies and organizations for their financial support of the following projects: UL1 TR000038: Primary Care Coordination by Dental Hygienists at Chairside: Developing and Evaluating an Electronic Tool (NIH/NCAT) R01DE0230721: Integrating Social and Systems Science Approaches to Promote Oral Health Equity (NIH/NIDCR, OBSSR) 003140: Family Based Dental Health Promotion in the Sikh Community (DentaQuest Foundation) 12-JV-11242309-095 (Northridge/Svendsen/Metcalf): Integrating Grey and Green Infrastructure to Improve Health and Well-Being for Urban Populations (USDA Forest Service) Slide 25 Dentists are expensive M: Talking about your opinion about dentists, what do people say? P1: They are expensive, they are expensive. P2: Yeah! They are expensive. M: Something that is confusing to me is that Medicaid/Medicare does not cover dental services. P3: Not everything. P4: Medicaid covers it. Medicare doesnt. M: For people that have Medicaid, if they are covered, well basic care is covered, why dont they go? P5: Well, you know, have you ever heard the proverb that says: I hate going to the dentist. Ask me why. [Everyone laughs] - Group 24: Puerto Rican men, with dental care Slide 26 Dentists out to make money M: What is the perception of dentists out in the community? P1: Bad, bad, bad. [Multiple women repeat bad.] M: And why is that? P2: I see them as dollar signs, thats what. Not helpful. P3: In my case, I wanted them to pull my teeth. I told them, This is costing me money. Why dont you just take them out? They talked me out of pull my teeth because its more money. Im like, Im tired of coming back for the same teeth over and over again and every time I look, its a new bill. Then I find out a while denture, you could get a whole plate for like $900. Nine hundred dollars in comparison to one tooth for $2000?... Who have $2000 just to give up? I am on Social Security. - Group 9: African American women, with dental care Slide 27 Dentists out to make money There are still dentists with no scruples. I had four back molars taken out and a dentist on 11 th Ave told me, Dont take them out. I will heal you. But do you know what happened? He charged a lot and I was, at that time, I was disabled. Well the dentist said, But this will cost you a bundle. Do you have money? Well I said I did not have the money that he was asking for. So I went to [another] dentist. The man looked like a butcher. He took out the four molars and I bled for four days. I ended up checking into Presbyterian [Hospital]. I went back and said, Look doctor, you are not a dentist, you are a butcher because look at the state you left me in. And you know what the dentist said? Look I could have fixed it. But I had to take them out because I earn more taking out molars than fixing them. Thats exactly what he said. - Group 10: Dominican women, with dental care Slide 28 Mistrust of dentists Come on, man! Dentists are unreal. You have to be very careful with them! They are thieves. They are thieves. How do they steal from you? Messing up your teeth so they can call you in six months. Oh come in, we have to do a cleaning. Every six months. Medicaid pays for you to get a cleaning. But they mess one tooth up, so they know that in six months, when they come and take X-rays again, Oh you have a caries inside. But it doesnt hurt you. That tooth never hurt. That was the last thing a dentist did to me. [Had not returned since this experience.] - Group 6: Dominican men, without dental care Slide 29 Mistrust of dentists [Following an earlier conversation about how expensive it was for daughter to have wisdom tooth extracted.] P1: In certain situations, as far as dental care goes, like you said, in the case with his daughter, it could have been a possibility that there wasnt nothing wrong with her wisdom tooth. But in order to make money, they will do that. P2: They dont make money by finding nothing not right. P1: Thats one of the reasons why people being afraid to go to the dentist. Im one of them. Thats why Im afraid of them, because it happened to me before. P3: Same situation. P2: Something is not messed up. Theyll mess something up for you to come back. P1: Exactly. - Group 8: African American men, without dental care Slide 30 Dentists cause pain M: What do seniors in the community think about dentists in general? P1: There are people who say, I wont go to the dentist even if they [teeth] kill me. I will die with my teeth like this. Even if my head comes off from a toothache, I wont put my mouth under the control of a dentist. M: Why would they say that? P1: Fear. They are afraid. They are not afraid of the toothache, but they are afraid of having the tooth extracted. M: And what else do people say? P2: That they are savages. People say that dentists are savages - Group 15: Dominican men, with dental care Slide 31 Need dental information P1: I think that in this community, we need a lot more information. Many times we are orphaned of information. Those of us who have information are those of us who go to the centers are a paying attention to what is happening. But there are a lot of people, who dont even know what is happening in their community. We need a lot of communication at the level of the [senior] centers, public offices, the libraries. We need information via radio. P2: At the drug store! P1: On television. The Hispanic community needs television. In other words, more information. Because its through more information that you do consciousness building. More conscientious people accesses more easily those services than those who dont know that those things exist. - Group 15: Dominican men, with dental care Slide 32 Need affordable services P1: I say, if a clinic is there or there, Id choose any of them but they have to treat me for free and it belongs to the government. P2: Yup. P1: But that doesnt exist. P5: Or at least a clinic that charges low fees so one can pay. P1: A minimum fee. P5: Something thats not free, but that is reasonable. P1: According to your income. P2: Its not possible another way, its too expensive. -Group 5: Dominican men, with dental care. Slide 33 Need mobile services M: What kinds of things would you do to try to get seniors to go who arent already going? P2: They have the childrens dental truck. They have it for children. Vans. So why dont they have one for grownups? P5: Thats a good idea. P3: People would just go, take a morning and do all the screening and then once a month theyll do it or something every other week. Because its easy. They dont have to travel anyplace. They offered screening, or everything, even if theyre just a screening, okay. And then I refer you back to your own dentist or back to a regular dentist. - Group 3: African American women, without dental care Slide 34 Need dental home visits P1: I would get nurses or dentists, you know, go check the teeth out and in your apartment, you know. M: Home visits? P1: Visits to your apartment to check all the elderly people. So they dont have to come. Give me all the number of all the elderly people and all the kids. You go to the families, you check all the families. People are scared. If there was one person or a women who says lets check your teeth, they open their mouth to check them and do not take anything out. You wouldnt need to go to the dentist if there was a bus that comes to your house. They take their teeth out, they get surgery, they do everything. There are many countries that have a bus. In Puerto Rico they have buses that go for the elderly people to fix their teeth and everything. - Group 24: Puerto Rican men, with dental care Slide 35 Need respect and caring P3: Then you have a follow up person. Mrs. So and so, did you go? How are you feeling today? People like hearing others caring about them, you know, especially seniors. We wanna know that somebody does care and then it makes you feel guilty. They care about me, why dont I care for myself? P1: Yeah. P3: Why dont I go to the dentist and get it taken care of. -Group 3: African American women, without dental care