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19/20: Epidemiology of Dental Caries

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08/07/14
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  Transcribed by Amit Amin August 07 th , 2014 1 [Diagnosis of Oral Diseases] [21&22] –  [Cariology I & II] by [Dr. Dasanayake] [1] –  [Title] [Dr. Dasanayake]   –   So tell me when you guys want me to start. I’ll be happy to talk to 10 people. No problem. Do you have an exam today? What? Tomorrow? Do you know where the rest of the class is? This is it? Ok. Fantastic. You want to go home? No. Ok. Alright. So attendance is not mandatory for this one ok. Fantastic. I’ll give you the choice. I have 2 hours to talk to you guys. Let me go ahead and get started. So is the lighting ok? Can you see the slides on the screen? You can. Thank you. Is it? It is. To me, it’s not you.  Alright. Somebody. Can somebody tell me what you see on this particular slide and what is the relevance of that? Caries. Arising from? There are two potential sources right? Lateral incisor and the caninal premolar in the primary dentition. The lesion is on the palate so what is your diagnosis here? Other than caries? Do you see this lump on the roof of the mouth? What do you call that? It’s a classical dentinal alveolar abscess. In the mid 70s this is what I dealt with on a daily basis. This is imagine, pre-facemask, surgical glove era. The moment I open this up, I collect about a gallon of pus coming out of that full of various organisms so next day sore throat. You guys are lucky that you don’t have to deal w/ that. This is what we will talk about today, dental caries, not the dentinal alveolar abscess. [2] –  [No title] [Dr. Dasanayake]   –  I want to talk about that within this context. What is the distribution of caries in your population and what are their determinants of dental caries. We probably have a vague understanding of what some of these are. [3] –  [Topics of Discussion] [Dr. Dasanayake]   –   But this is where I’m going to frame my discussion. Why do we care? You are here right? You want to learn about this. You’re  in the dental school. You’re spending thousands of dollars to become dentist so let’s look at it from different angles. How many people are affected in your own communities where you end up as a practitioner? If there is 0 prevalence you’re not going to have a good practice. Maybe you can do other things but not treating tooth decay and to what magnitude? When I say what magnitude for a given mouth, how many teeth/ how many surfaces are effected by tooth decay and you can multiply that by what you need to do to rest or form and function in those oral cavities. Any trends in this patterns? This is getting very interesting to first/ second year dental students. If I tell you by the time you finish there won’t be any tooth decay, it’s a good thing in a sense but at the same time you may want to think about other options. What is causing caries? Where is the evidence? Cause you know sugar in your drink you’re drinking right now may contribute to a certain extent to tooth decay. Where is the evidence? My intention is to show you the highest level of evidence or factors that are implicated in the etiology of tooth decay. Why do we do all of these things? Because you have a better sense of how you can prevent and treat caries when you get out of school. This is my framework for the discussion. It’s Thursday at 3 o’clock, I don’t want you to fall asleep so I’m going to keep it a two-way interaction. Please participate ok. [4] –  [Question 1]  Transcribed by Amit Amin August 07 th , 2014 2 [Dr. Dasanayake]   –  Why is oral health important? If a mother of a little child comes to you in your clinic and asks you doctor these are baby teeth. Why is it important why do we care? Yes sir. Fantastic, very good answer. Anybody else? I would like everybody to participate then you will stay awake. Anything else? Fantastic. Primary dentition probably has a direct correlation that happens w/ permanent teeth. You’re   answering a different question. I’m asking what it’s important to have good proper oral health. You’re saving if    you’re not going to chew, fantastic. Anything else. Yes sir? Systemic health. Of course. There are a number of studies that shows what is going on here, the inflammation can travel to other parts of the body and cause havoc in various systems including the heart and pancreases and other places in the body and pre-termed deliveries expel. This is how I see this one. Number one. This is highly prevalent. If I ask you in your particular age group what is the prevalence of tooth decay in the United States. Prevalence is a proportion right? It can range from 0 to 100 percent. Your age group, young adults, what is the prevalence of tooth decay in this country? Take a guest. 80%? 50%? I’m talking about the permanent teeth. Let me clarify further. This is highly prevalent  . You’re going to see the numbers in a moment. A little bit higher than what you thought. Oral diseases and access to dental care show great racial, ethnic, and economic disparities. Midtown Manhattan is a totally different story from Queens. From Birmingham, Alabama. If you look at the Mexican Americans and this country and the poor Mexican Americans, that’s a double whammy right there right? This is another reason why you need to care. Dental care is very costly. I’ll ask you later how much money you think we spend in this country to take care of people’s teeth? So think of that so when I come to that question you have the answer. Oral diseases might be linked to overall health and even death. There are cases in the literature where children and young adults have died due to neglected untreated tooth decay. [5] –  [Common Childhood Diseases] [Dr. Dasanayake]   –   This is the famous report of the surgeon general in 2000. That’s the only report that talks about oral health specifically in this country. What are they saying here? This is the commonest ailment in children, asthma. Prevalence, 10%. The second, hay fever is 7%. Look at what you’re dealing w/. 50% prevalence. What is this telling you, 5x more prevalent than the commonest children disease (#1). #2. If you remember, your primary school days, idk if you had any tooth decay when you were a primary school child. 51 million school hours are lost each year as a result of this condition ok? Among poor children, what you called the restricted activity d ays, you’re sitting in a corner b/c of the pain and swelling due to caries are 12x higher if you are one of these poor/ minority kids. These are greater social issues as well as public health issues. [6] –  [Figure 1-C] [Dr. Dasanayake]   –  So this is that access to care when I was in Alabama. I look at the data from 1990-1997 looking at access to care, about 1.5 millions records that I was looking at (Medicaid data). This is no surprise to you right? There is a great racial disparity in terms of utilizing oral health services. Even though you have Medicaid, you don’t necessarily go unless you have an emergency right? This limited access to care and not using the care would compound this particular problem. So now I’m going back to that slide again. Burden of this inadequate access to care. Can this be  Transcribed by Amit Amin August 07 th , 2014 3 fatal? You already know this answer since I told you. So here is a Washington post article from March 2007. About a week ago or just before that a 12-year-old boy died as a result of complications from a tooth abscess. Kind of infection, but common among people that don’t have access to care. If you go back and think of your oral pathology, dental anatomy, and everything else, this infection can spread from here to the intracranial structures such as? What’s the c ommonest place? Cavernous sinus remember? This can spread if it is unchecked. As in this particular case, this child had2 operations, spent 6 weeks in the hospital, yet the end result was fatal. [7] –  [ Deamonte’s Law ] [Dr. Dasanayake]   –  So this actually led to some silver lining in this dark cloud. U.S. Congress immediately acted upon that. That was May 17 th . The child died in March. By May Congress had passed this particular law, HR 2371, and in that particular law they said there was a 15%in early childhood caries b/w 1988 & 1994 and 1994& 2004 (data from the Center for Disease Control). You should be thinking why is there an increase? We are in one of the richest countries in the world. 28% young children had experienced cavities b/w 1999&2004 and 80% of dental decay occurs in just 25% of children. Tooth decay is the single most common childhood chronic disease and disproportionally affects poor and minority children. [8] –  [ Deamonte’s L aw Part II] [Dr. Dasanayake]   –  Just to give you some interesting facts so you can talk about these things at cocktail parties in the summer. 9 million children as of 2007 don’t have medical insurance. More than 2x (20 mil) don’t have dental insurance. Does   that surprise you? 20 mil in our country don’t have dental insurance. If you’re a parent, you’re 3x more likely to report that your children’s dental needs are unmet when compared w/ general medical care. Child has fever, stomachache , you’ll take the child to the doctor. The dentistry will come later when you have enough money saved and you can take time off work. It’s not necessarily preventive care, it’s usually emergency care. These are the realities that you will face w/ your patients when you graduate. More than 31 million people in this country live in what we call dental health, provider shortage areas. Go to upstate NY just below Canadian border you have dental provider shortage areas. People have to travel hundreds of miles to see a dentist. This report says we needed about 5,000 additional dentist to serve in these particular areas. [9] –  [Melissa Rogers] [Dr. Dasanayake]   –  So this is the press report in May 18 th  saying that this is again, I can’t remember what, Washington post. They passed this  law by Representative Cummings and it is interesting for you to see and whether something came out of this congressional action. What they were proposing here, 2 steps. #1 Establish 2 5 year 5 million pilot programs. First provide money to staff and equip community clinics. The second was to help recruit and train pediatric dentist. I was looking to see if there was a follow up to this one. Maybe you will be able to find something along these lines. [10] –  [Breaking News] [Dr. Dasanayake]   –  This is the other sign of the coin. Tell me what you think of this right. Real stories. This is Philadelphia 2007. Mother was sentenced to time behind bars for failing to treat 5-year-old son’s dental problems. There is a solution to this  Transcribed by Amit Amin August 07 th , 2014 4 problem. Put the mother, father, or grandmother in jail b/c they have untreated tooth decay, no access to care, and no insurance. That’s the other side of the coin. You can have an entire session debating on that. [11] –  [24 year old dad] [Dr. Dasanayake]   –  This is an adult. Those were children I was talking about. This man from Cincinnati, Ohio went to the emergency room, infection, inflammation, and acute pain. Emergency room, giving two prescriptions. One for pain, one for infection. Guess which one he purchased. He could only afford one. He went and bought the pain medication. End result? Death. This is happening in your communities. This is why you’re sitting here and you’re trying to take a closer look at this particular problem b/c of tooth decay. [12] –  [Emergency Room Visits for Dental Conditions] [Dr. Dasanayake]   –  So these people that have no access to care. No insurance. What do they do? The go to the emergency room for dental care. This is 2009 data. About a million visits to the emergency room related to dental visits. That  ’s not where you should go right? It should be preventive care by dental hygienist or local dentist. These people end up in the emergency room. Look at the hospitalizations, about 13,923 treated and released just like the Cincinnati gentleman. Fill a prescription, no follow up, go home, and anything can happen to them. [13] –  [Measuring Ways of Impact of Oral Diseases] [Dr. Dasanayake]   –  Any other ways of measuring impact of oral disease? Yes. I think that is emergency room protocol. They give the prescription, take care of the acute problem, and tell them to go see a dentist. Sometimes there are dentist affiliated w/ the hospital in the emergency rooms. I’m sure there are protocols related to that.  Any other ways of measuring this true impact? These are talking points for you to convince the parents who come to your practice or the adults about oral health. Anybody? Any other ways of addressing the impact of oral diseases. Why is it critically important to have good oral health. I’m just trying to s timulate your thinking. Participate in the discussion please. [14] –  [Picture of $50 bill] [Dr. Dasanayake]   –   How about this? Let’s put some numbers. [15] –  [How much money do we spend?] [Dr. Dasanayake]   –   I told you I’m going to ask you how many dollars we spend in this country to keep the Americans healthy? Not orally, healthy. Somebody give me a guess. $4 billion. Any other guesses? These are interesting numbers to remember as healthcare professionals. $200 billion. What proportion of that expenditure do you think we spend to take care of oral health? What percent? 10%. 2% [16] –  [Percentage Distribution of Health Care spending] [Dr. Dasanayake]   –  Alright. Here are the real numbers. Ok. $1.3 trillion. This is 2011. I can’t find anything after that. There’s a lag. These are government numbers. Where do we spend all this money? Hospital inpatient, these are the office based visit, prescribed medications, hospital outpatient. Here is you. 6.4%, which is greater than what we spend in emergency rooms. That’s mind-boggling. Oral health or dental services expenditure is about 6.5% of the total expenditure on overall health, $1.3 trillion dollars. After Obamacare I don’t know what these numbers are. [17] –  [How many are affected by caries?]
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