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Opportunities to Reduce Oral
Health Disparities: Basic
Sciences to Clinical Practice
Peter Milgrom, DDS
University 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
Dental Health
Oral hygiene
Diet
Host Defense
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.
Beverly A. Dale-Crunk, PhD
Richard Jurevic, DDS
Norma Wells, RDH, MPH
Marjorie Tsutsui, Dental Stud
Nancy Chino, Science Stud
People
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
GM
Bacteria
Defensins
JE
Diet
Tooth
Decay
Oral hygiene
Defensins are natural antibiotic peptides
- and we make them !!!
They are inherited like hair color and height.
Our study explores possible links between
beta-defensins and dental caries in children.
Measure the amount of
beta-defensins in saliva
Look at genetic differences
Is there a difference in children with low and high
dental decay?
Subject Population
We 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,
Preliminary data shows a
deleterious, or even
possible protective effect
advantageous.
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
Number
SNP -44
0
50
0.40
Lo
47
0.47
Hi
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
b-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 Medicaidfunded 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
Medicaid
Patients
Early TX
(n=75)
Observation
(n=75)
A
I
M
Observation
A
I
M
1
Matched
Private-Pay
Patients
(n=65)
3
Full TX
A
I
M
2
Full TX
Medicaid
Patients
Early TX
(n=75)
Observation
Randomization
(n=75)
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
Timeline
Year
1
Aim 1 Recruitment
Aim 1 Clinical Phase
Aim 3 Clinical Phase
Aim 2 Recruitment
Aim 2 Clinical Phase
Data Analysis and Reports
2
3
4
5
6
7
Early childhood caries
prevention with xylitol
Turku sugar studies
7
Sucrose
Fructose
Xylitol
6
5
4
3
2
1
0
0
2
4
6
8
10
12
14
16
18
20
22
24 Month
20
Xylitol/clinical studies…
36
Xylitol
Control
18
16
36
14
30
36
30
12
30
10
36
0
Baseline
29
1
Years
2
3
Final
8
Xylitol/clinical studies…
7
6
control
5
candy
4
gum
3
2
1
10
11
12
Age (years)
13
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
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
CHX
XYLITOL
SORBITOL
Mean plaque scores following use of chlorhexidine-, xylitol-, and sorbitol-containing
chewing gum in absence of mechanical plaque control measures for 6 days.
Xylitol makes mutans streptococci
to shed more easily to the saliva