Opportunities to Reduce Oral Health Disparities: Basic Sciences to Clinical Practice Peter Milgrom, DDS University of So

1. Opportunities to Reduce Oral Health Disparities: Basic Sciences to Clinical Practice Peter Milgrom, DDS University of Southern California, February 2003

2. University of Washington Northwest/Alaska Center for Research to Reduce Oral Health Disparities

3. This project is designed to study a biological marker that may influence susceptibility to tooth decay Beta-Defensins in Caries-Prone Children Goals 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.

4. Beverly 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 People

5. 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 More People

6. GM Tooth JE Oral hygiene Defensins Bacteria Tooth Decay Diet Defensins are natural antibiotic peptides - and we make them !!! They are inherited like hair color and height.

7. 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 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.

8. Hum subjects, fall 01 Meet with Toppenish school and community group representatives 2/02 Meet with parents and children - educational presentation 5/02 Time Line

9. 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).

10. 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%)

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.

12. 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

13. Sign up and Be part of the Solution

14. 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.

15. Early Orthodontic Intervention Under Medicaid

16. OBJECTIVE To examine the usefulness of early orthodontic intervention as a means of increasing access to orthodontic services for children of low-income families

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. Observation Early TX (n=75) AIM 1 AIM 3 Medicaid Patients Observation (n=75) Full TX AIM 2 Matched Private-Pay Patients (n=65) Full TX

24. CD-ROM (n=30) Standard consult (n=30) AIM 1A Early TX (n=75) Medicaid Patients Observation (n=75) Randomization AIM 1

25. 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

26. Timeline

27. Early childhood caries prevention with xylitol

28. Turku sugar studies

29. 2 0 Xylitol/clinical studies… 3 6 X y l i t o l C o n t r o l 1 8 1 6 3 6 3 0 1 4 3 6 3 0 1 2 3 0 2 9 1 0 3 6 0 1 2 3 Years B a s e l i n e F i n a l e r

30. Xylitol/clinical studies…

31. 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 (?)

32. 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

33. Xylitol reduces plaque formation

34. Xylitol makes mutans streptococci to shed more easily to the saliva