Abstract
Recently, it has been recognized that poor oral health conditions, especially periodontitis, have been a contributing factor to several systemic diseases. Evidence shows that Missouri should be concerned about the current state of caries and its prevention. The prevalence of caries and lack of preventative care in Missouri warrants an examination of the current efforts in place to reduce caries and the creation of novel approaches that bridge the gap between oral and medical care. This paper discusses this problem in depth.
Dental Caries in Missouri
The prevalence of dental caries in Missouri is significant, creating a critical health problem in Missouri. Missourians do not visit the dentist as often as citizens of other states, contributing to some very troubling oral health statistics. In 2008, 63% of Missourians reported visiting a dentist while the national average is 71.3%.1 Inadequate oral health care in Missouri has resulted in a significant number of caries cases. More than 26% of Missouri’s residents age 65 or older have had all of their teeth extracted. The national average is 18.5%.1 Furthermore 53.5% of those 65 years and older have lost six or more teeth, while the national average is 43%.2 Dental caries in children is significant as well, with 27% of third grade students with untreated tooth decay and 54.7% having a caries experience.2
The effects of poor dental hygiene of Missouri children are astounding. During the 2004 – 2005 school years the Missouri Department of Health and Senior Services conducted a statewide oral health survey of third grade children enrolled in Missouri’s public elementary schools. Of the 113 schools that agreed to participate, there were 7,266 children enrolled in the participating schools with 3,525 children screened; a 49% response rate. The majority of the students screened (97%) were either eight or nine years of age. Fifty-five percent of the children screened had decay experience, untreated decay, or fillings in their primary and/or permanent teeth while 27% had untreated decay at the time of the screening. About 28% of the children needed dental treatment, including 5% in need of urgent dental care because of pain or infection. More than half of Missouri’s third graders (55%) have a history of tooth decay, meaning they had at least one tooth that was either decayed or had been filled because of decay. This is five times higher than the prevalence of the next most common chronic disease of childhood-asthma (11%).3 See Figure 1.
Figure 1.
According to the CDC, dental caries is the most common chronic disease of children aged 6 to 11 years (25%) and adolescents aged 12 to 19 years (59%). Tooth decay is four times more common than asthma among adolescents aged 14 to 17 years (59% compared with 15%).
Missouri Compared to Neighboring States
The prevalence of dental caries is a nationwide concern. Every state that borders Missouri provides fluoridated water as well as other programs in an effort to reduce the prevalence of caries. Using data obtained from the National Oral Health Surveillance System, a comparison of Missouri to all eight neighboring states was made (See Table 1). The comparison focuses on the percentage of adults in each state that are 65 years of age or older who have lost six or more teeth. The results of the comparison show that Missouri has a higher prevalence of teeth loss than nearly all of its neighbors. Only Oklahoma has a slightly higher prevalence at 54%. This also indicates that Missouri adults are at greater risk for teeth loss than adults in all neighboring states, with the exception of Oklahoma.
Table 1.
Percentage of Adults 65+ With 6 or More Teeth Lost2
Health Conditions Affected by Poor Oral Health
Role of Periodonitis
Periondonitis is a destructive inflammatory disease that affects the soft and hard structures that support the teeth. Known in its early stages as gingivitis, the gums become swollen due to inflammation, a response to the presence of harmful bacteria. As the condition progresses, the gums pull away from the tooth and the supporting gum tissues are destroyed which can lead to the loss of teeth and bone.4 Periodontitis has been proposed as having an etiological or modulating role in cardiovascular disease, diabetes, adverse pregnancy outcomes, and respiratory disease.5 A meta – analysis perfomed by Huck et al., concluded three biological mechanism supporting the etiological role of periodontitis: bacterial, inflammatory, and immune.6
Cardiovascular Disease
P. gingivalis, a Gram – negatve anaerobe, has been considered an important pathogen associated periodontal disease. It has been determined that this organism along with the host immune response is critical to the destruction of the supporting structures of the teeth. It has been suggested that periodontal disease can lead to low-level bacteremia, an elevated white cell count, and systemic endotoxemias, which could affect endothelial integrity, metabolism of plasma lipoproteins, blood coagulation, and platelet function. It has been well established that PP. gingivalis is a catalyst for local inflammation. A response to this inflammation can lead to gingival ulceration and local vascular changes, which have the potential to increase the incidence and severity of transient bacteremias.7 Numerous studies have shown that patients with periodontal disease have elevated levels of systemic inflammatory mediators. Extensive periodontal disease has been associated with increased levels of C-reactive protein.8 Moderately elevated C-reactive protein is a systemic indicator of inflammation and a known risk factor for cardiovascular disease.9 Research has shown that people with periodontal disease are almost twice as likely to suffer from coronary artery disease as those without periodontal disease.10
Diabetes
People with diabetes are more likely to have periodontal disease than people without diabetes. It has been theororized that this is a result of diabetics being more susceptible to contracting infections. In fact, periodontal disease is often considered the sixth complication of diabetes.11 Individuals with diabetes typically have a more serious form of periodontitus than those without diabetes. Diabetics exhibit more severe pocket depths, alveolar bone loss, frequent abscess formation, and poor healing following treatment than non-diabetics. 12 One study presented a correlation between periodontitus and glucose tolerance status. Patients with deep periodontal pockets (mean pocket depth >2.0 mm) were significantly associated with having impaired glucose tolerance and diabetes compared to a group with shallow pockets (<1.3 mm). Subjects with normal glucose tolerance at baseline and who developed impaired glucose tolerance were significantly more likely to have deep pockets.13
Pregnancy
Preterm birth is the leading cause of neonatal morbidity in the United States, costing approximately $26.2 billion per year.14 In 2009, there were 6,393 births of low weight which accounted for 8.3% of all live births in the state of Missouri.15 There are many factors that contribute to adverse pregnancy outcomes such as socio-economic status, race, age of mother, reproductive history, and drug use. Infections can also be a source of adverse pregnancy outcomes and it has been suggested that periodontopathic bacteria, or inflammatory mediators generated in response to them, reach the uterine cavity through the bloodstream and elicit an inflammatory cascade that leads to spontaneous preterm labor.16 Multiple studies have shown that Porphyromonas gingivalis, a periodontopathic bacterium, in the placentae of women whose delivery was preterm17 and in the amniotic fluid of pregnant women at risk for premature delivery.18 Porphyromonas gingivalis was also present in patients diagnosed with pre-eclampsia, one of the most common and dangerous pregnancy complications.19 In a recent study conducted by Hasegawa – Nakamura et al., the effects of P. gingivalis lipopolysaccharide (LPS) on production of proinflammatory molecules using cultured choroin-derived cells was investigated. It was determined that P. gingivalis LPS induced IL – 6 and IL – 8 generation by chorion – derived cells at significantly higher levels than control cultures. These findings suggest that P. gingivalis detected in chorionic tissues might affect preterm labor by stimulating production of proinflammatory molecules, including IL-6 and IL – 8, in the microenvironment.20
Respiratory Disease
Chronic lower respiratory diseases is the fourth leading cause of death for all ages in the United States and Missouri.21,22 Respiratory diseases is the term for diseases of the respiratory system, including lung, pleural cavity, bronchial tubes, trachea, and upper respiratory tract.23 Poor oral health has been associated with respiratory conditions such as pneumonia and COPD. Studies have suggested that teeth and periodontium serve as a reservoir for respiratory pathogen colonization and infection. In a longitudinal study conducted by Hayes et al., it was determined that alveolar bone loss at baseline is an independent risk factor for COPD and increased ABL is associated with increased risk for COPD.24 In a study examining the relationship between oral health and respiratory tract infections in the elderly, it was concluded that poor oral hygiene could be a major risk factor for respiratory tract infections among the elderly. In this study 302 elders with a mean age of 85 years were examined by one dentist. One-third of the subjects had experienced at least one episode of respiratory tract infection, and a fifth had visited the dentist in emergency. The incidence of respiratory tract infection was greater among dentate subjects and those who came to the dentist in emergency.25
A review conducted by Kuo et al.,26 found several proposals to explain how bacteria can participate in the pathogenesis of respiratory infection. Similar to other systemic diseases discussed in this artice, the same biological mechanisms have been determined to be a factor.
Oral pathogens such as P. gingivitas may be aspirated into the lung.
Periodontal disease-associated enzymes in saliva may modify mucosal surfaces to promote adhesion and colonization by respiratory pathogens.
Periodontal disease-associated enzymes may destroy salivary pellicles, thus diminishing the protection of non – specific hist defence against respiratory pathogens.
Cytokines (IL - 1α, IL - 1β, IL – 6, IL – 8, and TNF – α) released from periodontal tissue may alter respiratory epithelium and increase its susceptibility to colonization by respiratory pathogens. Subsequent inflammatory responses also continue to break down the pulmonary tissues.
Fluoride for the Prevention and Control of Oral Health Issues
The effectiveness of fluoride in the treatment of dental caries has been known for decades. Fluoride controls caries by inhibiting the demineralization of sound enamel and aids in the remineralization of enamel that has been demineralized. Fluoride also affects cariogenic bacteria, by inhibiting the ability of the bacteria to metabolize carbohydrates and produce acid.27 There are two major modes of fluoride delivery: topical and systemic. Topical delivery includes the use of toothpastes, gels, varnishes, paint – on formulations, and mouth rinses. Systemic delivery of fluoride relates to fluoride that is ingested - received in water, supplements, or products made with fluoridated water. Community water fluoridation is the primary source of systemic fluoridation.
Topical Fluoride Delivery
Topical use of fluoride has been shown to be a very effective form of caries prevention and control. There are several different forms of topical delivery including supplements, gels, varnish, mouth rinses, and toothpaste. Fluoride products such as supplements, gels, varnishes or high concentration mouth rinses are prescribed or applied by a dentist of physician.28 The most common form of topical delivery, toothpaste, is readily available over the counter. In a recent analysis of seven systematic reviews which focused on the effectiveness of topical fluorides, it was shown that the evidence in support of topical applications is strong and consistent. Using evidence from randomized control trials, more than 65,000 children and adolescents in over 130 controlled trials showed that fluoride toothpastes, mouthwashes, gels, and varnishes can reduce dental caries, regardless of water fluoridation or other sources of fluoride exposure.29 Evidence suggested that toothpaste can protect children and adolescents against dental caries as much as other topical fluorides. Furthermore, it was suggested that children using another form of topical fluoride therapy with fluoride toothpaste will experience additional reductions in dental caries, compared with children using only fluoride toothpaste. However, when utilizing multiple forms of fluoride delivery the risk of ingesting too much fluoride increases.29
Systemic fluoride delivery. Since the inception of community water fluoridation in 1945, the fluoridation of public water supplies to prevent dental decay has been one of the most effective public health interventions ever devised. Scientific evidence compiled over more than six decades demonstrates that fluoridation is a safe, cost-effective, and equitable intervention that benefits everyone in a given community regardless of financial status.30 Comparison of four different studies that occurred between 1971 and 1994, show both an absolute decline in total number of dental caries in all age groups from five to 17 years as well as a dramatic “flattening out” of the increase from age five to age 17.31 This data demonstrates a reduction in dental caries of over 50%, as well as a reduction in the rate of increase among children age five to 17.31
Systematic reviews of the scientific evidence related to fluoride have concluded that community water fluoridation is effective in decreasing dental caries prevalence and severity.32,33,34,35 Effects included significant increases in the proportion of children who were caries-free and significant reductions in the number of teeth or tooth surfaces with caries in both children and adults.32,33
Cost Effectiveness of Water Fluoridation
Fluoridation in Missouri
Based on the latest statistics from the CDC, in 2008 Missouri fluoridated 79.8% of the Public Water Supply (PWS). Missouri has made great progress in fluoridation, but there are over one million Missouri residents serviced by a PWS not receiving fluoride. This deficiency accounts for 20% of Missouri’s total population based on 2008 census estimations.36,37 Table 2 details Missouri’s participation in community water fluoridation using data reported by Missouri to the CDC Water Fluoridation Reporting System in 2008 as well as U.S. Census Bureau estimates from the same year. Extending the benefits of fluoridation to the consumers of non-fluoridated PWS would be relatively inexpensive and in fact would produce significant cost savings.
Table 2.
Fluoridation in Missouri16,17
| Est. Population of Missouri 2008 | 5,911,605 |
| Population Served by PWS | 4,971,878 |
| Population Served by PWS Receiving Fluoride | 3,965,831 |
| Population Served by PWS not Receiving Fluoride | 1,006,047 |
Analysis of Cost Effectiveness
According to a study conducted by Griffin, Jones, & Tomar, in larger communities with a population greater than 20,000 residents, it costs approximately .50 cents per person to optimally fluoridate the water. Every $1 invested in this preventative measure yields approximately $38 savings in dental treatment costs. Furthermore, under typical conditions, the annual per person cost savings in fluoridated communities ranged from $16 in very small communities (<5000) to nearly $19 for larger communities (>20,000).38, 39 The analysis takes into account the cost of installing and maintaining necessary equipment and operating water plants, the expected effectiveness of fluoridation, estimates of expected cavities in non-fluoridated communities, treatment of cavities, and time lost visiting the dentist.38
To illustrate the economic value of fluoridating a PWS, five counties were selected from the 2011 Census of Missouri Public Water Systems40 based on two criteria; the water system serves the public and is not fluoridated. Utilizing the findings from the Griffin, Jones, & Tomar study, the following cost and annual savings was calculated for these counties. As displayed in Table 3, the analysis shows that each county would experience a positive economic impact if fluoridation is included in their water treatment process.
Table 3.
Cost Analysis of Non-Fluoridated Counties in Missouri38,40
| County and PWSD | Population | Est. Fluoridation Cost Per Person | Est. Cost of Fluoridation | Annual Person Cost Savings | Total Annual Savings |
|---|---|---|---|---|---|
| Bates PWSD 2 | 1,492 | $3.00 | $4,476 | $15.95 | $23,797 |
| Clay PWSD 3 & 8 | 5,930 | $2.00 | $11,860 | $17.48 | $103,656 |
| Jasper PWSD 1 & 2 | 8,080 | $2.00 | $16,160 | $17.48 | $141,238 |
| McDonald PWSD 1, 2, & 3 | 3,060 | $3.00 | $9,180 | $15.95 | $48,807 |
| Ray PWSD 2 | 8,222 | $2.00 | $16,444 | $17.48 | $143,721 |
Concerns Associated with Fluoride
Fluorosis
Fluoride is one of the most common elements on earth and its concentrations in the United States fluctuate from minimal to highly concentrated. Given the abundance of fluoride in the environment, drinking water should be monitored to prevent fluorosis and other health problems from occurring. Dental fluorosis is a change in the appearance of the tooth’s enamel, which can vary from barely noticeable white spots to staining and pitting in more severe forms. Dental fluorosis only occurs in younger children during the formative years and is the result of consuming too much fluoride over a long period of time.41 Furthermore, long-term ingestion of large amounts of fluoride can lead to potentially severe skeletal problems.42 There have been several sources of fluoride that have been attributed to fluorosis. These include overexposure to fluoride toothpaste, unregulated well water, infant formula and beverages produced with fluoridated water, food grown in soil containing fluoride or irrigated with fluoridated water, and cow’s milk from livestock raised on fluoride – containing water, feed, and soil.43
Fluoride Controversy
For decades there has been much controversy surrounding the addition of fluoride to community water. Those that oppose fluoridation believe it was inadequately studied and that the act of fluoridating water amounted to compulsory medication, thus violating civil liberties..44 Opponents have also suggested that fluoride has adverse effects on the brain, kidneys, reproductive system, and gastrointestinal tract.45 The fluoride controversy is still very active today, recently being fueled by the government’s new fluoride level guidelines. On January 7, 2011, the U.S. Department of Health and Human Services proposed that community water systems adjust fluoride amounts to 0.7 mg/L, down from 0.7 – 1.2 mg/L.46
Discussion
The prevalence of dental caries and lack of preventative care in Missouri is alarming. Missouri has made improvements in the implementation of preventative measures such as community water fluoridation, but nearly one million residents (20% of the population) receive public water that is not fluoridated. Non-fluoridated communities that receive public water should explore the cost effectiveness of implementing a water fluoridation program. An analysis on naturally occurring fluoride should be performed as well. If fluoride content is properly regulated, community water fluoridation can be a safe and effective way to prevent tooth decay. Missouri should also explore methods of increasing education related to preventative oral care, especially in school aged children. Oral health education could be increased through greater collaboration between oral health and medical providers. If primary care providers are informed of their patients’ oral health status, it could influence greater avocation of oral health prevention.
Research has shown a correlation between oral health conditions and systemic diseases. It has become evident that dental information is valuable to overall patient care, particularly for complex medical conditions such as diabetes or cardiovascular disease, where access to a patient’s dental information could assist early detection of chronic conditions.47 As health care becomes more accountable, it will become necessary for oral health and medical care providers to increase collaboration. The recent passage of the HITECH Act has promoted the adoption of Electronic Medical Records (EMRs) and their meaningful use. Absent from these incentives and integration models are the oral health providers. As we work towards increasing interoperability among providers and making patients the center of care, we must begin to eliminate the silos that exist between oral health and medical providers, allowing for a complete dissemination of health information.
Missouri is currently in the process of developing a Health Information Exchange (HIE), which is overseen by Missouri Health Connection. The HIE is intended to increase interoperability amongst providers and empower Missourians to take control of their own healthcare. The Missouri HIE project presents Missouri with an opportunity to examine methods to bridge the oral health - medical care gap. Missouri Health Connection should consider including oral health providers that are electronically capable in the program design and implementation to explore possible solutions. Missouri has a great opportunity to work towards a complete integrated health care model that supports wellness, quality of care, safety, and increased communication between medical and dental professionals. Missouri can be a leader in the integration of oral health, serving as a model to other organizations in the pursuit of a truly complete medical record.
Figure 2.
CDC data shows that Many adults also have untreated tooth decay—28% of those aged 35 to 44 years and 18.5% of those aged 65 years and older.
Biography
Joshua Hayes (top) works at Cerner Corporation in Kansas City. Christopher Wyatt, BHS, CNMT, (left) is the Director of Operations at Lee’s Hill Mary Washington Healthcare. R. Aaron Wiles, MHS, RDCS, RVT, (right) is the Manager of Outpatient Imaging Services for St. David’s Medical Center of Austin, Tx. All are University of Missouri Health Management and Informatics graduate students.
Contact: Jih927@googlemail.com
Footnotes
Disclosure
None reported.
References
References exceed space. Email lfleenor@msma.org for listing.