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Profile in Oral Health Prada or Prevention: A Look at Public Health and Oral Health by Rhoda P. Kublickis, RDH, MHSc

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by Rhoda P. Kublickis, RDH, MHS

Even though patients might choose to spend money on a Prada purse rather than investing on maintenance of their children's oral health, it makes you wonder if they really understand that making a choice in favor of preventive services provided by a dental hygienist has the potential to last a lifetime. Parents need to be aware of the consequences of keeping the deciduous teeth in the mouth, therefore allowing for guidance of permanent teeth into the correct position. If permanent teeth are clean and healthy, it usually results in healthy bone around teeth, allowing teeth to be kept for a lifetime. Effective prevention services last longer and are more valuable than any Prada purse!

This message was lost with my grandmother who grew up in the Philippines. It was too late for prevention when my mother had a toothache and the dentist gave two choices: fill the tooth for $4 or extract the tooth for $4. My grandmother's logic was to extract the tooth, as then it would no longer be in the mouth to cause pain. Filling the tooth left it in the mouth and perhaps it would decay again and cause more pain and more expense. By the age of 17, my mother had no maxillary teeth and wore a denture. Her mother thought she has made the right decision for her daughter. It was my mother who broke the cycle of extractions and ignorance about dental health in our family. As a child, I remember her brushing her upper denture and telling us stories of how poor her family was, so poor that my grandmother could not properly pay for dentistry until my mother was in such pain that she had no choice but to extract the tooth.

I was nine when my family moved to the U.S. from the Philippines. Every six months my siblings and I would go to our dentist and hygienist for our bi-annual check-ups. My sister and I always had several carious lesions. I did not realize at the time that it was not just home care, but other multi-factorial issues that contributed to our dental demise.

In the pursuit of saving my teeth and avoiding the dreaded denture my mother had, I completed my college education in the field of dental hygiene, becoming licensed in 1983. I worked toward my master's degree in a program that challenged me and helped me find my passion for public awareness of dental hygiene as the oral health profession. Just thinking about dental decay, brought up many questions to ponder: Why should enamel, the hardest substance in the body simply breakdown? Why should a person need to have the hardest surface in the whole body drilled open to place a filling? Why should a patient have a nerve removed from a live tooth? Why should teeth be extracted? Why should a patient die because of a dental abscess? These questions puzzled me since dental disease is preventable. A more haunting question is why don't people know that dental disease is preventable? Why do they believe caries and periodontal disease are inevitable? Why is the preventive message of the dental profession falling on deaf ears?

During this soul-searching time, I was working for a dentist in Fort Lauderdale. This luxurious and upscale dental practice faced the Intracoastal Waterway. It was not uncommon to have families put off regular dental hygiene visits with the excuse they were too expensive. One family in particular had six children and by the time all of them had radiographs, prophylaxis and fluoride, it cost the parents the equivalent of an expensive Prada purse! Strangely enough, some people would rather buy the Prada purse than purchase preventive dental care. It was puzzling to me that my own mother had a matching purse for every pair of shoes she owned, but in her family growing up, there wasn't enough money for preventive care. Why is more value placed on discretionary purchases than on oral health care?

Remarkably, even those with free dental care choose to have the best shoes and electronic games for their children rather than pay for preventive services to ensure good oral health. This interest in prevention provided the foundation for my master's degree research project. At the request of my adviser, Dr. Inge Ford, I gathered emergency room data on dental visits in Martin County, Florida. According to the 2010 Martin County Community Health Assessment, the most difficult health service to obtain was dental care. A majority of the respondents, 69 percent, received routine physicals whereas only half received routine dental exams. Quiñonez (2011) noted that lower and middle income groups were the populations who reported to the emergency room for dental emergencies. The lower and middle income groups earned too much for public support and worked in jobs that did not offer dental insurance as part of the benefits package. This combination of circumstances led them to the emergency room for care rather than paying for regular dental visits. No value was placed on preventive services.

According to the Martin County Health Assessment, in 2010 there were 243 dentists serving 139,794 people and 9.3 percent were enrolled in Medicaid. However, of those 243 dentists, only two took Medicare for children up to 21 years of age and only two clinics perform free services for adults with Medicare. With such limited number of dentists providing services for those 22 to 61 years old, many end up in emergency rooms for routine treatment of dental disease as well as treatment of painful dental abscesses. Providing dental care for those with acute disease addresses the immediate need for treatment, but it doesn't address the need for more valuable prevention information. With oral health education, these people could avoid the damage done by caries and periodontal disease and the need for expensive dental treatment.

There are many preventive oral health programs now available to educate parents or caregivers of young children, so why don't people value oral health? Why don't they know dental disease is preventable? The information is out there and has been for many years, but the message isn't getting through with our current educational programs. People would still prefer to buy a purse than spend money on prevention because they do not see the value of good oral health.

If people realize that dental disease is preventable and that parents are the source of Strep mutans in their children's mouths, values might change. Right now, people don't believe they have any part in the oral health of their children. They believe dental disease is inevitable. They have experienced tooth decay and they fully expect their children to have tooth decay. The concept of preventing tooth decay is as foreign to parents today as it was to my grandmother years ago. Despite the dental profession's efforts to educate people about the dangers of sugar, the importance of good nutrition and the value of regular dental visits and daily oral hygiene, many still believe dental disease is inevitable and only seek dental care in emergency rooms when the disease has progressed to severe pain.

From my own family experience, the message of the contagiousness of dental caries was missed. Babies "catch" tooth decay from their parents and caregivers, from whoever shares saliva with them. Strep mutans are transmitted via saliva through kissing, sharing eating utensils and sharing food. Numerous studies have reported similar Strep mutan genotypes among mother, father and children and suggest vertical transmission from parent to child and horizontal transmission between siblings sharing utensils, straws, glasses and kissing. In Domejéan's study of unrelated kindergarten children, the risk of caries transmission was found to be relatively low in one out of six children due to less contact time amongst each other (2010). My mother's Strep mutan colonizations and subsequent dental disease was very likely due to my grandmother's generous sharing of her saliva. She just didn't know she was also sharing Strep mutans that would be responsible for future tooth decay.

According to research done by Caufield et al. in 1993, if a child can avoid exposure to Strep mutans during their first two years, they have a better chance of establishing a healthy oral flora rather than one conducive to caries. The best way to do this is by changing the mother's oral flora so mom shares a healthy oral flora with her baby. Early childhood caries is known to strike before the age of two, so waiting until the child is two or three for their first dental visit may be too late. They might already need extensive restorative work. The first dental visit for the child should be during pregnancy to make sure the mother has good oral health and low Strep mutan levels.

Several research studies have demonstrated the value of mothers chewing xylitol-sweetened gum three to five times daily to reduce their Strep mutan levels and consequently, reduce the chance for colonization in the baby's mouth by fivefold (Soderling 2006, Naki 2010). Intervening early is the best hope of stopping the caries process that if left unchecked will result in tooth decay, expensive restorative work and many extractions. In the case of my mother, it led to full arch extractions and a denture at the age of 17. Backing up to the point before the Strep mutans colonize the mouth and the first carious lesions occur is true primary prevention. Waiting to address the problem when dental decay has ravaged the mouth and expensive and extensive work is needed is too late. Early intervention is the key. Had my grandmother thought about the end result for my mother when her deciduous teeth first erupted, perhaps my mother could have had healthy teeth today rather than the denture she has now. The price of early prevention over a lifetime is worth much more than a purse.

References
  1. Cohen, L., Bonito, A., Akin, D., Manski, R., Macek, M., Edwards, R., & Cornelius, L. (2008, Sept). Toothache pain: a comparison of visits to physicians, emergency departments and dentists. Journal of American Dental Association (JADA), 139(9): 1205-16. Retrieved from http://jada.ada.org/content/139/9/1205.full
  2. Caufield, P., Cutter, G., Dasanayake, A. (1993). Initial acquisition of mutans streptococci by infants: evidence for a descrete window of infectivity. J Dent Res 72(1):37-45.
  3. Ford, personal communication, September, 2010
  4. Nakai, Y., Shinga-Ishihara, C., Kaji, M. et al (2010). Xylitol gum and maternal transmission of mutans streptococci. J Dent Res 89(1):56-60
  5. Quiñonez, C. (2009). Self-reported emergency room visits for dental problems. International Journal of Dental Hygiene 9(1): 17–20. DOI: 10.1111/j.1601-5037.2009.00416.
  6. S öderling E. (2009). Xylitol reduces mother-child transmission of mutans streptococci. Finnish Dent J Supplement 1/2006:8-11.
Author's Bio
Rhoda Kublickis was born in the Philippines. She received AS in Dental Hygiene from Fairleigh Dickinson University and her BASDH from St. Petersburg College. She is received High Honors for her MHSc at Nova Southeastern University. She is active in her component, Vice-President for the Florida Dental Hygiene Association, and Atlantic Coast delegate for ADHA. This year she was recipient of the leadership workshop with ADHA's Unleashing Your Potential in Chicago. One day a week she practices dental hygiene in a general practice in Fort Lauderdale. She is the Southeast Coast Regional Xylitol Educator for Wasatch Sales Force, the leading manufacturer of xylitol dental defense products. She also is trained in mass disaster and assists forensic odontologists in identifying deceased in three counties. Since 1987 she has been married to Alex and together they have raised three sons, Steven, Jordan and Ty.
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