Oral health in North Carolina: innovations, opportunities, and challenges

Dental disease can have negative and lasting effects on overall health and quality of life. The Institute of Medicine of the National Academy of Sciences reported last year that close to 5 million children in the United States did not receive needed care in 2008 because of costs. Increasing use of dental care has been selected by the U.S. Department of Health and Human Services as one of a small number of national leading health indicators, designating it as a national priority. Innovative initiatives have been undertaken in North Carolina to promote oral health, and there have been improvements in the state. For example, both the use of dental services among children and their oral health status are improving. Yet persistent and difficult challenges remain, such as ensuring an adequate workforce for the future, improving oral health literacy, maintaining existing programs, and resolving disparities in oral health and lifetime access to preventive and treatment services for all North Carolinians. This issue brief reviews some oral health initiatives and their outcomes--with a focus on youth. Commentaries in the policy forum also focus on access to oral health care; assessing, educating, and building the dental workforce; new practice models and trends; insurance innovation; and patients with special needs.     

Disparities in children's oral health and access to dental care

Dental caries can be prevented by a combination of community, professional, and individual measures including water fluoridation, professionally applied topical fluorides and dental sealants, and use of fluoride toothpastes. Yet, tooth decay is the most common chronic disease of childhood. Dental care is the most prevalent unmet health need in US children with wide disparities existing in oral health and access to care. Only 1 in 5 children covered by Medicaid received preventive oral care for which they are eligible. Children from low income and minority families have poorer oral health outcomes, fewer dental visits, and fewer protective sealants. Water fluoridation is the most effective measure in preventing caries, but only 62% of water supplies are fluoridated, and lack of fluoridation may disproportionately affect poor and minority children. Childhood oral disease has significant medical and financial consequences that may not be appreciated because of the separation of medicine and dentistry. The infectious nature of dental caries, its early onset, and the potential of early interventions require an emphasis on preventive oral care in primary pediatric care to complement existing dental services. However, many pediatricians lack critical knowledge to promote oral health. We recommend financial incentives for prioritizing Medicaid Early and Periodic Screening, Diagnostic, and Treatment dental services; managed care accountability; integration of medical and dental professional training, clinical care, and research; and national leadership. JAMA. 2000;284:2625-2631.     

我国21世纪的口腔医学教育和口腔医疗服务

２１世纪社区口腔卫生保健在我国的需求将呈上升趋势。根据对国外高等口腔医学专业教育考察,作者认为,国外发达国家在口腔医学教育和口腔医疗服务上的经验值得借鉴,在此基础上建立适合我国国情的口腔医学教育和口腔医疗服务模式。我国的口腔医疗服务体系应向“牙科诊所－牙病防治所－口腔医院”等三级口腔专科医疗机构管理模式发展,口腔医学教育体系也应由单一的口腔医学专业,向口腔颌面外科专业、牙医学专业的口腔医学专业并存     

DENTAL CARIES AND PERIODONTAL DISORDERS IN CHRONIC LIVER DISEASE

Bacterial infections are frequent complications in patients with chronic liver disease (CLD). A potential source of infection may be dental foci. This study was carried out to assess the association of CLD with dental caries and periodontal disease. Dental caries and periodontal examinations were performed prospectively in patients with CLD (group A) and controls without any liver disease (group B). Similar examination was also carried out in alcoholics without liver disease (group C) as well as in cases with portal hypertension but no liver disease (group D) i.e. patients with Non Cirrhotic Portal Fibrosis and Extrahepatic portal obstruction. A total of 231 subjects (Group A:83, group B: 75, group C:46 and group D:27) were studied. Group A included 32 cases with chronic hepatitis B&C, 26 with alcoholic cirrhosis, 14 with postnecrotic cirrhosis, and 11 with cryptogenic cirrhosis. Measures of oral hygiene (p < 0.01), dental care (p < 0.001), and periodontal parameters were worse and the number of teeth requiring treatment (p < 0.05) was higher in alcoholics with or without cirrhosis than in healthy subjects and nonalcoholic patients with cirrhosis. Alcoholics had a lower, total number of teeth than patients without alcohol abuse and healthy controls (p < 0.01). The dental caries and periodontal status of patients with nonalcoholic cirrhosis did not differ significantly from group B. The severity and duration of liver disease had no influence on dental caries and periodontal disease. The presence of chronic alcohol abuse rather than cirrhosis or portal hypertension is a major predisposing factor for dental caries and periodontal diseases. In alcoholics, these diseases appear to be caused primarily by bad oral hygiene and poor dental care.KEY WORDS: Alcohol abuse, Chronic liver disease, Dental caries, Periodontal disease     

Factors influencing early diagnosis of cancer of the oral cavity

Factors associated with stage at time of diagnosis and with interval between recognition of the first symptom and histologic diagnosis were assessed in a consecutive series of patients with primary epithelial tumours of the oral cavity. Of the 160 patients 55% had stage I or II disease. The proportion was significantly higher among patients with a high socioeconomic status, those with low levels of alcohol consumption and those who regularly received dental care. The interval between recognition of the first symptom and diagnosis was not significantly related to these factors, but it was shorter for the men. These relations were specific to the patients with cancer of the oral cavity, not being seen in those with other head and neck tumours. Dental practitioners are an important source of early diagnosis of oral cavity cancers. The impact of the disease might thus be lessened by more regular dental care.     

大学生口腔卫生与患龋情况分析

目的探讨大学生口腔卫生与龋病发病情况,指导学生口腔保健。方法采用标准检查法,以DMFT评价患龋状况,同时对学生进行口腔卫生习惯、生活习惯及口腔保健知识问卷调查。结果1200名大学生患龋率为46．7％,龋、失、补指数（DMFT）为1．54,女生患龋率显著高于男生（P=0．037）。龋病发病率与日常生活习惯、口腔卫生情况、定期行口腔检查的观念有显著相关性（P〈0．01）。结论大学生口腔卫生保健知识较差,应加强大学生口腔卫生观念的健康教育,改变不良生活习惯,提高口腔保健意识。     

英国牙医学对中国口腔医学教育的比较与借鉴

口腔医学教育制度和口腔医师的培养模式对口腔医疗体系有重要影响,英国的牙医学教育经过多年的探索与发展,已经较为成熟,对中国的口腔医学教育有积极的借鉴意义。英国牙医学教育由英国牙科委员会（General Dental Council, GDC）统一规划和监管,形成了牙医学5年本科、2-3年硕士、3-5年博士的学历教育体系。毕业后职业教育以2年毕业后执业医师基础培训（Dental foundation training,DFT）为基础,包括3-5年二级学科专科培养和强调终身学习的继续教育培养。中英两国口腔医学／牙医学在院校教育和继续教育教学内容设计上有可比性,在住院医培训和专科医师的培训制度等方面,值得我国口腔医学教育所借鉴。     

Getting dental services to the rural 85 percent.

For the past 30 years the organization of government dental services in Papua New Guinea has been modelled on the School Dental Service in New Zealand. Although the two most important mouth diseases occur in adults, children have been given priority. The dental work has been done by a workforce of less than 200 dental officers and dental therapists. Dental services are invisible to the mass of Papua New Guineans. Such organization of dental services has been disastrous for the oral health of the rural population. The need is urgent to integrate dental services within the mainstream health services, doing as much as possible at the aid posts, and referring on to health centres only what cannot be done at the local level. Both the present cadre of 2250 orderlies in aid posts plus the planned new 4750 community health workers by the year 2000 need to be trained in basic dental skills. The 2400 aid posts need to be equipped with a kit of basic dental materials and instruments, costing about K250 each. Training in basic dental care can be done in six weeks, and should take place within the province, under conditions as close as possible to real life. The benefits of providing a basic dental service at aid posts are obvious--the population coverage will be much higher, the range of diseases that are preventable or controllable will increase, and many of the deaths that now occur from cancer of the mouth will be prevented or delayed.     

云南省口腔医疗服务能力调查

［摘要］目的　了解云南省口腔医疗服务能力及状况，包括云南省口腔医疗机构的分布、口腔卫生人力资源分布状况、人均门诊费用、患者就诊率等情况．方法　采用问卷调查的方式，对云南省口腔医疗机构进行调查研究．结果　云南省2011年有口腔医疗机构1 045家，其中公立机构416家．昆明市口腔医疗机构305家，每千平方米口腔机构为14.2，口腔卫生人力指数为15，患者就诊率为14.19%，口腔疾病支出为139.9元/人，以上指标昆明市均居各州市首位．结论　云南省口腔医疗资源分布严重不均，口腔医疗服务能力参差不齐，需建立完善的口腔疾病诊疗质量控制体系，培养专科护士缓解口腔医疗资源紧张现状，大力推行四手操作，有效提高医疗服务质量．     

Assuring access to dental care for low-income families in North Carolina. The NC Institute of Medicine Task Force Study

Following publication of the Task Force's recommendations for improving dental care access among low-income populations, North Carolina has taken several steps forward. The Division of Medical Assistance and the NC Dental Society are forming an advisory committee (comprising Medicaid patients, providers, and representatives from all elements of organized dentistry in the state) to review dental coverage and reimbursement rates. Using existing state funds, the NC Office of Research, Demonstrations and Rural Health Development has recruited 15 additional dentists and 1 dental hygienist to practice in community facilities serving low-income and uninsured patients. In 1999, the NC General Assembly revised the NC Dental Practice Act. Now, under the general direction of a licensed public health dentist, specially trained public health dental hygienists can perform oral health screenings and preventive and educational services outside the public school setting. The NC Institute of Medicine has begun exploring how to use dental hygienists to expand preventive dental services to underserved populations in federally-funded community or migrant health centers, state-funded health clinics, and the not-for-profit clinics that serve predominantly Medicaid, low-income or uninsured populations. A report is to be sent to the Governor and the Joint Legislative Commission on Governmental Operations no later than May 1, 2000. In 1999, the General Assembly directed the NC State Board of Dental Examiners to establish a procedure for streamlined licensing of dentists and dental hygienists who have been practicing in other states. This should increase the number of qualified dental practitioners in the state. The proposed rules governing the new licensing pathway are to be prepared by May 15, 2000. The Board of Dental Examiners will determine which new procedures will be needed to allow less burdensome and more timely entry of qualified out-of-state licensed applicants, while still affording the public the same protection as under current law and procedures. The NC Institute of Medicine is organizing a work group to study the feasibility of new residency programs in pediatric dentistry in addition to the current program located in Chapel Hill. The Institute will present a report to the General Assembly, no later than May 1, 2000. On April 1, 1999, the state Medicaid program authorized use of ADA Procedure Code 1203, which allows reimbursement for the application of dental fluoride varnishes without a full prophylaxis. It also authorized pediatricians, nurse practitioners, or physician's assistants to apply these varnishes to the teeth of young children, allowing more rapid dissemination of this proven preventive procedure among the state's low-income children. Implementation began in Carolina Access II and III project sites in the fall, 1999, and should spread statewide in 2000. Furthermore, the General Assembly's 1999 session expanded NC Health Choice to cover dental sealants, fluoride treatment, simple extractions, stainless steel crowns, and pulpotomies. Since publication of the Task Force Report in May 1999, considerable forward movement has taken place. It was apparent that the problems associated with poor dental care were severe, of immediate concern, and needed a broad, nonpolitical analysis followed by action from public and private-sector policy makers and shapers. The key recommendation of the Task Force (to increase the level of payment to dentists for services provided to Medicaid beneficiaries) was not acted on in the 1999 session of the General Assembly, but it was seriously discussed in legislative hearings and will be considered further in the year 2000 legislative session. Given the number of problems surrounding adequate health care for North Carolina's low-income populations, inquiries such as that described here can point the way to the concrete and feasible steps that need to be taken. (ABSTRACT TRUNCATED)     

养老机构内老人牙科焦虑症流行病学调查

[目的]调查养老机构内老人牙科焦虑症(DA)的流行情况。[方法]采用改良的牙科焦虑量表(MDAS)对养老机构140位老人的DA发生情况进行问卷调查和统计分析。[结果]养老机构内老人MDAS平均得分为(6.80±3.28)分;DA发生率为7.86%;MDAS得分在不同文化程度、对疼痛的不同耐受程度以及不同的看牙经历间有显著性差异;对MDAS得分的影响因素前5项为:疼痛的耐受程度、年龄、当天精神状态、文化程度、性格,其中疼痛的耐受程度有非常显著性影响(P=0.001)。[结论]养老机构内老人DA发生率较低,疼痛的耐受程度和年龄对DA的发生有显著性影响。     

Health care needs of the homeless of O'ahu

An interview study of 162 homeless individuals on O'ahu demonstrated that the homeless studied were 3 times more likely than the general population of O'ahu to rate their health as fair to poor, despite the fact that 77% of interviewees had medical insurance and 66% a regular health care provider Better self ratings of health were only associated with younger age and self report of having dental insurance when demographic variables were controlled for. Qualitatively the homeless population interviewed described 'good health' as avoiding illness and being able to make healthy lifestyle choices, finding emotional balance and caring for others. Commonly reported barriers to accessing care included financial factors such as being unable to purchase medications; environmental challenges such as clean drinking water and a safe place to stay; and general discomfort with the health care system. Clinical implications of this study indicate the need for providers caring for the homeless be alert to challenges particular to the homeless, such as barriers to following medical advice (high fiber/low salt diet, exercise, refrigerating medications, etc.). The surprising relationship between knowledge of having dental insurance and better self ratings of health deserves additional research, as does the lack of association between health ratings and having health insurance and a regular provider.     

The Kilkenny integrated Oral Health Project

The Kilkenny Health Project, started in 1985, aims to reduce the level of risk factors in the community for coronary heart disease through health promotion. Dental disease and coronary heart disease share risk factors of tobacco use, alcohol consumption and poor dietary patterns. A baseline oral health survey demonstrated significant levels of dental disease in Kilkenny in the 429 adults and 523 children who were examined there in 1987. Seventy one per cent of adults required treatment for periodontal disease and 49% of children surveyed required treatment for dental decay. The Kilkenny Oral Health Project was developed as a community participation project aiming to reduce the level of common risk factors in the community for coronary heart disease and dental disease. It has run parallel with the main Kilkenny Health Project and is one of the first health promotion projects which has an integrated health message preventing dental disease and coronary heart disease.     

多层螺旋CT Dental成像技术在磨牙区牙种植术前设计中的临床应用

目的 探讨多层螺旋CT（MSCT）Dental成像技术在磨牙区牙种植术中的临床应用价值。方法 对27例磨牙区部分缺失牙患者行多层螺旋CT薄层容积扫描，重建出二维图像后导入工作站，通过专用Dental软件包及3D重建技术进行图像后处理。结果 应用Dental软件及3D重建技术可以获得拟种植区颌骨的全景形态，局部牙槽骨的高度、宽度、骨质密度及牙槽骨与下颌管及上颌窦的关系，牙列的空间关系等。结论 多层螺旋CT Dental成像技术是磨牙区牙种植术前设计和评估的有效工具。     

砷氟联合中毒和单纯氟中毒患者的口腔疾病情况

本文报道了奎屯地区60例砷氟中毒患者及111例单纯氟中毒患者的口腔疾病情况。单纯氟中毒患者中龋齿和牙周病患病率较低,而氟牙症的患病率较高。氟牙症和龋齿的病情呈反比关系。砷氟联合中毒患者中龋齿和牙周病的患病率较高,而氟牙症的患病率较低。     

Experiences in the implementation of a national policy: A retrospective analysis of the Australian Chronic Dental Disease Scheme

Background

The Chronic Dental Disease Scheme (CDSS) is the first public dental policy in Australia to attract Medicare benefits for dental services.

Aims

This study examines the utilisation of a new federal method of funding dental care in Australia and provides an insight into the implications of government dental programs. The program titled; Chronic Dental Disease Scheme, provided government-subsidised dental care for people suffering from a chronic medical condition.

Method

A retrospective analysis of activity data using the relevant item numbers were extracted from the open source Medicare Benefits Schedule database (MBS) for years 2007-2009.

Results

During the study period, a total of approximately five million dental services were provided. There was a disproportionate use of services between jurisdictions. The highest proportion (66%) of services was provided in the state of New South Wales (NSW) with Victoria second (22%). The adjusted value of care provided as a proportion of comprehensive examinations ranged from $1937 in the northern territory (NT) to $2900 in NSW. The value of care per dentist ranged from nearly $80 000 down to less than $1000 and the value of care per adult of the population ranged between $53 and $1 across Australia. The highest was always in NSW and the lowest always being the NT. Fixed prosthodontics (reconstruction) accounted for the significant costs associated with the program.

Conclusion

The scheme has been utilised above its budget estimate with prosthodontics accounting for the majority of expenses. Treatment plans differed between jurisdictions. The increase in utilisation of the scheme was coincident with periods of increased in subsidy and remuneration and has been postulated to be a main driver for its utilisation rather than the improvement in chronic health.     

海军某部特勤人员龋病流行病学调查

目的了解海军特勤人员龋病流行病学情况。方法自行设计调查表,调查对象为海军某部400名特勤人员,均为男性,年龄19-47岁,平均25.43±5.31岁。调查人员均为口腔科专科医师,采用现场调查的方式对每位参检对象进行口腔检查。结果患龋人数为161人,患龋率（DMF）40.3%,龋失补数（DMFT）237颗,龋均（DMFT）0.91,需治疗的龋齿数占龋补总数（DF）的68.3%。结论海军特勤人员口腔健康状况不容乐观,需要改善口腔医疗条件、加强口腔疾病预防工作、尽快建立口腔疾病防治程序。     

口腔医疗行为中的核心伦理准则

牙科伦理行为是促进口腔健康服务与提高口腔职业意识的重要因素。通过分析北美牙科医师和口腔卫生师的伦理行为准则的基础上，结合国内现状，首次提出了尊重病人自主性、严守病人私密、秉持社会诚信、不伤害病人、让病人受益、公正对待病人、实事求是、忠诚于病人、家长式关爱病人和以最大效用平衡行为等口腔医疗行为中的10个核心伦理准则。这对于推动我国口腔伦理道德标准的规范化管理具有积极促进作用。     

牙髓干细胞多向分化能力的研究进展

文中从牙髓干细胞(dental pulp stem cells,DPSC)多向分化潜力、研究进展及应用方面进行探讨,综合分析了DPSC多向分化能力的研究进展。DPSC可向三胚层细胞分化,例如向成牙本质细胞、软骨细胞等细胞分化,这将有助于DPSC的鉴定、牙齿再生、牙体牙髓疾病及其他疾病的治疗。     

多排螺旋CT全景齿科成像技术的临床价值探讨

目的探讨多排螺旋CT（MSCT）全景齿科成像技术的临床应用价值。方法对38例患者的牙齿、颌骨部位的容积数据进行后处理,重建出全景齿科图像和牙槽骨的矢状面和冠状曲面图像,与原始图像结合,对牙科疾病进行分析。结果行MSCT检查的38例口腔疾病患者中,均能全方位立体再现齿科全貌：包括牙冠、牙体、牙根、牙髓腔的局部细节以及牙齿排列及咬合关系,可以从多个角度完整地显示了单个牙体的表面形态、各牙所在的位置、倾斜角度以及各牙之间的距离、牙列的整体形态和牙根的走行方向。结论多排螺旋CT全景齿科成像可对牙、颌骨内微小病变的诊断治疗提供重要的客观依据,为牙科疾病提供了一种新的先进的检查手段及诊断方法。