Inequity in Children’s Oral Health
As a pediatric anesthesiologist, my clinical experiences place me in a unique position to inform research and interventions on surgical patients. Through my clinical observations, I became interested in understanding the factors that contribute to poor oral health outcomes for pediatric patients. Childhood caries is a largely preventable disease process and use of operating rooms and associated resources can be an expensive, inefficient use of scarce resources. My work outlines the limitations of health systems (e.g. emergency departments) and policies (access to preventive dental care or community water fluoridation) to improve a population’s oral health status. Pediatric dental surgeries represent great financial burden to Medicaid programs, with estimates for surgical procedures in hospitals and ambulatory surgery centers alone to be approximately $450 million per year.
My research focuses on the intersection of medicine and dentistry to assess inequities in the following areas:
- Developing and Testing Interventions to Change Oral Health Outcomes in High-Risk Children
I have been working closely with Dr. Molly Martin (PI) as a co-investigator on a randomized clinical intervention trial, COordinated Oral health Promotion (CO-OP) Chicago (https://co-opchicago.ihrp.uic.edu/who-we-are/). COordinated Oral health Promotion (CO-OP) Chicago was one of nine studies in the Oral Health Disparities and Inequities Research Consortium, and one of four studies selected to test oral health interventions. The Consortium, funded by the National Institute of Dental and Craniofacial Research Consortium, aims to reduce inequities in access to care and oral health disparities of U.S. children. Consortium studies are supported by a single data coordinating center.
CO-OP Chicago brings together a team of clinical pediatricians and dentists, researchers, health psychologists, and policy experts to rigorously test the ability of an oral health promotion intervention to improve child and family oral health. The primary intervention is family-focused education and support from community health workers (CHWs). The trial is registered on ClinicalTrials.gov.
COVID-19 Supplement [NIDCR UH3DE05483-05S1]
We received additional support to study the impact of COVID-19 on oral health. COVID-19 brought new changes to household dynamics and unforeseen stressors to families already experiencing oral health disparities. The medical clinics and social service agencies that service these families were also majorly affected. This supplement aimed to determine specific intervention needs regarding dental care access, oral health behaviors, nutrition, and mental health for CO-OP Chicago families and communities following COVID-19.
CO-OP Chicago Cohort Study [NIDCR U01DE030067]
The CO-OP Chicago Cohort Study transitions trial participants and newly enrolled families into a longitudinal cohort to determine predictors of oral health behaviors and caries risk in low-income, urban young children over time.
Links to Representative Work
- Martin MA, Lee HH, Landa J, Minier M, Avenetti D, Sandoval A.Formative research implications on design of a randomized controlled trial for oral health promotion in children. Pilot Feasibility Stud. 2018;4:155. doi: 10.1186/s40814-018-0344-y. eCollection 2018. PubMed PMID: 30305918; PubMed Central PMCID: PMC6171134.
- Martin M, Rosales G, Sandoval A, Lee H, Pugach O, Avenetti D, Alvarez G, Diaz A.What really happens in the home: a comparison of parent-reported and observed tooth brushing behaviors for young children. BMC Oral Health. 2019 Feb 21;19(1):35. doi: 10.1186/s12903-019-0725-5. PubMed PMID: 30791896; PubMed Central PMCID: PMC6385429.
- Parental stress, parenting style, and caregiver support are critical factors in predicting children’s brushing
behaviors. In collaboration with a multi-disciplinary team, I conducted key informant interviews of parents while their child was under general anesthesia for dental surgery. Caregivers reported that their ability to change oral health behaviors (dietary choices, tooth brushing) was influenced by family dynamics, including conflict related to parenting styles. Caregivers reported great motivation, perhaps informed by reported guilt and parental accountability, to change oral health behaviors at the time of surgery and improve their child’s long-term oral health. However, the ability to maintain change appeared variable, partially due to gaps in oral health knowledge, parenting style, and sense of dental and parenting self-efficacy.
- Lee HH, LeHew C, Avenetti D, Buscemi J, Koerber A. Understanding Oral Health Behaviors Among Children Treated for Caries Under General Anesthesia. J Dent Children. 2019 86(2): 3-10.
- Avenetti DA, Lee HH, Rosales G, Sandoval A, Gonzalez G, Pugach O, Berecki J, Martin M. Brushing Behaviors and Fluoridated Toothpaste Use in an Urban Pediatric Dental Population: A Pilot Study. J Dent Child 2020;87(1):30-7.
- Lee HH, Ochoa N, Moragne-O’Neal N, Rosales GF, Pugach O, Shadamoro A, Martin MA. Can an Instrument Validated to Assess Parent-Child Interactions in the Laboratory Setting Be Applied to Home-Based Observations?.Front Pediatr. 2020;8:550922. doi: 10.3389/fped.2020.550922. eCollection 2020. PubMed PMID: 33520881; PubMed Central PMCID: PMC7845142.
- Pediatric Dental Sedation Safety: Risk Factors and Ethical Implications. Patient safety is an important clinical outcome of caries treatment under anesthesia, yet identifying prevalence, etiologies, and effective interventions is stymied by a lack of publicly available data. An analysis of 30 years of media reports concerning deaths occurring in the context of pediatric dental sedation or general anesthesia yielded informative trends related to the types of anesthesia provider, facility, and patients who were predominantly represented. This manuscript led to an important commentary on what adverse events really represent, from the perspectives of anesthesiology, health systems, dentistry, and bioethics. I followed up with an OpEd in the SF Chronicle to point to the opportunities to improve safety by decreasing the variability in state dental sedation licenses.
- Lee HH, Milgrom P, Huebner C, Weinstein P, Blacksher E, Burke W, Lantos J. Ethics Rounds: Death After Pediatric Dental Anesthesia: An Avoidable Tragedy? Pediatrics. 2017 Dec;140(6) e20172370. DOI:10.1542/peds.2017-2370. PMID: 29114060.
- Lee HH, Milgrom P, Starks H, Burke W. Trends in Deaths Associated with Pediatric Dental Sedation and General Anesthesia. Pediatric Anesthesia. 2013 Aug;23(8):741-6. PMCID: PMC3712625.
- San Francisco Chronicle OpEd. January 3, 2022 – California Doesn’t Ensure The Safe Use Of Sedation On Kids At The Dentist…
- Emergency department (ED) visits represent the intersection of inadequate access to timely, appropriate dental care and tertiary medicine. A body of my work has focused on emergency department (ED) utilization for a toothache. An initial study reported an increasing trend in ED visits for toothache over time, which was not reflected in ED visits for asthma exacerbation. Because toothaches and asthma exacerbations may reflect inadequate access to preventive care, increasing ED visits for toothache in the context of stable asthma exacerbations visits suggest a considerable gap in the dental delivery system. Subsequent studies showed racial/ethnic disparities on how toothache pain is treated in the ED and the vulnerability in access to dental care amongst young adults.
- Lee HH, Lewis CW, Saltzman B, Starks H. Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008. Am J Public Health. 2012 Nov;102(11):e77-83. PMCID: PMC3477981.
- Lewis CW, McKinney C, Lee H, Melbye M. Emergency Department Visits for Toothache in 20 to 29 Year-olds. J Am Dent Assoc. 2015:146(5): 295-302. PMCID: PMC4418214.
- Lee HH, Lewis CW, McKinney C. Disparities in Emergency Department Pain Treatment for Toothache, JDR Clinical & Translational Research, October 2016 vol.1 no.3: 226-233. PMCID: PMC5576301
- Determining Factors that Influence Utilization of Services Within the Pediatric Dental Surgical Population
It isn’t clear what drives utilization of dental general anesthesia. I led several studies to elucidate factors that may influence population level utilization of dental surgery amongst Medicaid enrolled children. There is wild state to state variation in dental surgery utilization. Utilization trends did not correlate to factors that we typically think of as predictive drivers of health care services (e.g., provider reimbursement, availability of facilities, markers for access and disease severity), which we think may represent opportunities for improvement in quality of care and possible unmet needs. Access to preventive dental care has been variable in its impact on utilization of tertiary oral health services. Employing a quasi-experimental observational study (difference-in-differences model) to look for the impact of increased preventive dental care on tertiary oral health services (emergency department visits, sedation visits, and surgical visits), we did not find that increased access to preventive dental care translated into lower dental surgical rates. Finally, I led a study to access if community water fluoridation, an established public health intervention to reduce caries, was associated with lower population-level utilization of dental surgeries. The absence of an association has led me to focus on factors at the level of the household, specifically oral health behaviors, in order to change oral health outcomes for the surgical population.