Oregon Ranks at the Bottom in Oral Health

Dr. Bruce Austin, 10 months into his job as Oregon’s first state dental director, says poor oral health is Oregon’s “hidden epidemic,” leading to worse overall health especially in children; he advocates statewide fluoridation among other solutions.

According to a 2012 Oregon Smile Survey taken at 82 schools statewide, 17,000 Oregon kids between ages six and nine – about 13 percent -- have seven cavities or more with rampant decay including rows of black bumps for teeth. Three percent of that age group – some 3,800 Oregon children -- are in pain needing urgent care.

Dental issues are the most common health problem for Oregon children, Austin said -- four times more common than asthma in teens. Dental infections can lead to blood or even brain infections.

Yet in 2013, Oregon ranked last out of 50 states for getting kids at least one preventive dental visit during the year.

Children rely on emergency rooms when pain becomes unbearable, a “costly option and dental problems aren’t solved in the emergency room,” Austin said. At best, ERs can give antibiotics and painkillers without addressing the cause of the pain.

A metric for dental sealants was incorporated into the Coordinated Care Organizations earlier this year. But that school-based program, while effective at reducing decay, costs an average of $40 per child with costs rising to $138 per child when dental teams must travel long distances to schools.

The Oregon Community Foundation has a $3 million, five-year initiative with other funders to provide grants to nonprofits to put dental coordinators in 15 counties. Counties, schools, CCOs, dental providers and others coordinate to give care and kits. “A lot of these kids don’t even have their own toothbrushes,” said Melissa Freeman, director of strategic projects.

Freeman is the first to acknowledge the initiative’s limitations. No coordinators serve the far southeastern Oregon counties where the 2012 Smile Survey showed 73 percent of first- through third-graders had a cavity compared with about half the kids in that age group in the rest of the state. The program received no applications from Harney, Malheur or Baker counties although her foundation is talking to the Eastern Oregon CCO to remedy that in later funding rounds.

“We’re entering new territory here,’ said Dr. Joe Robertson, president of Oregon Health & Science & University. “We haven’t’ seen other philanthropic efforts intertwined with CCOs.”

Oregon Health Authority Director Lynne Saxton countered that she’s “excited to be entering new territory” with an independent philanthropic organization that sees a problem and tries to solve it. Saxton also applauded the foundation for supporting water fluoridation to fight dental disease in the failed 2014 Portland fluoridation ballot measure campaign.

Oregon ranks 48th out of 50 states in optimally fluoridated public water systems. For every $1 spent on water fluoridation, an average of $38 is saved on dental treatment costs per person per year, Austin said.

Oregon’s State Health Improvement Plan calls for nearly 80 percent of Oregon’s communities to have optimally fluoridated water, which will require Oregon to join 15 states with statewide fluoridation laws.

“[Community water fluoridation] is the most cost-effective and equitable way to reduce decay across the population and lifespan regardless of geography, income, race and ethnicity,” Austin said.

Jan can be reached at [email protected] 

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There is a lot we can do in Oregon to improve oral health, but the title “Oregon Ranks at the Bottom in Oral Health” is inaccurate and misleading at best.

While it is true that the percentage of water fluoridation in Oregon is lower than the national average, according to CDC data for 1st-3rd graders, Oregon’s cavity rates are about equal to the national average of 52-53%.

Data tells us that children of color, children of low income, and children that speak English as a second language are at the most risk for dental caries and for not having access to a dental provider. And while this data reflects the trend across the nation, policy can be implemented to better serve these at-risk populations without increasing adverse health risks due to adding fluoridation chemicals to our water supply.

Recently I participated in a Portland City Club study investigating alternatives to water fluoridation. This study has data regarding Oregon’s oral health, references, and recommendations for the state at various levels to improve oral health outcomes at local, county, and state levels. http://www.pdxcityclub.org/Files/Reports/Children%27s%20Dental%20Health%20Task%20Force%20report.pdf

Water fluoridation policy is not equitable. Water fluoridation places the very children we are trying to help at increased risk.  According to the CDC, children of color are 2-3 times more at risk than white children for all forms of dental fluorosis, including mild, moderate and severe. Fluorosis is the first visible sign of over exposure to systemic sources of fluoride. Water fluoridation is one source of this over exposure.  The Department of Health and Human Services recently reduced its recommended concentration of fluoride in water by 40% due to concerns about fluorosis.

While some will say that fluorosis is only cosmetic, it is the first visible sign of over- exposure to fluoride. Fluorosis reduces the enamel integrity of the teeth, allowing them to be more porous and at more risk for decay.

In addition, the CDC has issued a warning for use of fluoridated water with infant formula due to risk of fluorosis. Breastfeeding data indicates families of color and families of low income use infant formula at a higher percentage, further making this policy not equitable.  If we as policy makers support water fluoridation, we must also support alternative water sources for formula, which is not only fiscally expensive but also time intensive to educate our citizens of such risk.

There are methods for fluoride delivery that are more effective and safer than adding fluoridation chemicals to water that allow for personal choice. For example, fluoride varnish is a topical application of fluoride and is much more effective than water fluoridation at preventing cavities. Fluoride varnish is 43% effective. It is also a cost effective policy, as each application is $12-$13. It is a CDC and U. S. Preventive Task Force best practice recommendation, and yet it is not available to all children in our state.

Fluoride varnish as a state-wide policy could easily be administered in a school- based or daycare setting. In addition, it would be possible following the successful model of First Tooth training and certification that additional mid-level providers could be trained to apply fluoride varnish and to make referrals to a dental provider as indicated.

Clean Water Oregon was proud to collaborate with state legislators, Portland City Club, NWHF, and other community based organizations to pass dental health policy in the 2015 legislative session that truly improves oral health in our community. HB 2024, passed under the leadership of Rep. Keny-Guyer, is one example of such a bill.

When you look across the nation at cities that have implemented water fluoridation, children of color, children of low income, and children who speak English as a second language continue to have elevated rates of cavities and lack of access to a dental provider. We can and we should do better in Oregon.

It is time to work collaboratively to improve oral health in our state with policy that is effective and has a high return of investment.  We can all agree that we desire improved oral health, and collaboratively we can achieve this goal.  Water fluoridation does not achieve this goal. However, improving access to dental providers, including those that accept Medicaid, and implementing fluoride varnish when indicated, would be a positive first step in the direction of improved oral health for all of our citizens. 

Kellie Barnes

Kellie Barnes points correctly to elements of Oregon's dental care system that need improving.  No reasonable person thinks that fluoridation is the only important element with respect to oral health and cavity prevention.   But to argue that because other things can and should be done means fluoridation is unnecessary is profoundly mistaken.

Her City Club report failed completely to attend to other than children's oral health.   No proposal at all was made as an alternative to the protection elders enjoy for cavities on expose root surfaces.  No real public health data exists which shows that there are any affordable public health interventions which can replace or avoid community water fluoridation. . My challenge is for her to supply references . .there aren't any.

She is profoundly mistaken with respect to fluorosis.

Firstly fluoridation is simply not the cause of moderate or severe fluorosis.  These problems happen in non-fluoridated communities.  Children who use too  much fluoridated toothpaste are the ones with moderate and severe fluorosis.  The recent consolidation from a target range to a single value of 0.7 ppm was specifically created to ensure that fluoridation is not causing severe and moderate fluorosis.

It is also important to remember that tooth fluorosis is positively beneficial.   The caries protection of fluorosis in a 1st molar is equal to placing and maintaining 1-3 sealants - see Iida and Kumar (2009).   

Further, fluorosis has NO negative impact on the quality of life while cavities have a huge negative effect. . . see Do (2007), Onoriobe et al (2014) and Chankanka et al (2010).   Shall I repeat that . . . .the type of fluorosis from fluoridation causes no harm; cavities cause big time harms

Billy Budd