smilegeneration

Challenges in Adolescent Oral Health: Teen Toothache Sucks!

Mon, 13 Sep 2010 00:05:00 -0400

A newborn’s smile is perhaps one of the greatest gifts to humankind. The ability to smile is often magically rediscovered by grownup’s upon witnessing an infant’s smile. This innocence and pure sense of joy and carefree love associated with such a seemingly simple facial expression is one of the grandest gifts we are born with. It is a gift universally recognized and cherished by all cultures with no need for translation, and one that we long for preservation for the rest of our lives. Rumi and Sufi philosophy credit the attraction we all experience to a child’s smile for its wealth of free love. It is thought that the occasional elder who’s face we are drawn to has managed to somehow keep that magical essence of love and innocence despite the cruelties of everyday life. On my daily commute from Brooklyn’s DUMBO to Manhattan’s Upper East Side, I often find myself reading the many faces surrounding me, from those inches away to those across the platform. It is amazing to realize that we have all been there once, as a child, an infant smiling carelessly sharing our most wonderful gift with those around us. I consider myself among the most privileged professionals for the awesome responsibility and joy in helping safeguard this most precious gift for children.

And while I feel quite skilled and proud of my ability to help care for a child’s smile, I find the challenge daunting more often than I’d like when I’m faced with the concerned look of Aisha, a 15 year old who has just lost her two upper central incisors after a traumatic incident in The South Bronx, or when I see the discouraged face of Roberto’s mother, Ms. Mendez, who has not been able to find a “root canal specialist” willing to see her unruly sixth grader from the Spanish Harlem. In the time of ever increasing difficulties with access to care and age of evidence based medicine, adolescent oral health seems to be finding itself not with the “short end of the stick” but rather with “no stick” to hang on to altogether!

Adolescence is the transitional period between puberty and maturity and is often characterized using terms such as tumultuous and turbulent well known to parents and Hollywood, think James Dean’s A Rebel Without a Cause, The Breakfast Club or more recently, Napoleon Dynamite or Juno. Although there is no standard definition of adolescence, this complex intersection of accelerated physical growth and dynamic hormonal change is accompanied by intensified self-awareness and the conflicting forces of acculturation to the demands of society. The distinct healthcare needs associated with this crucial period of development were formally recognized in the 1950’s leading to the establishment of specialty training programs in adolescent medicine which went well beyond general pediatrics. These differential healthcare needs only become more dramatic with respect to oral health, and although they have been somewhat recognized within the spectrum of the pediatric dental specialty, they certainly lag in the strides made in adolescent medicine. Although very important in the context of teenagers’ newfound interest in body image, this goes well beyond the proper management of malocclusion and orthodontics in a growing child. We know that with adolescence come more independent and new diet habits, less stringent home care compliance, and a renewed increase in caries incidence. Two-thirds of all 15-year-olds experience dental decay and almost 1.7 million adolescents have unmet dental needs. Additionally, there are dramatically increased risks for gum disease particularly when linked to obesity and or diabetes. Among parents reporting their children’s unmet needs, 57% reported unmet dental needs nearly five times the number reporting the need for eyeglasses. The breadth of behavioral issues that emerge during adolescence from engagement in more risky behaviors to emergence psychiatric disorders add new dimensions to the spectacle through which such patients with teenage pregnancy, substance abuse or depression should be managed for their oral health needs. Not surprisingly, twice as many parents claimed unmet dental treatment for their adolescent children as those who claimed medical needs.

Sadly we are all too well aware of disparities in access to oral health where those who need the care most are least likely to receive it. The limited access problem casts a darker shade onto this spectrum; Vargas and colleagues detailed the caries experience of NHANES III youths of differing races/ethnicities and socioeconomic statuses. These researchers report that approximately 20% & 40% of Black and Hispanic 6–14 and 15–18 year olds living at or below 200% of the federal poverty line had untreated caries. Still, in a more recent study of the oral health status of adolescents in northern Manhattan by Dennis Mitchell and colleagues, more than half of over 3,200 adolescents examined had at least one carious tooth. This elevated caries levels found in Mitechell’s study may well represent the increased vulnerability of the under-served urban youth when compared with the national figures. The problem is critical for these kids, for whom the consequences of a “simple cavity” can escalate through their childhood and well into their adult lives, from missing significant numbers of school days to risk of associated social, psychological and serious health problems to diminished prospects in the job market. Considering that the number of White, non-Hispanics adolescents is projected to decrease by 21% between 2000 and 2040 in the United States, these oral health disparities will only continue to grow more rapidly with their associated costs to the society as a whole.

The lack of clear and well established clinical guidelines in adolescent oral health only further complicates this picture for an often ignored population that is wished upon to simply “grow up”! Historically, this age group has not been focused on clinically and has been handed off to others in the dental community. Most pediatric dental residency programs have been focused on treatment of the younger pediatric patients age 1 to 9 and lack a strong emphasis on adolescent dental medicine and surgery. The prevailing tendency among dental professionals has been to see adolescents as too old to be treated by pediatric dentists or too young for general dentists. An American Academy of Pediatric Dentistry 2004 survey of a pilot group of pediatric dentists revealed that regarding their residency training experience, 90% reported that fewer than 25% of patients were adolescents. Additionally, almost two-thirds of respondents report having had no formal instruction in dental care for the adolescent. Despite the fact that adolescents are identified within the scope of practice of the specialty of pediatric dentistry, the vast majority of adolescents seek and receive dental care from general practitioners. The wide range of physical, emotional and dental changes that are experienced during the adolescent years create unique clinical challenges that often require a multidisciplinary approach that crosses various sub-specialties in both dentistry and medicine. However, few providers have both the behavioral and technical skills necessary for appropriate coordination of care of this uniquely complex patient population. Much work is needed in this area and as a community of professionals in children’s oral health, the buck stops here and we bear the burden of leadership in making a difference. The formation and work of AAPD’s Adolescent Committee has been a positive step forward. While a good portion of well established pediatric dentists are now competently treating a significant number of adolescents in their practice, the same cannot be said about the large cohort of the more recent graduates or the care of predominately socioeconomically disadvantaged youth. I look forward to working with my fellow colleagues and the AAPD to help bring a renewed focus to both standards of care and access to care for this most vulnerable and promising population.

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Dr. Attaie is the co-founder and Associate Director of the new Adolescent Dental Clinic at Mount Sinai Adolescent Health Center (AHC) in Spanish Harlem due to open in fall of 2010. The Mount Sinai Adolescent Health Center is one of few centers of its kind in the world, providing comprehensive medical and mental health and soon dental services to more than 10,000 of the city’s most vulnerable adolescents each year, ages 10 to 22, regardless of their ability to pay.

He will be running the New York Marathon to raise money for the AHC and will be happily accepting your contributions online :)

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Top Photo: the younger cast from Stand By Me 1985. From left to right, Wil Wheaton, 13, River Phoenix, 15, Corey Feldman 14, and Jerry O’Connell 12. River Phoenix died of drug intoxication at age 23 in Los Angles.

Middle Photo: from Ahmad Ghobadi’s Turtles Can Fly 2004; Agrin, the very young teenage mother as a result of rape by an Iraqi Soldier from Saddam’s Army who also happened to suffer form sever toothache in the movie & Satellite (Soran Ebrahim), the resourceful camp leader.

As human beings we bear the responsibility of being the highest...

Sun, 21 Mar 2010 03:36:00 -0400

As human beings we bear the responsibility of being the highest life form on the planet. Our larger brains evolved to enabling us to be humored, laugh, be happy, mourn and of course fall in love. The ability to care for next of kin or even a distant one for that matter is far more primitive however. “Kin Selection” was first described in the 1960’s as organisms’ tendency to exhibit strategies that favor the reproductive success of their relatives, even at a cost to their own survival. Seen among squirrels in alarm calling, or helpers at the nest in scrub jays, and sterile worker castes in honey bees, in which these animals cooperate despite an obvious disadvantage to the donor. Our ability to exercise kin selection seems to have continued an upward challenge by our evolved ability to exercise “greed”. Potential for human greed is thought to have been accentuated in the Western World after the Black Death and has only gotten worse with the explosion in the human population and ever shrinking pool of resources. This greed has and continues to greatly contribute to widespread poverty where nearly half the world population lives under 2 dollars a day. Some estimate that an equitable division of existing wealth in the world among the entire global population would leave everyone with about $120 a day. Such division of wealth is not forthcoming but the tide may finally be changing. The maturing industrialized revolution, continued economic development, and a decrease in the rate of population growth seem to have finally reversed some trends in poverty. The percentage of the world’s population living in extreme poverty has halved since 1981 albeit there are geographical variations. Most of this improvement has happened in East and South Asia. Meanwhile Sub-Saharan Africa has experienced an increase of poverty, from 41 percent in 1981 to 46 percent in 2001. As we learn to make technology less expensive and more accessible to masses at a dizzying rate, we can finally move beyond “hopes” and literally plan for eliminating poverty even in Sub-Saharan Aftrica within our lifetime! In fighting poverty, satisfying the basic human needs of food, shelter, clothing ,sanitation and education seem to often be distinct from healthcare. Historically, despite other basic human needs, “health” has been a commodity that does not have an absolute price. Clean drinking water and sufficient nutrition can most certainly prevent diarrhea related early infant mortality and Vitamin D supplement may prevent Rickets, but a child born with heart deformity or a cleft lip/palate needs advanced surgical intervention which people at or near poverty simply can not afford. Here is where health care social entrepreneurship comes in. Finding ways to deliver healthcare in win win situations that serve the poor. Some of heroic individuals and organizations most successful in addressing this problem happen to be in India. Dr. Devi Shetty’s team at Narayana Hrudayalaya Hospital believe in what I have always thought to be the intuitive grasp of the obvious …that: “children belong to the society….they are not the sole property of their family and so if parents are not in the position to pay the cost of a heart operation, and if the babies come to us, we have to do the operation…” It really is that simple, daaaah! Dr. Shetty and his team are making it possible everyday by continuing to combine a mission drive efficiency and high tech approaches to their socially driven business model. The founding father of this approach in our modern times is another giant from India whose organization continues to lead the world in innovative approaches to delivering socially conscious high-quality health care to the masses, Dr. Venkataswamy of the Arivand Eye Hospitals: Dr. V believed in absolute and unrelenting belief in one’s value system, working hard to maximize on all resources available, and the financial arrangement where the more better off patients payments for services would cover the cost for those less fortunate. Exploring, understanding and realizing the principles that the organizations of Dr Shetty and Dr. V embody are the first steps in making a once distant dream of affordable health care for all possible. With this comes the society’s ability to get another step closer to safeguarding the sacredness of children’s laughter and eliminating one of the primary causes of human poverty, health care disparities. The question is where, when and how will this transformation happen in your community and if YOU will have had anything to do with it.

A newborn’s smile is perhaps one of the greatest gifts to...

Tue, 16 Mar 2010 00:33:00 -0400

A newborn’s smile is perhaps one of the greatest gifts to humankind. The ability to smile is often magically rediscovered by grown ups upon witnessing an infant’s smile. This innocence and pure sense of joy and carefree love associated with such a seemingly simple facial expression is one of the grandest gifts we are born with. A gift that is universally recognized and cherished by all cultures with no need for translation, one that we long for preservation for the rest of our lives. Rumi and sufi philosophy credit the attraction we all experience to a child’s smile for its wealth of free love. It is thought that the occasional elder who’s face we are drawn to has managed to somehow keep that magical essence of love and innocence despite the cruelties of everyday life. What I like to do when I am on the subway on my regular DUMBO to Upper East side commute is to read the many faces surrounding me, from those inches away to those across the platform. It is amazing to realize that we have all been there once, as a child, an infant smiling carelessly sharing our most wonderful gift with those around us. Facing the complexities of the plethora of life events that rob us of this most beautiful treasure are the essence of what our lives are all about. As children we are vulnerable to much of what happens to us. Children are at the mercy of their genetic, environmental and socioeconomic risk factors and their ability to exercise their simple joy of laughter can vary a great deal based on these circumstances. As the most evolved creatures on the planet, we have come a long way towards realizing the gravity of this issue and albeit quite imperfectly, we are now closer to helping safeguard children’s smile in more ways and for more kids than ever before.Though the road is long and children left behind far too many. One does not need to go to Republic of Congo or Somalia to see this, just take the 20 minute ride from the heart of New York City on the 7 train to 108th St. in Queens or the 4/5 to Bronx’ Jerome Ave where you’ll see plenty of kids left behind. Even one child denied of this most basic right is one child too many for any society to allow. It may sound like a crazy proposition but so was Edison’s wish to bring us light with the turn of a switch. So the road is long and the room for progress abundant in our quest to give every child the best possible chance to grow old with their power of youth.