Periodontal Disease Prevention

and Control in Urban American

Indian Adolescents
Kristen Nadeau, MS, MD
Associate Professor, Pediatric Endocrinology
Center for Native Oral Health Research
Centers for American Indian and Alaska Native
Health
University of Colorado Denver and The
Childrens Hospital
Prairie Band Potawatomi and Otawa
Periodontal (gum) disease
A chronic bacterial infection that affects the
gums and bone supporting the teeth
Gingivitis: Early stage of disease
Red, swollen, and bleeding gums
Usually reversible through good oral hygiene and
preventive care
Not uncommon in young adults and even youth
Periodontitis: Advanced stage of disease
Chronic inflammatory response leading to irreversible
destruction of tissues and bone that support the teeth
Treatment requires more aggressive surgical care
Periodontitis affects 8.5% of U.S. adults and is the most
common cause of tooth loss.

Source: American Academy of Periodontology
Natural History of Periodontal Disease Progression
Mediating Risk
Factors
Modifiable
Plaque Promoting
Diet
Poor Oral Hygiene
Lack of Dental
Cleaning
Smoking
Smokeless Tobacco
Teeth Grinding
Stress
Obesity
Hyperglycemia
Non-modifiable
Family History
Sex

Gingivitis
(reversible)
-Inflammation of
the gums
-Bleeding on
probing
-Periodontal
pockets (<4
mm)
Periodontitis
(irreversible)
-Periodontal
pockets (>4
mm)
-Loss of clinical
attachment
around the
tooth (>3 mm)
-Loss of
supporting bone
structure
Figure 1. Natural History of Periodontal Disease
Progression
-Plaque:
evidence of
recent oral
hygiene behavior
-Calculus
(calcified plaque):
evidence of
chronic oral
hygiene behavior
Colonization
of Disease-
Promoting
Bacteria
Type 2 Diabetes and Periodontal
Disease
Type I Diabetes
Cardiovascular
Disease
Insulin
Resistance
??
Obesity

Type 2
Diabetes
Periodontal
Disease
Oral Health Disparity: AI/AN
adults suffer from high rates of
periodontal disease.
Source: 1999 IHS Oral Health Survey Report
Significant Periodontitis is present
even in AI/AN 15-19 year olds.
0
20
40
60
80
100
Periodontal
Pockets
Loss of
Attachment
%

o
f

a
d
o
l
e
s
c
e
n
t
s
Healthy
Moderate
Severe
Source: 1999 IHS Oral Health Survey
Clinical Markers
Obesity and Diabetes Disparities in AI/AN
AI/AN pediatric obesity prevalence highest of any
ethnic group (>20%)
Childhood obesity has more than tripled in last 30
years, but rates leveled since 2003 in all ethnic
groups except AN/AN
In CA, obesity prevalence no longer rising except for
AI and black girls (Madsen 2010)
1,758 AI/AN adolescents have type 2 diabetes (T2D)
(2005)
T2D increased 68% from 1994-2004 in AI/AN
adolescents
16.3% of AI/AN adults have T2D vs 8.7% of
nonHispanic whites
3 times higher death rate due to T2D for AI/AN
compared with the general U.S. population (2004)
Ethnic Differences in Pediatric Diabetes
Source: SEARCH for Diabetes in Youth Study.NHW=Non-Hispanic White; AA=African American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian
Very High Rates of Tobacco Use in AI/AN
Cigarette smokers have 2-4 times the risk of
coronary heart disease as nonsmokers. (US
DHHS, 1989)
Larger % (32%) of AI/AN adults smoke than
any other racial/ethnic group (CDC 2006)
Smokeless tobacco also more prevalent than
other ethnic groups, especially in girls

AI/AN adolescents are appropriate target
population for periodontal disease
prevention and control.
1 IHS Oral Health Survey (1999) 2 Mealey and Ocampoa (2007) 3 Robin et al (1997)
Periodontal disease already prevalent
1
.
High metabolic risk trajectory increases risk for
periodontitis. T2D is 4-8 times more common in some
AI/AN groups
2
. Diabetes is an established risk factor for
periodontitis and is increasingly common in AI/AN youth.
AI/AN youth and young adults also have high rates of
obesity, stress
3
and tobacco use
1
, particularly smokeless
tobacco, other risk factors for periodontal disease.
The opportunity exists to promote and establish
independent oral hygiene behaviors and healthy habits to
prevent periodontitis in later adulthood, and to intervene
while changes are still reversible.

Study to address Adolescent
Urban AI/AN Periodontal
Health in relation to Type 2
Diabetes and Obesity
Kristen Nadeau, Judith Albino, Terry
Batliner, Lonnie Johnson, Anne
Wilson, Angela Barega, William
Henderson
Specific Aims of Project
Aim 1: Assess periodontal health status of urban AI/AN adolescents

Aim 2: Assess modifiable oral health behavioral risk factors,
knowledge, attitudes in urban AI/AN adolescents at high risk for T2D,
and determine whether these factors are associated with severity of
periodontal disease as assessed by attachment loss (periodontitis) and
mean percent bleeding sites (gingivitis).

Aim 3: Based on the findings from SAs 1-2, and in partnership with
the CNOHR and DIHFS Community Advisory Committees, develop a
culturally-appropriate behavioral intervention focused on the factors
identified as key mechanisms influencing periodontal disease in AI/AN
adolescents and develop a protocol to evaluate its effectiveness.
Hypothesis
Periodontal disease will be high in
urban AI/AN youth
Unique modifiable risk factors
contributing to periodontal disease can
be indentified in this population
Proposed Study Design
Cross-sectional epidemiology cohort study
N ~ 200 urban AI/AN adolescents (age 12-20 years)

Three groups:
Nl weight
High risk for T2D (obese, prediabetes)
T2D

Study Measures
Clinical (age, sex, BMI, BP, diabetes history, glucose,
HbA1c, total cholesterol, HDL, non-HDL cholesterol)
Behavioral and Attitudinal Questionnaires (oral health,
smoking, smokeless tobacco use, dietary intake, stress
and social/family support)
Behavioral Dyscontrol Scale (Executive functioning)
Dental Examination (periodontal disease and caries)
Free cleaning, oral hygiene instruction, given floss,
toothpaste, toothbrush
Clinical recommendations for f/u care
F/U phone call in 6 weeks and asked to mail back dental floss

Why Urban Clinic?
Health Care and especially Dental Care is
less accessible to AI/AN not living on
reservations and away from IHS clinics
Urban Youth lack social support and
extended family, more frequently drop out
of school, have cultural identity clash
Thus a particularly underserved
population
Urban American Indians:
Definitions
Long term residents: in a city for multiple generations,
some the descendants of people who traditionally
owned land that became an urban center.
Forced residents: forced to relocate to urban centers
by government policy or by the need to access
specialized health or other services.
Medium and short term visitors: in a city to visit family
or friends, to pursue an education, job.

Urban American Indians: Stats
The number of Indians living in urban settings greatly accelerated in the
1950s and 1960s, due to the Indian termination policy of that era. The
Bureau of Indian Affairs (BIA) developed a "relocation" program which
relocated >160,000 AI to cities. The program was abolished in the
1970s because of the coercion and ineffectiveness.
Since that era, many AI/AN people have moved to urban areas on their
own for jobs, better opportunities, etc
The number of urban AI/AN is increasing: 1970 census 38% non-
reservation or other Native lands; 2000 census 61%.[6]; 2007 67%
urban (of 4.1 million)
Social Data In Urban AI/AN
Poverty rate of 20.3%, vs. a general urban poverty rate of 12.7%.
Unemployment rate 1.7 times higher than the general urban population.
Homeownership <46%, vs. 62% for non-Indians.
Homes (owned or rented) significantly less likely to have plumbing (1.8
times more likely than non-Indian urban residents), kitchen facilities (2
times more likely) and telephone service (>3 times more likely).
1.7 times less likely to have a high school diploma than non-Indians.
Three times more likely to be homeless than non-Indians.
A higher rate of child abuse and neglect (5.7 cases per 1,000 children
per year, vs. 4.2 for the total U.S. population).
[8]


Health Data In Urban AI/AN
Urban AI/AN suffer from many of the same health
problems as on the reservations. Rates of prenatal
care are even lower than on reservations, and rates
of infant mortality even higher. Furthermore,
compared to the general population, urban Indians
have:
38% higher rates of accidental deaths
54% higher rates of T2D
126 % higher rates of liver disease and cirrhosis
178% higher rates of alcohol-related deaths.
[8]


Health Care in Urban AI/AN
Some urban AI/AN are members of the 561 federally recognized tribes
(qualifying only for health care on reservations)
Other urban AI/AN are from the 109 tribes terminated in the 1950s
and qualify for nothing
Only 1% of the Indian Health budget is allocated to urban programs
despite 2/3 of AI/AN living in urban settings and even this 1% remains
under threat
Barriers to care: time constraints; transportation issues; distrust of
government programs; cost of traveling to receive government-provided
health care; depression; few AI/AN providers; changing addresses if
transient



Data In Urban Adolescent AI/AN
The oral health data form the IHS focuses on IHS
clinics, so not clear what the rates are in urban
populations, which are now the majority of AI/AN
people, especially youth
Relatively little is known about CVD risk factors
among urban AI/AN specifically.
Only one study identified of CVD risk factors among
urban AI, conducted nearly 25 years ago.
It found that those living in Minneapolis had an
extremely high prevalence of T2D, cigarette smoking
and obesity and a moderately high prevalence of high
BP and cholesterol. (Gillum et al., 1984)
Urban American Indians: Denver
Denver: relatively high urban AI/AN population because it was: an
original relocation site, houses AI/AN veterans, and housed a former
BIA office
Metropolitan area home to more than 20,000 Native Americans. These
descendents of the Cheyenne, Lakota, Kiowa, Navajo, Ute, and at least
a dozen other tribal nations are an integral part of the citys social and
economic life.
Many Denver AI/AN have lived here for over 30 years
Many Denver AI/An are 2cnd or third generation
Also houses large transient population who move to and from
reservations on a regular basis
Ute reservation is in the SW corner of Colorado
Research Site
Denver Indian Health and Family Services Clinic (DIHFS)
Incorporated in 1978 as a non-profit with some funding from IHS for
outreach, staff of 2
Grew to include limited health care services with volunteer nurses
and MD in agreement with Denver HHS
Could not handle the large number of uninsured, discontinued in
1991
1996 tried to partner with an outside non-native community health
clinic but not sufficient services and not liked by AI/AN clients
1998 board of directors tried to start again, AI MD (Lori Kobrine)
added in 1999, clinic became licensed, since 2000 staffed with full
time NP and volunteer MD and rapidly expanded
Now 5,000 AI/AN patient base, in 2010 1681 unique people seen, 160
with T2D
T2D grant for 15 years, some get T2D care at Denver Health

Research Site: DIHFS
Services: NP and volunteer MD, substance abuse,
mental health, CDE, weight loss, exercise
counseling, energy services, limited medication
stock, low-cost dental, very simple labs (glucose,
HbA1c, lipids)
Missing Services: subspecialists (in particular
endocrinology, cardiology, psychiatry), more
expensive medications, diabetes supplies,
procedures, imaging, comprehensive laboratory
Main barriers: 77% of clients uninsured (many
insured are vets), some waive benefits at work
expecting IHS clinic to cover needs like on
reservation, if insured, co-pays/deductibles high
Was not affiliated with HMO so couldnt bill
medicaid, lacked IHS funds for training and
improvements; now Title V funded and now Medical
Assistance site so can proccess medicaid
Lessons Learned from
Designing Study of Urban
AI/AN Adolescents
Challenges
IRB: Local COMIRB, IHS, NIDCR
Recruiting
Who is caregiver?: in Urban setting child may be off
of reservation and living with other family members
Hippa: access to lists of names at DIHFS
Advertising: Credibility
Working in a clinic that doesnt typically do research
Lack of Centralized Place to disseminate information
Transportation for subjects
Lack of Data on urban AI/AN populations to design
study
Successes
Community Health Advisory Board: tribal IRB head,
health care workers, tribal college president, tribal
education specialist, DIHFS coordinator, all AI/AN
Staff meetings of DIHFS: Clinic Coordinator,
Diabetes educator, Physical Activity Trainer,
psychologist, social services, CAN, lab tech
DIFRC
Denver Indian Center
JEFCO: AI/AN urban student coordinator,Pow-Wow
DIHFS newsletter
Cultural Immersion Program at UCD
ADA expo
Tocabe
Offering free cleanings to take burden off DIHFS staff

Best Practices for Communications
and Partnerships

Address what the community needs, what the
community perceives are its issues
Solicit partnerships from within the community to be
involved on the project
Address consent, how the data will be collected, data
sharing issues
Address dissemination of the data back to the
community once the study is completed
Ask what the community would use as a measure of
success

Cultural Appropriateness
Gift Card- Target vs. Wal-Mart vs Visa:
ask the community what they would
prefer, dont make assumptions
Name of Program that will be appealing
Using colors and icons
General approaches for preserving culture
and promoting health among urban AI/AN

Traditional dance and running as a form of exercise
Healthier Native foods
Urban AI/AN much more likely to seek health care
from urban Indian health organizations than from
non-Indian clinics: Expand number of AI health
professionals: work w/ local colleges; encourage
UIHOs to serve as training sites to encourage AI
students
Support integration of traditional medicine in health
care
Other Successes to Emulate
Seattle Indian Health Board in Seattle operates
Family medicine residency-training program
A special initiative was started in 1999 to address
diabetes in AI. Urban Indian health organizations
were a utilized to reach urban AI. Data for 2000-2005
show significant improvements in most urban areas,
showing the ability of community-based organizations
reach and better serve hard-to-reach populations.
Native American Cancer Research Corp (NACR) in
Denver partnered with local urban Indian groups and
the American Indian Clinic in LA to develop, test and
implement programs that train female urban Indian
volunteers (Native Sisters) to guide others through
the often bewildering medical system
Other Successes to Emulate

Research conducted in conjunction with the NACR project has
expanded knowledge about urban Indian health.
NACR also developed a culturally appropriate American Indian
tobacco education and cessation program in the Denver region,
hosts an annual wellness event and powwow honoring local
Native American cancer survivors, sponsors weekly weekend
health walks at Denver public parks, and has launched a
community obesity prevention initiative
The Alaska Native Medical Center in Anchorage offers patients
traditional healing services and counseling by elders upon
referral from a staff clinician

National Urban Indian Family Coalition (NUIFC), Urban Indian America:
The Status of American Indian and Alaska Native Children and
Families Today, The Annie E. Casey Foundation; National Urban
Indian Family Coalition; Marguerite Casey Foundation; Americans for
Indian Opportunity; National Indian Child Welfare Association, 2008.
Online at
http://www.aecf.org/KnowledgeCenter/Publications.aspx?pubguid={CC
B6DEB2-007E-416A-A0B2-D15954B48600}, click to view PDF.
Acknowlegments
NIH/NIDCR for funding of the
developmental project highlighted
UCD Center for Native Oral Health
Research
UCD Centers for American Indian and
Alaska Native Health
SEARCH for Diabetes in Youth