Need for addressing oral health disparities in rural Appalachia

Abstract

While urban centers exist in Appalachia, such as Pittsburgh, the region is characterized by the rural communities in which 42% of the population lives, more than double the national average.2 Although the economic disparity of the region has improved in the last century, disparities remain in terms of income, education, access to medical care, and health behaviors.3 Rural areas of Appalachia have historically been economically distressed and medically underserved. Symptoms such as a local pain or difficulty chewing are often ignored by individuals living in this region.4 Tobacco usage is most often implicated in cases of oral cancer, causing an estimated 75% to 90% of all cases.4 It is not surprising, then, that the percentage of current smokers among the Appalachian population is higher than the national average, with approximately 20% of men and 16% of women considered to be smokers,2 reaching 26.8% in West Virginia.3 Other important issues pertaining to oral health, and certainly more common than oral cancers, are dental caries and periodontal disease. Rather, rates of unmet dental needs are higher in rural populations, leading to increased rates of oral disease, caries, and edentulism among adults.9 Untreated dental pathologies may result in a visit to the emergency department, which not only puts a strain on the healthcare system but also rarely results in definitive treatment.8 In the year 2000, the Center for Oral Health Research in Appalachia (COHRA) was established by The University of Pittsburgh and West Virginia University to study the high rates of oral health problems seen in Northern Appalachia.10 The first study, COHRA 1, conducted from 2000 to 2010 found high levels of dental caries in children: 5% in 2-year-olds, 21% in 3-year-olds, 35% in 4-year-olds, and 51% in 5-year-olds.11 Another study, COHRA 2, is ongoing and involves the assessment of pregnant mothers and their babies.11 Another impediment to establishing a pattern of routine treatment is a "present time orientation" (i.e. patients seek treatment the day their symptoms appear, rather than utilizing preventative methods). Present time orientation has been found to be prevalent among Appalachian communities; however, lack of education was found to be more strongly correlated with delayed dental care than any such cultural beliefs.8 A recent study found that while 93% accepted that oral health is important, 40% did not brush their teeth at least once daily, and 70% did not floss.7 Infrequent tooth brushing has been associated with severe forms of periodontal disease.12 Among those who had not seen a dentist in over 2 years, 70% stated that cost or lack of insurance were the reasons.7 While recruiting medical professionals to distressed regions can be difficult, there has been an increase in the number of physicians recruited to the Appalachia region in recent years (growth of 11/100000 compared to the national average of 5/100 000).4 Involving primary care physicians in basic dental surveillance, such as checking for caries and giving referrals to dentists, was found to be an effective means of preventing childhood caries, leading some to suggest that oral health competencies be included in the curriculum of non-dental healthcare professionals.7 Individual-level health behaviors are largely shared by a community, such that low rates of teeth brushing and high rates of soda consumption are common to many members, illustrating the need for community-wide education initiatives.13 Public education initiatives should focus on increasing self-efficacy regarding oral hygiene to increase healthy behaviors such as brushing daily, as well as addressing dental fear so that regular dentist visits may occur.