A Systemic and Coordinated Approach to Offering Oral Health Care Services to Amish Population with High Incidence of Hemophilia

Tamar Diamond D.M.D.Scenic Bluffs Community Health Center,

Cashton, WI

Objective

To highlight special concerns regardingoral care for the Amish patient.

Background of Clinic and Community

Staffing

There are 52 staff members including:1 physician3 dentists2 nurse practitioners1 physician assistant1 chiropractor1 optometrist2 pharmacists4 dental hygienists

Economic Impact

$4 million annual businessHealth Centers’ economic impact on local communities is $6.2 million on local communities

Since 1994, Health Centers brought in $6.48 million in federal grant dollars for primary care in our communitiesSince 2001, Health Centers secured $1.10 million in state grant dollars specifically targeted at primary care access

Health Center Overview

Section 330 funded Community Health Center - receive federal grant funds from US Department of Health and Human Services, Bureau of Primary Health CareHave a published sliding fee scale – Healthy Neighbor PlanGoverned by a community based Board of Directors – currently 10 membersServe a federally designated medically underserved area

Patients and Encounters

4,071

6,528

9,826

2,0743,156

8,474

8,449

2,715

3,270

3,309

8,968 9,817

3,949

4,648

8,750

15,133

3,526

4,996

8,689

15,301

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

Users- Med. Users-Dental Encounters-Med. Encounters- Dental

200020012002

20032004

Other Patient Data

90% of patients are white6% are Hispanic44% have Medicaid/BadgerCare insurance26% uninsured50% live at or below the federal poverty level

Old Order Amish Community

Greater demand for emergency carePreventive care not as high a priorityObstacles in putting patients on recall schedule

Caries Triad

1. Bacteria a. Mother has poor oral health and bacterial composition in

mouth is passed to child

2. Host a. Importance of brushing teeth is often not culturally

transmitted from parent to child b. Brushing once a week is not uncommon c. Heavy plaque bio-film

3. Sugar a. Very high sugar diet b. Bakery goods, candy, and maple syrup are part of the

livelihoods of families c. Mountain Dew and other sugary drinks are very popular

Early childhood cariesCaries on newly erupted teethCaries on 4 surfaces

Common Incidence of Caries

1. Misgivings about the restoration of primary teeth leading toa. Painb. Emergency appointmentsc. Space maintenance issues

2. Unwillingness to have dental cleaningsa. Fear of harming the tooth ("Stripping the enamel") b. When asked to schedule cleaning, patient says that they will call clinic if desiredc. Heavy gingival bleeding during operative procedures

Cultural Barriers to Care

Extensive intermarriage leading to consanguinityBottle neck populationRecessive genetic diseases become more prominentLevels of clotting factor remain stable for lifeDegrees of severity run in the familyAdditional clotting factor needed for routine dental care

Hemophilia in the Amish Population

Cashton Amish Population

Tends toward mild to moderate hemophiliaModerate = 1 - 5 % clotting factor of the normal rangeSpontaneous bleeding does not occur, but prolonged bleeding after injury does occurGiven factor prior to treatment, a patient can receive the normal range of dental servicesPreventive factor improves the clinical prognosis

Hemophilia Screening Day

Begun as a collaboration between the clinic and the area blood center in nearby La CrosseGoal is to identify needs of hemophiliac patients and decrease emergency care situationsPatients register for 15 minute screenings to determine urgent care needs or potential problemsAt the end of the screening, both a medical appointment and dental appointment are made for the same dayDuring the medical appointment, the patient receives factorDuring the dental appointment, the most pressing dental issues are addressed

Conclusion

We are working to address the needs of this special population byEducating parents about the importance of primary teethEncouraging dental cleaningsAttempting to reduce reliance on emergency appointmentsIncreasing awareness of the importance of oral hygiene in tooth retention and overall health