According to one author, there is growing consensus among health researchers that they have a responsibility both to acquire scientific knowledge and to apply it in a way that benefits the public health.⁴ An extension of that argument is that dental scientists and educators cannot say they are committed to improving oral health and then not accept the task of disseminating the results of research to the community. In the past, the results of research have failed to reach those studied and facing health disparities. However, results-oriented, community-based research requires greater efforts to establish and maintain networks and trust. Developing readiness in a community to sanction and participate in research takes time. Funding for such research requires flexibility,⁵ and universities must provide incentives for faculty members to apply their research findings to the reduction of disparities.⁶

In 2001, NIDCR responded to the surgeon general’s landmark report and the greater need to support community-based research by cofunding—with the National Center on Minority Health and Health Disparities, the National Institutes of Health’s Office of Behavioral and Social Sciences and the Indian Health Service—five Centers for Research to Reduce Oral Health Disparities for seven years. The sites of the centers were identified after an exhaustive national competition. The centers are based at Boston University; New York University, or NYU; the University of Michigan in Ann Arbor; the University of Washington in Seattle; and the University of California, San Francisco, or UCSF (Figure 1). An important part of each center’s mission is developing a cadre of health-disparities scientists from underrepresented groups—the same groups the surgeon general identified. The centers are sponsored in part by the National Center on Minority Health and Health Disparities, or NCMHHD, at the National Institutes of Health. In response to a question about why NCMHHD was sponsoring oral health research, Dr. John Ruffin, director of the center, responded, "We are pleased to help support these centers through this promising interdisciplinary effort with the NIDCR. This partnership ... demonstrates how we can work together with our communities to build the collaborative biomedical and behavioral research enterprise we need to eliminate health disparities" (written communication, June 2003).

View larger version (86K): [in this window] [in a new window]   Figure 1. Directors of the Oral Health Disparity Centers of the National Institute for Dental and Craniofacial Research, or NIDCR (from left to right): Dr. Raul Garcia, Boston University; Dr. Jane Weintraub, University of California, San Francisco; Dr. Amid Ismail, University of Michigan; Dr. Ruth Nowjack-Raymer, NIDCR project officer; Dr. Ralph Katz, New York University; and Dr. Peter Milgrom, University of Washington.

	THE CENTERS

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The regional Centers for Research to Reduce Oral Health Disparities funded by NIDCR are as diverse in their goals and natures as the people and problems they address.⁷ Each center has identified target populations, and research focuses on different geographical areas. For example, the primary goal at the UCSF center is to conduct research aimed at preventing early childhood caries, or ECC, in members of underprivileged socioeconomic groups and ethnic/racial minorities. Researchers at New York University are working to cut the rate of oral cancers in male adolescents and adults. Each of the five centers has forged partnerships that include ties with component dental societies, state and local health agencies, community and migrant health centers, American Indian tribal nations and institutions that serve other diverse patient populations.

Center for Research to Evaluate and Eliminate Dental Disparities. The Center for Research to Evaluate and Eliminate Dental Disparities, or CREEDD (as in "we believe"), is based at the Boston University Goldman School of Dental Medicine and is a collaborative effort involving institutions in the Boston area and New England such as Boston Medical Center, the Boston Public Health Commission, the Forsyth Institute and others⁸ (Figure 2). It also has projects based at Children’s National Medical Center in Washington and the Columbus Children’s Hospital in Columbus, Ohio.

View larger version (91K): [in this window] [in a new window]   Figure 2. Third-graders from Boston’s Blackstone school, a Center for Research to Evaluate and Eliminate Dental Disparities site, on their annual "day as dental students" field trip to the Boston University Goldman School of Dental Medicine. More than 97 percent of Blackstone schoolchildren are minorities.

Essential to the CREEDD’s research objectives is its Community Liaison Core (the main interface between the CREEDD and the community), building on its experience in creating and implementing model prevention programs and in effecting their transfer to new settings beyond the Boston metropolitan area. Investigators also are studying the best ways to involve physicians in oral health promotion. One research project in this area is examining the use of patient-centered counseling, by pediatricians and nurses, with the goal of reducing caries risk in infants and young children.

In work led by investigators at Children’s National Medical Center and Columbus Children’s Hospital, one project aims to determine whether severe dentoalveolar infection in young children can slow their growth and whether such effects are mediated by nutritional factors. The center also is conducting microbiological studies of children and caregivers from various racial and ethnic groups to identify the microbes that may cause oral diseases and how these microbes may be acquired.

The CREEDD also is working to enhance the research pipeline by providing training opportunities for talented high school, college and dental students, in addition to training doctoral and postdoctoral investigators. Support for trainees has come from NIDCR research training grant and minority research supplement programs. The CREEDD expects that its research, training and outreach programs will result in measurable improvements in the oral health status of its target populations. To assess its effectiveness in meeting such outcomes, the center is being guided by the oral health goals and objectives of Healthy People 2010.

The New York University Oral Cancer Research for Adolescent and Adult Health Promotion, or RAAHP, Center. Unlike the other centers, which seek to reduce dental disparities among young children, this center concentrates its research on adolescents and adults—specifically on oral cancer in these groups.⁹ The NYU Oral Cancer RAAHP Center, which involves 12 collaborating universities and health agencies, is conducting epidemiologic and health promotion studies focused on reducing the incidence and mortality of oral cancer. Among these studies are the following:

– a study on environmental and genetic risk factors for oral epithelial dysplasia, or OED, in Puerto Rico, aimed primarily at estimating the association between OED and the use of smoking tobacco and alcoholic beverages, as well as nutritional factors, in a Hispanic population living in Puerto Rico;

– the first study comparing the five oral cancer detection methods currently available for use by general dentists against the "gold standard" of surgical biopsy regarding validity of diagnosis, a study expected to provide insights that lead to new ideas about biomarkers for oral cancer and their exploitation for the prevention, early detection and treatment of oral cancer;

– a dental practice–based smoking-cessation randomized clinical trial comparing a technique called "personalized risk feedback" with more traditional educational interventions on inner-city adolescent and adult populations;

– a questionnaire survey to determine whether—and if so, why—minorities’ participation in cancer screenings and as research participants differs from that of whites, using a random digit dial telephone technique to contact 1,800 participants in New York City, Baltimore and San Juan.

To strengthen the future base of researchers on issues of minority health and health disparities, the NYU center has begun research training with minority faculty and dental students at the University of Puerto Rico, Health Science Campus, San Juan; Howard University, Washington; and Tuskegee University, Tuskegee, Ala. Additionally, the NYU Oral Cancer RAAHP Center has partnered with Tuskegee University’s National Center for Bioethics in Research and Health Care in establishing a national bioethics research competition for pilot studies funded by the NYU Oral Cancer RAAHP Center for studies relevant to cancer research and care.

If successful, the NYU Oral Cancer RAAHP Center research will produce model strategies for reducing the burden of oral cancer in minority and underserved communities that can be applied widely. It also will provide opportunities for students and minority faculty from partnering schools to gain skills and assert greater control over the health of people in their own communities.

Detroit Center for Research on Oral Health Disparities at the University of Michigan. Detroit’s inner-city families face many circumstances similar to those of families in other inner cities in the United States: deteriorating housing, high unemployment, limited health care resources, large numbers of uninsured people, a faltering school system, disproportionate rates of adult men in prison, and a crumbling safety net of health care for those who are uninsured or who have limited access to health care.

Researchers report that when they observe the obstacles inner-city families face in their daily lives, it is impossible to isolate their oral health status from the rest of their lives. The team of researchers at the Detroit Center for Research on Oral Health Disparities at the University of Michigan is seeking to learn why some families have good oral health and others do not, even when they live in the same neighborhoods and share similar racial, economic and social environments. Researchers look beyond traditional oral health status indicators to examine and attempt to understand oral health disparities in communities that face difficult social, economic and environmental challenges.

The Detroit center has brought together researchers from the University of Michigan’s schools of dentistry, public health, social work and nursing and its Institute for Social Research. In addition, it also has the involvement of two community partners: the Detroit Department of Health and Voices of Detroit Initiative (a community-based organization that collaborates with the major health care systems in Detroit to provide primary health care for Detroit’s uninsured residents).¹⁰

The University of Michigan center has a unique focus because most of its research programs concentrate on a single population group: African-American children younger than 6 years old, and their main caregivers, who live in low-income neighborhoods in Detroit. More than one thousand families participate in the Detroit Dental Health Project, as the Detroit center has come to be called (Figure 3). The center began monitoring participants in 2002 and will continue to do so until at least 2007. The center incorporates a strong service component, which researchers believe is important to their goals and to the community at large. In addition to the Detroit inner-city work, the center funds a project to evaluate a unique "real-life experiment" in Michigan in which Medicaid recipients are covered in a system equivalent to private dental insurance.

View larger version (83K): [in this window] [in a new window]   Figure 3. One of the children who receive care at the Detroit Dental Assessment Center, the office of the Detroit Center for Research on Oral Health Disparities.

Northwest/Alaska Center to Reduce Oral Health Disparities at the University of Washington. In terms of addressing oral health disparities, the Seattle target groups are unique and diverse. They include Alaska natives, American Indians, Hispanic migrant farm workers, African-American and Hispanic families from local military bases, Pacific Islanders and low-income rural whites.¹¹

The diversity of the targeted populations requires Washington researchers to translate dental knowledge and techniques into means of care that will work in culturally appropriate and effective ways. Here are some key facts about the populations with whom the Northwest/Alaska center works:

– 57 percent of native children in Alaska have dental caries by age 3 years. Ninety-eight percent of their mothers have dental caries.¹²

– Children in Washington have a relatively high rate of dental caries compared with children in other states. More than one-half of Hispanic children in Washington have dental caries.¹³

Following are descriptions of some of the Northwest Alaska Center’s projects:

– Center researchers from the University of Washington, or UW, schools of medicine and dentistry are conducting a clinical trial with young native Alaskan mothers as participants to determine whether two weeks of using chlorhexidine mouthrinses followed by two years of chewing xylitol gum will prevent dental caries in the children of these mothers. The mothers also receive dental care and oral hygiene instruction. If results show better oral health in the test group, researchers predict the chlorhexidinexylitol regimen could result in a change in the standard of dental care for this population. As part of the UW center’s commitment to this native community, researchers are providing continuing education for health care providers and working to identify other ways that findings can be used. Results also could reinforce a movement to modify insurance programs and Medicaid to more adequately cover mothers.

Other UW center research focuses on the development of vehicles for xylitol that are acceptable to children and their parents. One project has developed xylitol-containing gummy bear candies and other snack foods that can be used in community Head Start classroooms.

– Other center researchers are testing the hypothesis that natural antibodies in epithelial cells lining the mouth protect against dental caries (Figure 4). Their participants are Hispanic children in the Yakima Valley of eastern Washington. Staff from the Yakima Valley Farm Workers Clinic and students from Heritage College in Toppenish, Wash., are collaborating. If tests bear out their hypothesis, researchers will work with caries-prone children to determine whether these participants experience a breakdown in antibody protection. This project is of special note because it was the first experience of a senior bench scientist in conducting research in a community setting and in being responsible for providing direct benefits to the children and the schools that participated.¹⁴

– Another group at the Washington center is testing streamlined interceptive orthodontic treatment for children from low-income families during the transitional phase of dentition growth. This study is under way in Seattle’s inner city with a focus on black and African immigrant children. The investigators hypothesize that most of these children will not need regular orthodontic treatment after this relatively inexpensive intervention. Furthermore, the treatment methods may be taught to pediatric dentists and general practitioners, who then might work in collaboration with orthodontists to reduce oral health disparities in this particular aspect of care.

– In a pilot project, a general dentist serving a rural Hispanic population is developing a secure Web site to share records with orthodontists in Seattle to get advice about how to treat his rural patients who lack access to orthodontic care.

View larger version (39K): [in this window] [in a new window]   Figure 4. "Oral Science" is a comic book developed for middle-school students participating in basic research about oral ß-defensins in the Yakima Valley, Washington. The research is part of the University of Washington program. The cover was drawn by Pat Brown and the University of Washington Oral Health Collaborative.

The CAN DO center works from two directions—from past to present and from present to future—to delineate the problems and find ways to ameliorate them. From the past, researchers collect data to reveal factors associated with dental inequalities. Looking to the future, they use the data to predict which groups of children are most likely to be susceptible to dental disease and that can be targeted for interventions. CAN DO researchers are conducting clinical trials to determine which treatments might be most effective.

Following are two examples of the several programs and research studies the CAN DO center has sponsored in San Ysidro, Calif.

– An infant oral health care program is providing information on preventing dental caries in children to the families enrolled in this study at the San Ysidro Community Health Center, which is near the U.S.-Mexico border (Figure 5). All of the pregnant women participating in this randomized clinical trial receive counseling before and after delivery. New mothers in the intervention group receive chlorhexidine mouthrinse to prevent transmission of cariogenic bacteria from mother to child, and infants, once their teeth erupt, receive applications of fluoride varnish to prevent dental caries.

– In a study being conducted with the San Francisco Department of Public Health, focus groups have been conducted in English and other languages to determine if cultural factors affect access to preventive oral health care for young children. The community participants are African-American, Chinese, Filipino and Hispanic caregivers of children between 1 and 5 years of age, both U.S.-born and non–U.S.-born. Little is known about oral health beliefs and practices among many specific racial/ethnic groups and cultures in the United States. Researchers plan to use the results of this study to develop culturally appropriate programs and interventions. Collaborators with UCSF are the San Francisco Department of Public Health, the San Ysidro Community Health Center and 12 other agencies and institutions along the West Coast. The projects involve considerable community participation in study design and implementation, as well as in interpretation of findings.

View larger version (90K): [in this window] [in a new window]   Figure 5. The San Ysidro Health Center in California near the U.S.-Mexico border: site of a major University of California, San Francisco oral health disparities research program to prevent early childhood caries.

	CONCLUSION

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Hence, a major part of the effort of these new oral health research centers is to build community networks and establish long-term relationships. Center investigators also recognize that solutions to these vexing problems must be built on an understanding of the social, economic, racial, educational, political and behavioral factors that influence most health care issues.

Collectively, the centers at these five universities and their community partners will contribute new model strategies and an understanding of oral health disparities that can be applied with communities throughout the United States.