Category: News

In its November 2020 edition, Annals of Global Health published an opinion piece on creating oral health research capacity on low- and middle-income countries (LMIC). This is a remarkable opportunity for expanding advocacy for decreasing inequalities in global health. Below are relevant highlights.

The COVID-19 pandemic has emphasized the social, economic, and health inequalities in our society, including existing global oral health inequalities. In the past, the NIH has focused on broadening the public health and medical research capacity present in low- and middle- income countries. There is a global shortage of dentist-scientists as well, especially in developing countries, such as Thailand. Investing in research in a recent project with the University of Washington (UW) DeRouen Center for Global Oral Health and the National Institute of Dental and Craniofacial Research (NIDCR) has not only impacted trainees’ career development but enhanced advancement of oral health research of South East Asia. The success of partnership calls for expanding oral health research training in other low-income countries.

The UW, NIH and NIDCR partnered with 2 universities in Thailand to address the shortage of dentist-scientists all over the world who would advance research that impacts public health. At Thammasat University and Khon Kaen University, the Fogarty International Center Training Program in Clinical, Public Health and Behavioral Oral Health Research for Thailand has successfully trained over 200 individuals from 18 countries, bringing Thailand to the international forefront of oral health research.

The program employed curricula in short-, medium-, and long-term instruction to provide research training. From a 5-day seminar, including education on levels of evidence in evidence- based clinical research, to a yearlong research program at the UW, the curricula provide a broad and applicable introduction to careers in clinical research.

While Thailand is the only NIH funded training site for oral health, we hope that the success of this program can be replicated in other LMIC like Peru and Kenya.

Arcora Foundation is Washington state’s largest foundation dedicated exclusively to improving oral health. A nationally recognized catalyst for change, Arcora ensures policymakers, advocates, and the public have the right information to make wise decisions that lead to better health. Their goal is to change the trajectory of oral health so that in the future everyone can enjoy the benefits of good oral health.

The Timothy A. DeRouen Center for Global Oral Health was recently awarded an Arcora Foundation New Opportunities grant that will help us achieve our overarching goal of integrating oral health within comprehensive medical care that refugees received soon after resettlement in Washington state. Currently, there are seven clinics in the state of Washington that are approved by the department of health to conduct such assessments.  For this project, we aim to collaborate with each of these sites.

Via virtual and in-person meetings at each site around the state, we aim to learn about the current clinical procedures, logistical approach, and electronic chart systems to design a custom-made protocol for oral health integration. We will be the first state in the US to implement oral health among the health outcomes that are mandated for refugees’ resettlement. To accomplish our aim, we will use evidence-based mixed-methods techniques informed by the Consolidated Framework for Implementation Research. Integrating oral health within required health screenings in Washington can serve as a model for a national oral health program for refugees.

At the end of 2019, approximately 79.5 million people were forcibly displaced worldwide. Washington State is consistently among the top five states with the highest refugee populations, most from Burma, Bhutan, the Former Soviet Union, Iraq and Eritrea. The long journey of a refugee results in many ignored or otherwise unmet health needs that begin at their country of origin and continue during their time in refugee camps. In the United States, refugees become legal citizens gaining Medicaid coverage, and go through a comprehensive medical assessment. However, this assessment does not require a comprehensive oral health exam.

In 2020, the COVID-19 pandemic reshaped all of our lives. However, the DeRouen Center team managed to continue collaborations with World Relief, DOH, DSHS and HCA. In the last few months, we teamed up with ARCORA Foundation to develop oral health-training modules for refugee caseworkers and care navigators. With our current collaboration with World Relief, a non-profit refugee resettlement organization, we hope to bring this training to their attention and ask for their advice in shaping the curriculum to refugees resettling to the United States. We believe this partnership will lead to further training for World Relief caseworkers and bring more oral health care access to the refugee community in the Seattle area.

Untreated dental caries in permanent teeth is the most prevalent disease, and dental caries of the primary teeth affect more than 530 million children. Oral diseases manifest as pain, impairment, and loss of function, and can affect individuals throughout their lifetime. At the most extreme end of the socioeconomic spectrum, growing populations of marginalized individuals worldwide reside in slums. Iquitos, Peru, is the largest city in the Peruvian Amazonian rainforest, and due to recent immigration into the city from the surrounding jungle, lack of housing has resulted in floating structures built on the Amazon River. Unfortunately, due to such precarious housing and poor environmental conditions, residents of these communities experience chronic illnesses, vector borne and infectious diseases, exposure to severe storms and flooding, and lack of water, sanitary infrastructure, and access to food.

In 2017, a collaborative group from the University of Washington (UW) schools and departments of Dentistry, Civil and Environmental Engineering, Environmental and Occupational Health, Global Health, Landscape Architecture, Neurology, and Nursing teamed up with the Centro de Investigaciones Tecnológicas Biomédicas y Medioambientales (CITBM), the Universidad Nacional de la Amazonía Peruana (UNAP) and the Instituto Nacional de Salud (INS) in Peru and developed a transdisciplinary action research program, InterACTION Labs, to design and implement research projects aimed at advancing the health, community strength, and future development of residents of one of these informal river communities – the Community of Claverito.  As a contributor to InterACTION Labs, dental faculty collected information about the community’s oral health status and the impact of oral health on the residents’ quality of life. The purpose of this study was twofold: 1) to describe the prevalence and distribution of dental caries among the pediatric and caregiver populations of a slum community located on the Amazon River in Iquitos, Peru; and 2) to evaluate the relationships between the children’s dental health status and the OHRQoL of the children and the impact on their families.

The results of this study reveal poor oral health status for the children and caregivers and an association between child dental health status and family quality of life. The prevalence of untreated child dental caries was 97%, with only six children having filled teeth and only eight children having missing teeth. A significant positive association was observed between child decayed and filled teeth scores and family impact scores. Significant associations were also observed between child decayed and filled teeth scores and caregiver age and child scores and caregiver decayed and filled teeth scores. Collectively, these results indicate a high level of dental disease and limited access to dental care.

There are an estimated 90,000 people living in riverine slum communities in Iquitos that could benefit from an increase in oral health services. Policy changes to improve availability and access to oral health services are needed to achieve better health for informal communities like the one of Claverito.

The Peru Education, Action, & Research (PEAR) Network is an informal network of UW faculty, graduate students, and community partners with research interests, projects, collaborators, and/or student programs in Peru.

PEAR aims to serve as a UW community resource linking people with different areas of expertise and experiences relevant to Peru to catalyze new forms of interdisciplinary collaboration, identify joint funding opportunities, and enhance existing partnerships. By leveraging common and complementary strengths, experiences, existing partnerships, and networks, we can diversify and expand the scope of research in Peru, build new opportunities for student study, research, internships and community service in the country, create reciprocal opportunities for Peruvian’s in Seattle, and advance the scholarly and societal impact of both UW and its Peruvian partners.

Partnering with the UW Office of Global Affairs, the Latin American and Caribbean Studies (LACS) Program serves as the central hub for the network and participating faculty are drawn from across multiple schools and colleges.

Although oral diseases are largely preventable, they are among the most non-communicable diseases globally, and they disproportionately burden disadvantaged communities, specially within low- and middle-income nations. There is a shortage of dentist-scientist all around the world, especially in developing countries, such as Thailand.

Thailand is an active member of the Association of South East Asian Nations interested in creating oral health research capacity and training. While governmental efforts towards increasing clinical providers have been successful, there has been a gap in the training and education required to create a cadre of dental researchers beyond clinical expertise, who would advance research that impacts public health.

For over 20 years, the University of Washington, School of Dentistry, has partnered with Thammasat University and Khon Kaen University to train a new generation of oral health researchers who have impacted the dental public health arena in South East Asia. As a result of this partnership, these institutions created the Fogarty International Center Training Program in Clinical, Public Health and Behavioral Oral Health Research for Thailand with assistance by the Fogarty International Center (FIC) and the National Institute of Dental and Craniofacial Research (NIDCR) (Grant Funding: D43 TW007768 and D43 TW009071, PI: DeRouen). By training over 200 trainees from 18 countries, this training site has brought Thailand to the international forefront of oral health research.

The training involved a combination of short, medium, and long-term pathways. Short-term workshops were five days and included general and scientific principles of planning and carrying out clinical research projects, clinical research, study design, statistical concepts, behavioral models, and ethical issues. Medium-term training involved attending the six-week Summer Institute in Clinical Dental Research Methods held at University of Washington in Seattle. The program was designed to provide a short but intensive research training program for dental school faculty and professionals interested in clinical research. Long-term training was designed to augment and strengthen oral health research pathways in existing PhD programs in Oral Science at Thammasat and Khon Kaen Universities. Trainees with English language skills spent one year in Seattle at University of Washington to a) take courses in biostatistics, epidemiology, or health services at UW School of Public Health, b) worked with one or more UW mentors on research projects they were developing to enhance their learning experience, or c) plan and finalize a dissertation research project that they would work on over the period of the next year in Thailand.

With the purpose to provide a perspective on the impact of the FIC and NIDCR support on creating training and research capacity in South East Asia, we conducted a survey of former trainees to inform us on their perception on how the Fogarty International Center Training Program in Clinical, Public Health and Behavioral Oral Health Research for Thailand impacted their professional paths. Most participants (74.3%) were enrolled in short-term training, 17.6% enrolled in medium-term training and 5.4% enrolled in long-term training. The perceived impact on how these training types influenced trainees at personal and at professional levels was assessed through open-ended question. Three major themes emerged, and responses were not exclusive: a) Improved knowledge of research methods (90.2%); b) Better equipped to teach and supervise students’ thesis and research (12.2%); and c) Connections made with other attendees (14.6%).

As a result of this unique training partnership, Thai universities have become the regional resource for oral health research in South East Asia. We believe this to be one of many models to be used to increase research capacity in global oral health for other low- and middle-income countrie

At the end of 2019, the UW Timothy A. DeRouen Center for Global Oral Health interns took part in a breakfast meeting with Dr. Gary Chiodo, Dean of the University of Washington School of Dentistry. The interns shared snapshots of their work in furthering the DeRouen Center’s mission.

Our very first interns, Sydney Russell and Marina Martinez, presented their stories on early growth of various international sites in collaboration with the DeRouen Center, and also shared how their intern experiences have led them to their career path after graduation. After leaving UW, Marina worked as Senior Quality Improvement Specialist at Sea Mar Community Health Centers, and currently is a Business Operations Consultant at The Spur Group. Sydney is a Public Health Analyst with the Health Resources and Services Administration (HRSA) at DHHS.

Susan Lee (at that time, senior dental student) shared her role in administration and advocacy. She excelled at promoting global oral health to the general public through social media, monthly newsletters, and fundraising events. Justin Kahng (current third year dental student) was one of our newer interns who presented his activities on advocacy through social media. Other interns spoke about awards and fellowships in public health. Jennifer Liu was one of the lead applicants in the Morrell Research Fund which was awarded to the Timothy A. DeRouen Center for Global Oral Health in July 2019 for the project “Refugees’ Endeavors for Utilizing Governmental Existing Efforts in the State (REFUGEES); Dental Health Care Utilization Among Newly Resettled Refugees 2015-2018.” Poojashree Rajanbabu was awarded the Northwest Center for Public Health Practice (NWCPHP) Student Collaborative Project Stipend, which is intended to help students defray living expenses during their hands-on public health training experience for public and nonprofit health organizations in Washington, Alaska, Idaho, and Oregon. Pooja was awarded this stipend for her cross-sectional study entitled, “Evaluating Refugee Children’s Oral Health in Washington State.”

After a brief presentation from the interns, Dean Chiodo shared inspiring stories about his journey in public health dentistry and how the field has changed over the years. Especially poignant was the early days of the HIV crisis in the 1980’s where he was one of the first oral health providers to treat HIV/AIDS patients.

This was a great experience for our interns to present their activities and to learn more about the Dean’s journey in dentistry and to understand more of the historical knowledge of dental public health. Opportunities like this enrich student experience and increases networking for future career development.

Since 2015, the University of Washington (UW) DeRouen Center for Global Oral Health has developed a partnership with UW Global Health, University of Nairobi and Kenyatta National Hospital in Kenya to set up the Children’s Healthy Oral Management Project (CHOMP). The CHOMP project investigates the connection between oral health and HIV. By developing research, training, and implementing pediatric oral health and HIV agenda, CHOMP sets an example for working towards improving oral health care for children with HIV. These partnerships not only advance oral health research, they also strengthen institutional collaborations which pave the way for future opportunities.

As a result of this collaboration, CHOMP developed a project focusing on the oral manifestations of HIV infection within current clinical trial pediatric cohort as perceived by parents and caregivers. Oral lesions are often among the earliest clinical signs of HIV infection, highlighting an important opportunity for improved oral care for HIV-infected children.  The routine clinical care schedule for HIV-infected children may provide an opportunity to engage parents in more prompt diagnosis of oral morbidities and improve access to appropriate treatment. Training HIV care providers, or caregivers in the identification and management of oral comorbidities may improve referrals and early treatment.

Currently, we obtained a Sunstar (School of Dentistry) and CFAR (UW Center for AIDS Research) award that allows us to conduct examinations and oral health assessments as well as analyzing the association between salivary AMP and serum vitamin D levels. This pilot study data will inform the design of a randomized clinical trial of vitamin D supplementation in HIV-infected children and adolescents in Kenya.

These collaborations will be enhanced by creating research training opportunities in Kenya. With this is mind, we have applied for a 2020 D71 Planning Grant with the NIH Fogarty Center which will provide the basis for developing a training program with the ultimate goal of creating sustainable institutional capacity in research and training for oral health and HIV/AIDS.

The Fogarty International Center (FIC) is dedicated to advancing the NIH mission by supporting and facilitating global health research conducted by the U.S. and international investigators, building partnerships between health research institutions in the U.S. and abroad, and training the next generation of scientists to address global health needs. By facilitating exchanges among investigators, providing training opportunities and supporting promising research initiatives in developing countries, FIC has served as the bridge between NIH and the greater global health community for more than 50 years. While the initial FIC support has traditionally been allocated to infectious diseases, new opportunities for noncommunicable diseases have been opened and that includes oral health.

The Global Burden of Disease Study 2017 estimated that oral diseases affect close to 3.5 billion people worldwide, with caries of permanent teeth being the most common condition. Globally, it is estimated that 2.3 billion people suffer from caries of permanent teeth and more than 530 million children suffer from caries of primary teeth. Investing in oral health will improve global health.

For the last 2 years, FIC Fogarty Fellowship awarded two fellows in oral health. The 2019-2020 fellow is Ashley Karczewski with her project titled “The association between levels of salivary antimicrobial peptides (LL-37) and the presence of periodontal disease in HIV-infected adolescents,” and the current 2020–2021 fellow is Catherine Mwesigwa with her project titled “Feasibility of integrating oral health in the primary care of HIV-positive pediatric patients in a low-resource setting.”

We hope FIC continues its support to in building up research training and capacity for global oral health.

Course sets an example for integrating Global Health into UW Dental School Curriculum

Dental students have demonstrated an interest in international topics but are largely unaware of global health topics. To improve students’ global health awareness, the University of Washington (UW) Timothy A. DeRouen Center for Global Oral Health at the UW School of Dentistry (UWSOD) created an elective course for dental and public health students. In 2018, UW began a partnership with Harvard School of Dental Medicine (HSDM) aimed to increase global oral health courses at educational institutions. Belle Chen (2020 graduate) received the 2019 Academic Careers in Oral Health Fellowship for her work in facilitating and developing the course integration. The result of this collaboration will be featured in Annals of Global Health, showing the effect on students’ knowledge and attitude towards global health.

The integration of global oral health into the dental curriculum increases an understanding of the current global environment, raises awareness for the global burden of oral disease and health inequities. Undergraduate, pre- and post-doctorate students from the Schools of Dentistry and Public Health not only increased their knowledge of these topics, but they also had the opportunity to meet and work with colleagues from different health professions. Students worked together on a final group project to create a research question for a project of their choice. This interprofessional exchange of ideas and perspectives provided an invaluable experience for students. Overall, creating this collaboration with Harvard sets an example for other institutions to follow in integrating global health courses into the dental school curriculum.