Studying disparities in children’s oral health may seem like an unconventional choice for an anesthesiologist, but for Helen Lee MD, MPH, it’s a calling. In this ASA Member Spotlight, Dr. Lee discusses her research at the intersection of medicine and dentistry, with a strong focus on the young patients who are disproportionately affected by poor oral health.
What first drew you to the subject of oral health disparities in kids?
I was a new attending at Seattle Children’s Hospital, I noticed an interesting trend. Operating room time was regularly dedicated to providing general anesthesia for healthy children with really severe cavities. This caught my attention because I was accustomed to caring for children for indications that are not preventable, like appendicitis or scoliosis. Cavities are preventable. The severity of disease was like nothing I had seen before. What was happening that led to such severe disease? Why was intervention occurring so late in the disease process? Why were racial and ethnic minorities overrepresented in this patient population?
I understood, vaguely, that social determinants of health were a large factor in the supply of the pediatric dental surgical population—but the health disparities were to a degree that I had never noticed with other diseases or surgical indications. I started educating myself about this silent epidemic, and I was struck by the disconnect between medicine and dentistry in the care for these children. I was shocked by the fact that childhood cavities, globally, is the most prevalent chronic disease of childhood.
Sounds like you certainly had your work cut out. Tell us a bit about your research – what are you studying, and what are you learning?
With the support of Drs. Debra Schwinn, Marge Sedensky, and Lynn Martin, I became a T32 Research Fellow to focus on how pediatric oral health disparities manifest at the intersection of medicine and dentistry—specifically, when children present for treatment under general anesthesia, moderate sedation, or in emergency departments.
At the time, the idea of an anesthesiologist studying oral health and health disparities was considered unconventional at best, but I was lucky to be in an environment that encouraged innovation. I’ll forever be grateful to the support of a multidisciplinary mentoring team that shared my vision to reduce health disparities. Dr. Wylie Burke, then the chair of University of Washington’s Department of Bioethics, was my primary mentor and constantly challenged me to think through the larger societal implications of what I observed in the clinical realm.
I learned that pediatric dental surgery is, in many respects, an ineffective intervention to change population oral health. As a clinician, that was a revelation. The idea that removing disease did not result in a cure seemed like a cultural shift. I now work at a safety-net hospital in Chicago that treats a predominantly Medicaid-enrolled population. Our patients wait for over a year to get into the OR to treat their cavities. Imagine being three years old with tooth decay that extends into the nerve root, then multiply that pain by ten. Then imagine living with that pain for a year because access to a hospital-based operating room is difficult.
Limited access to general anesthesia services can put pressure on existing systems to treat children under moderate sedation. I studied media reports of children who died at the dentist office, and it became apparent to me that there are several systems-level factors that contribute to safety. The state-to-state variation of these factors, such as how minimum clinical training is defined, is troubling. I studied patterns and outcomes when children and adults went to the emergency department for a toothache. Toothache pain is treated differently for non-Hispanic Black adults, who are less likely to receive narcotics compared to white patients. Oral health disparities, particularly when medicine and dentistry intersect, represent health inequality and inequity.
The idea of equity in healthcare has gotten more attention lately from the general public, yet access to dental care is often overlooked. What’s at stake for improving access to care for the pediatric dental general anesthesia population?
I think access to care gains attention from the general public at the point of catastrophe. Deamonte Driver was a boy in Maryland who did not have access to a dental provider, even though he was enrolled in his state’s Medicaid program. Insurance coverage does not translate into access. Deamonte had a cavity which, due to lack of care, developed into a brain abscess. He died after surgical intervention for his brain abscess.
Primary prevention is clearly the best way to prevent children from dying, but this proves to be quite challenging. My recent work, which was supported by a FAER mentored research training grant and my chair, Dr. David Schwartz, studied public health interventions as levers to improve population oral health and reduce utilization of pediatric dental surgical services. I looked at Medicaid policy aimed at increasing access to preventive dental care and also studied community access to fluoridated water. I did not observe changes in surgical utilization in association with either of these interventions.
This has led to my current focus on factors that could be changed at the household level. I have interviewed families who present for their child’s dental surgery under general anesthesia. What these families have shared with me has completely altered my research perspective.
Helen Lee, MD, MPH, is Associate Professor of Anesthesiology and Adjunct in Pediatric Dentistry at the University of Illinois at Chicago.