Disparities Research: Center for Native Oral Health Research

April 2009

In the early 1970s, the Christian Science Monitor ran a series of feature newspaper articles on American Indian tribes across the United States.  In one article, the reporter repeated a then popular joke on Navajo reservations.  “Definition of a Navajo family:  Papa, Mama, four children – and an anthropologist.”  The joke highlighted the fact that Navajos – and really scores of American Indian tribes – have been studied and restudied over the years to tap into their rich cultural traditions.  But nearly 40 years later, many fundamental aspects of American Indian and Native Alaskan health remain to be fully understood and systematically addressed.  Numbered prominently among them is oral health.  In late 2008, NIDCR began supporting a new oral health disparities center in Denver as step one in the research process.  To hear more about this center in the making, The Inside Scoop spoke to two of its primary investigators:  Judith E. N. Albino, Ph.D., Clinical Professor in the University of Colorado School of Public Health and the director and principal investigator of the NIDCR-supported Center for Native Oral Health Research, and Spero M. Manson, Ph.D., who heads the Centers for American Indian and Alaska Native Health at the University of Colorado School of Public Health and is a member of the Pembina Chippewa tribe.  He is the oral health center’s associate director.

Your newly awarded oral health disparities center is based at the University of Colorado at Denver, where you’ve already established the American Indians and Alaska Natives Programs. These programs address a range of health issues such as diabetes, elder care, and mental health.  What was the impetus for adding an oral disparities center?

Manson:  That’s a bit of a story.  Several years ago, I was teaching a class to a group of medical students and residents on alternative approaches to health and healing, and I invited a medicine man to come talk to the class.  About half an hour into his talk, the medicine man discovered, as often is the case, the students were either asleep, reading papers, or just dismissive of his perspective.  He stopped in mid sentence, grabbed his right braid, and said, “Look, my way in the world and my way of helping my people are represented by how I wear my hair.” 

How so?

Manson:  Holding out his right braid for everyone to see, the medicine man said, “This braid stands for human nature.  You can see that it’s comprised of three strands, each intimately wound within the other.”  He unwound one of the strands, held it out, and said, “This strand stands for the mind.  It’s what you give to your clinical psychiatrists and psychologists.”  He let the strand drop.  He unraveled the second strand.  “This is what you give to your real doctors, your surgeons and your cardiologists.”  That left the third strand dangling there, and he grabbed it and said, “This represents the spirit.  It’s what you give to your priests and your ministers.”  He dropped the last strand and said, “But where lies human nature?”  He reached over and grabbed his left braid and said, “My way of looking at mind, body, and spirit is inextricably linked, one in harmony with the other.  We can’t take them apart.” 

Manson:  Absolutely.  I’m reminded of that story virtually every day as we work in Native communities.  My work began in the alcohol, drug, and mental health field and expanded gradually into diabetes and vascular disease.  Within that context, I began to realize that all aspects of life, including oral health, are in harmony.  Without an understanding of this whole, we’ll never understand the human condition.  Judith [Albino] and I are colleagues, and I discovered that she, as a social and behavioral scientist, also had a background in oral health research. Our discussions evolved from there about the importance of oral health with respect to the full spectrum of health status and well being of Native people.

Where will you and your colleagues conduct your research?

Albino:  We hope to work with the Oglala Sioux Tribe in Pine Ridge, South Dakota and the Navajo Nation in New Mexico, Arizona, and Utah.  The main thrust of our research will be the prevention of childhood caries, or tooth decay.  As I’m sure we’ll touch on in a moment, Native American children have the highest rates of caries in America, and the rampant decay leads to “bad teeth” and often extensive tooth loss in adulthood.  Our research not only is necessary to establish a better baseline understanding of the problem, it will be of great translational value.  By “translational,” I mean our results will help to advance the concept of preventive dentistry for Native Americans in a manner that is harmonious with their culture and personal well being.

I noticed you said “we hope to work.”

Albino:  That’s right.  We engaged the tribal councils very early in the planning of our center.  But our proposed studies have since been modified in significant ways.  So, at this point in time, we need final approval from the tribal councils that the changes are acceptable.

How have the studies changed?

Albino:  The designs have changed.  It’s a little technical, but the NIDCR, I think wisely, decided that our center and two others that will study early childhood caries in different races and ethnicities should standardize their methods and terms of data collection.  These changes will ensure that our results are comparable across the board and give everyone a better idea of the overall national picture.  We now are in almost daily contact with the other NIDCR-supported centers [Boston University and University of California at San Francisco] as part of the brainstorming process of deciding which clinical measures to incorporate.  Once that’s settled, as I just mentioned, we’ll go back to our tribal partners – and they are truly partners – and discuss the changes over a six-month period, and hopefully prepare to move forward thereafter. 

Manson:  Judith is absolutely right about the partnership.  A six-month community review period might seem like a real hindrance to the research process.  But when undertaking community-based participatory research, in general – and working with Native communities, in particular - these timelines are realistic and important.

I’ve read there’s a sensitivity about previous encounters with so-called “parachute research,” i.e., researchers dropping into a community, extracting their data, and vanishing without a trace or explanation?

Manson:  Exactly.  I would say, though, we’re not trying to get away from parachute research; we must get away from it.  Stories of past exploitation, although perhaps unintended, have now been codified in many Native communities, including those with which we are working.  Many Native communities have now established local research review boards.  They have policies and procedures in place that are designed explicitly to allow them more of a voice in the research process from start to finish.  And I think very appropriately so. 

Dr. Albino, you just mentioned that Native American children have the highest rates of caries in America.  How high is the rate?

Albino:  Information isn’t available across all American Indian/Alaska Native communities.  But the rates are clearly very high.  When Native American children start school, the number of tooth surfaces that are decayed, missing, or filled sometimes can be 20 or higher depending on the particular tribe.  Nationally, the average rate is 4.3 decayed or filled surfaces in children age six to eleven.  So we know there’s a huge problem.  But we don’t know why it is so much more of a problem in Native communities than in other sectors of the population. 

How is oral health perceived in Native communities?

Manson:   We don’t know in great detail.  Apropos to Judith’s comments, we don’t know how salient oral health problems are among the American Indian/Alaska community.  We also don’t know where exactly they fall in the spectrum of health concerns.  For example, we’ve done a wonderful job, by and large, in highlighting cardiovascular disease, tobacco cessation, cancer prevention, and, most recently, diabetes.  But we’ve got a ways to go on the oral health component.

So, a more systematic approach is needed?

Albino:  That’s right.  It’s my experience when tribes realize they can address a public health issue, there’s an enormous commitment to do so.  The problem is many tribal groups have been so poor for so long, they view chronic health conditions as unfortunate facts of life.   They expect their members to have bad teeth.  From that mindset, rampant tooth decay in childhood is a given.  Once tribal members realize that tooth loss doesn’t need to be a fact of life, I think we’ll start to see some of the changes that we’re beginning to see with other health issues. 

Manson:  Judith makes an important point.  I think many Native people view the solution to oral health problems as basically a mechanical one.  When a tooth hurts, have it pulled.  When your teeth are gone, get dentures.  Returning to the message of the medicine man that I mentioned a moment ago, oral health doesn’t stand in isolation.  It is inextricably woven into the whole of the human condition.  From that perspective, the prevention of oral disease contributes to one’s overall sense of well being.  And from that perspective, bad teeth are not the inevitable destiny of Native people, nor should the problem simply be mechanically repaired.

What about teaching parents the value of oral health to prevent decay in young children?  In other words, not looking at the patient only, but reaching families.

Albino:  Absolutely.  There are a lot of things that can be done in infancy to help prevent caries.  One of our proposed studies on the Pine Ridge reservation will provide women with pre and post-natal care that engages them in understanding and deciding how to adopt home oral health practices and thus reduce caries as their infants move into the years that carry high caries risk.  Because family structures sometimes turn out to be nontraditional, it’s also possible someone other than the mother may have primary responsibility for the child’s care.  So, we’ll build in approaches that allow those who have major responsibility for the child’s care to choose things that they can control and thus build ownership of the prevention strategies. 

Albino:   We try to do that.  In Pine Ridge, we’ve already identified a couple of people who will serve as data coordinators and, as we call them, interventionists.  With the Navajos, one of our project coordinators will be native.  Also, in that program, we hope to use an approach that is entirely dependent on tribal members to deliver the intervention.  So, we’re very much looking in that direction.  We want to use the resources that are available in the tribes and to attract more American Indians into research careers.  That’s a priority. 

Manson:  Well, the Centers for American Indian and Alaska Native Health already work with over 100 American Indian and Alaska Native communities.  The communities that are participating in our oral health studies have worked with us in the past.  In several cases, their participation involves a variety of different ongoing projects.  What our oral health center does is extend on that work to underscore the importance of continuing our relationship and broadening the scope of those partnerships.