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Download PDF Datastream AUTHORIZATION TO LEND AND REPRODUCE THE THESIS As the sole author of this thesis, I authorize Brown University to lend it to other institutions or individuals for the purpose of scholarly research. Date: 4/18/17 Nithya Puttige Ramesh, BDS, Author I further authorize Brown University to reproduce this thesis by photocopying or other means, in total or in part, at the request of other institutions or individuals for the purpose of scholarly research. Date: 4/18/17 Nithya Puttige Ramesh, BDS, Author i Association between Perfluoroalkyl Substances and the Prevalence of Dental Caries Amongst US Children Aged 12 to 19 years. (NHANES 1999-2012) By Nithya Puttige Ramesh B.D.S., D.A. Pandu Memorial R.V. Dental College, 2014 Thesis Submitted in partial fulfillment of the requirements for the Degree of Master of Public Health in the Brown University School of Public Health PROVIDENCE, RHODE ISLAND MAY 2017 ii This thesis by Nithya Puttige Ramesh is accepted in its present form by the Brown University School of Public Health as satisfying the thesis requirements for the degree of Master of Public Health. Date: 4/16/17 Joseph M. Braun, MSPH, PhD Advisor Date: 4/19/17 Manish Arora, BDS, MPH, PhD, FICD Reader Date: 4/20/17 Patrick M. Vivier, MD, PhD Director, Master of Public Health Program Approved by the Graduate Council Date _______________ _________________________________ Andrew Campbell, Dean of the Graduate School iii VITA Dr. Nithya Puttige Ramesh was born to Puthige Ramesh and Latha Ramesh. She attended D.A. Pandu Memorial R.V. Dental College where she completed the Bachelor’s in Dental Surgery program, and graduated at the top of her class in 2014. With a deep interest in Public Health, Nithya entered Brown University in 2015 to get a better understanding of health disparities, and to equip herself with the skills required to improve the quality of health care. Nithya’s interest in oral health research culminated in the development of this thesis focusing on the effects of Perfluoroalkyl substance exposure and its association with dental caries prevalence. iv Preface and Acknowledgement The data used in this manuscript was collected from adolescents participating in the National Health and Nutritional Examination Survey (NHANES) between the years 1999 to 2012. First and foremost, I would like to thank my advisor and mentor Dr. Joseph Braun without whom this study would not have been possible. Thank you for your endless encouragement, and for instilling me with the confidence I needed to complete this project. Your guidance has truly allowed me to become a better writer and a researcher, and I’m forever grateful to you for teaching me the proper usage of the oxford comma! I am also grateful to my thesis reader, Dr. Manish Arora, whose insights have been invaluable to this thesis. Thank you for thoughtfully reviewing my drafts and showing immense patience through this process. Additionally, I would like to thank Dr. Patrick Vivier, Joann Barao, and Diane Schlacter for being my support system throughout the time I have spent at the School of Public Health. I am also deeply indebted to Dr. Murali Rao, Dr. M.R. Dinesh, Dr. Harikiran, and all the other faculty members at my alma mater for giving me such a wonderful introduction to healthcare practices, and for encouraging me to pursue a Master’s program. Finally, I would like to thank my family for their unwavering support and love. Thank you for your unflinching belief in my dreams and abilities, even during the times I doubted myself. You are the pillars of my strength and I would not have been here without you. v TABLE OF CONTENTS Part 1: Literature Review- “Association Between Perfluoroalkyl Substances and The Prevalence of Dental Caries Amongst US Children Aged 12 To 19 Years.” Public Health Importance Of Dental Health……………………………………………………………………....01 Etiology……………………………………………………………………………………………………………………………...03 Chemical Exposures and Their Potential Role in Dental Health Among Children…………….....03 Relationship Between Perfluoroalkyl Substances and Dental Health………………………………….05 References…………………………………………………………………………………………………………………………10 Figure 1……………………………………………………………………………………………………………………………..14 Figure 2………………………………….………………………………………………………………………………………….15 Figure 3……………………………………………………………………………………………………………………………..16 Part 2: Research Paper- “Association Between Perfluoroalkyl Substances and The Prevalence of Dental Caries Amongst US Children Aged 12 To 19 Years. (NHANES 1999-2012)” Abstract…………………………………………………………………………………………………………………………….18 Introduction………………………………………………………………………………………………………………………20 Methods…………………………………………………………………………………………………………………………….21 Results……………………………………………………………………………………………………………………………….24 Discussion………………………………………………………………………………………………………………………….26 References…………………………………………………………………………………………………………………………30 Table 1……………………………………………………………………………………………………………………………….31 Table 2……………………………………………………………………………………………………………………………….32 Table 3……………………………………………………………………………………………………………………………….33 Table 4……………………………………………………………………………………………………………………………….34 vi LITERATURE REVIEW : ASSOCIATION BETWEEN PERFLUOROALKYL SUBSTANCES AND THE PREVALENCE OF DENTAL CARIES AMONGST US CHILDREN AGED 12 TO 19 YEARS Public Health Importance of Dental Health: Dental health is known to be a reflection of the general health and well-being of an individual. Poor dental health has a detrimental effect on quality of life and has also been associated with numerous systemic diseases including stroke, cardiovascular diseases and cancer.1–3 Nutritional deficiencies, microbial infections, immune disorders, and injuries can be detected through thorough oral examinations. Facial expressions and daily activities such as chewing and talking are also affected by poor dental health and oro-facial pain. Amongst disease that affects the oral cavity, dental decay or caries, and periodontal infections are the two most common.3 Since the start of the twentieth century, there has been remarkable progress in reducing the burden of dental decay through implementation of preventive measures such as brushing, flossing, and water fluoridation.3 However, dental decay leading to tooth loss continues to be an important public health issue since more than 25% of United States (US) adults over the age of 60 have complete tooth loss as a result of tooth decay or caries.1,2,4 The American Dental Association (ADA) reports that approximately 100 million Americans fail to see their dentist once a year despite evidence which states that regular dental visits can prevent the progression of most dental diseases.5 Poor dental health can affect the emotional, functional, social, and psychological dimensions of health and in children, these can have lasting effects.6 It can be a cause of poor sleep, poor growth, behavioral problems, nutritional deficiencies, reduced school attendance, and poor learning abilities.7–9 In the US alone, children between the ages of 5 to 7 have lost an estimated 7 million school hours per year due to poor oral health as a result of dental caries that began as early as when they were preschoolers.10 In children, especially those from vulnerable or at risk populations, a common type of dental decay known as Early Childhood Caries (ECC) 1 occurs, which severely impacts the child’s overall well-being.10,11 The sequelae of ECC can range from chronic pain and discomfort to medical complications and poor quality of life. There are also substantial costs, estimated to be around $1,000 per child, incurred due to expensive treatment procedures such as restorative treatments and in some cases, extraction of teeth at an early age. 11–13 A report by The Medical Expenditures Panel Survey found that 19.4% of children under the age of 5 had incurred dental costs for a total amount of approximately $729 million in 2006.10 A systematic review on the cost effectiveness of routine dental visits revealed that an average cost of 73 USD per carious surface could be avoided by visiting the dentist at regular 12 month intervals as compared to no routine assessments, which emphasizes the importance of dental health maintenance and prevention.14 In 2000, a report by the Surgeon General of the US identified dental care as one of the most prevalent and unmet health need in the US and since then, there are several efforts being made to improve the research and policy governing dental care practices.15 However, an update to this report released in 2009 identified that the prevalence of dental decay is still on the rise as a major public health burden and has a prevalence of nearly 50% amongst 5-year-old children from poor economic backgrounds.10 The Oral Health Report released by the WHO states that globally, around 60-90% of children and nearly 100% of adults have dental cavities.16 The United States Center for Disease Control (CDC) reports that dental caries are the most common chronic condition that affects children below the age of 17, with approximately three in five adolescents having experienced dental caries in permanent teeth, and 15% with untreated tooth decay.17 Notably, this prevalence is five times that of asthma.18 Using data from the National Health and Nutrition Examination Survey, 2011–2012, the CDC reports that 37% of children below the age of 8 had experienced dental caries in deciduous teeth. Racial disparities were present as the caries prevalence was higher for Hispanic (46%) and non-Hispanic black (44%) children 2 compared with non-Hispanic white children (31%) within the same age group. Similar disparities were noticed
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