Erinne Kennedy

	Recently, I was afforded the opportunity to attend the Water Innovations for Healthy Arctic Homes (WIHAH) in Anchorage, Alaska.

	WIHAH was the first conference of its kind, and I was one of two dentists to attend. My mentor, Dr. Brittany Seymour, Assistant Professor of Oral Health Policy and Epidemiology at Harvard, and I were invited to take part in this interdisciplinary opportunity. This conference brought together the Department of Environmental Conservation of Alaska, 

	Environmental Protection Agency (EPA), One Artic, the Center for Disease Control (CDC), Artic Research Commission, United States Department of Agriculture by rural development and of course, two dentists under one roof to brainstorm innovative ways to address the impact of climate change on arctic human health. 

	Our attendance at the conference not only sparked interest in the impact of dental caries in Alaskan native children, but it elicited stories about the magnitude of the burden of oral disease. With a profession full of technology, we sometimes forget one of the first technologies that provided improved health outcomes was clean running water. In Anchorage, we were able to participate in conversations around water fluoridation, water borne and washed diseases, and the impact of water insecurity on overall health.

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	You might ask, what is water insecurity? Simply put, water insecurity is the human experience of not knowing where your water is going to come from. Can you imagine not knowing when you were going to get your next glass of water? Or how you were going to wash your clothes? And not knowing when your next opportunity would be to take a shower, or even brush your teeth? For me, the idea of water insecurity was mind-boggling.

 (WHO), there are five factors that influence water insecurity: amount, distance, time, quality and affordability.

	In some areas of Alaska, they have less than 13.2 gallons per person per day, and when they are able to receive water they have to haul water for more than 100 meters which can take 30 minutes to a few hours.

 But the difficulty doesn’t stop there-many times their water is full of minerals, making it unpalatable and expensive. By definition, not only do areas of rural Alaska suffer from water insecurity, but they also have increased health disparities as a result. 

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	Health disparities can be a product of poor water quality or minimal water quantity. Poor water quality is due to contamination from bacteria or viruses consequently producing water borne disease. Water insecurity leads to lower quantities of water, producing water-washed diseases.

	Water-washed diseases are an outcome from an inability to maintain proper hygiene, which results in bacterial skin infections, respiratory infections and diseases such as dental caries. 

	Astoundingly, 40 percent of rural Alaskan children under the age of five have been hospitalized for full mouth rehabilitation under sedation due to dental infections.

	Up next: What are some solutions to this problem?

	The impact of oral diseases and common risk factors for disease is apparent; a focus on prevention, health promotion and an interdisciplinary approach are integral parts of changing the disease burden of oral health in rural communities. Horizontal approaches to community change include capacity building, and infrastructure development is another cornerstone needed to create healthy Alaskan communities. Infrastructure development includes developing the systems and workforce needed to provide running water.

What is capacity building? The goal of capacity building is empowering communities to gain knowledge, understand the data and apply the information in order to solve their own community’s problems in a sustainable and targeted way. In the case of western Alaska, the WIHAH conference invited community leaders to participate, learn about the issues facing their land and see current pilot innovations. The Kivalina project, for instance, is a pilot project that has been implemented in nine Arctic homes, and it is a self-contained fresh water and toilet system that provides clean running water and sanitation to homes without an underground piping system.

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	The beauty of this conference was that community members were able to ask questions, spark conversation, review the pros and cons of these pilot systems and give feedback to engineers about what works in their homes. 

	Climate change creates challenges in simply maintaining the current regulations, and adapting to the changing landscape. The impact of climate change on infrastructure is costly. Every year the temperature is changing in Alaska, which results in melting permafrost. This changes not only the existing landscape and the stability of the soil, but also the existing infrastructure.

	In addition to physical infrastructure, each water treatment facility has to have staff that meets state requirements, which can be difficult in rural communities. Changing the education to provide enough manpower to continue to provide running water existing piping systems is a pertinent next step. 

	Changing the burden of oral health in Alaska has to start with technology aimed at providing clean running water in these rural communities.

	Making horizontal changes such as this, has demonstrated improved health care costs by leading to fewer absences from work, increased labor earnings, and increased attendance and performance in school.

	It was an amazing experience to participate in a conference focused on collaboration in order to change communities and health in groups-like Alaska’s rural arctic and subarctic populations-that face water insecurity due to climate change.

	2. Adapted from Sphere. Also see WHO, 2011. Guidelines for drinking-water quality, 4th edition. World Health Organization, Geneva. 

http://www.who.int/water_sanitation_health/publications/2011/dwq_guidelines/en/

	3. Thomas, T. K., Ritter, T., Bruden, D., Bruce, M., Byrd,., Goldberger, R., . . . Hennessy, T. (2015). Impact of providing in-home water service on the rates of infectious diseases: Results from four communities in Western Alaska. Journal of Water and Health, 14(1), 132-141. doi:10.2166/wh.2015.11

Articles

Dr. Erinne Kennedy discusses some of the health challenges facing rural Alaskan communities.

Horizontal approaches to improving oral health in rural communities

	Have you ever had a tough time convincing your patient to brush and floss? After the recent debacle about no flossing, I think we can all agree, improving oral hygiene is a challenge for most patients.

	With anti-flossing ads stringing across every media site, let’s review seven ways you can increase oral hygiene in your orthodontic patients.

	A hygiene menu is a revolutionary idea for allowing patients to choose their hygiene, that I recently heard when learning about the 

 in Massachusetts. No one can do a 180-degree turn during appointments, it takes small reachable goals and time. Creating a color-coded menu with different activities: drinking more water, eating healthy snacks like nuts and cheese, brushing two times per day, flossing one time per day, using your water pick one time per day, or allowing the toothpaste foam to sit on your teeth after flossing. These are just some of the healthy habits that you can place on your menu. When your patient comes in allow them to choose their new goal, and give them a sticker etc. when the set a goal. Then on the way out, have everyone in their office ask them about their new goal This encourages positive behavior that they want to do!

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	I am sure you all have at least one Best Buy card, Panera card or Giant Eagle card. Today, every store has a promotion card that encourages shopping and allows for increased marketing, so why can’t you? Create a card for your dental office and place points on the card for good behavior to increase compliance. Examples include: excellent oral hygiene, being on time, not losing a bracket, no missing an appointment, referrals, tagging your office on social media or participating in community service. These points can be exchanged for super killer prizes or gift cards on your office website.

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	Tokens are similar to the rewards card-they give points based on good behavior. This is one of the old-school methods in increasing oral hygiene but I think that it is particularly good for young kids. They have some tangible treasure in their hand when they leave so that it is easier to understand.

	Using an app to track oral hygiene and then rewarding patients based on how frequently and how many times they performed oral hygiene is a great tool that can be integrated into the tokens or reward card system. Perhaps each patient can receive one point per two-minute brushing performance and five points for flossing with braces (come on, SuperFloss is tough!)

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 or number of weeks without a lost bracket. Tickets can be used to enter the raffle for each referral submitted, each week without a lost bracket or share on social media. Every month or so you can raffle the prize, take a picture with your winner and use this as an amazing internal marketing source and patient motivator.

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	You can select the “patient of the month” and interview them. Kids love recognition and love to see their smile in your office. This can be something that they work toward and you can even take a video (with permission from the parents) and promote their awesome oral-hygiene practices in your practice. A new Sonicare or Waterpik is always a great prize for patient of the month! 

Have you ever had a tough time convincing your patient to brush and floss? After this week’s recent debacle about no flossing, I think we can all agree, improving oral hygiene is a challenge for most patients. With anti-flossing ads stringing across every media site, let’s review seven ways you can increase oral hygiene in your orthodontic patients.