Factors affecting North Carolina dental hygienists' confidence in providing obesity education and counseling

PURPOSE

Obesity is a major public health issue in the United States. Dental hygienists influence their patients' oral health by providing dietary and behavioral recommendations that encourage good oral health practices. However, it is not known if they are ready to provide behavioral counseling strategies for weight loss. This study investigates whether dental hygienists in North Carolina are confident to counsel patients who are at-risk for obesity.

METHODS

A questionnaire was used to survey 246 dental hygienists attending a continuing education (CE) course. It investigated self-reported confidence in providing obesity counseling, educational preparation, outcome expectations and self-efficacy. The primary outcome was confidence in providing weight loss counseling. Mantel Haenszel statistics were used to compare group of interest.

RESULTS

Of the dental hygienists surveyed, 43% perceived an increase of overweight patients in their practices. Nearly all (95%) felt that dental hygienists have a role in helping patients improve nutrition. Over half (65%) expressed confidence in discussing obesity-related health risks. On average, the confidence in getting patients to follow weight loss advice was significantly different (p=0.02) for those with a 2 year degree and those with a 4 year degree.

CONCLUSIONS

The findings indicate that many North Carolina dental hygienists are willing to discuss obesity with patients.

Two case reports of complicated permanent crown fractures treated with partial pulpotomies

The partial pulpotomy can offer a superb outcome for the treatment of traumatic complicated crown fractures. The procedure is often used for dental trauma in children when the major aim of treatment is to preserve tooth vitality while providing a favorable environment for continued root development. The purpose of this paper was to review scientific evidence supporting partial pulpotomy and its high success rate and illustrate the clinical technique by presenting 2 challenging cases of complicated crown fractures with long-term follow-up.

Permanent tooth replantation following avulsion: using a decision tree to achieve the best outcome

An avulsion injury is a challenge to manage and there are many treatment options to consider to obtain the best prognosis depending on the avulsion scenario. In 2001, Lee et al published decision analysis paradigms for the management of avulsed permanent teeth to provide busy clinicians with user-friendly, referenced-based flowcharts to facilitate the best possible outcomes for managing these teeth in children and adolescents. The flowchart was updated in 2007 by McIntyre et al. The purpose of this paper is to update the 2001 and 2007 flowcharts and decision analyses with current concepts, recent literature-based findings, new treatment philosophies, and expert consensus from the 2008 AAPD Dental Trauma Symposium.

Nutritional counseling practices: how do North Carolina pediatric dentists weigh in?

It has been demonstrated that nutrition/healthy lifestyle counseling can help alleviate the childhood obesity crisis. Because pediatric dentists see children with regular frequency, they are uniquely positioned to help provide such counseling.

PURPOSE

To document current nutrition/healthy lifestyle counseling practices of pediatric dentists in NC and examine factors associated with those practices.

METHODS

A 65-item survey instrument was developed by an expert committee, pilot-tested and revised. The instrument contained questions in 6 domains: Academic Preparation, Knowledge, Confidence, Opinions, Practice Patterns and Barriers. It was sent to all clinically active pediatric dentists in NC.

RESULTS

The response rate was 69% (70/102). Less than 25% provided nutrition counseling services. Academic preparation in residency training was statistically significant (P<.05) in determining those who practiced nutritional counseling. Logistic regression revealed that respondents with higher overall knowledge (OR=18.2), those comfortable discussing weight-related issues (OR=47.7), those in practice >10 years (OR=20.6), and females (OR=173) were more likely to provide nutrition/healthy lifestyle counseling.

CONCLUSIONS

All respondents believed that childhood obesity is a major health concern and expressed a willingness to assist other health professionals in addressing this problem. These findings offer a rich source of data that can be used for educational initiatives and strategic planning.

Development and testing of the Test of Functional Health Literacy in Dentistry (TOFHLiD)

OBJECTIVE

This study aims to evaluate the reliability and validity of the Test of Functional Health Literacy in Dentistry (TOFHLiD), a new instrument to measure functional oral health literacy.

METHODS

TOFHLiD uses text passages and prompts related to fluoride use and access to care to assess reading comprehension and numerical ability. Parents of pediatric dental patients (n = 102) were administered TOFHLiD, a medical literacy comprehension test (TOFHLA), and two word recognition tests [Rapid Estimate of Adult Literacy in Dentistry (REALD), Rapid Estimate of Adult Literacy in Medicine (REALM)]. This design provided assessments of dental and medical health literacy by all subjects, both measured with two different methods (reading/numeracy ability and word recognition). Construct validity of TOFHLiD was assessed by entering the correlation coefficients for all pairwise comparisons of literacy instruments into a multitrait-multimethod matrix. Internal reliability of TOFHLiD was assessed with Cronbach's alpha. Criterion-related predictive validity was tested by associations between the TOFHLiD scores and the three measures of oral health in multivariate regression analyses.

RESULTS

The correlation coefficient for TOFHLiD and REALD-99 scores (monotrait-heteromethod) was high (r = 0.82, P < 0.05). Coefficients between TOFHLiD and TOFHLA (heterotrait-monomethod: r = 0.52) and REALM (heterotrait-heteromethod: r = 0.53) were smaller than coefficients for convergent validity Cronbach's alpha for TOFHLiD was 0.63. TOFHLiD was positively correlated with OHIP-14 (P < 0.05), but not with parent or child oral health. TOFHLA was not related to dental outcomes.

CONCLUSIONS

TOFHLiD demonstrates good convergent validity but only moderate ability to discriminate between dental and medical health literacy. Its predictive validity is only partially established, and internal consistency just meets the threshold for acceptability. Results provide solid support for more research, but not widespread use in clinical or public health practice.

Evaluation of a Word Recognition Instrument to Test Health Literacy in Dentistry: The REALD-99

OBJECTIVE

This study aims to evaluate a dental health literacy word recognition instrument.

METHODS

Based on a reading recognition test used in medicine, the Rapid Estimate of Adult Literacy in Medicine (REALM), we developed the Rapid Estimate of Adult Literacy in Dentistry (REALD-99). Parents of pediatric dental patients were recruited from local dental clinics and asked to read aloud words in both REALM and REALD-99. REALD-99 scores had a possible range of 0 (low literacy) to 99 (high literacy); REALM scores ranged from 0 to 66. Outcome measures included parents' perceived oral health for themselves and of their children, and oral health-related quality of life of the parent as measured by the short-form Oral Health Impact Profile (OHIP-14). To determine the validity, we tested bivariate correlations between REALM and REALD-99, REALM and perceived dental outcomes, and REALD-99 and perceived dental outcomes. We used ordinary least squares regression and logit models to further examine the relationship between REALD-99 and dental outcomes. We determined internal reliability using Cronbach's alpha.

RESULTS

One hundred two parents of children were interviewed. The average REALD-99 and REALM-66 scores were high (84 and 62, respectively). REALD-99 was positively correlated with REALM (PCC = 0.80). REALM was not related to dental outcomes. REALD-99 was associated with parents' OHIP-14 score in multivariate analysis. REALD-99 had good reliability (Cronbach's alpha = 0.86).

CONCLUSIONS

REALD-99 has promise for measuring dental health literacy because it demonstrated good reliability and is quick and easy to administer. Additional studies are needed to examine the validity of REALD-99 using objective clinical oral health measures and more proximal outcomes such as behavior and compliance to specific health instructions.

A prospective study of 2 sedation regimens in children: chloral hydrate, meperidine, and hydroxyzine versus midazolam, meperidine, and hydroxyzine

The aim of this study was to compare both the behavioral and physiological effects of 2 drug regimens in children: chloral hydrate (CH), meperidine (M), and hydroxyzine (H) (regimen A) versus midazolam (MZ), M, and H (regimen B). Patients between 24 and 54 months of age were examined by crossover study design. Behavior was analyzed objectively by the North Carolina Behavior Rating System and subjectively through an operator and monitor success scale. Physiological data were recorded every 5 minutes and at critical points throughout the appointment. Sixteen patients completed this study. No significant differences in behavior were noted by the North Carolina Behavior Rating System or the operator and monitor success scale. A quiet or annoyed behavior was observed 93% and 90% of the time for regimen A and regimen B, respectively. Using the operator and monitor success scale, 63% of regimen A and 56% of regimen B sedations were successful. No statistically significant differences were noted in any of the physiological parameters between the 2 regimens. Ten episodes of hemoglobin desaturation were detected with regimen A sedations. There were no differences between the sedative drug regimens CH/M/H and MZ/M/H for behavioral outcomes or physiological parameters.

Management of avulsed permanent incisors: a comprehensive update

An avulsion injury is a challenge to manage, and there are many factors to consider to obtain the best prognosis in each scenario. In 2001, Lee and colleagues published decision analysis paradigms for the management of avulsed permanent teeth for the purpose of providing busy clinicians with user-friendly, reference-based flow-charts to facilitate the best possible outcomes for managing these teeth in children and adolescents. The purpose of this article was to update the 2001 flow-charts and decision analyses with: (1) current concepts; (2) recent literature-based findings; and (3) new philosophies.

Effectiveness of an Educational Intervention in Oral Health for Pediatric Residents

OBJECTIVE

To evaluate the effectiveness of an oral health educational intervention designed to increase proficiency of pediatric residents in oral health.

METHODS

Pediatric residents at the University of North Carolina at Chapel Hill (UNC) participated in oral health education that included didactic sessions, hands-on instruction by pediatric dentists and residents, preventive dentistry prompts, and change strategies to introduce oral health into practice. Pediatric residents at East Carolina University (ECU), who had a short practicum in oral health, and Wake Forest University (WFU), who had no specific oral health instruction, served as comparison groups. All residents completed questionnaires before and 12 months after instruction began at UNC. Effects were tested for each school separately by repeated-measure analysis of variance.

RESULTS

The mean percentage of UNC residents who answered 18 knowledge questions correctly and reported frequently performing 10 preventive dental practices increased by 17.7% and 65.1%, respectively, from baseline levels. Residents' confidence in performing 10 counseling and oral health screening activities improved by 17.9%. Opinions about including oral health in their clinical care improved only slightly. Changes at ECU and WFU were small, but low response rates in those schools preclude substantive conclusions from between schools comparisons.

CONCLUSIONS

Multifaceted instruction in oral health was effective in improving pediatric residents' knowledge about oral health, their confidence in providing oral health services, and the delivery of these services in their ambulatory care practices. Residents also adopted the use of fluoride varnish, an innovation in pediatrics. More studies are needed to define the most efficient and effective residency-based instruction.

Examining the cost-effectiveness of early dental visits

The subject of early dental visits as an integral dimension of anticipatory guidance and the related supporting scientific evidence for this concept is a critical and timely issue for the dental profession. The purpose of this paper was to review the scientific evidence and rationale for early dental visits. In theory, early dental visits can prevent disease and reduce costs. During the age 1 dental visit, there is strong emphasis on prevention and parents are given: (1) counseling on infant oral hygiene; (2) home and office-based fluoride therapies; (3) dietary counseling; and (4) information relative to oral habits and dental injury prevention. There is evidence that the early preventive visits can reduce the need for restorative and emergency care, therefore reducing dentally related costs among high-risk children. Preschool Medicaid children who had an early preventive dental visit by age 1 were more likely to use subsequent preventive services and experienced less dentally related costs. These finding have significant policy implications, and more research is needed to examine this effect in a low-risk population.

Access to dental care for young children in North Carolina: history and current status of workforce issues

The 2000 North Carolina IOM report contained 23 recommendations. To date 16 have been fully or partially implemented. This represents progress, but accomplishing full compliance remains a goal. Absent new training programs in our state, as current federal training grants phase-out, identifying financial support to continue training an adequate number of pediatric dentists for North Carolina will be a challenge.

The childhood obesity epidemic: a role for pediatric dentists?

Since the 1970s, the incidence of obesity has more than doubled for children 2 to 5 years of age and adolescents 12 to 19 years of age, and has more than tripled for children 6 to 11 years of age. The increasing numbers of overweight and obese children and youth has led federal policymakers to rank it as a critical health threat. The purpose of this review article is to raise awareness within the pediatric dental community about the childhood obesity epidemic. This article reviews the underlying causes of childhood obesity and discusses the links between both nutrition and obesity to caries. Because pediatric health professionals have daily contact with children and their caregivers, the role of pediatric dentists in preventing and managing obesity is proposed and discussed. In addition, methods are presented that pediatric dentists can use to elevate awareness and address childhood overweight and obesity issues from practice-based, community-based, and advocacy/policy-based perspectives. The authors share an array of ideas that can be incorporated by the pediatric dental team in their practice and beyond.

Assessing cost-effectiveness of sealant placement in children

OBJECTIVE

The lack of cost-effectiveness information regarding sealant placement strategies is thought to have influenced reimbursement policies and subsequent sealant utilization in dental practice. This study compared three strategies for managing the occlusal surfaces of first permanent molars: seal all (SA), risk-based (RBS), and seal none (SN).

METHODS

A decision tree was developed for various possible outcomes following each of the above strategies. Due to the complexity of the decision tree, a Markov model was used to allow for the construction of a chain of events representing the natural history of sealant retention, caries formation, and their associated health states. The outcome measures were the incremental cost per month gained in a cavity-free state over a ten-year period.

RESULTS

Our theoretical model showed that RBS strategy improved clinical outcomes, in the form of cavity-free months, and saved money over SN. The strategy of sealing both high and low risk teeth (SA) further improved outcomes but at an additional cost compared to RBS. However, the cost was small, .08 dollars for each additional cavity-free month gained per tooth. Further, minor changes in the baseline assumptions resulted in the SA strategy being the dominant strategy.

CONCLUSION

This study provides evidence that sealing children's first permanent molars can improve outcomes and save money by delaying or avoiding invasive treatment and the destructive cycle of caries. In a time of limited funds for dental services, these results can assist payers in establishing more rational sealant reimbursement policies.

Early preventive dental visits: effects on subsequent utilization and costs

OBJECTIVE

To determine the effects of early preventive dental visits on subsequent utilization and costs of dental services among preschool-aged children.

DESIGN

This investigation studied North Carolina children who were enrolled continuously in Medicaid from birth for a 5-year period. Our research design was a longitudinal cohort study that relied on 4 large administrative datasets, including North Carolina composite birth records from 1992, Medicaid enrollment and claims files from 1992 to 1997, and the Area Resource File. Our outcome measures included type of use and dentally related costs.

RESULTS

Of the 53591 Medicaid-enrolled children born in 1992, 9204 were continuously enrolled for 5 years and met our inclusion criteria. Twenty-three children had their first preventive dental visit before 1 year of age, 249 between 1 and 2 years, 465 between 2 and 3 years, 915 between 3 and 4 years, and 823 between 4 and 5 years. Children who had their first preventive dental visit by age 1 were more likely to have subsequent preventive visits but were not more likely to have subsequent restorative or emergency visits. Those who had their first preventive visit at age 2 or 3 were more likely to have subsequent preventive, restorative, and emergency visits. The age at the first preventive dental visit had a significant positive effect on dentally related expenditures, with the average dentally related costs being less for children who received earlier preventive care. The average dentally related costs per child according to age at the first preventive visit were as follows: before age 1, 262 dollars; age 1 to 2, 339 dollars; age 2 to 3, 449 dollars; age 3 to 4, 492 dollars; age 4 to 5, 546 dollars.

CONCLUSIONS

Our results should be interpreted cautiously, because of the potential for selection bias; however, we concluded that preschool-aged, Medicaid-enrolled children who had an early preventive dental visit were more likely to use subsequent preventive services and experience lower dentally related costs. In addition, children from racial minority groups had significantly more difficulty in finding access to dental care, as did those in counties with fewer dentists per population.

The effects of the Women, Infants, and Children's Supplemental Food Program on dentally related Medicaid expenditures

OBJECTIVE

This study estimates the effects of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on dentally related Medicaid expenditures for young children.

METHODS

We used a five-year cohort study design to compare dentally related Medicaid expenditures for children enrolled in WIC versus those not enrolled for each year of life up to age 5 years. There were 49,795 children born in North Carolina in 1992 who met the inclusion criteria for the study. Their birth records were linked to Medicaid enrollment and claims files, WIC master files, and the Area Resource File. Our analysis strategy included a logit and OLS two-part model with CPI dollar adjustments.

RESULTS

Children who participated in WIC at ages 1 and 2 years had significantly less dentally related expenditures than those who did not participate. WIC participation at age 3 years did not have a significant effect. Fewer WIC children received dental care under general anesthesia than non-WIC children.

CONCLUSIONS

The WIC program has the potential for decreasing dentally related costs to the Medicaid program, while increasing use of dental services.

Effects of WIC participation on children's use of oral health services

OBJECTIVES

We estimated the effects of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on dental services use by Medicaid children in North Carolina.

METHODS

We used linked Medicaid claims and enrollment files, WIC files, and the area resource file to compare dental services use for children enrolled in WIC with those not enrolled. We used multivariate models that controlled for child clustering and employed 2-step methodology to control for selection bias.

RESULTS

Children who participated in WIC had an increased probability of having a dental visit, were more likely to use preventive and restorative services, and were less likely to use emergency services.

CONCLUSIONS

Children's WIC participation improved access to dental care services that should lead to improved oral health.

Parental evaluation of quality of life measures following pediatric dental treatment using general anesthesia

The purpose of this study was to examine (a) parental satisfaction with the dental care their child received under general anesthesia, and (b) perception of the impact of this care on physical and social quality of life. The sample included 45 children (median age 50 months, 26 boys and 19 girls). Data were collected using a 1-page survey instrument completed by the parent at the first follow-up appointment. Dichotomous dependent variables were developed to measure parental satisfaction, dental outcome, and social impact of treatment. There was an overwhelmingly positive impression with dental outcomes (pain relief and improved masticatory efficiency). Parental perceptions in the social dimension were also positive. Parents reported more smiling, improved school performance, and increased social interaction. Relative to overall health, the majority of parents reported an improvement. Logit regression analysis revealed that absence of pain (P < .05) and increased social interaction (P < .01) had a significant impact on parents' perception of overall health. Our findings indicate that dental care under general anesthesia for preschool children has a high degree of acceptance by parents and is perceived to have a positive social impact on their child.

Accuracy of pediatric primary care providers' screening and referral for early childhood caries

PURPOSE

Tooth decay is one of the more common diseases of childhood. Slightly >40% of US children are already affected by the time they reach kindergarten. Primary care physicians can play an important role in prevention and control of this disease because of their ready access to this population. Unlike dentists, they see a large percentage of children during their infant and toddler years. However, few studies have been conducted on oral screenings and referrals by primary care physicians or the effectiveness of their oral health preventive activities. The purpose of this study was to determine the accuracy of pediatric primary care providers' screening and referral for Early Childhood Caries.

METHODS

We sought to compare independent, blinded oral screening results and referral recommendations made by primary care providers with those of a pediatric dentist, considered for purposes of the study to be the reference gold standard. The study was conducted at a private pediatric group practice in North Carolina. The practice was selected because it serves a large volume of Medicaid patients and includes a large number of pediatric primary care providers (11 pediatricians and 1 nurse practitioner). Study participants included Medicaid-eligible children younger than 36 months of age with erupted teeth. The pediatric primary care providers in this practice received 2 hours of training in infant oral health. The training consisted of a review of the study methods and clinical slides illustrating dental caries in various stages of progression. Specific instructions were given to the providers on how to recognize a cavitated carious lesion and how to determine when a dental referral is needed. Providers were instructed to refer any child with 1 or more cavitated carious lesions, soft tissue pathology, or evidence of trauma to the teeth or mouth. Before commencing the study, calibration and a comparative analysis were performed to establish reliability and validity of the examinations performed by the pediatric dentist. Both a pediatric dentist and a pediatric primary care provider conducted a dental screening on each child and recorded carious teeth and whether a dental referral was needed. Sensitivity and specificity were calculated to compare the pediatric primary care providers' screenings to the gold standard (pediatric dentist) in 3 categories: caries at the tooth level, caries at the patient level (1 or more affected teeth), and need for referral.

RESULTS

The final study sample consisted of 258 preschool-aged children (122 males and 136 females) with a mean age of 21.2 months (standard deviation [SD]: 9.13). One hundred eighty-four (71.3%) of the participants were white, 58 (22.5%) were black, and 16 (6.2%) were Hispanic. Tooth-Level Analysis: The pediatric dentist reported an average of 0.30 (SD: 0.005) cavitated teeth per child, whereas the pediatric primary care providers reported a mean of 0.25 (SD: 0.004). This difference was not statistically significant (t test). The pediatric dentist identified 80 (2.4%) teeth with cavitated carious lesions, whereas the pediatric primary care providers identified 64 (1.9%), 25 of which were false-positives. Their screening results include 41 false-negative teeth. Thus, the primary care providers tended to under-count the number of teeth with carious lesions. They achieved a sensitivity of 0.49 (95% confidence interval [CI]: 0.47-0.51) and a specificity of 0.99 (95% CI: 0.99-1.0) when their screening results for individual teeth were compared with the gold standard. Patient-Level Analysis: At the patient level, the pediatric dentist identified 25 (9.7%) children with 1 or more teeth affected by cavitated lesions. The pediatric primary care providers collectively identified 30 (11.6%) children who had cavitated lesions. They achieved a sensitivity of 0.76 (95% CI: 0.71-0.81) and a specificity of 0.95 (95% CI: 0.93-0.98) in identifying those children with cavitated carious lesions. There were 6 false-negatives and 11 false-positives when the pediatric primary care providers' findings were compared with the gold standard. At the patient-level, the positive predictive value of the dental screening was 0.63 and the negative predictive value was 0.97. Dental Referral: The pediatric dentist referred a total of 27 (10.5%) children to a dentist. Two of these children were referred for trauma and the other 25 were referred for cavities. The pediatric primary care providers referred a total of 23 (8.9%) children to a dentist. Two referrals were made because the provider was concerned about stains on the teeth, whereas the remaining 21 were referred for cavities. The pediatric primary care providers achieved a sensitivity of 0.63 (95% CI: 0.57-0.69) and a specificity of 0.98 (95% CI: 0.96-0.99) when their recommendations for referral were compared with the gold standard. The number of children receiving a referral from a pediatric primary care provider for cavities (N = 21) was less than the number of children they identified as having cavities (N = 30). The providers as a whole tended to under-refer, and only 70% of children with evidence of dental disease received a referral.

CONCLUSIONS

After 2 hours of training in infant oral health, the pediatric primary care providers in this study achieved an adequate level of accuracy in identifying children with cavitated carious lesions. Additional training and research would be needed to optimize pediatric primary care providers' identification of carious teeth if that were the goal of screening. However, the purpose of screening by nondental personnel generally is to accurately identify those in need of referral, which does not require a tooth-by-tooth identification of cavities. Additional research is also needed to determine how to improve dental referrals by pediatric primary care providers. Results of our study suggest that dental screenings can easily be incorporated into a busy pediatrics practice and that pediatric primary care providers can significantly contribute to the overall oral health of young children by the identification of those children who need to be seen by a dentist.

Adverse events and outcomes of conscious sedation for pediatric patients: study of an oral sedation regimen

BACKGROUND

The authors report on adverse events and sedation outcomes for an oral sedation regimen of chloral hydrate, meperidine and hydroxyzine with 100 percent oxygen, or O2, supplementation.

METHODS

In a five-year retrospective study, the authors examined 195 records of conscious sedation performed in 111 healthy children aged 24 to 48 months (mean, 47 months). The authors analyzed age, sex, weight, methods of drug delivery, waiting time after drug administration, treatment rendered, treatment time, adverse events, sedation outcomes and the number of visits needed to complete treatment using descriptive statistics, chi 2 tests, t test and analysis of variance.

RESULTS

Adverse events--including vomiting, desaturation, prolonged sedation and an apneic event--occurred in 3 percent of all sedations and were minor. Seventy-two percent of sedations had satisfactory behavioral outcomes, 23 percent had unsatisfactory outcomes, and 5 percent of the cases were aborted because of disruptive behavior. Sex was not a significant factor for the success. Patient compliance with drinking medications (P = .013) and a longer waiting time after medication intake (P = .012) yielded better sedation outcomes.

CONCLUSIONS

Minimal minor adverse events occurred with this sedation regimen. The success rate was 72 percent. Compliance with taking oral medications and waiting time appeared to be important factors in predicting sedation success.

CLINICAL IMPLICATIONS

This oral sedation regimen offers reasonable outcomes with minimal adverse events under a strict protocol and use of O2 supplementation. The results also revealed associations that give guidance for case selection and outcome prediction.