Oral health opinions and practices of pediatricians: updated results from a national survey

Barriers and Facilitators to Optimal Fluoride Varnish Application

OBJECTIVE

National guidelines recommend that all children under age six receive fluoride varnish (FV) in medical settings. However, application rates remain low. This study aimed to update understanding of barriers and facilitators to guideline concordant FV application.

METHODS

We conducted virtual semi-structured interviews with a purposive sample (eg, FV application rates, geographic location, practice size and type) of pediatric primary care clinicians and medical assistants in Massachusetts between February 1 and June 30, 2022. The Consolidated Framework for Implementation Research (CFIR) served as the study's theoretical framework and data were analyzed using a modified grounded theory approach.

RESULTS

Of the 31 participants, 90% identified as White and 81% as female. Major themes, which linked to four CFIR domains, included: variation in perceived adequacy of reimbursement; differences in FV application across practice types; variation in processes, protocols, and priorities; external accountability for quality of care; and potential levers for change. Important subthemes included challenges for small practices; role of quality measures in delivering guideline-concordant preventive oral health care; and desire for preventive care coordination with dentists.

CONCLUSIONS

This study suggests that potential barriers and facilitators to guideline concordant FV application exist at multiple levels that may warrant further study. Examples include testing the effectiveness of quality measures for FV application and testing strategies for implementing consistent processes and protocols for improving FV application rates.

Oral Health Knowledge, Attitudes, and Clinical Practices of Pediatricians and Pediatric Residents: A Cross-Sectional Study

Background Pediatricians are the first line in the provision of healthcare for children. They can make an important contribution to the oral health of their patients because they usually see children and parents early and frequently in life. This study aims to assess the pediatricians' and pediatric residents' oral health knowledge, attitudes, and practices with patients. Methods A structured English survey was developed based on previous surveys in the literature. It collected data on oral health knowledge, attitudes, and practices. Pediatricians were visited and invited to take the survey. A link to the survey was sent via email to all pediatric residents. An oral health practice score was created based on participants' responses to the practice questions, and a linear regression assessed its predictors. Frequencies of oral health knowledge, attitudes, and practices were presented and compared between both groups by the chi-square test. Results A total of 218 pediatricians and residents were surveyed. The oral health knowledge was low overall, but it was higher among pediatricians, 10.0±1.9, compared to the residents, 8.2±2.5 (P<0.001). The attitude ranged from 66.3% agreeing with the statement "Limited time with patients makes it difficult to integrate oral health into primary care practice" to 87.4% agreeing with the statement "Primary healthcare physicians should know their local dentists to facilitate dental referral and treatment." Overall, pediatricians practice positive oral health behaviors more than pediatric residents, and higher knowledge levels predicted more positive oral health practices. Conclusion Despite acknowledging their important role in promoting oral health, pediatricians' and future pediatricians' knowledge is poor, and their participation in oral health continues to be limited. The potential for the non-dental workforce to greatly improve children's oral health is underexploited. The healthcare system should seek to integrate medical and dental practices better. Incorporating oral health into residency programs and providing continuous education courses are strongly encouraged.

Physicians' Examination and Referral Practices on Orthodontic Problems Among 6-12-Year-Old Children in Saudi Arabia

Background

Physicians are more likely to examine children than dentists; thus, they may have a significant role in detecting oral and dentofacial problems. This study aimed to determine the rate and comprehensiveness of examinations, the rate and quality of referral practices, and the predictors of referral practice of physicians regarding orthodontic problems among children.

Methods

In a multi-center cross-sectional study, a total of 518 physicians in Saudi Arabia were subjected to an e-questionnaire of four sections: (1) Physicians' demographic and work-related characteristics; (2) Physicians' comprehensiveness of oral and orthodontic examinations; (3) Physicians' referral practices to orthodontists and reasons considered for referral; and (4) Physicians' sources of orthodontic education. Logistic regression analysis was applied to identify the significant predictors of referral practice. The significance was set at p < 0.05.

Results

Most physicians reported partial oral (78.5%) and orthodontic (72.2%) examinations, while the full examination was reported by only 12% and 2.5% of physicians, respectively. Referral to orthodontists was practiced by most of the physicians (83.8%), yet for the majority of them, the quality of referral was poor (40.3%) or fair (46.1%), with only 13.6% who practiced quality referral. Dental development issues (53.3%) and functional issues (51.5%) were reported as the main reasons for referral, followed by family/patient request (42.9%), dental alignment (42.5%), oral respiratory issues (32.4%), and finally jaw relation (26.1%). Referral practice was predicted by the comprehensive oral (OR = 2.37, p = 0.007) and orthodontic (OR = 4.26, p < 0.001) examinations, number of patients seen by the physician (OR = 1.58, p = 0.007), and level of training (OR = 1.88, p = 0.03).

Conclusion

Although most physicians reported high rates of examination and referral practices on orthodontic problems among children in Saudi Arabia, only a small portion showed comprehensive examinations and quality referral practice. Including dental courses in medical curricula and improving oral and orthodontic examination guidelines for physicians are recommended.

Factors perceived by health professionals to be barriers or facilitators to caries prevention in children: a systematic review

BACKGROUND

Considered the most prevalent noncommunicable disease in childhood, dental caries is both an individual and a collective burden. While international guidelines highlight prevention as a major strategy for caries management in children, health professionals still struggle to implement prevention into their clinical practice. Further research is needed to understand the gap between the theoretical significance of dental prevention and its lack of implementation in the clinical setting. This systematic review aims to identify and classify factors perceived by health professionals to be barriers or facilitators to caries prevention in children.

METHOD

A systematic literature search was conducted in three electronic databases (Medline, Web of Science and Cairn). Two researchers independently screened titles, abstracts and texts. To be selected, studies had to focus on barriers or facilitators to caries prevention in children and include health professionals as study participants. Qualitative and quantitative studies were selected. The factors influencing caries prevention in children were sorted into 3 main categories (clinician-related factors, patient-related factors, and organizational-related factors) and then classified according to the 14 domains of the theoretical domains framework (TDF).

RESULTS

A total of 1771 references were found by combining manual and database searches. Among them, 26 studies met the inclusion criteria, of which half were qualitative and half were quantitative studies. Dentists (n = 12), pediatricians (n = 11), nurses (n = 9), and physicians (n = 5) were the most frequently interviewed health professionals in our analysis. Barriers and facilitators to caries prevention in children were categorized into 12 TDF domains. The most frequently reported domains were Environmental Context and Resources, Knowledge and Professional Role and Identity.

CONCLUSION

This systematic review found that a wide range of factors influence caries prevention in children. Our analysis showed that barriers to pediatric oral health promotion affect all stages of the health care system. By highlighting the incompatibility between the health care system's organization and the implementation of caries prevention, this study aims to help researchers and policy-makers design new interventions to improve children's access to caries prevention.

TRIAL REGISTRATION

PROSPERO CRD42022304545.

Five-year follow-up of an interdisciplinary oral health education program: Clinical practice behaviors in working pediatric nurse practitioners

ABSTRACT

Many interdisciplinary oral health education programs have been implemented for pediatric primary care providers (e.g., pediatric nurse practitioner [PNP]) to raise awareness and gain skills related to the prevention of early childhood caries (ECC). However, no studies have evaluated if these educational programs provided to PNPs during their training resulted in clinical practice behavior changes. A 33-item survey was designed on a web-based platform (Survey Monkey) and distributed to 71 PNP graduates. The survey included demographics, current clinical practice, clinical practice behaviors, and perceived barriers to practice. Descriptive statistics were used to assess the survey items and thematic analyses on the open-ended questions. The survey response rate was 70% (50/71 PNPs). Most practicing PNPs were in acute care or specialty clinics (n = 33; 66%) where oral health was not part of the focused visit. Majority used knowledge learned in assessment and anticipatory guidance skills. However, only 14% of primary care providers were applying fluoride varnish with 10% billing for this procedure. Barriers to application were time, available supplies, COVID protocols, lack of support staff, or not billing due to minimal reimbursement. Many primary care-trained PNPs were practicing in acute or subspecialty areas where prevention of ECC is not viewed as part of their focused visit. Pediatric nurse practitioners working in primary care demonstrated some clinical practice changes. However, areas for improvement are time to perform a risk assessment and application of fluoride varnish, access to these supplies, and standard billing and insurance reimbursement for these preventable services.

Predicting Dental Caries in Young Children in Primary Health Care Settings

Young children need increased access to dental prevention and care. Targeting high caries risk children first helps meet this need. The objective of this study was to develop a parent-completed, easy-to-score, short, accurate caries risk tool for screening in primary health care settings to identify children at increased risk for cavities. A longitudinal, prospective, multisite, cohort study enrolled (primarily through primary health care settings) and followed 985 (out of 1,326) 1-y-old children and their primary caregivers (PCGs) until age 4. The PCG completed a 52-item self-administered questionnaire, and children were examined using the International Caries Detection and Assessment Criteria (ICDAS) at 12 ± 3 mo (baseline), 30 ± 3 mo (80% retention), and 48 ± 3 mo of age (74% retention). Cavitated caries lesion (dmfs = decayed, missing, and filled surfaces; d = ICDAS ≥3) experience at 4 y of age was assessed and tested for associations with questionnaire items using generalized estimating equation models applied to logistic regression. Multivariable analysis used backward model selection, with a limit of 10 items. At age 4, 24% of children had cavitated-level caries experience; 49% were female; 14% were Hispanic, 41% were White, 33% were Black, 2% were other, and 10% were multiracial; 58% enrolled in Medicaid; and 95% lived in urban communities. The age 4 multivariable prediction model, using age 1 responses (area under the receiver operating characteristic curve = 0.73), included the following significant (P < 0.001) variables (odds ratios): child participating in public assistance programs such as Medicaid (1.74), being non-White (1.80-1.96), born premature (1.48), not born by caesarean section (1.28), snacking on sugary snacks (3 or more/d, 2.22; 1-2/d or weekly, 1.55), PCG cleaning the pacifier with juice/soda/honey or sweet drink (2.17), PCG daily sharing/tasting food with child using same spoon/fork/glass (1.32), PCG brushing their teeth less than daily (2.72), PCG's gums bleeding daily when brushing or PCG having no teeth (1.83-2.00), and PCG having cavities/fillings/extractions in past 2 y (1.55). A 10-item caries risk tool at age 1 shows good agreement with cavitated-level caries experience by age 4.

Mixed methods evaluation of an oral health education program for pediatric dental, medical and nursing providers

PURPOSE

To evaluate the application of knowledge, attitudes, and skills learned in an oral health education program among pediatric dental and medical residents, and pediatric and family nurse practitioners (PNPs and FNPs).

METHODS

A mixed methods study design included a year-end online survey and focus groups. Eighty participants completed the survey (94%) and seven focus groups were conducted (n = 69) representing each of the four cohorts in 2020-2022. Analysis of variance was used to assess differences in survey responses by dental/medical specialty. Focus group audio recordings were analyzed using Atlas.ti.22 to identify common themes.

RESULTS

The program increased knowledge and skills in oral health core competencies and positive attitudes regarding oral health education. All PNPs (100%) and most pediatric medical residents (94%) and FNPs (91%) strongly agreed/agreed that the oral health program led to an increase in screening for early childhood caries, more confidence in applying fluoride varnish and providing oral health anticipatory guidance during patient visits. Most pediatric medical residents, PNPs and FNPS (98%) strongly agreed/agreed that primary care providers should incorporate oral health into their practice and provide referrals to dental professionals as part of well-child visits.

CONCLUSIONS

The program improved oral health-related knowledge, attitudes and skills among dental and medical primary care providers. Future oral health education programs for health care professionals can use this model to help bridge the gap between dental and primary care and ultimately improve access to preventive oral health care for children and families.

Impact on Dental Utilization of the Integration of Oral Health in Pediatric Primary Care Through Quality Improvement

OBJECTIVES

To evaluate child-level dental utilization and expenditure outcomes based on if and where children received fluoride varnish (FV) at quality improvement (QI) medical practices, at non-QI medical practices, at dental practices, or those who never received FV from any practice.

DESIGN

Retrospective claims-based analysis cohort study.

SETTING

Children with Medicaid insurance through an Ohio pediatric accountable care organization.

PARTICIPANTS

Children aged 1 to 5 years with 1 or more well-child visits between 2015 and 2017.

INTERVENTION

FV receipt versus no FV. Among children who received FV, categorized if FV delivered by a QI-participating medical provider, a non-QI-participating medical provider, and a dental provider.

MAIN OUTCOME MEASURE

Dental claims from 2014 to 2019 were collected for preventive dental visits, caries-related treatment visits, dental general anesthesia (GA) visit, and emergency department visit for a dental problem to examine utilization patterns, expenditures, and dental outcomes.

RESULTS

The QI group had a significantly higher incidence of preventive dental visits than the dental (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI], 0.91-0.96) or non-QI groups (IRR = 0.86; 95% CI, 0.84-0.88). Compared with the QI group, the non-QI (adjusted odds ratio [aOR] = 2.6; 95% CI, 2.4-2.9) and dental (aOR = 2.9; 95% CI, 2.6-3.3) groups were significantly more likely to have caries-related treatment visits. The dental group children were significantly more likely to have dental treatment under GA than the QI group (aOR = 5.3; 95% CI, 2.0-14.4).

CONCLUSIONS

Children seen at QI practices appear to have an increased uptake of preventive dental services, which may explain the lower incidence of dental caries visits and GA treatment.

Medicaid Payment and Fluoride Varnish Application During Pediatric Medical Visits

All Medicaid programs pay for fluoride varnish applications during medical visits for infants and toddlers, but receipt of care varies considerably across states. Using 2006-2014 Medicaid data from 22 states, this study examined the association between Medicaid payment and receipt of fluoride varnish during pediatric medical visits. Among 3,393,638 medical visits, fewer than one in 10 visits included fluoride varnish. Higher Medicaid payment was positively associated with receipt of fluoride varnish during pediatric medical visits. As policymakers consider strategies for increasing young children's access to preventive oral health services, as well as consider strategies for balancing budgets, attention should be paid to the effects of provider payment on access to pediatric oral health services.

Incorporating Oral Health into Pediatric Practice: National Trends 2008, 2012, 2018

OBJECTIVE

Oral health is a critical component of children's overall health, but past research has found that pediatricians report barriers to implementing oral health into practice. Recently, policies have further delineated the importance of oral health in primary medical care. We sought to determine how pediatricians' practices and perceived barriers related to oral health involvement have changed since 2008.

METHODS

There have been 3 nationally representative, cross-sectional, oral-health-focused periodic surveys of US American Academy of Pediatrics (AAP) members who provide health supervision: in 2008 (n = 1104; response rate (rr) = 69%), 2012 (n = 646; rr = 48%), and 2018 (n = 485; rr = 48%). The surveys asked about frequency of performing oral health tasks in children 3 years and younger, self-rated ability to perform these tasks, and attitudes about and barriers to oral health involvement. Predicted values from separate multivariable logistic regression models examined the independent effect of survey year.

RESULTS

In 2018, pediatricians reported they were more likely to provide fluoride varnish and dental referrals at a younger age and less likely to complete a caries risk assessment or oral examination. They reported diminished barriers to incorporating oral health into pediatric practice. Other oral health activities, notably the oral screening examination and caries risk assessment, remain underutilized by pediatricians.

CONCLUSIONS

From 2008 to 2018, more pediatricians reported performing a range of oral health tasks with fewer reported barriers. Ongoing efforts are needed to increase pediatricians' attention to oral screening examinations and caries risk assessments for all pediatric patients beginning in infancy, and to promote further use of fluoride varnish.

Variation in prices for an evidence-based pediatric preventive service

OBJECTIVE

To examine variation in prices paid by private medical insurers for fluoride varnish applications in medical settings, a newly reimbursed service that few children receive.

DATA SOURCES

Private-insurance medical claims from Connecticut, Maine, New Hampshire, and Rhode Island (2016-2018).

STUDY DESIGN

We examined prices paid for fluoride varnish by private insurers and compared these to prices paid by Medicaid.

DATA COLLECTION/EXTRACTION METHODS

Private claims for fluoride varnish during medical visits for children aged 1-5 years. State Medicaid rates for fluoride varnish were obtained from the American Academy of Pediatrics.

PRINCIPAL FINDINGS

Prices paid for fluoride varnish by private insurers varied within and across states, ranging from less than $5 to $50. Median prices closely followed Medicaid rates in three of the four states. In states covering a package of fluoride varnish plus additional preventive oral health services during medical visits, combined Medicaid rates were nearly double the median price paid by private insurers.

CONCLUSIONS

Fluoride varnish is a recommended service, but few children receive it. Price variation may contribute to the low uptake of this service. Ensuring sufficient Medicaid and private insurance rates could increase fluoride varnish applications in medical settings and improve oral health.

Variation in Current Guidelines for Fluoride Varnish Application for Young Children in Medical Settings in the United States

Background

The United States Preventive Services Task Force recommends that medical providers apply fluoride varnish (FV) to the teeth of all children under 6 years of age, but fewer than 10% of eligible children receive FV as recommended. Prior studies suggest that variation in clinical guidelines is associated with low uptake of other evidence-based health-related interventions, but consistency of national guidelines for the delivery of FV in medical settings is unknown.

Methods

Eligible guidelines for application of FV in medical settings for children under 6 years of age were published in the past 10 years by national pediatric or dental professional organizations or by national public health entities. Guidelines were identified using the search terms fluoride varnish + [application; guidelines, or recommendations; children or pediatric; American Academy of Pediatrics (AAP); American Academy of Pediatric Dentistry] and a search of Guideline Central. Details of the guidelines were extracted and compared.

Results

Ten guidelines met inclusion criteria. Guidelines differed in terms of periodicity recommendations and whether FV was indicated for children with a dental home or level of risk of dental caries.

Conclusion

Numerous recommendations about FV delivery in medical settings are available to pediatric medical providers. Further study is warranted to determine whether the variation across current guidelines detected in this study may contribute to low FV application rates in medical settings.

Impact of state-level training requirements for medical providers on receipt of preventive oral health services for young children enrolled in Medicaid

OBJECTIVES

Young children enrolled in Medicaid make few dental visits and have high rates of tooth decay. To improve access to care, state Medicaid programs have enacted policies encouraging nondental providers to deliver preventive oral health services (POHS) in medical offices. Policies vary by state, with some states requiring medical providers to obtain training prior to delivering POHS. Our objective was to test whether these training requirements were associated with higher rates of POHS for Medicaid-enrolled children <6 years.

METHODS

This study took advantage of a natural experiment in which policy enactment occurred across states at different times. We used Medicaid Analytic eXtract enrollment and claims data, public policy data, and Area Health Resource Files data. We examined an unweighted sample of 8,711,192 (45,107,240 weighted) Medicaid-enrolled children <6 years in 38 states from 2006 to 2014. Multivariable logistic regression models estimated the odds a child received POHS in a calendar year. Results are presented as adjusted probabilities.

RESULTS

Five or more years after policy enactment, the probability of a child receiving POHS in medical offices was 10.7 percent in states with training requirements compared to 5.0 percent in states without training requirements (P = 0.01). Findings were similar when receipt of any POHS in medical or dental offices was examined 5 or more years post-policy-enactment (requirement = 42.5 percent, no requirement = 33.6 percent, P < 0.001).

CONCLUSIONS

Medicaid policies increased young children's receipt of POHS and at higher rates in states that required POHS training. These results suggest that oral health training for nondental practitioners is a key component of policy success.

A systematic review to inform the development of a Canadian caries risk assessment tool for use by primary healthcare providers

BACKGROUND

Caries risk assessment (CRA) tools may assist in identifying children at risk of early childhood caries.

AIM

To complete a systematic review of CRA and develop a Canadian CRA tool for preschool children for use in non-dental clinical settings.

DESIGN

Systematic searches of relevant databases were conducted. Potential variables were based on strength of associations (odd ratios, relative risk, hazard ratios, etc), frequency of occurrence, and existing CRA tools. Quality of the evidence assessments were performed by at least two review teams through consensus following GRADE.

RESULTS

Overall, 25 publications met the inclusion criteria, all prospective in design. Based on this review, variables to be considered when developing a new CRA tool for use with preschool children are as follows: age, socioeconomic status, family toothbrushing habits, fluoride exposure, infant feeding practices, dietary habits/behaviours, dental home, caries experience, visible plaque, and enamel defects. The environmental scan identified 22 CRA tools suggesting other additional variables to consider including in a CRA tool, including special healthcare needs, enamel defects, and dental attendance.

CONCLUSIONS

This review informed the development of a Canadian CRA tool for use by primary healthcare professionals, which may improve access to oral health assessments and increase interprofessional collaboration.

Assessment of medical practitioners' knowledge about paediatric oral diagnosis and gaze patterns using eye tracking technology

BACKGROUND

Most studies regarding the oral health knowledge of medical practitioners are based on surveys.

AIM

To assess medical practitioners' knowledge in diagnosing and managing children oral health issues using eye tracking technology.

DESIGN

Forty-one medical practitioners completed a cross-sectional survey questionnaire and subsequently viewed 5 clinical images of children's oral cavities to indicate the issues observed and their management. Tobii eye tracking device captured each participant's visual search behaviours and mean length of fixation (LOF) for each area of interest (AOI). Participant self-reported confidence in examining the oral cavity, and qualification level was recorded for data analysis.

RESULTS

No correlation between time spent viewing the soft tissues and self-reported confidence examining the oral cavity was observed (P = .25). Self-reported confidence in examining the oral cavity was not associated with a correct diagnosis. LOF on the decayed teeth was significantly associated with a correct diagnosis of 'caries' (P < .05), and paediatric training was associated with a correct diagnosis of dental caries (P < .05).

CONCLUSION

Medical practitioners' diagnosis and management were poorly correlated with their objective visual search behaviours of the intraoral images. Self-reported confidence in examining and managing oral issues was not correlated with a correct diagnosis, with the majority not confident of examining children oral cavity.

An Ecological Model to Frame the Delivery of Pediatric Preventive Care

Screening and surveillance are integral aspects of child health promotion and disease prevention. The American Academy of Pediatrics recommends that primary care clinicians screen children and adolescents for a broad array of conditions, conduct surveillance of growth and development, identify social determinants of health, and identify protective and risk factors that might impact health over time. However, access to and outcomes of preventive services vary based on features of children’s social ecology, including family and community contexts. The proposed five-stage socio-ecological model considers multiple contextual dimensions of pediatric screening: (1) individual, (2) interpersonal, (3) organizational, (4) community/population, and (5) public policy. Incorporating this model into routine care might improve outcomes at the individual and population level. Future endeavors should focus on integration of this model with validated risk screening tools as part of a supportive electronic health record, culture, and incentive structure. Further research assessing the contributors and outcomes of differences in beliefs, resources, practices, and opportunities among individuals, families, providers, primary care organizations, communities, health systems, and policy partners will be essential in advancing knowledge and policies to improve preventive services delivery.

Racial/Ethnic Differences in Receipt of Oral Health Services in Medical and Dental Offices: Impact of Medicaid Policies on Young Children

Purpose: The purpose of this study was to examine receipt of preventive oral health services (POHS) by race/ethnicity for young Medicaid-enrollees following the enactment of state policies enabling medical providers to deliver POHS. Methods: Using Medicaid data (2006 to 2014) from 38 states for 8,711,192 child-years (aged six months to five years), logistic regressions were used to examine differences within and between racial/ethnic groups (white, black, Hispanic, and "other" race/ethnicity groups) in terms of adjusted probabilities of receiving POHS in medical offices or any medical or dental offices. Models were adjusted for years since policy enactment and estimated separately for states with and without requirements that medical providers obtain POHS training. Results: Receipt of any POHS was 10.9 percentage points higher for Hispanic children and 4.7 percentage points higher for "other" race/ethnicity group children than white children after five or more years of policy enactment in states with training requirements (P<0.05). Findings for medical POHS and states without training requirements were similar but smaller in magnitude. Conclusions: Hispanic and "other" race/ethnicity group children benefitted more from the integration of POHS into medical offices than white children. Policies enabling delivery of POHS in medical offices increased receipt of POHS among some minority groups and may help to reduce disparities.

Evaluation of an interprofessional education program in pediatric dentistry, medicine, and nursing

PURPOSE

The purpose of this study was to assess whether the Strategic Partnership for Interprofessional Collaborative Education in the Pediatric Dentistry (SPICE-PD) program at the UCLA School of Dentistry positively affected interprofessional experiences and practice patterns of pediatric and general dentistry residents, pediatric medical residents, and pediatric nurse practitioner students (PNPs).

METHODS

Data collection included a year-end online survey given to participants in the interprofessional program upon graduation from their UCLA dental/medical/nursing programs. Of the 318 participants who were recruited into SPICE-PD, 208 (65%; 208/318) completed the survey. Chi-square tests were used to assess differences in key outcome variables by dental/medical specialty.

RESULTS

Most dental, medical, and nursing participants thought SPICE-PD helped them learn to work more effectively with interprofessional colleagues and reported knowing more about the abilities and contributions of other health professionals as a result of the program. While most pediatric medical residents and PNPs thought SPICE-PD improved their skills to screen for early childhood caries (N = 91% and N = 100%), PNPs were more likely than pediatric medical residents to report SPICE-PD improved their skills to apply fluoride varnish (98% versus 72%; p < 0.001). Almost all pediatric medical residents and PNPs thought primary care providers should incorporate oral health into routine patient care and provide referrals to dental professionals when necessary.

CONCLUSION

Increased interprofessional education and coordination of care through programs such as SPICE-PD can help bridge the gap between dental and medical care and lead to improved oral health outcomes and more comprehensive and preventive patient care.

The Impact of COVID-19 on Preventive Oral Health Care During Wave One

Introduction: Early childhood caries burdens children, their families, and the health care system. Utilizing fluoride varnish at medical well-child visits with non-dental primary care providers can be an interprofessional strategy to combat early childhood caries. The COVID-19 pandemic dramatically altered preventive health care delivery and the effects on preventive oral health care delivery have not been previously described.

Methods: This analysis used descriptive statistics and non-parametric Wilcoxon Mann-Whitney tests to compare preventive oral health utilization among 1 to 5-year old children in two state Medicaid agencies before and during the pandemic. Fluoride utilization rates at dental visits and medical well-child visits were calculated as number of users per 1,000 enrolled children. Additionally, the proportion of well-child visits that included fluoride application was calculated for each state.

Results: During the pandemic, the quarterly fluoride utilization rate significantly decreased at dental visits (pre-pandemic = 153.5 per 1,000 enrolled children; pandemic = 36.1 per 1,000 enrolled children, p &lt; 0.001) and signficantly decreased at medical well-child visits (pre-pandemic = 72.2 per 1,000 enrolled children; pandemic = 32.3 per 1,000 enrolled children, p = 0.03) during the pandemic.

Conclusions: The findings highlight the importance of interprofessional collaboration among non-dental primary care providers and dental providers to provide access to preventive oral health services, particularly when access to dentists is limited. Future directions might include rigorous evaluations of co-located medical and dental services or the use of interprofessional telehealth technologies.

Evaluation of a community-based early childhood caries (ECC) intervention in Cambodia

OBJECTIVE

To critically evaluate an early childhood caries (ECC) intervention performed by non-dental primary healthcare providers.

METHODS

This mixed-methods investigation includes data from three sources: (a) a pilot non-randomized controlled trial to examine clinical outcomes at four health centres; (b) stakeholder focus group interviews; and (c) a survey of parents whose children were exposed to the intervention. The pilot study involved four Community Health Centres in rural Cambodia whereby mother-child (6-24 months of age)dyads received oral health education (OHE), toothbrushes, fluoride toothpaste and fluoride varnish on up to six occasions as part of the routine vaccination schedule. Outcomes were as follows: presence of ECC; impacts on oral health-related quality of life (OHRQoL); stakeholder perceptions of intervention delivery; and parental perceptions of fluoride varnish.

RESULTS

Participants in the intervention group had six times lower odds of developing ECC than those in the comparison group after controlling for socio-economic status (OR 0.13). Those in the intervention group also had a large reduction OHRQoL scale scores. Key knowledge and practice gaps were identified among stakeholders. Surveyed parents had favourable views of the fluoride varnish placement by medical professionals, and four out of five stated that they would recommend fluoride varnish for other children. Primary healthcare providers, commune council representatives and community health promoters supported oral health interventions being provided in CHCs.

CONCLUSIONS

OHE and fluoride varnish interventions provided by non-dental primary health workers were feasible and acceptable for stakeholders in a Cambodian setting. The intervention group had lower ECC experience and better OHRQoL at 2 years of age.

Awareness among pediatricians regarding oral health care in children including those with special health care needs: A cross- sectional survey

Background:

Pediatricians are the custodians of the overall health of children and are the ideal healthcare personnel to impart information and instruction about oral health care. The aim of this survey was to evaluate awareness of pediatricians regarding oral health care and prevention of oral diseases in children.

Methodology:

The study participants consist of 102 young pediatricians working as Junior and Senior Residents. A questionnaire was formulated to evaluate their knowledge about oral diseases and their prevention. The questionnaire also tested the attitude and practices of pediatricians towards oral health of children with special health care needs.

Results:

Majority of the pediatricians had correct knowledge about dental caries (60%), bottle feeding (88.2%), tongue cleaning (83.3%) and medication causing gum enlargement (92.2%). Few had correct knowledge about recommended age to start tooth brushing (35.3%) and maximum recommended sugar exposures per day (35.3%). Although, majority (62.7%) had correct knowledge about fluoride and its role caries prevention, very few (2.9%) knew about recommended fluoride concentration in toothpaste for children.

Conclusion:

There was a lack of knowledge amongst pediatrician about oral health care, prevention, and appropriate referral. The study result necessitates the emphasis of improving oral health related knowledge among pediatrician.

Formative and Pilot Study for an Effectiveness-Implementation Hybrid Cluster Randomized Trial to Incorporate Oral Health Activities into Pediatric Well-Child Visits

Background: Dental caries in pediatric patients are noted to have broad impacts on systemic health and well-being. Thus, utilizing an effectiveness-implementation hybrid I design, the Pediatric Providers Against Cavities in Children's Teeth (PACT) trial is investigating multi-level interventions at the practice (incorporation of oral health in electronic medical record [EMR]) and provider levels (theory-based didactic and skills training to communicate oral health facts to parent/caregiver, give a prescription to see a dentist and a list of area dentists) to increase dental utilization among 3 to 6 year old Medicaid-enrolled children attending well-child visits (WCV). The formative and pilot work for the larger main trial are presented. Methods: Formative work-Focus groups with 26 participants (Community leaders, providers, parent/caregivers); and key informant interviews with practice leadership (n = 4). Topics discussed were: core oral health (OH) information to communicate at WCVs and study logistics. Transcripts were coded and analyzed using Atlas.ti; Pilot study was refined using the formative findings and was conducted at two pediatric practices to test the implementation of: the provider didactic and skills training curriculum; EMR incorporation of four OH questions; logistics of incorporating OH activities at a WCV; and parent/caregiver recruitment. Results: Formative work showed that providers and parent/caregivers required knowledge of dental caries, and a list of area Medicaid-accepting dentists. Providers and practice leadership advised on the logistics of incorporating oral health into WCVs. All groups suggested asking parent/caregivers their preferred method of contact and emphasizing importance of OH to motivate participation. Utilizing these findings, the curriculum and protocol was revised. The pilot study in two practices successfully implemented the protocol as follows: all seven providers were trained in two 45 min didactic education and skills session; incorporation of OH questions into practices EMR; recruited 86 child-parent dyads (95% participation) at the WCV; providers delivered the OH intervention to parent/caregivers in <2 min and 90% completed EMR documentation of OH questions. These findings were instrumental in finalizing the main PACT trial in 18 practices. The RE-AIM framework is used in the main trial to collect effectiveness and implementation measures at baseline and follow-up visits. Conclusions: The formative and pilot findings were instrumental in refining the OH intervention and protocol which has resulted in successful implementation of the main trial. Trial Registration: Clinical trials.gov, Registered 9 November 2017, NCT03385629.

The knowledge and practice of pediatricians in children's oral health: a scoping review

BACKGROUND

Dental caries is a significant public health problem and one of the most common chronic conditions affecting children. The potential for the non-dental workforce to improve children's oral health is well documented. For well over a decade, there have been calls for pediatricians to address children's oral health, but the incorporation of oral health screening, referral, and oral healthcare in pediatric practice remains underdeveloped. Developing action to strengthen the role of pediatricians' in children's oral health requires an understanding of their current knowledge and practice. In this scoping review, we aimed to comprehensively map what is known about the knowledge and practice of pediatricians regarding children's oral health.

METHODS

Arksey & O'Malley's five-stage review process was used to comprehensively map studies undertaken on pediatrician's knowledge and practice regarding children's oral health. Key search terms were developed and a total of 42 eligible articles are included in the review.

RESULTS

The studies were conducted in 19 countries. The majority (41/42) were quantitative, with over 90% using self-reported surveys. Only four studies used previously validated survey tools, with most adapting questions from previous studies. Observational designs were used in two studies and one used qualitative methods. Sample size ranged from 15 to 862. Oral health knowledge amongst pediatricians was reported to be mostly poor, with many gaps in key areas including age for first dental visit, dental caries and oral health risk assessments. Studies on the translation of oral health knowledge to practice were limited, with wide variation in rates of assessment. Few studies assessed actual practice.

CONCLUSIONS

This scoping review highlights growing international interest in the role of pediatricians in children's oral health. Findings demonstrate that pediatricians have limited knowledge and understanding in critical areas, including; initial clinical signs of dental caries, recommended age for first dental visit, etiology of dental caries and recommended use of fluorides. Barriers for pediatricians include inadequate education and training, time constraints in practice and lack of referral pathways. Development of a validated tool to assess knowledge and practice is needed. This review provides a starting point to guide future research and areas for systematic reviews.

Implementation science: Changing practice in oral health

Caries remain the most common preventable chronic childhood disease. One state oral health program including fluoride varnish showed a decrease in presence of decay and improvement in overall oral health; however, early childhood caries did not improve. Implementation of an oral health preventive program during well-child medical visits may address this gap.

Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits?

In the United States, state Medicaid programs pay for medical and dental care for children from low-income families and support nondental primary care providers delivering preventive oral health services (POHS) to young children in medical offices ("medical POHS"). Despite the potential of these policies to expand access to care, there is concern that they may replace dental visits with medical POHS. Using Medicaid claims from 38 states from 2006 to 2014, we conducted a repeated cross-sectional study and used linear probability regression to estimate the association between the annual proportion of children in a county receiving medical POHS and the probability that a child received 1) dental POHS and 2) a dental visit in a given year. Models included county and year fixed effects and controlled for child- and county-level factors, and standard errors were clustered at the state level. In a weighted population of 45.1 million child-years (age, 6 mo to <6 y), we found no significant nor substantively important association between the proportion of children in a county receiving medical POHS and the probability that a child received dental POHS or a dental visit. Additionally, we found an almost zero probability (<0.001) that the reduction in dental POHS was at least as large as the expansion in medical POHS (full substitution) and a 0.50 probability that increased medical POHS was associated with an increase in dental POHS of at least 6.6% of the expansion of medical POHS. Results were similar when receipt of dental visits was examined. This study failed to find evidence that medical POHS replaced dental visits for young children enrolled in Medicaid and, in fact, offers evidence that increased medical POHS was associated with increased utilization of dental care. Given lower-than-desired rates of dental visits for this population, delivery of medical POHS should be expanded.

Working collaboratively across schools to promote oral health education through interprofessional education

PURPOSE

The Association of American Medical Colleges and American Dental Education Association have identified oral health knowledge, skills, and attitudes shared by both medical and dental professionals. Although oral health was deemed an essential competency for medical practitioners, our state struggled to ensure learners received proper training. This training deficit resulted in conducting a needs assessment and implementing an oral health interprofessional module at our schools.

METHODS

First-year medical students and clinical faculty were emailed surveys in 2016 to obtain baseline information. A team of faculty and students from the Schools of Medicine and Dentistry reviewed the curriculum to determine where to augment oral health content. An oral health module to teach a basic head, neck, and oral examination to first-year medical students during their patient-centered care small-group sessions was implemented and evaluated.

RESULTS

Only 13.6% of faculty respondents were aware of national oral health competency recommendations, and <50% rated oral health important for primary care physicians (PCPs) to include in history, physical exam, or oral health counseling. On baseline, ≤25% of PCP respondents reported integrating the listed skills in their practice, and most indicated lacking expertise to teach oral health. Teaching sessions were rated helpful by students and faculty. After the teaching sessions, ratings on the importance of including oral health significantly increased from baseline.

CONCLUSION

Collaboration between Schools of Dentistry and Medicine successfully integrated oral health into medical school curriculum and improved the tutors' attitudes of its importance.

Impact of a Medicaid policy on preventive oral health services for children with intellectual disabilities, developmental disabilities, or both

BACKGROUND

Integrating preventive oral health services (POHS) into medical offices may ease access to care for children with intellectual and developmental disabilities (IDD). The authors examined the impact of state policies allowing delivery of POHS in medical offices on receipt of POHS among Medicaid enrollees with IDD.

METHODS

The authors used 2006 through 2014 Medicaid data for children with IDD aged 6 months through 5 years from 38 states. IDD were defined using 14 condition codes from Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse. The length of the state's medical POHS policy (no policy, < 1 year, 1 year, 2 years, 3 years, or ≥ 4 years) was interacted with an indicator that the child was younger than 3 years. The authors used logistic regression models to estimate the likelihood that a child received POHS in a medical office or in a medical or dental office in a given year.

RESULTS

Among 447,918 children with IDD, 1.6% received POHS in medical offices. Children younger than 3 years in states with longer-enacted policies had higher rates of receiving POHS. For example, the predicted probability of receiving POHS was 40.6% (95% confidence interval, 36.3% to 44.9%) for children younger than 3 years in states with a medical POHS policy for more than 4 years compared with 30.6% (95% confidence interval, 27.8% to 33.5%) for children in states without a policy.

CONCLUSIONS

State Medicaid policies allowing delivery of POHS in medical offices increased receipt of POHS among Medicaid-enrolled children with IDD who were younger than 3 years.

PRACTICAL IMPLICATIONS

Few children with IDD receive POHS in any setting. Efforts are needed to reduce barriers to POHS for publicly insured children with IDD.

Implementing Pediatric Fluoride Varnish Application in a Rural Primary Care Medical Office: A Feasibility Study

INTRODUCTION

The objective of this study was to determine if the application of fluoride varnish (FV) to children 5 years and under was acceptable and practical for health care providers in a rural primary care office.

METHODS

We employed a quasi-experimental study design comprised of providers who received education and training in FV application. Pre- and post-study surveys regarding barriers and facilitators were administered. Data was collected on the number of FV applications, time spent on procedure, perceived barriers, and overall cost.

RESULTS

The total direct variable cost of providing FV was $4.35 per procedure, resulting in an $11.85 profit. FV application increased 9.57%. Potential barriers were lack of proper supplies, lack of adequate support staff, and lack of additional financial compensation for providers.

DISCUSSION

FV application is a service that can be delivered in a rural practice with existing resources, but the initiative needs support from practice management.

Oral health care: The experience of Australian paediatricians

AIM

Many Australian children have dental decay in their deciduous teeth. Poor oral health can negatively impact a child's ability to eat, speak, sleep and socialise, with adverse impacts later in life. Paediatricians are well placed to examine children's teeth and to provide advice and education about oral health. Using a sample of Australian paediatricians, we aimed to determine: (i) self-reported oral health knowledge and skills, (ii) frequency of office-based oral health-related discussions, (iii) perceived role of paediatricians and (iv) barriers to oral health-related discussions.

METHODS

Members of a national network of paediatricians - the Australian Paediatric Research Network - completed a multi-topic survey, which included questions designed to assess oral health knowledge, current practice and barriers to oral health-related discussions.

RESULTS

Of 430 active members, 178 (41%) completed the survey. Few paediatricians reported very good/excellent ability to assess plaque build-up (8%) and dental caries (17%). Only 10% reported broaching the issue of oral health with all patients. Significant barriers included lack of professional training (52%) and other more pressing issues needing to be addressed (67%).

CONCLUSIONS

The increasing (and inequitable) rates of dental decay in Australian children mean that paediatricians should play a key role in the management of children's oral health. Many paediatricians reported a lack of specific training in oral health and limited ability to assess children and educate families. Despite the traditional divide between medicine and oral health, this study highlights the opportunity for Australian paediatricians to improve oral health through early intervention in the consultation room and beyond.

Cost-Savings of Fluoride Varnish Application in Primary Care for Medicaid-Enrolled Children in Virginia

OBJECTIVES

To determine the cost-benefit of fluoride varnish application during pediatric well-visits for the Medicaid/Children's Health Insurance Program population in Virginia (VA) from a Medicaid payer perspective. To provide initial cost estimates from the primary care provider (PCP) perspective.

STUDY DESIGN

A systematic search of recent literature was completed to obtain input data for a Monte Carlo cost-benefit simulation and for the fluoride varnish application time, labor, and materials costs for PCPs. The analysis was conducted from a Medicaid perspective; costs and savings related to fluoride varnish application in primary dentition through 7.5 years were calculated for all Medicaid-eligible children up to 3 years of age in VA. Sensitivity analysis was performed to mitigate the effects of parameter uncertainty.

RESULTS

Delivering fluoride varnish to all children <3 years old in VA who annually receive well-visits through Medicaid but did not receive fluoride varnish at those visits would reduce the percent of 7.5 year olds with decay from 63.2% to 39.8%. Accounting for averted restoration cost, PCP fluoride varnish application would save $75.32 per child, or a total population savings of almost $2 million/year for VA Medicaid. From the PCP perspective, the Medicaid reimbursement rate for fluoride varnish is 3.8-12.0 times the direct fluoride varnish application cost (labor and materials).

CONCLUSIONS

Application of fluoride varnish by a PCP to children under 3 years of age is cost-saving in this study population. Costs to provide fluoride varnish from the PCP perspective are favorable compared with the Medicaid reimbursement, but additional studies on optimizing fluoride varnish application into the well-visit workflow are needed.

Pediatricians' awareness on orthodontic problems and related conditions-a national survey

Background

Correction of dentofacial deformities via orthodontics is an integral part of oral health as promotes optimal function, periodontal health, aesthetics and overall oral health-related quality of life. The aim of this study was to examine whether paediatricians refer their patients to orthodontists, whether they have sufficient knowledge in basic orthodontic principles and whether they examine their patients for orthodontic abnormalities.

Results

We conducted a survey study of paediatricians in Greece. Questionnaires were completed by 96 out of 123 paediatricians (response rate 78%). In the assessment of the examination of the oral cavity, a low frequency of examination of the position of the teeth (54%) and jaws (51%) was found. Reasons paediatricians referred patients to specialists varied from mouth breathing-snoring 24% (23/96) to face or teeth asymmetry 87% (84/96). In the multivariable analyses for the effect of gender, work sector or years of experience in the decision for orthodontic referral, we could not identify any significant predictors.

Conclusions

The results of this study indicate that there was variability regarding orthodontic knowledge among paediatricians. Although the majority were aware of the importance of examination of the oral cavity, they did not have the appropriate knowledge to perform a full and systematic screening for orthodontic problems. The probability of referral was different for the various orthodontic anomalies.

A Clinical Vignette-Based Study of Physicians' Adherence to Guidelines for Dental Referrals of Young Children

OBJECTIVES

The American Academy of Pediatrics (AAP) recommends an oral health risk assessment and referral to a dental home by a child's first birthday. We evaluated the adherence of primary care providers (PCPs) to AAP dental referral guidelines for children age <4 years and barriers to implementation of these guidelines.

METHODS

A cross-sectional survey of PCPs randomly selected from the 435 practices in North Carolina identified as providing well-child visits for Medicaid children age <4 years was completed in 2013. The PCPs' referral recommendations were assessed using 4 vignettes of 18-month-old children at various risk of dental caries (low, moderate, high, or highest) and different levels of dentist supply (adequate or inadequate). Barriers to guideline adherence specified in the Cabana framework were analyzed for their associations with PCP adherence, using logistic regression models stratified by caries risk and dentist supply.

RESULTS

The survey yielded 219 (50%) usable responses from the sample of 435 PCPs. On average for all vignettes, 61% of providers chose a referral recommendation in agreement with guidelines. Underreferral averaged 40%. With adequate workforce, guideline-adherent responses varied from 26% for low-risk children to >90% for high-risk children. An inadequate workforce reduced adherence for most levels of risk. Generally, correct knowledge of risk status, barriers to risk assessment, and pediatric practice were associated with adherence, but not always in the hypothesized direction.

CONCLUSIONS

PCPs' adherence to referral guidelines varies according to caries risk and dentist supply, but generally they underrefer low- to moderate-risk patients by a significant degree.

Delivery of Preventive Oral Health Services by Rurality: A Cross-Sectional Analysis

PURPOSE

Integrating oral health care into primary care has been promoted as a strategy to increase delivery of preventive oral health services (POHS) to young children, particularly in rural areas where few dentists practice. Using a multistate sample of Medicaid claims, we examined a child's odds of receiving POHS in a medical office by county rurality.

METHODS

We used 2012-2014 Medicaid Analytic extract claims data for 6,275,456 children younger than 6 years in 39 states that allowed Medicaid payment for POHS in medical offices. We used county-level characteristics from the Area Health Resources Files, including a 3-level measure of county rurality. We used logistic regression to estimate a child's odds of receiving POHS in a medical office by county rurality, while controlling for other patient and county characteristics.

FINDINGS

POHS in medical offices were received by 7.8% of children. Rates of POHS in medical offices were higher in metropolitan (metro) counties (8.4%) than nonmetro adjacent to metro (5.8%) and nonmetro not adjacent to metro (4.3%). In adjusted analysis, children living in nonmetro not adjacent to metro (OR = 0.79, 95% CI: 0.64-0.99) and adjacent to metro counties (OR = 0.70, 95% CI: 0.59-0.82) were significantly less likely to receive POHS in medical offices than children living in metro counties.

CONCLUSIONS

In this study of POHS in medical offices among young Medicaid-enrolled children, we found POHS rates were lowest in nonmetro counties. Given barriers to dental care in rural areas, states should take additional steps beyond allowing Medicaid reimbursement to increase delivery of POHS in medical offices.

Impact of Medicaid Policy on the Oral Health of Publicly Insured Children

Objective Fluoride varnish (FV) applications among non-dentist primary care providers has increased due to state Medicaid policies. In this study we examine the impact of FV policies on the oral health of publicly insured children aged 2-6 years old. Methods Using three waves of the National Survey of Children's Health (2003, 2007, 2011/12), we used a logistic regression model with state and year fixed effects, adjusting for relevant child characteristics, to examine the association between years since a state implemented a FV policy and the odds of a publicly insured child having very good or excellent teeth. We compared children with public insurance in states with FV policies to children with public insurance in states without FV policies, controlling for the same difference among children with private insurance who were unlikely to be affected by Medicaid FV policies. Results Among 68,890 children aged 2-6 years, 38% had public insurance. Compared to privately insured children, publicly insured children had significantly lower odds of having very good or excellent teeth [odds ratio (OR) 0.70, 95% CI 0.62-0.81]. Publicly insured children in states with FV policies implemented for four or more years had significantly greater odds of having very good or excellent teeth (OR 1.28, 95% CI 1.03-1.60) compared to publicly insured children in states without FV policies. Conclusions for Practice State policies supporting non-dental primary care providers application of FV were associated with improvements in oral health for young children with public insurance.

Fluoride Use in Health Care Settings: Association with Children's Caries Risk

Expanded partnership with the medical community is an important strategy for reducing dental caries disparities. The purpose of this study was to assess the relationship between fluoride (F) "in office" (drops/tablets and/or varnish), as prescribed or applied by a health care professional by age 1 y, and 1) caries development and 2) presence of other caries risk factors or mediators (e.g., socioeconomic status). Child-primary caregiver (PCG) pairs ( N = 1,325) were recruited in Indiana, Iowa, and North Carolina as part of a longitudinal cohort study to validate a caries risk tool for primary health care settings. PCGs completed a caries risk questionnaire, while children received caries examinations per the criteria of the International Caries Detection and Assessment System at ages 1, 2.5, and 4 y. Baseline responses regarding children's history of F in office were tested for association with other caries risk variables and caries experience at ages 2.5 and 4 y via generalized estimating equation models applied to logistic regression. The sample was 48% female, and many children (61%) were Medicaid enrolled. The prevalence of cavitated caries lesions increased from 7% at age 2.5 y to 25% by age 4 y. Children who received F in office were likely deemed at higher caries risk and indeed were significantly ( P < 0.01) more likely to develop cavitated caries lesions by ages 2.5 and 4 y, even after F application (odds ratios: 3.5 and 2.3, respectively). Factors significantly associated with receiving F included the following: child being Medicaid enrolled, not having an employed adult in the household, child and PCG often consuming sugary drinks and snacks, and PCG having recent caries experience. Increased F in office from a health care provider by age 1 y was associated with known caries risk factors. Most (69%) children had never been to the dentist, suggesting that risk factors could be alerting medical providers and/or parents, thereby affecting in-office F recommendations. Differences among states could also be related to state-specific F-varnish reimbursement policies (ClinicalTrials.gov NCT01707797).

Implementing an early childhood oral health program in a federally qualified health center in North Carolina

OBJECTIVES

To examine the Baby Oral Health Program's (bOHP) influence on dental visits for children 0 to 3 years and overall dental visits in four federally qualified health center (FQHC) clinics.

METHODS

Using an interrupted time series study design, administrative data were obtained for the year prior and following the intervention. The intervention included dental staff training on early childhood oral health, quality improvement, and monthly visits during the follow-up intervention period. Analysis included descriptive and segmented regression using aggregate patient visit data.

RESULTS

A total of 10,400 patients made 26,416 visits over the study period; 1,187 (11 percent) were children ≤3 years. Visit counts in the youngest age group increased 70 percent following the intervention. When controlling for the naturally increasing trend, the intervention added 8.7 (95 percent CI: 4.7, 12.8) early childhood patient-visits per clinic in the last month of the intervention period. The increase in visit counts in the youngest age group had no significant effect on other ages, except for a decline relative to the natural trend in patient-visits among 35-50 year olds (-32.3 less visits) following the intervention. The proportion of visits for all ages by ≤3 year olds increased from 5 to 8 percent following the intervention.

CONCLUSIONS

bOHP increased dental visits among children ≤3 years but the finding might be attributable to clinic changes coinciding with bOHP implementation that were not controlled with the study design. Additional studies are needed in populations experiencing challenges accessing dental care.

Fluoride varnish application, a quality improvement project implemented in a rural pediatric practice

OBJECTIVES

The United States has a public health crisis of dental caries in children's primary teeth. Fifty-five percent of children have dental caries by age 8. The majority of these children are nonwhite and poor. Caries could be decreased by 40% if fluoride varnish (FV) application started with tooth eruption.

DESIGN AND SAMPLE

A four-month FV application QI project was implemented in a rural pediatric practice. The staff was trained by the Vermont Department of Health using the From the First Tooth protocol. Children aged 9, 18, 24, and 30 months.

MEASURES

Pre- and postproject questionnaires were completed. A caries risk tool assessed a child's risk and access to dental care. Completed FV applications were recorded and staff interviewed weekly.

INTERVENTION

FV application was offered at well child checks (WCCs).

RESULTS

Fifty-six percent of sample patients received FV at their WCCs. Qualitative themes included the following: reasons subjects did/did not receive FV, ease of FV application, increased oral hygiene education, visit flow, application time, older children's FV need, and billing issues.

CONCLUSION

This economical, FV application program can be readily implemented by nurse practitioners and nurses in pediatric practices where children have inadequate dental care.

Promoting Oral Health in Childhood: A Quality Improvement Project

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends periodic oral health risk assessments (OHRAs) for young children to prevent early childhood caries and promote oral health. The objective of this quality improvement project was to incorporate OHRAs, including documentation of the oral screening examination, into well-child visits for patients aged 12 to 47 months to drive (1) improved rates of preventive fluoride varnish (FV) application and (2) improved dental referrals for children at high risk for caries.

METHODS

We identified a quality gap in our OHRAs, oral examination completion, FV application rates, and dental referral rates via retrospective data collection. Plan-Do-Study-Act cycles targeted modification of electronic medical record templates, oral health education, and standardization of work processes. Process and outcome measures were analyzed with statistical process control charts.

RESULTS

At baseline, OHRAs and oral screening examinations were documented in <2% of patients. Of eligible children, 42% had FV applied. Routine dental referrals before age 3 years were uncommon. After multiple Plan-Do-Study-Act cycles, documentation of OHRAs and oral screening examinations (process measures) improved to 45% and 73%, respectively. The primary outcome measure, FV rates, improved to 86%. Referral of high-risk patients to a dentist improved to 54%.

CONCLUSIONS

A systematic, evidence-based approach to improving oral health, including electronic medical record-based interventions, resulted in improved documentation of oral health risks and oral screening, improved rates of FV application in young children, and increased identification and referral of high-risk patients.

Providers' preferences for pediatric oral health information in the electronic health record: a cross-sectional survey

BACKGROUND

The majority of primary care physicians support integration of children's oral health promotion and disease prevention into their practices but can experience challenges integrating oral health services into their workflow. Most electronic health records (EHRs) in primary care settings do not include oral health information for pediatric patients. Therefore, it is important to understand providers' preferences for oral health information within the EHR. The objectives of this study are to assess (1) the relative importance of various elements of pediatric oral health information for primary care providers to have in the EHR and (2) the extent to which practice and provider characteristics are associated with these information preferences.

METHODS

We surveyed a sample of primary care physicians who conducted Medicaid well-child visits in North Carolina from August - December 2013. Using descriptive statistics, we analyzed primary care physicians' oral health information preferences relative to their information preferences for traditional preventive aspects of well-child visits. Furthermore, we analyzed associations between oral health information preferences and provider- and practice-level characteristics using an ordinary least squares regression model.

RESULTS

Fewer primary care providers reported that pediatric oral health information is "very important," as compared to more traditional elements of primary care information, such as tracking immunizations. However, the majority of respondents reported some elements of oral health information as being very important. Also, we found positive associations between the percentage of well child visits in which oral health screenings and oral health referrals are performed and the reported importance of having pediatric oral health information in the EHR.

CONCLUSIONS

Incorporating oral health information into the EHR may be desirable for providers, particularly those who perform oral health screenings and dental referrals.

Pregnant Women's Infant Oral Health Knowledge and Beliefs: Influence of Having Given Birth and of Having a Child in the Home

Introduction Prenatal oral health interventions can positively impact maternal and child oral health, yet limited information exists concerning how to best educate pregnant women about infant oral health. Our objective was to examine the influence of having given birth on pregnant women's infant oral health knowledge and beliefs. Methods We conducted a secondary analysis of data collected from a cross-sectional survey of pregnant women ≥18 years old attending UNC's Ultrasound Clinic. Four binomial items were categorized as infant knowledge (IK) and five rated on a Likert scale (1-5) as infant belief (IB). Overall IK and IB scores were calculated, averaging the items within each construct. Respondents were categorized into two groups: multiparous (N = 268), women having at least one previous live birth and a child between 2 and 6 years old, or nulliparous (N = 186), women with no previous live births or a child between 2 and 6 years old. Regression models for IK and IB were conducted using SAS 9.2 with maternal demographic characteristics, dental utilization, and birth history as explanatory variables (p ≤ 0.05). Results IK was affected by race (p = 0.04), mother's oral health self-rating (p = 0.0002), and birth history (p < 0.0001). On average, IK was 0.12 units higher in subjects with a history of giving birth, adjusting for explanatory variables. IB was influenced by maternal oral health beliefs (p = 0.002) and history of access to dental care (p = 0.0002). IB did not differ based on birth history (p = 0.17). Discussion The influence of birth history on pregnant women's infant oral health knowledge and beliefs can be considered in future intervention designs to maximize available resources.

Electronic Immunization Alerts and Spillover Effects on Other Preventive Care

The impact of electronic health record (EHR) immunization clinical alert systems on the delivery of other preventive services remains unknown. We assessed for spillover effects of an EHR immunization alert on delivery of 6 other preventive services, in children 18 to 30 months of age needing immunizations. We conducted a secondary data analysis, with additional primary data collection, of a randomized, historically controlled trial to improve immunization rates with EHR alerts, in an urban, primary care clinic. No significant differences were found in screening for anemia, lead, development, nutrition, and injury prevention counseling in children prompting EHR immunization alerts (n = 129), compared with controls (n = 135). Significant increases in oral health screening in patients prompting EHR alerts (odds ratio = 4.8, 95% CI = 1.8-13.0) were likely due to practice changes over time. An EHR clinical alert system targeting immunizations did not have a spillover effect on the delivery of other preventive services.

Effectiveness on Early Childhood Caries of an Oral Health Promotion Program for Medical Providers

OBJECTIVES

To assess an oral health promotion (OHP) intervention for medical providers' impact on early childhood caries (ECC).

METHODS

We implemented a quasiexperimental OHP intervention in 8 federally qualified health centers that trained medical providers on ECC risk assessment, oral examination and instruction, dental referral, and fluoride varnish applications (FVAs). We measured OHP delivery by FVA count at medical visits. We measured the intervention's impact on ECC in 3 unique cohorts of children aged 3 to 4 years in 2009 (preintervention; n = 202), 2011 (midintervention; n = 420), and 2015 (≥ 4 FVAs; n = 153). We compared numbers of decayed, missing, and filled tooth surfaces using adjusted zero-inflated negative binomial models.

RESULTS

Across 3 unique cohorts, the FVA mean (range) count was 0.0 (0), 1.1 (0-7), and 4.5 (4-7) in 2009, 2011, and 2015, respectively. In adjusted zero-inflated negative binomial models analyses, children in the 2015 cohort had significantly fewer decayed, missing, and filled tooth surfaces than did children in previous cohorts.

CONCLUSIONS

An OHP intervention targeting medical providers reduced ECC when children received 4 or more FVAs at a medical visit by age 3 years.

Pediatric Workforce Issues

Untreated dental disease remains one of the most prevalent health conditions for children, driven in part by disparities in access to care. This article examines evidence-based workforce strategies being used to facilitate better access to pediatric health services and to improve oral health status and outcomes for children. The workforce strategies described in this article include promising new models in the dental field, with new and existing providers as well as emerging workforce models outside of the dental field. Case studies for some of these workforce strategies are also presented. Future directions and health policy implications are considered.

Parent Refusal of Topical Fluoride for Their Children: Clinical Strategies and Future Research Priorities to Improve Evidence-Based Pediatric Dental Practice

A growing number of parents are refusing topical fluoride for their children during preventive dental and medical visits. This nascent clinical and public health problem warrants attention from dental professionals and the scientific community. Clinical and community-based strategies are available to improve fluoride-related communications with parents and the public. In terms of future research priorities, there is a need to develop screening tools to identify parents who are likely to refuse topical fluoride and diagnostic instruments to uncover the reasons for topical fluoride refusal. This knowledge will lead to evidence-based strategies that can be widely disseminated into clinical practice.

Fluoride Supplementation Adherence and Barriers in a Community Without Water Fluoridation

BACKGROUND

To prevent early childhood caries, the American Dental Association recommends oral fluoride supplementation for children in communities lacking water fluoridation who are at high caries risk. However, patient adherence to oral fluoride supplementation has not been studied in this population. This study assessed adherence to oral fluoride and barriers to adherence in a community lacking water fluoridation.

METHODS

A self-administered survey was completed in a systematic sample of 209 parents of children aged 6 months to 4 years, during a primary care visit in an urban academic medical center. Participants reported frequency of administering oral fluoride to their children, as well as agreement or disagreement with proposed barriers to supplementation. Bivariate and multivariate analyses were used to assess adherence with oral supplementation and the association of barriers to supplementation and child receipt of fluoride on the day before.

RESULTS

More than half of parents either had not or did not know if their child had received fluoride on the day before. Approximately 1 in 4 of parents had given fluoride in 0 of the previous 7 days. Difficulty remembering to give fluoride and agreeing that the child does not need extra fluoride were associated with not receiving fluoride on the day before.

CONCLUSIONS

Adherence to oral fluoride supplementation in the primary care setting is low. Difficulty remembering to give fluoride daily is the greatest barrier to adherence. Further research on interventions to reduce common barriers is needed to increase fluoride administration and reduce early childhood caries in communities lacking water fluoridation.

North Carolina physician-based preventive oral health services improve access and use among young Medicaid enrollees

To combat disparities in oral health and access to dental care among infants and toddlers, most state Medicaid programs now reimburse physician-based preventive oral health services such as fluoride varnish applications. We used geospatial data to examine the distribution of dental and medical Medicaid providers of pediatric oral health services throughout North Carolina to determine if these services have improved access to care for Medicaid enrollees younger than age three. We then used claims data to examine the association between distance from these practices and use of dental services for a cohort of approximately 1,000 young children. Among one hundred counties, four counties had no physician-based preventive oral health services, and nine counties had no dental practice. While children who lived farther from the nearest dental practice were less likely to make dental visits, distance from physician-based preventive oral health services did not predict utilization. For young Medicaid enrollees, oral health services provided in medical offices can improve access and increase utilization.

Home Visits and Telephone Contacts for Preventing Early Childhood Caries could be Cost Effective

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Relative cost-effectiveness of home visits and telephone contacts in preventing early childhood caries. Koh R, Kularantna S, Gordon LG, Barnett AG, Walsh LJ, Seow WK. Community Dent Oral Epidemiol 2015;43:560-8.

SOURCE OF FUNDING

National Health and Medical Research Council of Australia (government) and Australian Centre for Health Services Innovation (nonprofit).

TYPE OF STUDY/DESIGN

Markov model and Monte Carlo simulation where parameters are obtained from longitudinal intervention study, program data, and published data.