School-Based Dental Sealant Programs Prevent Cavities And Are Cost-Effective

Innovative state oral health initiatives: A qualitative analysis of Centers for Medicare & Medicaid Services demonstrations

BACKGROUND

US health care delivery and financing arrangements are changing rapidly as payers and providers seek greater efficiency, effectiveness, and safety. The Centers for Medicare & Medicaid Services uses grants and technical assistance to drive such development through innovative demonstration programs, including for oral health care. The authors reviewed these dental demonstrations to identify common themes and identify barriers to and facilitators of implementation.

METHODS

The authors compared 12 identified demonstrations across 6 domains: grant and technical assistance, stakeholders, inner care settings, outer contextual settings, interventions, and outcomes. They developed program summaries for each demonstration and interviewed key informants using a semistructured guide to review, correct, clarify, and expand on program summaries.

RESULTS

Common across all programs were engagement of nontraditional providers, care in nontraditional settings, payment as a critical externality for program adoption, interventions that integrate medical and oral health care, use of alternative payment models, and tracking process measures. Adoption facilitators included an engaged oral health champion and obtaining mission support and alignment among stakeholders. Common barriers included unanticipated organizational disruptions, poor information technology infrastructure, cultural resistance to nontraditional care models, and lack of providers in high-need areas.

CONCLUSIONS

Descriptive findings suggest that oral health care may evolve as a more accountable, integrated, and accessible health service with an expanded workforce; collaboration between providers and payers will remain key to creating innovative, sustainable models of oral health care.

PRACTICAL IMPLICATIONS

The Centers for Medicare & Medicaid Services' efforts to advance health equity, expand coverage, and improve health outcomes will continue to drive similar initiatives in oral health care.

Second molar sealants among US adolescents and their association with select sociodemographic factors and first molar sealants: A cross-sectional study using National Health and Nutrition Examination Survey data

BACKGROUND

Caries is an important public health concern. Dental sealants are effective in preventing caries; however, their uptake is suboptimal and little is known about second molar (2M) sealants. The authors examined the prevalence of 2M sealants among US adolescents and investigated the factors associated with their presence.

METHODS

The authors conducted a cross-sectional analysis of 2011-2016 National Health and Nutrition Examination Survey data on adolescents aged 12 through 19 years with complete sealant data (n = 3,636). Race and ethnicity, income, and first molar (1M) sealant were primary variables of interest. The logistic regression models were used to estimate the factors associated with 2M sealants. All analyses used survey weights and accounted for complex survey design.

RESULTS

Only 34.6% of adolescents (95% CI, 31.2% to 38.0%) had 2M sealants. Approximately 89.0% of adolescents (95% CI, 86.1% to 92.0%) with 2M sealants and 19.6% (95% CI, 17.1% to 22.2%) without 2M sealants had 1M sealants. In the adjusted models, race and ethnicity were strongly associated with 2M sealant presence, but the association did not hold when 1M sealant was included in the model. 1M sealants were the most significant factor explaining the presence of 2M sealants (odds ratio, 0.03; 95% CI, 0.02 to 0.04).

CONCLUSIONS

Two of 3 adolescents lacked 2M sealants, with considerable disparities in their presence. To improve adolescent oral health, clinical and community programs should increase delivery of 2M sealants.

PRACTICAL IMPLICATIONS

Study findings highlight the need to evaluate adolescent sealant delivery programs to improve the uptake of 2M sealants.

Closing the gaps in adolescent vaccinations: Rhode Island's Vaccinate Before You Graduate program as a model for other jurisdictions

Objective

The northeastern state of Rhode Island (RI) has a Vaccinate Before You Graduate (VBYG) program that supplements the traditional primary care infrastructure by providing vaccines to adolescents while they are in school, with no out-of-pocket expenses. We analyzed data from RI's immunization registry to evaluate whether VBYG also reduces disparities in adolescent immunization rates.

Methods

We identified adolescent and catch-up vaccines administered in RI to people who were aged 11-18 at any point during the 5-year study period of 2019-2023, and conducted bivariate and multivariate analyses of vaccine administration data by setting (VBYG clinics, community health centers [CHCs], all other primary care practices [oPCPs], other school-based clinics, and other sites) and adolescent demographics (racial and ethnic identity, insurance status, sex, and age at time of vaccine).

Results

Of over 387,000 routine vaccines administered during the study period, 3.3 % were administered by a VBYG clinic despite significant declines during school closures associated with the early COVID-19 pandemic. VBYG-administered doses went to slightly older youth, and a higher proportion were catch-up doses (25.7 % versus 14.1 % for CHC doses and 6.5 % for oPCP). Youths received an average of 2.71 vaccines in VBYG clinics compared to 1.77 from oPCPs and 2.08 from CHCs. A higher proportion of vaccines administered by VBYG went to adolescents of color and those without private insurance than those administered by oPCPs.

Conclusions

VBYG provides a model to other jurisdictions of a vaccine safety net for adolescents who may not otherwise receive recommended vaccines before exiting the school system.

Global trends in incidence of caries in permanent teeth of children aged 5 through 14 years, 1990 through 2019

BACKGROUND

School-aged children are in the stage of permanent tooth eruption to replace primary teeth and this can be reached at a life stage when their health habits are being formed due to a large amount of time in school. However, data on the global trend in incidence of caries in permanent teeth in school-aged children are sparse. This study aimed to assess the trends in incidence of caries in permanent teeth in children aged 5 through 14 years from 1990 through 2019 at the global, regional, and national levels.

METHODS

The authors collected data on incidence of caries in permanent teeth in children aged 5 through 14 years from 1990 through 2019 from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to assess trends at the global, regional, and national levels.

RESULTS

Globally, incident cases of caries in permanent teeth in children aged 5 through 14 years increased by 15.25% from 1990 through 2019, and the incidence rate remained stable during this period, with incidence rates of 34.04% in 1990 and 33.93% in 2019. The incidence rate increased at an average annual percentage change of 0.08% (95% CI, 0.06% to 0.10%) and 0.07% (95% CI, 0.05% to 0.09%) from 1990 through 2019 in low and low-middle sociodemographic index regions, respectively. An increasing trend also was observed in nearly one-half of GBD regions and more than one-half of the world's countries from 1990 through 2019 (P < .05).

CONCLUSIONS

Global incidence of caries in permanent teeth remained stable at a high level in children aged 5 through 14 years, but there was a trend toward increasing rates in nearly one-half of sociodemographic index or GBD regions and more than one-half of the world's countries and territories from 1990 through 2019. These findings suggest that caries in permanent teeth is a priority health issue in school-aged children worldwide.

PRACTICAL IMPLICATIONS

Reducing free sugar intake and implementing school-based effective caries prevention programs, such as school water fluoridation, provision of fluoride tablets at school, and school dental sealant programs, are needed for school-aged children.

The effects of dental hygienist autonomy on dental care utilization

We investigate the effects of regulations governing the practice autonomy of dental hygienists on dental care use with the 2001-2014 Medical Expenditure Panel Survey. We measure the strength of autonomy regulations by extending the Dental Hygiene Professional Practice Index to the years 2001-2014, allowing us to capture changes in regulations within states over time. Using a difference-in-differences framework applied to selected states, we find that relaxing supervision requirements to provide dental hygienists moderate autonomy results in an increase in total dental visits due to greater use of preventive dental care. However, the use of dental treatment decreases when states adopt the highest level of autonomy. Both sets of estimates increase in magnitude when we subset the sample to dental care provider shortage areas. In support of these findings, we show that dental visits shift to dental hygienists in shortage areas when states expand the scope of practice of hygienists, and that there is an increase in tasks performed by hygienists, such as cleanings and dental exams.

The effectiveness of medical nurses in treating children with silver diamine fluoride in a school-based caries prevention program

BACKGROUND

The sustainability of school-based oral health programs depends on the utilization of effective, efficient treatments and the availability of a trained clinical workforce. The objective of this study was to determine whether registered nurses are comparable to dental hygienists in the application and effectiveness of silver diamine fluoride (SDF) and fluoride varnish (FV) for the prevention of dental caries.

METHODS

CariedAway was a school-based study of SDF and FV versus dental sealants and atraumatic restorations. Within the SDF + FV arm, participants were treated by either a licensed dental hygienist or a registered nurse, both under the supervision of a paediatric dentist. Although initial treatment assignment in CariedAway was randomized, assignment to provider was not. The proportion of children who remained caries free after 2 years was assessed for non-inferiority using two-group proportion tests, adjusting for the clustering effect of schools.

RESULTS

A total of 417 children with no untreated caries at baseline were analysed including 298 treated by hygienists and 119 by nurses. The proportion of children who remained caries free after 2 years was 0.81 and 0.80 for those treated by hygienists and nurses, respectively, for a difference of 0.01 (95% CI = -0.07, 0.098) and within the pre-determined non-inferiority margin.

CONCLUSIONS

Nurses may be effective in treating children with silver diamine fluoride and other fluoride varnishes in school-based oral health programs.

Cost-effectiveness analysis design for interventions to prevent children's oral disease

Introduction

In 2015, the National Institute of Dental and Craniofacial Research (NIDCR) launched the Multidisciplinary Collaborative Research Consortium to Reduce Oral Health Disparities in Children, supporting four randomized trials testing strategies to improve preventive care. A Coordinating Center provides scientific expertise, data acquisition and quality assurance services, safety monitoring, and final analysis-ready datasets. This paper describes the trials' economic analysis strategies, placing these strategies within the broader context of contemporary economic analysis methods.

Methods

The Coordinating Center established a Cost Collaborative Working Group to share information from the four trials about the components of their economic analyses. Study teams indicated data sources for their economic analysis using a set of structured tables. The Group meets regularly to share progress, discuss challenges, and coordinate analytic approaches.

Results

All four trials will calculate incremental cost-effectiveness ratios; two will also conduct cost-utility analyses using proxy diseases to estimate health state utilities. Each trial will consider at least two perspectives. Key process measures include dental services provided to child participants. The non-preference-weighted Early Childhood Oral Health Impact Scale (ECOHIS) will measure oral health-related quality of life. All trials are measuring training, implementation, personnel and supervision, service, supplies, and equipment costs.

Conclusions

Consistent with best practices, all four trials have integrated economic analysis during their planning stages. This effort is critical since poor quality or absence of essential data can limit retrospective analysis. Integrating economic analysis into oral health preventive intervention research can provide guidance to clinicians and practices, payers, and policymakers.

School-based caries prevention using silver diamine fluoride: A pragmatic randomized trial in low-income rural children

Background

Dental caries is the world's most prevalent noncommunicable disease, disproportionately affecting children from low-income families and rural geographic areas.

Methods

The CariedAway 3.0 study was a cluster-randomized pragmatic non-inferiority trial comparing silver diamine fluoride (SDF) to sealants and atraumatic restorations (ART) for the prevention and control of dental caries. All participants also received fluoride varnish. Analysis consisted of mixed-effects logistic regression for caries prevalence and weighted least squares and mixed-effects negative binomial regression for caries incidence. A non-inferiority margin of 10% for the difference between groups was used. Dental caries was defined as an ICDAS score of four or greater.

Results

A total of 3345 children were enrolled across 35 schools; however there was a large proportion of children who were noncompliant and received external dental care over the course of the trial. In adjusted analyses of compliant participants (n=1083; 543 in the SDF group and 540 in the sealant and ART group), there was no difference in the weighted risk difference between treatment groups (B=0.003, 95% CI = -0.0001, 0.0008). The odds of caries prevalence was elevated in the SDF group in longitudinal analyses (OR = 1.35, 95% CI = 0.86, 2.11) but was not significant and was below the non-inferiority margin. There were no significant differences between groups for caries incidence in adjusted models (IRR = 1.19, 95% CI = 0.81, 1.74). Results for intent to treat analyses were similar to that of per-protocol.

Discussion

In this school-based clinical trial, the prevalence of dental caries in children treated with SDF and fluoride varnish was non-inferior compared to those treated with sealants, ART, and fluoride varnish, although the overall risk was slightly higher. Unfortunately, a high rate of dropout and participant noncompliance was observed, likely due to the impacts of COVID-19 on study procedures. As a result, observed effects may be unreliable beyond the short-term.

Trial Registration

NCT03448107.

Noninferiority of Silver Diamine Fluoride vs Sealants for Reducing Dental Caries Prevalence and Incidence: A Randomized Clinical Trial

Importance

Dental caries is the world's most prevalent noncommunicable disease and a source of health inequity; school dental sealant programs are a common preventive measure. Silver diamine fluoride (SDF) may provide an alternative therapy to prevent and control caries if shown to be noninferior to sealant treatment.

Objective

To determine whether school-based application of SDF is noninferior to dental sealants and atraumatic restorative treatment (ART) in the prevalence of dental caries.

Design, Setting, and Participants

The Silver Diamine Fluoride Versus Therapeutic Sealants for the Arrest and Prevention of Dental Caries in Low-Income Minority Children (CariedAway) study was a pragmatic noninferiority cluster-randomized clinical trial conducted from February 2018 to June 2023 to compare silver diamine fluoride vs therapeutic sealants for the arrest and prevention of dental caries. Children at primary schools in New York, New York, with at least 50% of the student population reporting as Black or Hispanic and at least 80% receiving free or reduced lunch were included. This population was selected as they are at the highest risk of caries in New York. Students were randomized to receive either SDF or sealant with ART; those aged 5 to 13 years were included in the analysis. Treatment was provided at every visit based on need, and the number of visits varied by child. Schools with preexisting oral health programs were excluded, as were children who did not speak English. Of 17 741 students assessed for eligibility, 7418 were randomized, and 4100 completed follow-up and were included in the final analysis.

Interventions

Participants were randomized at the school level to receive either a 38% concentration SDF solution or glass ionomer sealants and ART. Each participant also received fluoride varnish.

Main Outcomes and Measures

Primary study outcomes were the prevalence and incidence of dental caries.

Results

A total of 7418 children (mean [SD] age, 7.58 [1.90] years; 4006 [54.0%] female; 125 [1.7%] Asian, 1246 [16.8%] Black, 3648 [49.2%] Hispanic, 153 [2.1%] White, 114 [1.5%] multiple races or ethnicities, 90 [1.2%] other [unspecified], 2042 [27.5%] unreported) were enrolled and randomized to receive either SDF (n = 3739) or sealants with ART (n = 3679). After initial treatment, 4100 participants (55.0%) completed at least 1 follow-up observation. The overall baseline prevalence of dental caries was approximately 27.2% (95% CI, 25.7-28.6). The odds of decay prevalence decreased longitudinally (odds ratio [OR], 0.79; 95% CI, 0.75-0.83) and SDF was noninferior compared to sealants and ART (OR, 0.94; 95% CI, 0.80-1.11). The crude incidence of dental caries in children treated with SDF was 10.2 per 1000 tooth-years vs 9.8 per 1000 tooth-years in children treated with sealants and ART (rate ratio, 1.05; 95% CI, 0.97-1.12).

Conclusions and Relevance

In this school-based pragmatic randomized clinical trial, application of SDF resulted in nearly identical caries incidence compared to dental sealants and ART and was noninferior in the longitudinal prevalence of caries. These findings suggest that SDF may provide an effective alternative for use in school caries prevention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03442309.

Cost-effectiveness of dental caries prevention strategies in South African schools

BACKGROUND

In South Africa, an estimated 85% of the population relies on the public sector for oral health services. With poor infrastructure and inadequate personnel, over 80% of children with dental caries remain untreated. To reduce this burden of disease, one key goal is to promote good oral health and address oral diseases through prevention, screening, and treatment among children. While all policies have been proven to be effective in the control and prevention of dental caries, it is unclear which of those strategies provide value for money. This study evaluated five caries preventative strategies in terms of the cost and benefits among South African school children.

METHODS

The study uses a hypothetical South African population of school aged learners aged 5-15. The context and insights of the strategies utilized at the schools were informed by data from both grey and published literature. Using Markov modeling techniques, we conducted a cost-effectiveness analysis of Acidulated Phosphate Fluoride (APF) application, atraumatic restorative treatment (ART), sugar-reduction and fissure sealants. Markov model was used to depict the movement of a hypothetical patient cohort between different health states over time. We assessed both health outcomes and costs of various interventions. The health outcome metric was measured as the number of Decayed, Missing, Filled Tooth (DMFT). The net monetary benefit was then used to determine which intervention was most cost-effective.

RESULTS

The results showed that school-based caries prevention strategies are cost-effective compared to the status quo of doing nothing. The average cost per learner over the 10-year period ranged from ZAR4380 to approx. ZAR7300 for the interventions considered. The total costs (including screening) associated with the interventions and health outcome (DMFT averted) were: sugar reduction (ZAR91,380, DFMT: 63,762), APF-Gel (ZAR54 million, DMFT: 42,010), tooth brushing (ZAR72.8 million, DMFT: 74,018), fissure sealant (ZAR44.63 million, DMFT: 100,024), and ART (ZAR45 million, DMFT: 144,035). The net monetary benefits achieved for APF-Gel, sugar reduction, tooth brushing, fissure sealant and ART programs were ZAR1.56, ZAR2.45, ZAR2.78, ZAR3.81, and ZAR5.55 billion, respectively.

CONCLUSION

Based on the net monetary benefit, ART, fissure sealant and sugar-reduction appear to be the most cost-effective strategies for preventing caries in South Africa. In a resource-scarce setting such as South Africa, where there is no fluoridation of drinking water, this analysis can inform decisions about service packages for oral health.

The role of income and frequency of dental visits in the relationship between dental sealant use and resin fillings after extended coverage: a retrospective cohort study

BACKGROUND

Prevention and treatment services use is closely associated with socioeconomic factors, such as income. This study aimed to investigate the relationship between implementing the sealant program and resin fillings restoration and to explore the role of income and frequency of dental visits in this relationship.

METHODS

This retrospective cohort study used the cohort database from the National Health Information Database of the National Health Insurance Service. The study population comprised 494,731 children born in 2007. A logistic regression model for the experience of resin fillings and a linear regression model for weighted utilization of them were used to identify the independent effects of dental sealants, income, and frequency of dental visits. All analyses were conducted using the SAS Enterprise Guide version 7.1 (SAS Institute Inc., Cary, NC, USA).

RESULTS

The ratio based on income level was almost proportional in all groups except the medical aid group, which had a rate as high as that of the wealthier group. Children without sealants were 1.05 times more likely to have resin fillings than others after adjusting for income level and frequency of visiting dental clinics in the final model. However, an opposite relationship between sealant experiences and resin fillings was observed in the previous model without dental visits. The gap in the weighted resin filling scores according to socioeconomic variables showed a similar tendency.

CONCLUSIONS

Income and frequency of dental visits might be confounding factors for the relationship between dental sealant and resin fillings. It is necessary to consider the complex relationship between socioeconomic indicators and service use while studying oral health inequality.

Cost-Effectiveness of Pit and Fissure Sealing at Schools for Caries Prevention in China: A Markov Modeling Analysis

The World Health Organization states that the application of pit and fissure sealants (PFSs) is an effective way to prevent dental caries. Estimates of potential health and economic impacts of PFS upon school-age children provide crucial evidence to support the extension of PFS coverage to all target populations. The China Children's Oral Disease Comprehensive Intervention Project was launched in 2009 to provide free oral health examinations, PFS application, and oral health education for children aged 7 to 9 years. However, the national-level health and economic impacts of the program are unclear. To provide higher quality evidence at the national level in China, we developed a multi-perspective, multistate Markov model to estimate the cost and effect of PFS application to prevent dental caries. The total cost of the PFS project was 2.087 billion CNY, which can prevent 16.06 million PFMs from caries lesions. Compared with no intervention, PFS application was cost-effective from payer and society perspectives (BCR = 1.22 from the payer's perspective, BCR = 1.91 from the societal perspective). The incremental cost-effectiveness ratio from both perspectives was negative (-61.46 CNY from the payer's perspective, and -125.75 CNY from the societal perspective), indicating that PFS was cost-effective and cost-saving. Expanding the coverage of PFS application in school can be a more cost-effective strategy for caries prevention in China.

Healthcare Utilization Among Children Receiving Permanent Supportive Housing

BACKGROUND AND OBJECTIVES

Permanent supportive housing (PSH) integrates long-term housing and supports for families and individuals experiencing homelessness. Although PSH is frequently provided to families with children, little is known about the impacts of PSH among children. We examined changes in health care visits among children receiving PSH compared with similar children who did not receive PSH.

METHODS

We analyzed Pennsylvania Medicaid administrative data for children entering PSH between 2011 and 2016, matching to a comparison cohort with similar demographic and clinical characteristics who received non-PSH housing services. We conducted propensity score-weighted difference-in-differences (DID) analyses to compare changes in health care visits 3 years before and after children entered PSH versus changes in the comparison cohort.

RESULTS

We matched 705 children receiving PSH to 3141 in the comparison cohort. Over 3 years following PSH entry, dental visits among children entering PSH increased differentially relative to the comparison cohort (DID: 12.70 visits per 1000 person-months, 95% confidence interval: 3.72 to 21.67). We did not find differential changes in preventive medicine visits, hospitalizations, or emergency department (ED) visits overall. When stratified by age, children ≤5 years old at PSH entry experienced a greater decrease in ED visits relative to the comparison cohort (DID: -13.16 visits per 1000 person-months, 95% confidence interval: -26.23 to -0.10). However, emergency visit trends before PSH entry differed between the cohorts.

CONCLUSIONS

Children in PSH had relatively greater increases in dental visits, and younger children entering PSH may have experienced relative reductions in ED visits. Policymakers should consider benefits to children when evaluating the overall value of PSH.

Cost-effectiveness of Dental Workforce Expansion Through the National Health Service Corps and Its Association With Oral Health Outcomes Among US Children

Importance

Despite considerable efforts to improve oral health for all, large disparities remain among US children. A dental professional shortage is thought to be among the determinants associated with oral health disparities, particularly for those residing in underserved communities.

Objective

To evaluate the cost-effectiveness of expanding the dental workforce through the National Health Service Corps (NHSC) and associations with oral health outcomes among US children.

Design, Setting, and Participants

A cost-effectiveness analysis was conducted to estimate changes in total costs and quality-adjusted life years (QALYs) produced by increasing the NHSC funding for dental practitioners by 5% to 30% during a 10-year period. A microsimulation model of oral health outcomes using a decision analytic framework was constructed based on oral health and dental care utilization data of US children from 0 to 19 years old. Data from the nationally representative National Health and Nutrition Examination Survey (NHANES, 2011-2016) were linked to county-level dentist supply and oral health professional shortage areas (HPSAs) information. Changes in prevalence and cumulative incidence of dental caries were also estimated. Sensitivity analyses were conducted to assess the robustness of results to variation in model input parameters. Data analysis was conducted from August 1, 2021, to November 1, 2022.

Exposures

Expanding dental workforce through the NHSC program.

Main Outcomes and Measures

Changes in total QALYs, costs, and dental caries prevalence and cumulative incidence.

Results

This simulation model informed by NHANES data of 10 780 participants (mean [SD] age, 9.6 [0.1] years; 5326 [48.8%] female; 3337 [weighted percentage, 57.9%] non-Hispanic White individuals) found that when funding for the NHSC program increased by 10%, dental caries prevalence and total number of decayed teeth were estimated to decrease by 0.91 (95% CI, 0.82-1.00) percentage points and by 0.70 (95% CI, 0.62-0.79) million cases, respectively. When funding for the NHSC program increased between 5% and 30%, the estimated decreases in number of decayed teeth ranged from 0.35 (95% CI, 0.27-0.44) to 2.11 (95% CI, 2.03-2.20) million cases, total QALY gains ranged from 75.76 (95% CI, 59.44-92.08) to 450.50 (95% CI, 434.30-466.69) thousand QALYs, and total cost savings ranged from $105.53 (95% CI, $70.14-$140.83) to $508.23 (95% CI, $598.91-$669.22) million among children residing in dental HPSAs from a health care perspective. Benefits of the intervention accrued most substantially among Hispanic children and children in low-income households.

Conclusions and Relevance

This cost-effectiveness analysis using a decision analytic model suggests that expanding the dental workforce through the NHSC program would be associated with cost savings and a reduced risk of dental caries among children living in HPSAs.

The impact of dentists' availability in delivering dental care in Florida Elementary Schools

OBJECTIVE

This study evaluates the dentists' availability to deliver preventive dental care to children in schools and the impact of school-based programs on access.

METHODS

The study population included Florida elementary-school children, differentiated by dental insurance (Medicaid, CHIP, private, or none). We considered the implementation of school-based programs using optimization modeling to (re)allocate the dentists' caseload to schools to meet demand for preventive care under resource constraints. We considered multiple settings for school-based program implementation: (i) school prioritization; and (ii) dentists' participation in public insurance. Statistical inference was used to identify communities to improve access and reduce disparities.

RESULTS

School-based programs reduced unmet demand (3%-12%), being more efficient if prioritizing schools in communities targeted to improve access. The access improvement varied by insurance status and geography. Uninsured urban children benefited most from school-based programs, with 15%-75% unmet need reduction. The percentage of urban communities targeted to improve access decreased by 12% against no-school program. Such percentage remained large for suburban (15%-100%) and rural (50%-100%) communities. Disparity in access for public-insured vs. private-insured children persisted under school-based programs (32%-84% identified communities).

CONCLUSION

School-based programs improve dental care access; the improvement was however different by insurance status, with uninsured children benefiting the most. Accounting to the dentists' availability in prioritizing schools resulted in effective resource allocation to school-based programs. Access disparities between public and private-insured children did not improve; school-based programs shifted resources from public-insured to uninsured. School-based programs are effective in addressing access barriers to those children experiencing them most.

Effect of Silver Diamine Fluoride on Caries Arrest and Prevention: The CariedAway School-Based Randomized Clinical Trial

IMPORTANCE

Dental caries is the most common global childhood disease. To control caries, the Centers for Disease Control and Prevention recommends school-based caries prevention, and the World Health Organization lists glass ionomer cement and silver diamine fluoride as essential medicines for oral disease.

OBJECTIVE

To determine the noninferiority of silver diamine fluoride with fluoride varnish vs traditional glass ionomer sealants with fluoride varnish after 2 years when provided to children via a school-based health care program.

DESIGN, SETTING, AND PARTICIPANTS

The CariedAway study is an ongoing single-blind, cluster randomized, noninferiority trial conducted between February 1, 2019, and June 1, 2023, among 2998 children in 47 New York City primary schools. Children aged 5 to 13 years of any race and ethnicity were recruited from block-randomized schools. Inclusion criteria for schools were a student population of at least 50% Hispanic or Latino or Latina ethnicity and/or Black race and at least 80% of students receiving free or reduced-cost lunch. Statistical analysis is reported through March 2022.

INTERVENTIONS

Children received a single application of silver diamine fluoride with fluoride varnish or an active comparator of glass ionomer sealants and atraumatic restorations with fluoride varnish.

MAIN OUTCOMES AND MEASURES

Primary outcomes were caries arrest and incidence after a 2-year follow-up, assessed using mixed-effects multilevel models and clustered 2-sample proportion tests. The noninferiority margin was 10%. Intention-to-treat analysis was performed using multiple imputation.

RESULTS

A total of 2998 children (1566 girls [52.2%]; mean [SD] age at baseline, 6.6 [1.2] years; 1397 Hispanic or Latino or Latina children [46.6%]; 874 [29.2%] with untreated dental caries) were recruited and treated from September 16, 2019, to March 12, 2020. Follow-up observations were completed for 1398 children from June 7, 2021, to March 2, 2022. The mean (SE) proportion of children with arrested caries was 0.56 (0.04) after experimental treatment and 0.46 (0.04) after control treatment (difference, -0.11; 95% CI, -0.22 to 0.01). The mean (SE) proportion of patients without new caries was 0.81 (0.02) after experimental treatment and 0.82 (0.02) after control treatment (difference, 0.01; 95% CI, -0.04 to 0.06). Analysis of imputed data for the full sample did not deviate from per-protocol analyses. There were no adverse events.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, silver diamine fluoride with fluoride varnish was noninferior to sealants and atraumatic restorations with fluoride varnish for caries arrest and prevention. Results may support the use of silver diamine fluoride as an arresting and preventive agent in school-based oral health programs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03442309.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review

OBJECTIVES

To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis.

METHODS

Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal.

RESULTS

Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis.

CONCLUSIONS

Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Impact of school sealant programs on oral health among youth and identification of potential barriers to implementation

BACKGROUND

School sealant programs (SSPs) increase sealant prevalence among children lacking access to oral health care. SSPs, however, are substantially underused. From 2013 through 2018, the Centers for Disease Control and Prevention funded 18 states for SSP activities in high-need schools (≥ 50% free and reduced-price meal program participation). From 2019 through 2020, the authors assessed SSPs' impact in reducing caries and how states expanded SSPs. The authors also discuss potential barriers to expansion.

METHODS

For Aim 1, the authors used a published methodology and SSP baseline screening and 1-year retention data to estimate averted caries over 9 years attributable to SSPs. For Aim 2, the authors used state responses to an online survey, phone interviews, and annual administrative reports.

RESULTS

Using data for 62,750 children attending 18.6% of high-need schools in 16 states, the authors estimated that 7.5% of sound, unsealed molars would develop caries annually without sealants and placing 4 sealants would prevent caries in 1 molar. Fourteen states reported SSP expansion in high-need schools. The 2 most frequently reported barriers to SSP expansion were levels of funding and policies requiring dentists to be present at assessment or sealant placement.

CONCLUSIONS

The authors found that SSPs typically served children at elevated caries risk and reduced caries. In addition, the authors identified funding levels and policies governing supervision of dental hygienists as possible barriers to SSP expansion.

PRACTICAL IMPLICATIONS

Increasing SSP prevalence could reduce caries. Further research on potential barriers to SSP implementation identified in this study could provide critical information for long-term SSP sustainability.

Caries Management in Special Care Dentistry

The objective of this article is to provide a summary of the current evidence-based recommendations for caries management in patients with special health care needs (SHCNs). Considerations regarding caries risk assessment and preventive measures are also discussed with the goal of helping clinicians to manage the caries disease process using a person-centered approach and risk-based interventions. Importantly, most of the evidence is still based on the general population, because the evidence for those with SHCNs is still limited.

Expert consensus on dental caries management

Dental Caries is a kind of chronic oral disease that greatly threaten human being's health. Though dentists and researchers struggled for decades to combat this oral disease, the incidence and prevalence of dental caries remain quite high. Therefore, improving the disease management is a key issue for the whole population and life cycle management of dental caries. So clinical difficulty assessment system of caries prevention and management is established based on dental caries diagnosis and classification. Dentists should perform oral examination and establish dental records at each visit. When treatment plan is made on the base of caries risk assessment and carious lesion activity, we need to work out patient‑centered and personalized treatment planning to regain oral microecological balance, to control caries progression and to restore the structure and function of the carious teeth. And the follow-up visits are made based on personalized caries management. This expert consensus mainly discusses caries risk assessment, caries treatment difficulty assessment and dental caries treatment plan, which are the most important parts of caries management in the whole life cycle.

Community-Academic Partnership to Improve the Oral Health of Underserved Schoolchildren in Rural North Carolina

BACKGROUND

Dental caries is the most common chronic illness for children. Caries can reduce the quality of life, cause missed classroom hours, and decrease cognition. Strategies to improve children's oral health must be evidence-based, developed, and implemented in consultation with communities.

METHODS

A community-academic partnership was formed between East Carolina University School of Dental Medicine and the Bertie County Public School District to develop and implement a school-based oral health prevention program using the PRECEDE-PROCEED Model.

RESULTS

The PRECEDE component involved social, epidemiological, environmental, educational, ecological, administrative, and policy factors that informed the development of the oral health program. The PROCEED component consisted of implementation and evaluation.

CONCLUSIONS

School-based oral health programs can increase access to care for vulnerable children and improve learning. The application of the PRECEDE-PROCEED model proved to be a valuable method for developing, implementing, and evaluating a school-based oral health program.

Silver diamine fluoride and oral health-related quality of life: A review and network meta-analysis

OBJECTIVE

Silver diamine fluoride (SDF) is an effective non-surgical treatment for dental caries which may also impact oral health-related quality of life (OHRQoL). The objective of this study was to conduct a network meta-analysis of SDF versus other standard of care therapies on OHRQoL.

DATA SOURCES

Studies published in PubMed/MEDLINE, Scopus, or Web of Science through July 2021 with no date or language restrictions.

STUDY SELECTION

Any randomized controlled trial, cohort, or case-control study that included silver diamine fluoride as either a single or combinative treatment for dental caries and a quantitatively measured outcome for oral health-related quality of life was included.

DATA EXTRACTION AND SYNTHESIS

Potentially eligible studies were screened by two independent reviewers trained in conducting systematic reviews. Studies meeting inclusion criteria underwent a full-text review with data being extracted using a standardized form, including publication details, study methodology, outcomes, assessors, and sample information. Studies underwent a risk of bias assessment. Quantitative synthesis was performed using fixed effects meta-analysis and individual comparisons were assessed via network meta-analysis.

MAIN OUTCOME(S) AND MEASURE(S)

Oral health-related quality of life.

RESULTS

19 articles were returned following search strategies. Following screening, ten studies were evaluated for full-text eligibility and five were retained for meta-analyses. Results across all treatments indicate no differences in OHRQoL when compared to SDF (SMD = -0.06, 95% CI = -0.20, 0.08). Direct and indirect estimates from network meta-analysis indicated that OHRQoL in children was not significantly different when treated with SDF versus atraumatic restorations (d = 0.02, 95% CI = -0.32, 0.36) or placebo (d = 0.03, 95% CI = -0.16, 0.22).

CONCLUSIONS

Evidence from the literature consistently shows no discernible impact on OHRQoL across various non-surgical treatments for dental caries. Overall oral health-related quality of life may increase regardless of treatment protocol due to treatment of the underlying disease. Concerns over the staining of dental decay and oral mucosa resulting from treatment with silver diamine fluoride do not seem to affect OHRQoL.

Comprehensive, School-Based Preventive Dentistry: Program Details and Students' Unmet Dental Needs

BACKGROUND

In this paper, we describe the design, program details, and baseline demographics and oral health of participants in ForsythKids, a regional, comprehensive, school-based mobile caries prevention program.

METHODS

We solicited all Massachusetts elementary schools with greater than 50% of students receiving free or reduced-price meals. Six schools initially elected to participate, ultimately followed by over 50 schools. Interventions were based on systematic reviews and randomized controlled caries prevention trials. Participating students received semiannual dental examinations, followed by comprehensive preventive care. Summary statistics regarding oral health indicators were derived from individual tooth- and surface-level data.

RESULTS

Over a 6-year period, data were collected on 6927 children. The number of students per school ranged from 58 to 681. The overall participation rate was 15%, ranging from 10% to 29%. Overall, 57% of the children were younger than 8 years at baseline. Approximately, 54% of children experienced dental decay on any tooth at baseline; 32% had untreated decay on any tooth, 29% had untreated decay on primary teeth, and 10% untreated decay on permanent teeth.

CONCLUSIONS

Untreated dental decay was double the national average, even in schools within several blocks of community dental clinics. These data demonstrate the need for caries prevention beyond the traditional dental practice.

Oral Health Among Children and Youth With Special Health Care Needs

OBJECTIVES

We sought to estimate the prevalence of oral health problems and receipt of preventive oral health (POH) services among children and youth with special health care needs (CYSHCN) and investigate associations with child- and family-level characteristics.

METHODS

We used pooled data from the 2016-2018 National Survey of Children's Health. The analytic sample was limited to children 1 to 17 years old, including 23 099 CYSHCN and 75 612 children without special health care needs (non-CYSHCN). Parent- and caregiver-reported measures of oral health problems were fair or poor teeth condition, decayed teeth and cavities, toothaches, and bleeding gums. POH services were preventive dental visits, cleanings, tooth brushing and oral health care instructions, fluoride, and sealants. Bivariate and multivariable logistic regression analyses were conducted.

RESULTS

A higher proportion of CYSHCN than non-CYSHCN received a preventive dental visit in the past year (84% vs 78%, P < .0001). Similar patterns were found for the specific preventive services examined. However, CYSHCN had higher rates of oral health problems compared with non-CYSHCN. For example, decayed teeth and cavities were reported in 16% of CYSHCN versus 11% in non-CYSHCN (P < .0001). In adjusted analyses, several factors were significantly associated with decreased prevalence of receipt of POH services among CYSHCN, including younger or older age, lower household education, non-English language, lack of health insurance, lack of a medical home, and worse condition of teeth.

CONCLUSIONS

CYSHCN have higher rates of POH service use yet worse oral health status than non-CYSHCN. Ensuring appropriate use of POH services among CYSHCN is critical to the reduction of oral health problems.

A Technical Assistance Curriculum for Expanding Sustainable School-Based Oral Health Programs in the Carolinas' Dental Safety Net

PURPOSE

School-based oral health programs (SBOHPs) provide opportunities to address oral health inequities by providing convenient access points for care. No published guidelines on SBOHP implementation existed. Our work describes how philanthropic, public, and academic organizations partnered to support dental safety net providers with designing comprehensive SBOHPs in North and South Carolina.

DESCRIPTION

A multi-sector leadership team was established to manage a new SBOHP philanthropic-funded grant program organized into two phases, Readiness and Implementation, with the former a 6-month planning period in preparation of the latter. Readiness included technical assistance (TA) delivered through coaching and 15 online learning modules organized in four domains: operations, finance, enabling services, and impact. Organizations could apply for implementation grants after successful TA completion. Process evaluation was used including a Readiness Stoplight Report for tracking progression.

ASSESSMENT

Ten Readiness grantees completed the TA. A variety of models resulted, including mobile, portable and fixed clinics. Descriptive analysis was conducted on the readiness stoplight reports. Components of the operation and finance domains required were the most time-intensive, specifically the development of policy manuals, production goals, and financial performance tracking.

CONCLUSION

The program's structure resulted in (a) a two-state learning community, (b) SBOHP practice and policy alignment, and (c) coordinated program distribution. TA improvements are planned to account for COVID-19 threats, including school closures, space limitations, and transmission fears. Telehealth, non-aerosolizing procedures, and improved scheduling and communication can address concerns. Organizations considering SBOHPs should explore similar recommendations to navigate adverse circumstances.

Redesign of an informed consent form to increase participation in a school-based dental program

OBJECTIVES

The study aimed to determine if modifications to the design of a consent form and consenting process increased participation rates in the Indiana University School of Dentistry's Mobile School-Based Dental Program (Seal Indiana).

METHODS

Kaizen methodology was followed to identify problem areas in the consenting process. Additionally, stakeholders were invited to participate in focus groups and fill out surveys to identify issues preventing participation in the Seal Indiana program (N = 48) and later to evaluate the changes made (N = 48). The redesigned form and process were then used in a pilot study at 14 sites to determine the impact that changes had on levels of participation as measured by the number of consent forms completed and returned.

RESULTS

There was a statistically significant increase in the number of consent forms returned. The measured change represented a 32 percent increase in program participation (P value = 0.035). A statistically significant increase was observed in how participants viewed the attractiveness of the form and how easy it was to read and comprehend.

CONCLUSIONS

In order to increase consenting rates, our results indicate modifications to the consent form should be focused on the following characteristics: esthetics, ease of reading and comprehending information, and making the Health Insurance Portability and Accountability Act of 1996 (HIPPA) privacy regulations easier to read and comprehend.

Important aspects of conducting an interdisciplinary public preventive oral health project for children in areas with low socioeconomic status: staff perspective

Background

To achieve good and equal oral health in children, interdisciplinary preventive oral health actions, directed toward disadvantaged areas, can be an important means. Staff play a crucial role in the implementation of these actions. The aim of the present study was to analyze circumstances of importance for conducting an interdisciplinary public preventive oral health project for children, directed toward parents in areas with low socioeconomic status from the interdisciplinary perspective of the involved staff.

Method

The present study consisted of a qualitative content analysis with an inductive approach, based on interviews with interdisciplinary staff who had participated in a public preventive oral health project directed toward parents in areas with low socioeconomic status. The interviews were analyzed using text-driven analysis.

Results

The main category concerned the staff members’ prerequisites and understanding necessary to perform their tasks in interdisciplinary public preventive oral health project. To have the right prerequisites and understanding regarding the oral health project enabled staff to be committed, able and willing to perform in it. Important aspects of this are to have knowledge, motivation and to experience a supportive professional context, to have good leadership and for certain resources to fulfilled. A crucial aspect was to reach the targeted mothers.

Conclusions

For interdisciplinary cooperation in preventive oral health care to be achieved, it is essential for the involved disciplines and professions to embrace a common view on the project’s aim, their duties, and oral health, from the leadership to the individual level. Staff require competent leadership but also allocated time and adapted method support to be successful in this context. When allocating preventive health actions directed at low SES areas, it is important to acknowledge the risk of stigmatization and for staff to understand that families might be facing social challenges that prevent them from taking part in health-promoting actions. An important conclusion is that to be able to reach people, it is important for both those who design preventive programs for oral health and the staff who administer them to have sufficient knowledge about the target group.

Atraumatic Restorative Treatment-Sealed versus Nonsealed First Permanent Molars: A 3-Year Split-Mouth Clinical Trial

To investigate the efficacy of atraumatic restorative treatment (ART) sealants vs. no sealant in preventing the development of dentine caries lesions in first permanent molars over a period of 3 years. A total of 187 schoolchildren (aged 6-8 years) from a low-income population presenting the 4 first permanent molars without clinically detectable dentine caries lesions were selected to be part of a split-mouth clinical trial. All 4 first permanent molars were investigated in this trial and the children's mouth was split vertically into left and right sides; therefore, 2 molars were randomly allocated to receive ART sealants, while the other 2 molars remained nonsealed. All children received toothbrushing instructions and dietary advice every 6 months for a period of 3 years. Clinical evaluations were performed after 3, 6, 12, 18, 24, and 36 months and both sealant retention and dental caries were scored. Kaplan-Meier survival analysis, log-rank test, and Cox regression with shared frailty analysis were performed. A cavitated dentine caries lesion was considered a failure. The cumulative survival rates of dentine cavity-free first permanent molars were 90% for ART-sealed molars and 90.8% for nonsealed molars, with no statistically significantly difference between sealed and nonsealed molars (p = 0.70). The retention of sealants was not associated with the development of cavitated dentine caries and children presenting a higher baseline caries experience had greater chances of developing dentine lesions. In conclusion, the application of ART sealants was not more efficacious than nonsealing in reducing the development of dentine cavitated lesions in first permanent molars.

Relationship between Socioeconomic Inequalities and Oral Hygiene Indicators in Private and Public Schools in Karachi: An Observational Study

Background: The study investigated the relationship between socioeconomic status and oral hygiene indicators in two schools located in Karachi, Pakistan. Oral hygiene indicators of public and private school children were compared. Private schools cater to children of relatively wealthier families compared to public school, whose attendees are generally children from less affluent backgrounds. The aim of this study was to determine whether socio-economic differences and inequalities have an impact on key oral hygiene indicators. Methodology: Primary data for this research was collected from community school visits conducted by the community dentistry department of Jinnah Medical and Dental and Medical College from January to September 2019. A convenience sample of the two schools, comprising 300 school students was selected. Data was collected using modified World Health Organization (WHO) oral health care forms. A pre-tested/customized dental hygiene form based on WHO forms was created by the research team. This form was used to measure DMFT/dmft scores and key oral hygiene indicators in the sample. Results: A total sample size of 300 school-children affiliated with public and private schools was selected. The children’s age ranged from 2 to 18 years. The mean DMFT scores of private and public-school children were not significantly different (private (1.82) vs. public (1.48)). (p = 0.257). The mean of carious teeth was 1.69 in private school children compared to 1.34 in government school children, whereas the mean values of other key indicators of oral hygiene including plaque deposition (p = 0.001), dental stains (p < 0.001) and bleeding gums/gingivitis (p < 0.001), were statistically significant between public and private school children. Conclusion: Oral health inequalities can be reduced with increased awareness and public funding to cater for the oral health needs of children of less affluent families. A dynamic and practical community-oriented program is fundamental for enhancing pediatric oral hygiene status, particularly for children attending government schools.

A Validation and Cost-Analysis Study of a Targeted School-Based Dental Check-Up Intervention: Children's Dental Program

Background: Limited evidence exists to inform best practice approaches to implement school-based dental screening to address child retention via referral for dental services. This research tested the null hypothesis that a targeted school-based dental check-up program (intervention) has a 75% child retention rate for public dental care (H₀ = 0.75). Methods: A prospective non-randomised controlled trial was conducted with a convenience sampling approach in metropolitan Melbourne, Australia. Children in the intervention group were recruited from two preschools and two primary schools from a low socioeconomic area. Children in the standard care group were recruited from the local public dental service. Statistical analysis was performed using Stata IC Version 12. Results: Children in the intervention (45%) were significantly less likely to have never had a dental check-up compared to standard care (20%) (p < 0.001). There was no significant difference for the child retention rate for the intervention group when compared against the null hypothesis (p = 0.954). The total society costs were AU$754.7 and AU$612.2 for the intervention and standard care groups, respectively (p = 0.049). Conclusions: This validation study provides evidence that a targeted school-based dental check-up program can achieve a 75% child retention rate and should be considered for program expansion.

Identifying heterogeneity in the risk factors of dental caries status in Chinese adolescents using Poisson mixture regression

OBJECTIVE

The purpose of this study was to cluster individuals into groups with different dental health characteristics and make statistical inferences on the effect differences among different groups simultaneously to identify the heterogeneity of risk factors in Chinese adolescents by analysing the data from the 4th Chinese National Oral Health Survey.

METHODS

For decayed, missing and filled permanent teeth (DMFT), mean values were statistically analysed for their relationships with different categories of all involved variables. As DMFT scores only have discrete values, Poisson mixture regression was adopted to model the heterogeneity and complex patterns in the association and to detect the subgroup. The Bayesian information criterion (BIC) was used to determine the optimal number of subgroups. A series of Wald tests were used to explore the relationship between risk factors including the interaction effects and the number of DMFT.

RESULTS

A total of 100 986 individuals aged 12-15 years old were analysed. The model clustered different individuals into three subgroups and built three submodels for detailed statistical inference simultaneously. The number of individuals in the three subgroups were 52 576 (52.1%), 41 969 (41.5%) and 6441 (6.4%), respectively. The mean (SD) of DMFT of the three subgroups was 0.50 (1.05), 0.99 (1.21), 5.59 (2.50). The model fitting results indicated that the effects of all risk factors on DMFT appear to be different in three subgroups. Controlling the confounding effects, our analysis implied that the regional inequality was the main contributing factor to dental caries among adolescents in Chinese mainland.

CONCLUSIONS

The risk factors of dental caries exhibited heterogeneity in groups with different characteristics. The Poisson mixture regression model could cluster individuals into groups and identify the heterogeneous effects of risk factors among different groups. The findings support the need for different targeted interventions and prevention measures in groups with different dental health characteristics.

Does the Registered Dentists' Program Alleviate the Socioeconomic Gap in the Use of Dental Sealants?

Many countries provide preventive dental care for children to reduce inequalities. In Korea, the registered dentists' program was implemented to promote oral health and prevent oral diseases in primary school students. This study aimed to evaluate the registered dentist program through the sealant utilization rate using national cohort data and to compare the socioeconomic gap of the cohorts by participation. The sample cohort data were obtained from the National Health Insurance Sharing Service (NHISS) in South Korea. The utilization of dental sealants was analyzed using the chi-square test according to the independent variables of each year. To identify the independent effects of participation in the registered dentists' program, a panel logistic regression analysis of the utilization of dental sealants was performed. The participants were 1.35 times more likely to have dental sealants than non-participants. The significance of income quintiles disappeared in the case groups. The gap became more obvious in the employees of the control group even after adjusting for all variables. Implementing oral health programs can alleviate inequality with a relative increase in utilization in vulnerable populations.

Demonstration of payer readiness for value-based care in a fee-for-service environment: Measuring provider performance on sealant delivery

OBJECTIVES

Previously published sealant measures are not useful when applied to Medicaid claims data in states where dental services are carved out of managed care. A novel sealant measure was developed to assess the degree to which dental providers seal eligible teeth during preventive dental visits (PDVs) in an effort to ascertain if such a measure can be used to valuate provider performance, as condition of potential value-based care model implementation.

METHODS

A single-county feasibility study was conducted using Medicaid claims. A study cohort included children aged 8 years and enrolled 12 months during 2018. Prospective analysis was used to determine whether dental sealants were applied by the same dentists during PDVs or up to 9 months thereafter. Eligible teeth included first permanent molars. Teeth previously restored, sealed or missing were excluded. PDV was defined as any encounter with prophylaxis, fluoride treatment, or EPSDT. Claims were compared to public health surveillance for measurement validation.

RESULTS

Single-county results showed 11 percent of eligible teeth were sealed. Only 9 percent of dentists applied sealants to at least 40 percent of eligible teeth. Face validation of sealant rate was 23 percent Medicaid versus 36 percent Public Health. The former measures incidence and the latter prevalence with greater heterogeneity that included partially retained sealants.

CONCLUSIONS

A sealant measure that assesses provider adherence to sealant standards of care was produced. It has potential application for assessing performance of pediatric preventive services and informing value-based performance expectations.

Association between Medicaid expansion, dental coverage policies for adults, and children's receipt of preventive dental services

OBJECTIVE

To examine whether low-income children's use of preventive dental services is linked to variation in state Medicaid policies that affect parents' access to dental care in Medicaid.

DATA SOURCES

Medical Expenditure Panel Survey (2011-2016), Area Health Resources File, and Medicaid adult dental coverage policies.

STUDY DESIGN

We conducted a quasi-experimental analysis using linked parent-child dyads in low-income families (≤125 percent of the Federal Poverty Level). We assessed whether expansions of Medicaid to low-income adults under the Affordable Care Act were associated with increases in the use of preventive dental services among low-income children when state Medicaid programs did vs did not cover these services for adults.

PRINCIPAL FINDINGS

Over the study period, 37.8 percent of low-income children received at least one annual preventive dental visit. We found no change in children's receipt of preventive dental care associated with Medicaid expansions in states that covered (1.26 percentage points; 95% CI: -3.74 to 6.27) vs did not cover preventive dental services for adults (3.03 percentage points; 95% CI: -2.76 to 8.81). (differential change: -1.76 percentage points; 95% CI: -8.09, 4.56). However, our estimates are imprecise, with wide confidential intervals that are unable to rule out sizable effects in either direction.

CONCLUSION

We did not find an association between Medicaid expansions with concurrent coverage of preventive dental services for adults and children's use of these services. Factors other than parental access to dental benefits through Medicaid may be more salient determinants of preventive dental care use among low-income children.

The relationship between portable school-based oral health prevention services and subsequent oral health treatment

OBJECTIVES

This study examines whether a portable, school-based, preventive oral health program was associated with reduced use of treatment services over time.

METHODS

We obtained encounter data from Community Health Center, Inc. (CHC) in Connecticut that operates such a program. We followed cohorts of children for 4 years, examining change in ratio of treatment to total services in the fourth year, following receipt of portable preventive care in the prior 3 years. The sample included 3,006 children 4.5 to 15 years old on their first visit during 2005-2015. We used structural equation path models to assess change in the dependent variable, controlling for available demographics and service use patterns. We conducted additional sensitivity analyses to assess robustness of our findings.

RESULTS

We found a reduction in ratio of treatment (particularly restorative) to total services in the fourth year, given receipt of portable preventive care in the third year (direct impact) and receipt of portable preventive care in prior years (indirect impact). Older children and those covered by Medicaid (versus privately insured) had a higher ratio of treatment to total services in the fourth year.

CONCLUSIONS

Our retrospective analysis showed CHC portable dental program may reduce the use of treatment services over time among underserved children. This program is an example of a viable approach that could be emulated elsewhere if regulations allow remote supervision of hygienists and reimbursement levels are adequate.

Did the extended coverage policy contribute to alleviating socioeconomic inequality in untreated dental caries of both children and adolescents in South Korea?

Background

Dental sealants have been covered by the National Health Insurance Service (NHIS) since December 2009 in South Korea. This study aims to determine whether the socioeconomic inequality in untreated dental caries decreased after implementing the extended coverage policy for dental sealant.

Methods

The data were derived from the fourth (2007–2009) and sixth (2013–2015) waves of the Korean National Health and Nutrition Examination Survey (KNHANES) conducted by the Korea Centers for Disease Control and Prevention (KCDC). Dental caries and sealant experience by income quartiles were tested using the Rao-Scott chi-squared test. In order to examine socioeconomic inequalities and their trends over time, the prevalence ratios (PRs), slope index of inequality (SII), and relative index of inequality (RII) were estimated for each wave and age group. All analyses were conducted using SAS version 9.3.

Results

The adjusted PRs of untreated dental caries and sealants in the poorest in the aged 6–11 group were significantly higher and lower, respectively, compared to the most affluent quartile group for the fourth wave; however, all significant differences disappeared for the sixth wave, after the sealant coverage. The gap between the lowest and the highest was similar for the aged 12–18 group but it widened in the untreated dental caries even after the sealant coverage. The statistical significance of the PRs was maintained at the sixth wave for both caries and sealants. Children showed decreases in both SII and RII over time so its significance disappeared. The SII among adolescents decreased over time but the RII of untreated dental caries increased.

Conclusions

This study found that the NHIS coverage expansion of dental care had a positive effect on overall status in dental health among children and adolescents. However, younger children benefited more in terms of inequalities. Our findings indicate that strategies to enhance access to preventive dental services should consider the differential effects for the vulnerable population in terms of socioeconomic status and age from the beginning stage of the policy.

Quality appraisal of economic evaluations done on oral health preventive programs-A systematic review

OBJECTIVES

If economic evaluations are to be used by decision makers, such evidence has to be robust so that the relevant policy maker use them. This study was undertaken with the purpose of identifying economic evaluations done on oral health preventive programs and to assess the standard of economic evidence in this field.

METHODS

A systematic search was conducted using four major electronic databases in order to search for economic evaluations done on oral health preventive programs. This included economic evaluations that were published between January 1975 and May 2018 on preventive interventions for periodontal disease, oral cancer screening, and other common oral health conditions. To avoid duplications with previous studies, for dental caries interventions, this review included studies from April 2012 and May 2018. "Guidance to undertaking reviews in health care," developed by York University, was used to assess the quality of reporting in the evaluations, using which strengths and shortcomings were identified.

RESULTS

A total of 2026 records were initially found. After title and abstract screening, and elimination by full text review, 33 relevant economic evaluations were identified. Majority of the economic evaluations included were conducted on dental caries prevention; a few were done on oral cancer screening, periodontal disease, and general preventive dentistry (health promotion, oral hygiene etc.).

CONCLUSIONS

In comparison to the findings observed in previous reviews, there has been improvements in the quality of reporting in economic evaluations. Several areas still in need for improve were identified (e.g., productivity costs, currency and prices, and generalizability issues).

School-based caries prevention and longitudinal trends in untreated decay: an updated analysis with Markov chains

OBJECTIVE

Dental caries (tooth decay) is the most prevalent childhood disease in the world. A school-based program for the prevention of dental caries providing bi-annual sealants, interim therapeutic restorations, and fluoride varnish to children aged 5-12 years was previously associated with a significant reduction in the prevalence of untreated tooth decay over time. The objective of this study was to explore potential nonlinear change in the risk of untreated decay in children receiving caries prevention.

RESULTS

Across all study participants, there was a significant increase in the odds of untreated tooth decay over time (OR = 1.90, 95% CI 1.51, 2.39), but the rate of this risk rapidly decreased with each observational visit (OR = 0.87, 95% CI 0.93, 0.91). Overall effects substantially depended on the oral health status of participants at baseline: for children with untreated decay at their first observation, the odds of untreated decay over time was 0.39 (95% CI 0.27, 0.55). A quadratic change for this subpopulation showed that the per-visit decrease in decay was attenuated with each subsequent observation (OR = 1.12, 95% CI 1.04, 1.20).

Teeth: Small but Mighty and Mighty Important. A Comprehensive Review of Children's Dental Health for Primary Care Clinicians

Healthy teeth allow us to eat and stay well-nourished. Although primary care clinicians receive limited training about teeth, given the common nature of dental problems, it is important that they understand and recognize normal and abnormal dental conditions and can implement primary and secondary prevention of dental conditions in their practice. PubMed has been used to search the scientific literature for evidence on the following topics: normal dental development, dental abnormalities, malocclusion, teething, dental caries and related epidemiology and prevention, fluoride, dental injury and its management and prevention; and identification, prevention and treatment of gingivitis and periodontal disease. Literature review relied on randomized controlled trials, meta-analyses, systematic reviews, and Cochrane reviews when relevant and available. Other sources of evidence included cohort and case-control studies. Consensus statements and expert opinion were used when there was a paucity of high-quality research studies. The literature has been synthesized on these topics to make them relevant to pediatric primary care clinicians, and as available, the strength of evidence has been characterized when making clinical recommendations.

The cost-utility of school-based first permanent molar sealants programs: a Markov model

BACKGROUND

Evidence of the cost-effectiveness of school-based first permanent molar sealants programs is not yet fully conclusive. The aim of this study was to determine the incremental cost-utility ratio (ICUR) of school-based prevention programs for the application of sealants in molars of schoolchildren compared with non-intervention.

METHODS

A cost-utility analysis based on a Markov model was carried out using probability distribution. The utility was measured in quality-adjusted tooth years (QATY). The assessment was carried out from the public payer's perspective with a six-year time horizon. Costs and benefits were discounted at 3% per year. Only direct costs were evaluated, expressed in Chilean pesos (CLP) at 7th May at 2019 values (exchange rate USD = CLP 681.09). Univariate deterministic sensitivity analysis and probabilistic analysis were carried out.

RESULTS

After a six-year follow up, the cost of sealing all first permanent molars was found to be higher than non-intervention, with a mean cost difference of USD 1.28 (CLP 875) per molar treated. The "seal all" strategy was more effective than non-intervention, generating 0.2 quality-adjusted tooth years more than non-intervention. The ICUR of the "seal all" strategy compared to non-intervention was USD 6.48 (CLP 4,412) per quality-adjusted tooth years. The sensitivity analysis showed that the increase in caries was the variable which most influenced the ICUR.

CONCLUSIONS

A school-based sealant program is a cost-effective measure in populations with a high prevalence of caries.

Nonrestorative Management of Cavitated and Noncavitated Caries Lesions

The objective of this article is to review evidence-based strategies available for the nonrestorative management of caries lesions, both cavitated and noncavitated. The goal is to help clinicians make appropriate decisions regarding nonrestorative management of caries lesions. In addition, in the decision-making process, clinicians must consider thresholds for restorative and nonrestorative care and strategies for nonrestorative management that are supported by best available evidence. It is important that this information be considered taking into account a provider's clinical expertise and a patient's treatment needs and preferences, in order to maintain health and preserve tooth structure.

Children's Dental Sealant Use and Caries Prevalence Affected by National Health Insurance Policy Change: Evidence from the Korean National Health and Nutrition Examination Survey (2007-2015)

We evaluated the effect of the National Health Insurance (NHI) policy including dental sealant on changes in the prevalence of sealant and caries, and examined how NHI affected sealant utilization and untreated caries in children from diverse income groups in South Korea. We used a multivariate logistic regression analysis to explore the effects of three stages of dental sealant policy (pre-policy: 2007-2009, first post-policy: 2010-2012, and second post-policy: 2013-2015) on the prevalence of dental sealant and untreated caries. Participant data (N = 8161, aged 6-14 years) were derived from the Korea National Health and Nutrition Examination Survey (2007-2015). We also conducted subgroup analysis to determine the effects of the NHI policy on dental sealant and untreated caries by income level. Implementation of dental insurance coverage was associated with higher likelihood of using dental sealant (odds ratio (OR) = 1.39 (95% confidence interval (CI): 1.18-1.63) for the first period and OR = 1.58 (95% CI: 1.33-1.87) for the second period) and lower odds of having untreated caries (OR = 0.79 (95% CI: 0.64-0.98) for the first period and OR = 0.65 (95% CI: 0.51-0.83) for the second period) after controlling for covariates. Results revealed that there was a greater prevalence of dental sealant and a lower prevalence of untreated caries in both middle- and low-income households compared to high-income households. The higher prevalence of dental sealant and lower untreated caries after the policy implementation. Moreover, we demonstrated children from low-or middle-income households were more associated with increasing dental sealant use and a declining prevalence of caries.

Impact of the Health Resources and Services Administration's state oral health workforce grant program on dental workforce density and access to oral health care

BACKGROUND

The Health Resources and Services Administration's Grants to States to Support Oral Health Workforce Activities, otherwise known as the State Oral Health Workforce Program (SOHWP), help states develop and implement innovations that address the workforce needs of dental Health Professional Shortage Areas in a manner appropriate to the states' individual needs.

AIM

This cross-sectional study explores the broad impact of the SOHWP by comparing measures of dental workforce density and access to oral health care in states with multiple years of funding versus states with few or no years of funding.

METHODS

We used data for 2006-2016 SOHWP awardees together with data from the 2016-2017 Area Health Resources Files and the 2016 Behavioral Risk Factor Surveillance System to compare numbers of dentists per 100,000 population and age-adjusted prevalence of annual dental visits among adults for long-term SOHWP-funded states versus states with few or no years of funding.

RESULTS

Multi-year SOHWP funding is associated with higher workforce density and greater access to oral health care, especially in the Midwest and West.

CONCLUSION

Allowing states funding utilization flexibility may result in improved outcomes. This finding can help inform planning and policy about whether and how to scale future training and workforce programs to achieve greater impact.

An Economic Evaluation of a Comprehensive School-Based Caries Prevention Program

INTRODUCTION

Current economic evaluations of school-based caries prevention programs (SCPPs) do not compare multiple types of SCPPs against each other and do not consider teeth beyond permanent first molars.

OBJECTIVES

To assess the cost-effectiveness of a comprehensive SCPP relative to an SCPP focused on delivering sealants for permanent first molars only and to a default of no SCPP. Based on a societal perspective, a simulation model was used that compared the health and cost impacts on 1) permanent first molars only and 2) all posterior teeth.

METHODS

To calibrate the model, we used data from CariedAway, a comprehensive SCPP that used glass ionomer to prevent and arrest active decay among children. We then evaluated the incremental cost-effectiveness of implementing 3 alternate school-based approaches (comprehensive, sealant only, and no program) on only first molars and all posterior teeth. Probabilistic, 1-, and 2-way sensitivity analyses are included for robustness. Cost-effectiveness is assessed with a threshold of $54,639 per averted disability-adjusted life year (DALY).

RESULTS

We first compared the 3 programs under the assumption of treating only first molars. This assessment indicated that CariedAway was less cost-effective than school-based sealant programs (SSPs): the resulting incremental cost-effectiveness ratio (ICER) for CariedAway versus SSPs was $283,455 per averted DALY. However, when the model was extended to include CariedAway's treatment of all posterior teeth, CariedAway was not only cost-effective but also cost-saving relative to SSPs (ICER, -$943,460.88 per averted DALY; net cost, -$261.45) and no SCPP (ICER, -$400,645.52 per averted DALY; net cost, -$239.77).

CONCLUSIONS

This study finds that economic evaluations assessing only cost and health impacts on permanent first molars may underestimate the cost-effectiveness of comprehensive SCPPs 1) preventing and arresting decay and 2) treating all teeth. Hence, there is an urgent need for economic evaluations of SCPPs to assess cost and health impacts across teeth beyond only permanent first molars.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by policy makers to understand how to evaluate economic evaluations of school-based caries prevention programs and what factors to consider when deciding on what types of programs to implement.

Awareness Among US Adults of Dental Sealants for Caries Prevention

INTRODUCTION

Dental sealants applied in childhood can help prevent caries, but knowledge of the availability of sealants and their function is not widespread. We assessed knowledge of dental sealants among US adults and adult parents of children younger than 18 and the differences in knowledge among demographic and socioeconomic groups.

METHODS

We used data on 3,550 respondents to the 2015 FallStyles B survey of noninstitutionalized US adults aged 18 or older. Authors constructed estimates by using weights provided to reflect the distribution of the US population. Knowledge of dental sealants was assessed by sex, age, race/ethnicity, education, household income, and parental status. Multivariate analysis was conducted by using a main effects logistic regression model.

RESULTS

Overall, 46.3% of adults and 55.1% of parents of children younger than 18 had knowledge of dental sealants. Sealant knowledge was highest among parents, women, respondents aged 45 to 59, and respondents with incomes greater than 200% of the federal poverty level and more than a high school education. Non-Hispanic blacks had less than half the odds of non-Hispanic whites of having knowledge of sealants (adjusted odds ratio [OR] = 0.4), and nonparents had half the odds as parents (OR = 0.5) of knowing. The strongest predictors of parental sealant knowledge were race/ethnicity, sex, and income.

CONCLUSION

Disparities in sealant knowledge correspond to disparities in sealant prevalence. Increasing knowledge among low-income and racial/ethnic minority parents could reduce disparities in sealant prevalence and untreated caries.

Evidence-Based Dentistry Caries Risk Assessment and Disease Management

The objective of this article was to provide a summary of evidence-based recommendations for the assessment of caries risk and management of dental caries. The goal is to help clinicians manage the caries disease process using personalized interventions supported by the best available evidence, taking into account the clinician's expertise and the patient's needs and preferences, to maintain health and preserve tooth structure.

Estimating the Cost Savings of Preventive Dental Services Delivered to Medicaid-Enrolled Children in Six Southeastern States

OBJECTIVE

To quantify the impact of multiyear utilization of preventive dental services on downstream dental care utilization and expenditures for children.

DATA SOURCES/STUDY SETTING

We followed 0.93 million Medicaid-enrolled children who were 3-6 years old in 2005 from 2005 to 2011. We used Medicaid claims data of Alabama, Georgia, Mississippi, North Carolina, South Carolina, and Texas.

STUDY DESIGN

We clustered each state's study population into four groups based on utilization of topical fluoride and dental sealants before caries-related treatment using machine learning algorithms. We evaluated utilization rates and expenditures across the four groups and quantified cost savings of preventive care for different levels of penetration.

DATA EXTRACTION METHOD

We extracted all dental-related claims using CDT codes.

PRINCIPAL FINDINGS

In all states, Medicaid expenditures were much lower for children who received topical fluoride and dental sealants before caries development than for all other children, with a per-member per-year difference ranging from $88 for Alabama to $156 for Mississippi.

CONCLUSIONS

The cost savings from topical fluoride and sealants across the six states ranged from $1.1M/year in Mississippi to $12.9M/year in Texas at a 10 percent penetration level. Preventive dental care for children not only improves oral health outcomes but is also cost saving.