Adoption and implementation of policies to support preventive dentistry initiatives for physicians: a national survey of Medicaid programs

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.

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.

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.

Fluoride Prescribing Behaviors for Medicaid-Enrolled Children in Oregon

INTRODUCTION

This study aims to examine physician and dentist fluoride prescription patterns and identify the factors associated with fluoride prescriptions for Medicaid-enrolled children. The hypothesis is that dentists will be the primary prescribers of fluoride and that caries risk factors will be associated with fluoride prescriptions.

METHODS

Data were analyzed for Oregon children aged 0-17 years enrolled in Medicaid for ≥300 days in both 2016 and 2017. The outcome variable was receiving a fluoride prescription in 2017. A 2-tailed chi-square test was used to assess fluoride prescribing differences between physicians and dentists. Multivariable logistic regression models were used to examine the likelihood of receiving a fluoride prescription in 2017 and to generate ORs. Model covariates included child's age, sex, race, ethnicity, Medicaid plan type, previous fluoride prescription, previous restorative dental treatment, and water fluoridation status.

RESULTS

Of 200,169 Medicaid-enrolled children, 6.7% (n=13,337) received fluoride prescriptions. Physicians were >3 times as likely to prescribe fluoride as dentists (73.4% vs 23.0%, p<0.001). Children with a history of fluoride prescriptions (OR=14.30, p<0.001) and any restorative dental treatment (OR=1.58, p<0.001) were significantly more likely to receive a fluoride prescription, whereas children living in areas with water fluoridation were significantly less likely (OR=0.50, p=0.01).

CONCLUSIONS

Physicians play an important role in prescribing fluoride to Medicaid-enrolled children, especially those at increased dental caries risk. Additional research is needed on strategies to ensure that all high-risk children have an opportunity to benefit from prescription fluoride.

A Framework to Foster Oral Health Literacy and Oral/General Health Integration

Science and technology advances have led to remarkable progress in understanding, managing, and preventing disease and promoting human health. This phenomenon has created new challenges for health literacy and the integration of oral and general health. We adapted the 2004 Institute of Medicine health literacy framework to highlight the intimate connection between oral health literacy and the successful integration of oral and general health. In doing so we acknowledge the roles of culture and society, educational systems and health systems as overlapping intervention points for effecting change. We believe personal and organizational health literacy not only have the power to meet the challenges of an ever- evolving society and environment, but are essential to achieving oral and general health integration. The new “Oral Health Literacy and Health Integration Framework” recognizes the complexity of efforts needed to achieve an equitable health system that includes oral health, while acknowledging that the partnership of health literacy with integration is critical. The Framework was designed to stimulate systems-thinking and systems-oriented approaches. Its interconnected structure is intended to inspire discussion, drive policy and practice actions and guide research and intervention development.

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.

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.

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.

Knowledgeability, attitude, and practice behaviors of primary care providers toward managing patients' oral health care in medical practice: Wisconsin statewide survey

BACKGROUND

In this study, the authors sought to explore the receptivity, preparedness, and rates of adoption of integrated medical-dental models of care (MOCs) in the practice setting among primary care providers (PCPs) treating patients with diabetes mellitus (DM).

METHODS

The authors conducted an anonymous statewide survey targeting PCPs across a range of Wisconsin-based practice settings to evaluate knowledgeability, attitude, practice behaviors, and perceived barriers to oral health screening in a medical setting. Qualitative analytical approaches included thematic analyses applied to evaluate the status of and barriers to integrated medical-dental MOC adoption.

RESULTS

The integrated medical-dental MOC adoption rate was 34%. Top perceived barriers to integrated medical-dental MOC adoption included insurance coverage (71%) and care access (70%). A total of 39% indicated competency for educating patients about the association between DM and periodontitis. Although 72% of PCPs indicated optimal periodicity for oral health assessment as frequent, 39% reported frequently conducting such assessments.

CONCLUSIONS

Although PCPs indicate receptivity to integrated medical-dental MOCs, PCPs identify suboptimal education, lack of adequate training in oral-systemic disease assessment, and barriers to oral health care access as barriers to integrated medical-dental MOC adoption.

PRACTICAL IMPLICATIONS

Integrated medical-dental MOC adoption in care delivery to patients with DM remains below average. Interdisciplinary efforts and education are needed to address identified barriers to care integration.

Context for implementing a gestational weight gain program nationally

OBJECTIVES

Use the Consolidated Framework for Implementation Research to describe the context in which a gestational weight gain (GWG) intervention, embedded within Parents as Teachers (PAT), will be implemented at PAT sites nationwide.

METHODS

Ten site leaders and six parent educators from ten PAT sites in eight states participated in semi-structured interviews and a survey. Audio-recordings and systematic notes were used in a deductive analysis. Scales were descriptively analyzed.

RESULTS

Surveys demonstrated positive perspectives of PAT+GWG. In interviews, participants described PAT+GWG filling a need for prenatal health education and confidence delivering this content, valued integration of PAT+GWG within the PAT curriculum, and recommended materials to meet their clients' needs.

CONCLUSIONS

Contextual information can help maximize PAT+GWG's impact.

From theoretical concepts to policies and applied programmes: the landscape of integration of oral health in primary care

BACKGROUND

Despite its importance, the integration of oral health into primary care is still an emerging practice in the field of health care services. This scoping review aims to map the literature and provide a summary on the conceptual frameworks, policies and programs related to this concept.

METHODS

Using the Levac et al. six-stage framework, we performed a systematic search of electronic databases, organizational websites and grey literature from 1978 to April 2016. All relevant original publications with a focus on the integration of oral health into primary care were retrieved. Content analyses were performed to synthesize the results.

RESULTS

From a total of 1619 citations, 67 publications were included in the review. Two conceptual frameworks were identified. Policies regarding oral heath integration into primary care were mostly oriented toward common risk factors approach and care coordination processes. In general, oral health integrated care programs were designed in the public health sector and based on partnerships with various private and public health organizations, governmental bodies and academic institutions. These programmes used various strategies to empower oral health integrated care, including building interdisciplinary networks, training non-dental care providers, oral health champion modelling, enabling care linkages and care coordinated process, as well as the use of e-health technologies. The majority of studies on the programs outcomes were descriptive in nature without reporting long-term outcomes.

CONCLUSIONS

This scoping review provided a comprehensive overview on the concept of integration of oral health in primary care. The findings identified major gaps in reported programs outcomes mainly because of the lack of related research. However, the results could be considered as a first step in the development of health care policies that support collaborative practices and patient-centred care in the field of primary care sector.

Barriers and facilitators in the integration of oral health into primary care: a scoping review

OBJECTIVE

This scoping study has been conducted to map the literature and provide a descriptive synthesis on the barriers and facilitators of the integration of oral health into primary care.

METHODS

Grounded in the Rainbow conceptual model and using the Levac et al six-stage framework, we performed a systematic search of electronic databases, organisational websites and grey literature from 1978 to April 2016. All publications with a focus on the integration of oral health into primary care were included except commentaries and editorials. Thematic analyses were performed to synthesise the results.

RESULTS

From a total of 1619 citations, 58 publications were included in the review. Barrier-related themes included: lack of political leadership and healthcare policies; implementation challenges; discipline-oriented education; lack of continuity of care and services and patients' oral healthcare needs. The facilitators of integration were supportive policies and resources allocation, interdisciplinary education, collaborative practices between dental and other healthcare professionals, presence of local strategic leaders and geographical proximity.

DISCUSSION AND PUBLIC HEALTH IMPLICATIONS

This work has advanced the knowledge on the barriers and facilitators at each integration domain and level, which may be helpful if the healthcare organisations decide to integrate oral health and dental services into primary care. The scoping review findings could be useful for both dental and medical workforce and allied primary healthcare providers. They could also guide the development of healthcare policies that support collaborative practices and patient-centred care in the field of primary care.

Medical Providers' Oral Health Knowledgeability, Attitudes, and Practice Behaviors: An Opportunity for Interprofessional Collaboration

OBJECTIVE

Evaluation of current knowledgeability, attitudes, and practice behaviors of medical providers from a large health care system toward oral health was undertaken as a pilot effort to better understand and integrate oral health into the overall health care delivery.

METHODS

Invitations to complete a 28-question survey, designed in a web-based platform (SurveyMonkey(®)), were emailed to 1407 medical multispecialty physicians, residents, and nurses within the health system. The questionnaire included sections on provider demographics, oral health knowledgeability and attitudes, and current practice conducting oral health screenings.

RESULTS

A 14% (n = 199/1407) response rate was achieved for survey completion. There were 16% who reported good coverage of oral/dental health topics in their medical training curriculum. Competency level was <30% for identifying tooth decay and oral pathology. There were 95% who reported never applying fluoride varnish in their practice, while >80% answered knowledge-based questions correctly. Frequency rates for dental referral by the medical providers were 32% 'frequently' and 68% 'infrequently.' Perceptions of optimal frequency for conducting oral health assessment in their professional practices ranged from 69% indicating 'frequently' to 25% indicating 'infrequently.'

CONCLUSION

Overall, positive attitudes were observed toward incorporation of oral health examination into medical practice. The study identified lack of oral health treatment and infrequent referral by medical providers to dental providers. Results support likelihood for acceptance of care models that incorporate a medical/dental team-based approach complemented by oral health training for medical providers to enhance holistic health care delivery. Limitations of this pilot study include potential selection bias and lack of generalizability beyond our institution; further studies are planned in additional settings statewide to validate findings.

Interprofessional oral health initiative in a nondental, American Indian setting

BACKGROUND AND PURPOSE

Tooth decay is the most common chronic childhood disease and American Indian (AI) children are at increased risk. Pediatric primary care providers are in an opportune position to reduce tooth decay. The purpose of this study was to integrate and evaluate a pediatric oral health project in an AI, pediatric primary care setting.

METHODS

The intervention set included caregiver education, caries risk assessment, and a same-day dental home referral. All caregiver/child dyads age birth to 5 years presenting to the pediatric clinic were eligible (n = 47).

CONCLUSIONS

Most children (n = 35, 91.1%) were scored as high risk for caries development. Of those with first tooth eruption (n = 36), ten had healthy teeth (27.8%) and seven had seen a dentist in the past 3 months (19.4%). All others were referred to a dentist (n = 29) and 21 families (72.4%) completed the referral.

IMPLICATIONS FOR PRACTICE

In fewer than 5 min per appointment (x = 4.73 min), the primary care provider integrated oral health screening, education, and referral into the well-child visit. Oral health is part of total health, and thus should be incorporated into routine well-child visits.

Does Patient-Centered Medical Home Recognition Relate to Accountable Care Organization Participation?

As of April 2015, less than 10% of Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs) included Rural Health Clinics (RHCs). In order to understand why RHCs are not participating in this ACO model in greater numbers, this study examined the influence of several factors on ACO participation. Data for this study were collected via a survey distributed during the summers of 2012, 2013, and 2014 to all RHCs in 9 states. This study had a cross-sectional design using survey research. The unit of analysis was the RHC; the total sample size was 178. This study found that those respondents who reported knowing very little about ACOs had the lowest "willingness to join an ACO" score and that the passage of time increased RHC willingness to join an ACO. Also, patient-centered medical home (PCMH) recognition was the most influential factor related to an RHC's adopting the ACO model. If ACO model adoption is to increase in rural areas, this study suggests that strategies would need to include methods for (1) targeting RHCs that have PCMH recognition; (2) increasing PCMH recognition in rural areas; and (3) increasing RHC knowledge about what an ACO is, how the model works, and why this model may benefit RHCs and other rural primary care providers.

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.

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.

Provision of Preventive Dental Services in Children Enrolled in Medicaid by Nondental Providers

OBJECTIVES

Aims of this study are to determine (1) the association of oral health services (OHS) provided by nontraditional providers with the percentage of Medicaid children 0 to 5 years of age who receive ≥1 preventive services from all provider types in the United States; and (2) characteristics of state Medicaid policies associated with provision of OHS.

METHODS

We conducted a time-series cross-sectional study of preventive services provided by nontraditional (OHS) and dental (PDS) providers for Medicaid-enrolled children from birth to 5 years of age in all states during 2010 to 2013 (204 observations). We applied panel data multiple regression analysis techniques to exploit year and state variation in aggregate data available in Centers for Medicare and Medicaid Services reports (form CMS-416). Total preventive dental services (TPDS =OHS + PDS) was predicted by months since state enactment of a policy to reimburse medical providers for OHS.

RESULTS

The 44 states with a policy reported 4.3% of children per state per year with any OHS. For all states, an average of 30.1% received PDS and 34.5% TPDS. The delivery of OHS was associated with a small increase in percentage with TPDS. One year of Medicaid OHS availability was associated with an increase of 1.5% in the percentage of children with TPDS per state per year.

CONCLUSIONS

Implementation of policies by Medicaid programs to support integration of OHS into primary care is associated with increases in overallTPDS use, but efforts are needed to improve implementation in practice to achieve national impact on access.

Increased Length of Awareness of Assisted Reproductive Technologies Fosters Positive Attitudes and Acceptance among Women

Background

The field of infertility medicine has witnessed a surge of scientific developments in recent years, but research on public attitudes towards infertility treatments has remained minimal. This study examined the social and demographic factors that affect women’s attitudes towards assisted reproductive technology (ART) in general, as well as their opinions of specific issues related to ART.

Materials and Methods

This cross-sectional study was conducted from March 2011 to April 2011 by means of an online survey administered to a sample of 287 women.

Results

Women with a longer length of awareness of ART had significantly greater attitudinal favorability towards ART. Political affiliation was also significantly related to general attitudes, as well as several specific aspects of ART issues.

Conclusion

The results of this study suggest that several factors influence attitudes that women hold in regards to ART. Identifying some of these factors serves as a crucial starting point for devising strategies to increase public acceptance of ART.

Impact of an interprofessional oral health education program on health care professional and practice behaviors: a RE-AIM analysis

BACKGROUND

Early childhood caries is the most common chronic childhood condition and largely preventable. Access to oral health preventive services (OHPS) for children at risk for caries is suboptimal and could be expanded if they were provided by non-dental professionals. Many state Medicaid programs in the USA now reimburse non-dental professionals for OHPS but require that they receive oral health education (OHE) to be reimbursed. Few OHE programs have been evaluated.

METHODS

We evaluated the impact of Colorado's OHE program on professional- and practice-level behaviors regarding the provision of OHPS to children by measuring its reach, effectiveness, adoption, implementation, and maintenance (ie, using the Reach Effectiveness Adoption Implementation Maintenance [RE-AIM] framework) with Medicaid claims data, online surveys, and key informant interviews.

RESULTS

From 2009 to 2012, the proportion of young, low-income children receiving OHPS from a medical professional increased 16-fold. We surveyed 703 OHE participants; post-OHE response rates were 61% at 12 months, 34% at 24 months (2009 participants), and 39% at 12 months (2011 participants). Respondents reported confidence in providing OHPS; favorable oral health knowledge, attitudes, and beliefs; and were providing OHPS to most eligible children. Approximately half of the practices had initiated practice-level changes to support program implementation and maintenance. Few barriers were reported to care. Eighteen interviewees reported factors facilitating program diffusion, which included quality materials, community need, and reimbursement; barriers included lack of time to provide services, resources to purchase supplies, and referral dentists.

CONCLUSION

This evaluation of a state interprofessional OHE program shows evidence of program diffusion and identifies facilitating factors and barriers to having medical professionals provide OHPS.

Effects of Physician-Based Preventive Oral Health Services on Dental Caries

BACKGROUND

Most Medicaid programs reimburse nondental providers for preventive dental services. We estimate the impact of comprehensive preventive oral health services (POHS) on dental caries among kindergarten students, hypothesizing improved oral health among students with medical visits with POHS.

METHODS

We conducted a retrospective study in 29,173 kindergarten students by linking Medicaid claims (1999-2006) with public health surveillance data (2005-2006). Zero-inflated regression models estimated the association between number of visits with POHS and (1) decayed, missing, and filled primary teeth (dmft) and (2) untreated decayed teeth while adjusting for confounding.

RESULTS

Kindergarten students with ≥4 POHS visits averaged an adjusted 1.82 dmft (95% confidence interval: 1.55 to 2.09), which was significantly less than students with 0 visits (2.21 dmft; 95% confidence interval: 2.16 to 2.25). The mean number of untreated decayed teeth was not reduced for students with ≥4 POHS visits compared with those with 0 visits.

CONCLUSIONS

POHS provided by nondental providers in medical settings were associated with a reduction in caries experience in young children but were not associated with improvement in subsequent use of treatment services in dental settings. Efforts to promote oral health in medical settings should continue. Strategies to promote physician-dentist collaborations are needed to improve continuity of care for children receiving dental services in medical settings.

Examining continuity of care for Medicaid-enrolled children receiving oral health services in medical offices

Children living in poverty encounter barriers to dentist visits and disproportionally experience dental caries. To improve access, most state Medicaid programs reimburse pediatric primary care providers for delivering preventive oral health services. To understand continuity of oral health services for children utilizing the North Carolina (NC) Into the Mouths of Babes (IMB) preventive oral health program, we examined the time to a dentist visit after a child's third birthday. This retrospective cohort study used NC Medicaid claims from 2000 to 2006 for 95,578 Medicaid-enrolled children who received oral health services before age 3. We compared children having only dentist visits before age 3 to those with: (1) only IMB visits and (2) both IMB and dentist visits. Cox proportional hazards regression was used to estimate the time to a dentist visit following a child's third birthday. Propensity scores with inverse-probability-of-treatment-weights were used to address confounding. Children with only IMB visits compared to only dentist visits before age 3 had lower rates of dentist visits after their third birthday [adjusted hazard ratio (AHR) = 0.41, 95 % confidence interval (CI) 0.39-0.43]. No difference was observed for children having both IMB and dentist visits and only dentist visits (AHR = 0.99, 95 % CI 0.96-1.03). Barriers to dental care remain as children age, hindering continuity of care for children receiving oral health services in medical offices.

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

BACKGROUND

Professional guidelines and state Medicaid policies encourage pediatricians to provide oral health screening, anticipatory guidance, and fluoride varnish application to young patients. Because oral health activities are becoming more common in medical offices, the objective of this study was to assess pediatricians' attitudes and practices related to oral health and examine changes since 2008.

METHODS

As part of the 2012 Periodic Survey of Fellows, a random sample of 1638 members of the American Academy of Pediatrics was surveyed on their participation in oral health promotion activities. Univariate statistics were used to examine pediatricians' attitudes, practices, and barriers related to screening, risk assessment, counseling, and topical fluoride application among patients from birth to 3 years of age. Bivariate statistics were used to examine changes since 2008.

RESULTS

Analyses were limited to 402 pediatricians who provided preventive care (51% of all respondents). Most respondents supported providing oral health activities in medical offices, but fewer reported engaging in these activities with most patients. Significantly more respondents agreed they should apply fluoride varnish (2008, 19%; 2012, 41%), but only 7% report doing so with >75% of patients. Although significantly more respondents reported receiving oral health training, limited time, lack of training and billing remain barriers to delivering these services.

CONCLUSIONS

Pediatricians continue to have widespread support for, but less direct involvement with oral health activities in clinical practice. Existing methods of training should be examined to identify methods effective at increasing pediatricians' participation in oral health activities.

Longitudinal discharge trends and outcomes after hospitalization for mouth cellulitis and Ludwig angina

OBJECTIVE

Objective is to provide longitudinal discharge trends and hospitalization outcomes in patients hospitalized because of mouth cellulitis or Ludwig angina.

METHODS

Nationwide Inpatient Sample for years 2004 to 2010 was used. All hospitalizations with primary diagnosis of cellulitis or Ludwig angina were selected. Discharge trends were examined.

RESULTS

A total of 29,228 hospitalizations occurred as a result of mouth cellulitis/Ludwig angina; 55% of all hospitalizations were male patients; 68% were aged 21 to 60 years. Non-whites comprised close to 40%. The uninsured comprised 22.3%. Ninety-nine patients died in hospitals. The total hospitalization charges across the entire United States over the study period was $772.57 million. Factors associated with increased hospitalization charges included, age, co-morbid burden, insurance status, race, teaching status of hospital, and geographic location.

CONCLUSIONS

Uninsured non-whites, those with high co-morbid burden, and those aged 21 to 60 years tended to be hospitalized consistently over the study period.

Preventive Services by Medical and Dental Providers and Treatment Outcomes

OBJECTIVE

Nearly all state Medicaid programs reimburse nondental primary care providers (PCPs) for providing preventive oral health services to young children; yet, little is known about how treatment outcomes compare with children visiting dentists. This study compared the association between the provider of preventive services (PCP, dentist, or both) with Medicaid-enrolled children before their third birthday and subsequent dental caries-related treatment (CRT) and CRT payment.

METHODS

We conducted a retrospective study of young children enrolled in North Carolina Medicaid during 2000 to 2006. The annual number of CRT and CRT payments per child between the ages of 3 and 5 yr were estimated with a zero-inflated negative binomial regression and a hurdle model, respectively. Models were adjusted for relevant child- and county-level characteristics and used propensity score weighting to address observed confounding.

RESULTS

We examined 41,453 children with > 1 preventive oral health visit from a PCP, dentist, or both before their third birthday. Unadjusted annual mean CRT and payments were lowest among children who had only PCP visits (CRT = 0.87, payment = $172) and higher among children with only dentist visits (CRT = 1.48, payment = $234) and both PCP and dentist visits (CRT = 1.52, payment = $273). Adjusted results indicated that children who had dentist visits (with or without PCP visits) had significantly more CRT and higher CRT payments per year during the ages of 3 and 4 yr than children who had only PCP visits. However, these differences attenuated each year after age 3 yr.

CONCLUSIONS

Because of children's increased opportunity to receive multiple visits in medical offices during well-child visits, preventive oral health services provided by PCPs may lead to a greater reduction in CRT than dentist visits alone. This study supports guidelines and reimbursement policies that allow preventive dental visits based on individual needs.

Care coordination among pediatricians and dentists: a cross-sectional study of opinions of North Carolina dentists

BACKGROUND

Care coordination between physicians and dentists remains a challenge. This study of dentists providing pediatric dental care examined their opinions about physicians' role in oral health and identified factors associated with these opinions.

METHODS

North Carolina general and pediatric dentists were surveyed on their opinions of how physicians should proceed after caries risk assessment and evaluation of an 18-month-old, low risk child. We estimated two multinomial logistic regression models to examine dentists' responses to the scenario under the circumstances of an adequate and a limited dental workforce.

RESULTS

Among 376 dentists, 52% of dentists indicated physicians should immediately refer this child to a dental home with an adequate dental workforce. With a limited workforce, 34% recommended immediate referral. Regression analysis indicated that with an adequate workforce guideline awareness was associated with a significantly lower relative risk of dentists' recommending the child remain in the medical home than immediate referral.

CONCLUSIONS

Dentists' opinions and professional guidelines on how physicians should promote early childhood oral health differ and warrant strategies to address such inconsistencies. Without consistent guidelines and their application, there is a missed opportunity to influence provider opinions to improve access to dental care.

Office-based preventive dental program and statewide trends in dental caries

OBJECTIVES

To evaluate the impact of a North Carolina Medicaid preventive dentistry program in primary care medical offices (Into the Mouths of Babes Program [IMBP]) on decayed, missing, and filled teeth (dmft) of kindergarten students statewide and in schools with a large proportion of students from low-income families.

METHODS

An ecologic study using panel data of 920,505 kindergarten students with 11,694 school-year observations examined the effect of the IMBP on dmft scores from 1998 to 2009. Ordinary least squares regression with fixed effects determined the association between IMBP visits per child 0 to 4 years of age per county and mean dmft scores per kindergarten student per school, controlling for school-level poverty and ethnicity, county-level Medicaid enrollment, and supply of dentists and physicians.

RESULTS

Mean dmft per kindergarten student per school increased from 1.53 in 1998 to 1.84 in 2004, then decreased to 1.59 in 2009. The mean number of IMBP visits per child 0 to 4 years of age per county increased from 0.01 in 2000 to 0.22 in 2009. A 1-unit increase in IMBP visits per county was associated with a 0.248 (95% confidence interval, -0.40 to -0.10) decrease in dmft per kindergarten student per school. For schools with more students at high risk for dental disease, a 1-unit increase in IMBP visits was associated with a 0.320 (95% confidence interval, -0.55 to -0.09) decrease in dmft.

CONCLUSIONS

IMBP reduced dental caries among targeted vulnerable children, which helped reduce oral health disparities among preschool-aged children in North Carolina.