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

Multilevel Interventions and Dental Attendance in Pediatric Primary Care: A Cluster Randomized Clinical Trial

Importance

Untreated tooth decay is disproportionately present among low-income young children. While American Academy of Pediatrics (AAP) guidelines require pediatric clinicians to implement oral health care, the effectiveness of these oral health interventions has been inconclusive.

Objective

To test the effectiveness of multilevel interventions in increasing dental attendance and reducing untreated decay among young children attending well-child visits (WCVs).

Design, Setting, and Participants

The Pediatric Providers Against Cavities in Children's Teeth study is a cluster randomized clinical trial that was conducted at 18 pediatric primary care practices in northeast Ohio. The trial data were collected between November 2017 and July 2022, with data analyses conducted from August 2022 to March 2023. Eligible participants included Medicaid-enrolled preschoolers aged 3 to 6 years attending WCVs at participating practices who were enrolled at baseline (WCV 1) and followed-up for 2 consecutive examinations (WCV 2 and WCV 3).

Interventions

Clinicians in the intervention group received both the practice-level (electronic medical record changes to document oral health) and clinician-level (common-sense model of self-regulation theory-based oral health education and skills training) interventions. Control group clinicians received AAP-based standard oral health education alone.

Main Outcomes and Measures

Dental attendance was determined through clinical dental examinations conducted by hygienists utilizing International Caries Detection and Assessment System criteria and also from Medicaid claims data. Untreated decay was determined through clinical examinations. A generalized estimating equations (GEE) approach was used for both clinical examinations and Medicaid claims data.

Results

Eighteen practices were randomized to either intervention or control. Participants included 63 clinicians (mean [SD] age, 47.0 [11.3] years; 48 female [76.2%] and 15 male [23.8%]; 28 in the intervention group [44.4%]; 35 in the control group [55.6%]) and 1023 parent-child dyads (mean [SD] child age, 56.1 [14.0] months; 555 male children [54.4%] and 466 female children [45.6%]; 517 in the intervention group [50.5%]; 506 in the control group [49.5%]). Dental attendance from clinical examinations was significantly higher in the intervention group (170 children [52.0%]) vs control group (150 children [43.1%]) with a difference of 8.9% (95% CI, 1.4% to 16.4%; P = .02). The GEE model using clinical examinations showed a significant increase in dental attendance in the intervention group vs control group (adjusted odds ratio, 1.34; 95% CI, 1.07 to 1.69). From Medicaid claims, the control group had significantly higher dental attendance than the intervention group at 2 years (332 children [79.6%] vs 330 children [73.7%]; P = .04) but not at 3 years. A clinically but not statistically significant reduction in mean number of untreated decay was found in the intervention group compared with controls (B = -0.27; 95% CI, -0.56 to 0.02).

Conclusions and Relevance

In this cluster randomized clinical trial, children in the intervention group had better dental outcomes as was evidenced by increased dental attendance and lower untreated decay. These findings suggest that intervention group clinicians comprehensively integrated oral health services into WCVs.

Trial Registration

ClinicalTrials.gov Identifier: NCT03385629.

Adoption of New Oral Health Interventions in Primary Care: Qualitative Findings

Introduction

This is the first study to use the Common-Sense Model of Self-Regulation theory for oral health interventions in pediatric practices. The objective of this qualitative study was to assess adoption and implementation of theory-based multilevel oral health interventions, by clinicians (pediatricians and nurse practitioners) participating in a cluster randomized clinical trial, to create an oral health toolkit for widespread dissemination into pediatric practices.

Methods

Semistructured interviews were conducted at the conclusion of the cluster randomized clinical trial with 21 clinicians from 9 practices participating in the intervention arm. Clinicians in this arm received Common-Sense Model of Self-Regulation theory-based education and resources to deliver oral health interventions to parents/caregivers and document in electronic medical record. Semistructured interview questions were based on the Diffusion of Innovations Theory, assessing adoption and implementation. The interviews were coded using NVivo (QRS International) software. Main themes were identified using a thematic analysis approach.

Results

Five themes identified from the interviews included strengths of theory-based oral health training for clinicians, oral health resources to improve quality of care, considerations for efficient future implementation, financial considerations, and parent benefits and challenges. Clinicians found that the theory-based training and resources increased knowledge and confidence when addressing oral health with parents and required only ≤2 minutes in their workflow with no financial consequences. Clinicians reported an increase in oral health awareness among parents but suggested an overall need for more pediatric dentists.

Conclusions

The Common-Sense Model of Self-Regulation theory-based education and resources were well received by clinicians and perceived to be beneficial without adverse impact on workflow or practice finances. An online toolkit is planned because these oral health interventions can be successfully implemented and delivered in medical settings.

Barriers to dental utilization among Medicaid-enrolled young children from primary care practices in Northeast Ohio

OBJECTIVES

To evaluate the individual and community factors that contribute to dental utilization among young children on Medicaid utilizing the Anderson Model and the Socio-Ecological Framework.

METHODS

This observational cross-sectional study was conducted using baseline data (socio-demographics, clinical dental need) from a cluster-randomized hybrid effectiveness-implementation trial among 1021 child-parent dyads recruited from primary care practices across northeast Ohio. The baseline data were then linked to dental Medicaid claims data (categorized as any dental visit, volume, and type in the past 12 months) and ICD-10 codes from the child's EHR data (individual-level) together with Dental Health Provider Shortage Area (HPSA) status and Area Deprivation Index (ADI) which were obtained at the neighbourhood-level using home address of each dyad (community-level). Multivariable analyses using generalized estimating equations (GEE) accounted for clustering by practice, and models included individual-level alone, and individual + community-level factors to evaluate their effects on dental utilization.

RESULTS

Medicaid claims data indicated that among the 1021 children (mean age: 4.3 ± 1.1 years; 54.4% males; 43.8% Black, Non-Hispanic), a majority of children were seeing the dentist at least once a year by the age of 4 (56.1%). The mean ADI of their neighbourhoods was 109.22 (20.2) and 27.5% lived in a HPSA area. The GEE analyses revealed that individual factors such as older children, parents being married, and continuous Medicaid enrollment were associated with significantly higher dental utilization. Among community factors, being in a HPSA had an OR = 1.53 (CI: 1.03, 2.27) associated with higher dental utilization.

CONCLUSIONS

Being in a HPSA was associated with higher dental utilization possibly due to dentists or safety net dental clinics in these areas accepting Medicaid-eligible children.

Dental Caries in Medicaid-Insured Preschool Children With or Without Special Health Care Needs in Northeast Ohio

IMPORTANCE

Children with special health care needs (CSHCN) are recognized to be at increased risk of developing dental caries (decay). Evidence is mixed regarding the association of preventive oral health care delivered by pediatric primary care clinicians with caries experience among CSHCN.

OBJECTIVE

To investigate caries experience, including untreated decay, among Medicaid-enrolled preschoolers with or without special health care needs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used baseline data from the Pediatric Providers Against Cavities in Children's Teeth study, a cluster-randomized hybrid effectiveness-implementation trial conducted among 1022 Medicaid-enrolled preschoolers aged 3 to 6 years attending well-child visits at 18 participating community pediatric primary care practices in northeast Ohio. Baseline data were collected from November 1, 2017, to August 31, 2019, with statistical analyses conducted from April to August 2022.

EXPOSURES

Presence of special health care needs, as assessed by applying the Pediatric Medical Complexity Algorithm to International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, was abstracted from electronic medical records. CSHCN were defined as having either noncomplex chronic disease (presence of only 1 nonprogressive chronic condition, or multiple nonprogressive chronic conditions in a single body system) or complex chronic disease (presence of any progressive chronic condition, malignant neoplasm, or significant chronic conditions involving multiple body systems).

MAIN OUTCOMES AND MEASURES

Untreated dental decay and caries experience as assessed through clinical dental examinations using International Caries Detection and Assessment System criteria.

RESULTS

A total of 1022 children aged 3 to 6 years from 18 practices were enrolled in the study. The mean (SD) age of the study population was 4.3 (1.1) years, 554 (54.2%) were boys, and of 988 with data on race and ethnicity, 451 (45.6%) were Black. Of these, 301 of 1019 (29.5%) had a likely special health care need (225 with noncomplex chronic conditions and 76 with complex chronic conditions). The most frequent chronic conditions included asthma (n = 209) and mental or behavioral health disorders (n = 146), including attention-deficit/hyperactivity disorder, autism, and developmental delays. Overall, 296 children (29.0%) had untreated decay, and 378 (37.0%) had caries experience (decayed and filled teeth). Accounting for sociodemographic characteristics, CSHCN had 34% reduced odds of untreated decay (adjusted odds ratio [AOR], 0.66 [95% CI, 0.48-0.92]) compared with those with without chronic disease. In addition, caries experience was lower among CSHCN (AOR, 0.79 [95% CI, 0.60-1.04]).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of Medicaid-enrolled children who attended well-child visits as preschoolers, untreated dental decay was lower among CSHCN compared with those without chronic conditions. This study suggests that CSHCN may have had better access to the various types of dental care facilitated in medical settings.

COVID-19 Impact on Community-Based Participatory Randomized Controlled Trials—Lessons From the Oral Health Disparities in Children Consortium

The COVID-19 pandemic has had a major impact on nearly every sector of science and industry worldwide, including a significant disruption to clinical trials and dentistry. From the beginning of the pandemic, dental care was considered high risk for viral transmission due to frequent aerosol-generating procedures. This resulted in special challenges for dental providers, oral health care workers, patients, and oral health researchers. By describing the effect that the COVID-19 pandemic had on four community-based randomized clinical trials in the Oral Health Disparities in Children (OHDC) Consortium, we highlight major challenges so researchers can anticipate impacts from any future disruptions.

Caries disparities among Medicaid-enrolled young children from pediatric primary care settings

OBJECTIVES

The objectives of this study are to determine the overall and racial differences in the extent of caries experience and to examine the association between child and parent/caregiver characteristics and caries among 3-6-year-old Medicaid-enrolled children.

METHODS

This study reports baseline cross-sectional data from a larger pragmatic clinical trial in pediatric primary care practices. Child-level clinical dental exams included decayed and filled teeth (dft) using ICDAS criteria and parent/caregiver questionnaire collected information on socio-demographics, child oral health behaviors, oral health related quality of life (OHQoL), and food environment.

RESULTS

A total of 1,024 parent/caregiver-child dyads participated in the study. The overall caries experience (dft) was 49 percent and untreated decay was 42 percent. Children who were Black had 1.3 and 1.2 times significantly higher frequency of untreated primary decay and caries experience compared to non-Black children. An overall logistic regression model predicted that race, increased age, receiving dental care in the past 12 months for a cavity/toothache, and lower caregiver OHQoL was significantly associated with increased odds of the child having caries. Non-Black caregivers with less education, whose child was older, and lower child OHQoL had increased odds of having a child with caries, but these same variables were not predictive for the Black children.

CONCLUSIONS

Racial disparities exist with respect to caries experience and untreated decay within a Medicaid-enrolled population of young children attending well-child visits. Pediatric primary care offices are well-positioned to provide dental surveillance and preventive care and could play an important role in decreasing oral health inequities.

Recruitment strategies for a pragmatic cluster randomized oral health trial in pediatric primary care settings

Objectives

To describe multilevel recruitment strategies for an ongoing clinical trial in pediatric primary care settings, and assess adoption and reach of these strategies via the RE-AIM framework.

Methods

This study is part of a larger pragmatic cluster randomized clinical trial focused on the effectiveness of interventions on the practice, provider, and caregiver levels on dental utilization for Medicaid-enrolled 3-6 year old children. Pediatric practices were recruited according to the proportion of Medicaid-eligible children, geographic region, and County. In accordance with the RE-AIM framework, providers reached were those approached directly and consented, and those who participated in the intervention training adopted to deliver the intervention. Caregivers reached were those approached and consented at their child's well-child visit to participate in the trial.

Results

Recruitment goals were met over a 21 month period, with an overall enrollment of 18 practices, 62 providers, and 1024 caregivers-child dyads. The majority of practices enrolled were small, suburban, and located in an urban county. The participation rates among approached providers and caregivers was 93% and 84% respectively. Enablers for recruitment was the one-on-one interaction with the provider and caregivers. Barriers to recruitment for caregivers included no-shows and cancellations at well-child visits. Adoption of intervention among providers was high, and caregiver reached were representative of the eligible target population.

Conclusions

Active approaches to recruitment, such as utilizing opinion leaders, in-person recruitment, and building relationships with practice staff, can result in successful enrollment and imp lementation of a multi-level intervention in pediatric primary care settings.