Identifying sources of variation in added sugar intake for Alaska Native children using a hair biomarker

Sugars from sugar-sweetened beverages (SSBs) are an important risk factor for tooth decay. The study goal was to determine if there was variation in added sugar intake across communities and between and within households. In this cross-sectional study, intakes of total sugar, added sugar, and sugar-sweetened beverages (SSBs) were estimated for 282 Alaska Native children ages 0-10 years from 131 households in three Yukon-Kuskokwim (YK) Delta communities using biomarker equations based on hair carbon and nitrogen isotope ratios previously developed for the Yup'ik population. ANOVA was used to assess associations between each predictor (community and household) and outcome (estimated total sugars, added sugars, and SSB intake). Between- and within-household variation was estimated using a linear mixed-effects model with a random intercept for households with three or more children. There was no significant difference in mean estimated total sugar (p = 0.29), added sugar (p = 0.24), or SSB intake (p = 0.40) across communities. Significant variations were observed between and within households, with within-household variation amounting to 59% of the between-household variation. Added sugar intake in Alaska Native children from the three study communities is higher than the recommended maximum, and the variation is greater within households than between households.

Using Policy Briefs to Communicate Dental Research Findings to Policymakers

OBJECTIVES

New scientific knowledge is not always available to decision makers. Policy briefs are a way that dental researchers can communicate research findings to policymakers. This study compares usefulness of 2 types of policy briefs about sugar-sweetened beverage (SSB) intake and tooth decay.

METHODS

We developed 2 policy brief types (data focused and narrative focused) and emailed a randomly assigned policy brief to 825 policymakers and staff from 3 levels of government (city, county, and state) in Washington State. Participants completed a 22-item online questionnaire. There were 4 study outcomes: whether the brief was understandable, whether the brief was credible, likelihood of use, and likelihood to be shared (each measured on a 5-point Likert-like scale). The t test was used to evaluate whether outcomes differed by policy brief type and government level (α = 0.05).

RESULTS

There were 108 respondents (adjusted response rate 14.6%). About 41.6% of participants were in city government, 26.9% were in county government, and 29.6% were in state government. Participants reported that both data- and narrative-focused briefs were understandable (mean rating [MR] and standard deviation [SD]: 4.15 ± 0.68 and 4.09 ± 0.81, respectively; P = 0.65) and credible (MR and SD: 4.13 ± 0.70 and 4.09 ± 0.70, respectively; P = 0.74), but they were not likely to use (MR and SD: 2.71 ± 1.15 and 2.55 ± 1.28, respectively; P = 0.51) or share it (MR and SD: 2.62 ± 1.04 and 2.66 ± 1.30, respectively; P = 0.87). The likelihood of sharing briefs differed significantly by level of government (P = 0.017). Participants at the state level were more likely to share information from the briefs (mean rating and SD: 3.10 ± 0.80) than city- and county-level participants (MR and SD: 2.62 ± 1.27, and 2.24 ± 1.21, respectively).

CONCLUSION

Both data- and narrative-focused policy briefs may be a useful way to communicate dental research findings to policymakers, but additional steps are needed to ensure that briefs are used and shared.

KNOWLEDGE TRANSFER STATEMENT

Researchers should disseminate their research findings to maximize scientific impact. Our study findings indicate that policy briefs may be a useful way to communicate dental research findings to policymakers, but additional research is needed on the best ways to disseminate findings.

Saliva sampling method influences oral microbiome composition and taxa distribution associated with oral diseases

Saliva is a readily accessible and inexpensive biological specimen that enables investigation of the oral microbiome, which can serve as a biomarker of oral and systemic health. There are two routine approaches to collect saliva, stimulated and unstimulated; however, there is no consensus on how sampling method influences oral microbiome metrics. In this study, we analyzed paired saliva samples (unstimulated and stimulated) from 88 individuals, aged 7-18 years. Using 16S rRNA gene sequencing, we investigated the differences in bacterial microbiome composition between sample types and determined how sampling method affects the distribution of taxa associated with untreated dental caries and gingivitis. Our analyses indicated significant differences in microbiome composition between the sample types. Both sampling methods were able to detect significant differences in microbiome composition between healthy subjects and subjects with untreated caries. However, only stimulated saliva revealed a significant association between microbiome diversity and composition in individuals with diagnosed gingivitis. Furthermore, taxa previously associated with dental caries and gingivitis were preferentially enriched in individuals with each respective disease only in stimulated saliva. Our study suggests that stimulated saliva provides a more nuanced readout of microbiome composition and taxa distribution associated with untreated dental caries and gingivitis compared to unstimulated saliva.

Validating a Conceptual Model on Topical Fluoride Hesitancy With Latino Parents

Fluoride hesitancy is a growing public health challenge and interventions to address it may need to be tailored for minoritized subgroups to address oral health inequities. The goals of this qualitative study were to investigate the extent to which an existing conceptual model on topical fluoride hesitancy is applicable to Latino parents and whether applicability differed between Spanish-speaking Latino (SL) and English-speaking Latino (EL) parents. We conducted semi-structured one-on-one interviews with non-Latino English-speaking parents (N = 50), SL parents (n = 8), and EL parents (n = 8). We coded the transcripts deductively and compared our findings both qualitatively and quantitatively to an existing model on topical fluoride hesitancy comprising 21 categories classified into six domains. We compared frequencies across model domains and categories for Latino versus non-Latino parents as well as for SL versus EL parents. Latino parents were represented across all six domains and 21 categories of the conceptual model. Comparing Latino and non-Latino parents, representation was similar across Domains 1 to 3 (necessity, chemicals, and harm); Latino parents were more highly represented in Domains 4 to 6 (uncertainty, pressure, and choice) compared with non-Latino parents. A larger proportion of EL parents thought a healthy diet was more important than fluoride (Category 1d) and a larger proportion of SL parents felt they did not know enough about fluoride (Category 4a). An existing conceptual model on topical fluoride hesitancy was generally a good fit for SL and EL parents. However, differential representation across model categories suggests that fluoride-related communication and intervention approaches may need to be tailored to Latino parents based on language preference.

Psychometric properties of the Fluoride Hesitancy Identification Tool (FHIT)

INTRODUCTION

Some caregivers are hesitant about topical fluoride for their children despite evidence that fluoride prevents caries and is safe. Recent work described a five domain model of caregivers' topical fluoride hesitancy. We developed the Fluoride Hesitancy Identification Tool (FHIT) item pool based on the model. This study sought to evaluate the FHIT's psychometric properties in an effort to generate a short, simple to score, reliable, and valid tool that measures caregivers' topical fluoride hesitancy.

METHODS

In 2021 and 2022, we conducted an observational, cross-sectional study of caregivers, collecting data from two independent caregiver samples (n1 = 523; n2 = 612). The FHIT item pool included 33 items. We used confirmatory factor analyses (CFA) to examine whether the FHIT items measured five separate domains as hypothesized and to reduce the number of items. We then fit item response theory (IRT) models and computed Cronbach's alpha for each domain. Last, we examined the construct validity of the FHIT and evaluated scoring approaches.

RESULTS

After dropping 8 items, CFA supported a five factor model of topical fluoride hesitancy, with no cross-loadings (RMSEA = 0.079; SRMR = 0.057; CFI = 0.98; TLI = 0.98). We further reduced the items to four per domain (20 items total). Marginal alphas showed that the item sets provided reliability of ≥0.90 at hesitancy levels at and above average. The domains correlated more strongly with each other and topical fluoride refusal than with other questions on the survey.

DISCUSSION

Our results support the FHIT's ability to reliably and validly measure five domains of topical fluoride hesitancy using the average score of the four items in each domain.

A Mixed-Methods Study on Topical Fluoride Beliefs and Refusal Behaviors for Caregivers of Children with Special Health Care Needs

OBJECTIVE

To understand topical fluoride-related beliefs and refusal behaviors for caregivers of children with special health care needs (CSHCN).

METHODS

This was an explanatory sequential mixed methods study. For the quantitative analyses, we surveyed 520 caregivers to (a) compare fluoride-related beliefs between caregivers of CSHCN and caregivers of healthy children and (b) evaluate the association between special health care need (SHCN) status and topical fluoride refusal. We used logistic regression models to generate unadjusted odds ratios, confounder-adjusted odds ratios (AOR), and 95% confidence intervals (CI). For the qualitative analyses, we interviewed 56 caregivers who refused or were hesitant about topical fluoride. Data were coded deductively and compared by SHCN status to an existing conceptual model of topical fluoride refusal.

RESULTS

In the quantitative analysis, 41.3% of caregivers refused or thought about refusing topical fluoride. There were no significant differences in fluoride beliefs by SHCN status (p-values > 0.05) nor was there a significant association between SHCN status and topical fluoride refusal (AOR: 0.65, 95% CI 0.37-1.14; p = 0.13). In the qualitative analysis, the relative importance of each domain of the conceptual model was similar between the caregiver groups. Two differences were that all caregivers of CSHCN thought fluoride was unnecessary and wanted to keep chemicals out of their child's body.

CONCLUSIONS FOR PRACTICE

While caregivers of CSHCN were not more likely to refuse topical fluoride than caregivers of healthy children, there may be important differences in the underlying reasons for refusing topical fluoride.

A Qualitative Study on Dentists' Communication Approaches in Managing Fluoride-Hesitant Caregivers

OBJECTIVES

Guidelines on effective provider-led communication are available but may be underused in dentistry, even if such guidelines could help dentists manage complex clinical scenarios like topical fluoride hesitancy. The purpose of this study was to investigate current chairside communication approaches used by dentists with fluoride-hesitant caregivers.

METHODS

A 27-item semistructured interview script was developed and pretested with 3 dentists, revised, and finalized. One-on-one interviews were conducted with a purposive sample of pediatric dentists and general dentists from April to June 2020. Interviews were digitally recorded, transcribed, and analyzed to identify dentists' communication approaches used during clinical interactions with fluoride-hesitant caregivers. Thematic analyses identified themes and subthemes, and exemplary quotes were provided to illustrate each theme.

RESULTS

Twenty-seven dentists participated (21 pediatric dentists and 6 general dentists). The mean age of participants was 43.0 ± 8.2 y (range, 30-73). Most participants were women (88.9%), white (51.9%), and non-Hispanic (85.2%). Participants had been practicing dentistry for a mean of 13.2 ± 10.5 y (range, 2-40). There were 4 themes: leaving topical fluoride decisions completely up to the caregiver, educating the caregiver about fluoride, insisting that the caregiver accept fluoride, and engaging the caregiver and child.

CONCLUSION

Most communications approaches used by interviewed dentists to manage fluoride hesitancy in clinical settings are not evidence based. Future dental education efforts should ensure that trainees are exposed to and can demonstrate competency in appropriate, evidence-based patient-provider communication strategies.

KNOWLEDGE TRANSFER STATEMENT

The study highlights the need for dentists to apply evidence-based communication strategies when managing difficult clinical scenarios like fluoride hesitancy, which is important in optimizing dentist-patient trust.

Fluoride hesitancy: A mixed methods study on decision-making about forms of fluoride

OBJECTIVES

To investigate whether professionally applied topical fluoride-hesitant caregivers are also hesitant about other forms of fluoride for their child.

METHODS

This was a mixed methods study of 56 caregivers hesitant about professionally applied topical fluoride for their child recruited from the University of Washington Center for Paediatric Dentistry and Seattle Children's Hospital's Odessa Brown Children's Dental Clinic. A 32-item semi-structured interview script was piloted and finalized. One-time interviews with caregivers were conducted by phone in 2019. Associations between hesitancy of topical fluoride, fluoridated water and toothpaste were assessed quantitatively via two-tailed chi-squared tests. Qualitative data were coded using an inductive approach and content analytic methods to investigate reasons for hesitancy.

RESULTS

There were significant associations between hesitancy in all three pairwise comparisons of fluoride form (p < .01). Similar proportions of caregivers strongly or somewhat opposed fluoridated water compared with toothpaste (75% and 65%, respectively), but four times as many caregivers strongly or somewhat favoured fluoridated toothpaste compared to water for their child (25% and 7%, respectively). Concerns about harm were the most common reason caregivers opposed both fluoridated water and toothpaste. However, fluoride-hesitant caregivers reported being more comfortable with fluoridated toothpaste because amount and frequency can be controlled, and ingestion can be prevented.

CONCLUSIONS

Professionally applied topical fluoride hesitancy is significantly associated with fluoridated water and toothpaste hesitancy, but caregivers who were hesitant about topical fluoride was more comfortable with fluoridated toothpaste than fluoridated water for their child.

Sugar-sweetened beverage intake and convenience store shopping as mediators of the food insecurity-Tooth decay relationship among low-income children in Washington state

INTRODUCTION

There are oral health disparities in the U.S. and children in food-insecure households have a higher burden of tooth decay. Identifying the mechanisms underlying the food insecurity-tooth decay relationship could inform public health interventions. This study examined how sugar-sweetened beverage (SSB) intake and frequent convenience store shopping mediated the food insecurity-tooth decay relationship for lower-income children.

MATERIALS AND METHODS

Cross-sectional study data included a household survey, beverage questionnaire, and dental examination. The sample included 452 lower-income, racially-diverse, child-caregiver dyads in 2018 from King County in Washington state. The exposure was household food insecurity, the outcome was untreated decayed tooth surfaces, and the proposed mediators were SSB intake and frequent convenience store shopping (≥2 times/week). Causal mediation analyses via the potential outcomes framework was used to estimate natural indirect and direct effects.

RESULTS

Fifty-five percent of participants were in food-insecure households, the mean number of decayed tooth surfaces among children was 0.87 (standard deviation [SD] = 1.99), the mean SSB intake was 17 fluid ounces (fl/oz)/day (SD = 35), and 18% of households frequently shopped at a convenience store. After adjusting for confounders, household food insecurity and log-transformed SSB intake (fluid ounces/day) were positively associated with decayed tooth surfaces, but not at the a α = 0.05 level (mean ratio [MR] 1.60; 95% confidence interval [CI] 0.89, 2.88; p = .12 and MR 1.16; 95% CI 0.93, 1.46; p = .19, respectively). Frequent convenience store shopping was associated with 2.75 times more decayed tooth surfaces (95% CI 1.61, 4.67; p < .001). SSB intake mediated 10% of the food insecurity-tooth decay relationship (p = .35) and frequent convenience store shopping mediated 22% (p = .33).

CONCLUSIONS

Interventions aimed at addressing oral health disparities in children in food-insecure households could potentially focus on reducing intake of SSBs and improving access to healthful foods in lower-income communities.

Preventive dental care utilization and dental caries for Medicaid-enrolled adolescents in Oregon

OBJECTIVES

This study aimed to evaluate the relationship between preventive dental care utilization and untreated dental caries for Medicaid-enrolled adolescents and to determine if the relationship is moderated by chronic conditions (CC).

METHODS

This analysis was based on 2015-2016 Medicaid claims files and survey data collected from adolescents ages 12-18 years enrolled in Oregon Medicaid, who received a dental screening between December 2015 and December 2016 (n = 240). To assess the relationship between preventive dental care utilization and untreated dental caries (defined as decayed tooth surfaces), prevalence ratios (PR) and 95% confidence intervals (CI) were generated using log-linear regression models. We also tested for an interaction between preventive dental care utilization and CC.

RESULTS

About 60.4% of adolescents utilized preventive dental care, 21.7% had CC, and 29.6% had ≥1 decayed tooth surfaces. There were no significant differences in untreated dental caries between adolescents who did and did not utilize preventive dental care (PR: 0.73, 95% CI: 0.33-1.60; p = 0.43). There was not a significant interaction between preventive dental care utilization and CC (p = 0.65). Preventive dental care utilization was not significantly associated with untreated dental caries for adolescents with CC (PR: 0.51, 95% CI: 0.10-2.65; p = 0.42) nor among adolescents without CC (PR: 0.79, 95% CI: 0.33-1.91; p = 0.61).

CONCLUSIONS

Preventive dental care was not shown to be associated with lower untreated dental caries for Medicaid-enrolled adolescents or those with CC. Future work that is adequately powered should continue to elucidate this relationship in Medicaid enrollees.

Qualitative evaluation of the pre-implementation phase of a rural dental clinic co-located within a health center in the Pacific Northwest of the United States

OBJECTIVE

The development of a dental clinic within an existing Rural Health Clinic (RHC) was proposed to improve access to dental care for Medicaid enrollees in Washington. This qualitative study assessed the implementation of a co-located dental clinic in a rural community during the pre-implementation phase. Additionally, we sought to determine the needs and expectations of community members living in this rural Washington county.

METHODS

This study took place in Jefferson County, Washington, a Dental Health Professional Shortage Area. Semi-structured interviews were conducted with 42 participants, consisting of administrators (n = 9), health providers (n = 9) and community members (n = 24). Administrators and health providers were interviewed by phone. Community members were interviewed in-person at Jefferson Healthcare primary care clinics or by phone. Interview data were deductively coded, and thematic analysis with a hybrid inductive-deductive approach was used to analyse coded data.

RESULTS

Five themes were identified regarding local needs and expectations: dental care as a major need in the community, persisting barriers to dental care access, expecting more than a 'Medicaid experience', visions for a clinic that serves the community, and solutions outside the clinic to improve community oral health.

CONCLUSIONS

By improving access to dental care, a co-located dental clinic is helping to address general dental care needs in rural communities. Policy-level solutions that address housing and food insecurity, improve public transportation, and retain and expand low-income adult Medicaid dental benefits may be needed to overcome persisting barriers to oral health.

Periodontitis Risk Factors in Adults with Cystic Fibrosis: A pilot study

Purpose Individuals with cystic fibrosis (CF) present with multiple condition-specific risk factors for periodontitis including CF-related diabetes, chronic inhaled treatments that induce xerostomia, and increased systemic inflammation because of frequent lung infections. General factors like age, oral hygiene, and diet may also contribute to the risk of periodontitis. However the relative importance of these specific risk factors and periodontitis in individuals with CF has not yet been evaluated. The purpose of this pilot study was to assess the associations between CF condition-specific and general risk factors and the prevalence of periodontitis in adults with CF.Methods This cross-sectional pilot study was designed to assess a multifactorial model of periodontitis risk factors in a population in adults with CF who were recruited from the University of Washington Adult CF center. Periodontitis was defined using the Centers for Disease Control and Prevention and the American Academy of Periodontology (CDC/AAP) case definition. Risk factors included condition-specific and general factors. Differences between participants with moderate/severe periodontitis and those with no/mild periodontitis was assessed using the Mann-Whitney test, the Fisher's exact test, and the exact chi-square test (α=0.05).Results Thirty-two participants were enrolled. Twenty-eight percent of the participants had moderate periodontitis, 72% had no/mild periodontitis; none of the participants had severe periodontitis. There were no significant differences in condition-specific factors between between the two study groups. Participants with moderate periodontitis were older (p=0.028) and reported daily flossing in higher proportions than those with no/mild periodontitis (p=0.023).Conclusions The findings from this pilot study suggest that future research is needed to determine whether sociodemographic and other general risk factors are more important contributors to periodontitis risk than CF-specific factors.

A Qualitative Assessment of Factors Influencing Fluoride-Hesitant Parents' Trust of Dentists

PURPOSE

The purpose of this study was to use fluoride-hesitant parents as a model to identify the factors that erode versus build trust in their child's dentists.

METHODS

A qualitative study was conducted using a semi-structured interview guide with fluoride-hesitant parents recruited from two dental clinics and through snowball sampling. A content analysis was performed to identify factors that erode versus build parents' trust in their child's dentist.

RESULTS

Of the 56 parents interviewed, most were female (91.1 percent) and white (57.1 percent) and had a mean age of 41±9.7 (standard deviation) years. Factors identified included five that erode trust (having trust violated previously, sensing discrepancies, getting pushed to accept fluoride, feeling dismissed, and sensing bias) and four that build trust (being treated as an individual, having a dentist who communicates, feeling supported and respected, and having a choice).

CONCLUSIONS

Dentists' understanding of the factors that erode and build trust with parents could help providers develop patient-centered communication strategies.

Topical fluoride hesitancy among caregivers: Development of a content-valid topical fluoride hesitancy identification item pool

OBJECTIVES

To develop a content-valid set of items to characterize different types of topical fluoride hesitancy among caregivers. We will use this information to develop and test tailor-made interventions directed to caregivers with varied types and levels of topical fluoride hesitancy, to ultimately improve child oral health.

METHODS

Caregivers participated in three study activities, in the following order: (1) semi-structured concept elicitation interviews (n = 56), (2) cognitive interviews (n = 9), and (3) usability interviews (n = 3). Interviews were conducted via telephone and audio-recorded and transcribed for qualitative analysis. Twelve pediatric dental providers and researchers participated in item review. An assessment of reading level of items was made with goal of 6th grade reading level or less.

RESULTS

Based on elicitation interviews, we initially developed 271 items, which the investigative team evaluated for conceptual clarity, specificity to topical fluoride hesitancy, and sensitivity to potential interventions. After four rounds of review and cognitive interviews, we retained 33 items across five previously identified domains. Changes after cognitive interviews included item revision to improve comprehension and item re-ordering to avoid order effects. Changes after usability testing including clarification regarding referent child for families with multiple children. The reading level of the item pool is grade 3.2.

CONCLUSIONS

The resulting 33-item fluoride hesitancy item pool is content valid and will address an important need for identifying and addressing topical fluoride hesitancy in the context of dental research and clinical practice. Next steps include psychometric evaluation to assess scale and test-retest reliability and construct validity.

Understanding topical fluoride hesitancy and refusal behaviors through the extended parallel process model and health belief model

OBJECTIVES

Topical fluoride helps prevent dental caries. However, many caregivers are hesitant about topical fluoride for their children and may refuse it during clinic visits. In this qualitative study, we assessed the relevance of the extended parallel process model (EPPM) and health belief model (HBM) in caregivers' decision-making about topical fluoride.

METHODS

We interviewed 56 fluoride-hesitant or fluoride-refusing caregivers using a semi-structured interview script that included questions based on select constructs from the EPPM (perceived severity, susceptibility, response efficacy) and HBM (perceived benefits and consequences). Two team members conducted a thematic analysis of the interview data.

RESULTS

Most caregivers acknowledged the severity of cavities but did not believe their child was susceptible. Caregivers also understood the general benefits of fluoride in preventing tooth decay, but reported low response efficacy of fluoride for their children especially compared to the other ways of reducing caries risk like reducing sugar intake and toothbrushing. Many caregivers had concerns about topical fluoride, especially regarding safety, with the potential consequences of fluoride outweighing its benefits.

CONCLUSION

Our findings were generally consistent with the EPPM and HBM, which appear to be relevant in understanding fluoride hesitancy behaviors. Additional research is needed on ways to improve provider communications about topical fluoride with caregivers.

Silver diamine fluoride-associated delays in procedural sedation in young children: A retrospective cohort study

BACKGROUND

This analysis evaluated the time to first sedation or general anesthesia (GA) encounter for children treated with and without silver diamine fluoride (SDF).

METHODS

This retrospective cohort study used dental claims of privately insured children from birth through age 71 months with a sedation or GA claim from 2016 through 2020. The exposure was SDF use (yes, no). The outcome was time to first sedation or GA. Descriptive and multivariable negative binomial analysis was performed. The analysis tested the hypothesis that among children who received sedation or GA for their caries treatment, those who received SDF would show a longer time to first sedation or GA than children who did not.

RESULTS

Among 175,824 children included, SDF use increased the time to first sedation or GA encounter by 63 days when treated by different dentists (405 days vs 342 days; P < .001) and by 91 days when treated by the same dentist (337 days vs 246 days; P < .001), after controlling for the effects of age at first encounter, sex, and region of the country.

CONCLUSION

Children treated with SDF had a longer time to first sedation or GA, which was magnified when treatment was performed by the same dentist.

PRACTICAL IMPLICATIONS

Within an individualized caries management plan, SDF could provide benefits for patients, dental offices, and health systems.

Association between caregiver opposition to topical fluoride and COVID-19 vaccines

PURPOSE

Caregivers who oppose topical fluoride in dental settings may be opposed to other preventive health treatments, including COVID-19 vaccines. The study objective was to examine the association between caregiver opposition to topical fluoride and COVID-19 vaccines.

METHODS

The study took place at the University of Washington in Seattle, WA. English-speaking caregivers of children aged < 18 years were eligible to participate. An 85-item REDCap survey was administered from February to September 2021. The predictor variable was topical fluoride opposition (no/yes). The outcome was COVID-19 vaccine opposition (no/yes). The models included the following covariates: child and caregiver age; caregiver race and ethnicity, education level, dental insurance type, parenting style, political ideology, and religiosity; and household income. Logistic regression models generated odds ratios (OR) and 95 % confidence intervals (α = 0.05).

RESULTS

Six-hundred-fifty-one caregivers participated, and 403 caregivers with complete data were included in the final regression model. Mean child age was 8.5 years (SD 4.2), mean caregiver age was 42.1 years (SD 9.1), 53.0 % of caregivers were female, 57.3 % self-reported as white, and 65.5 % were insured by Medicaid. There was a significant positive association between topical fluoride and COVID-19 vaccine opposition (OR = 3.13; 95 % CI: 1.87, 5.25; p < 0.001). Other factors associated with COVID-19 vaccine opposition included conservative political views (OR = 2.77; 95 % CI: 1.26, 6.08; p < 0.011) and lower education (OR = 3.47; 95 % CI: 1.44, 8.38; p < 0.006).

CONCLUSIONS

Caregivers opposed to topical fluoride in dental settings were significantly more likely to oppose COVID-19 vaccines for their child. Future research should identify ways to address both topical fluoride and vaccine opposition to prevent diseases in children.

Health insurance is associated with dental care use among university students in Washington State

BACKGROUND

The goal of this study was to examine the association of health insurance and preventive dental care use among university students.

METHODS

This secondary analysis of cross-sectional data focused on students at University of Washington in Washington state (WA) who completed a health insurance survey in 2017 (n = 3768). The exposure was health insurance (private insurance in WA [reference group], not insured, Medicaid or Medicare [public insurance], university insurance, private insurance not in WA, other) and the outcome was receiving a dental cleaning in the past 6 months. Logistic regression was used to generate odds ratios and 95% confidence intervals (CI) adjusted for confounders.

RESULTS

About 5% of university students did not have health insurance and 37% did not have a dental cleaning in the past 6 months. Compared to students with private health insurance based in WA, the odds of not receiving a dental cleaning were 3.90 times greater for university students with no health insurance (95% CI 2.74, 5.55; p < .001) and 3.08 times greater for publicly-insured university students (95% CI 2.52, 3.76; p < .001).

CONCLUSIONS

University students are at risk for poor oral health behaviors. Those without health insurance and those with public insurance face barriers to preventive dental care. Efforts should be made to connect uninsured university students with insurance, dental services, and other oral health promotion activities.

Introducing dental students to dental public health: An analysis of US predoctoral course syllabi

Dental public health competencies in predoctoral dental education ensure that students have the skills to succeed in an increasingly complex professional environment. This study examined existing public health curricula in US dental education and their alignment with national recommendations from the American Association of Public Health Dentistry (AAPHD) and guidance from the Healthy People Curriculum Task Force for health professions education programs. We contacted all US dental schools (N = 66) in November 2020-January 202 and requested syllabi for schools' first course with dental public health content. We received 34 syllabi, which provided textual data for content analysis. The authors used an initial content analysis tool to extract descriptive course characteristics. Then, direct and emergent coding was performed to summarize course content. Direct codes included the 23 dental public health topics specified by AAPHD recommendations. Uncategorized content was coded using an inductive approach to identify emergent course themes. Frequently covered topics included principles of dental public health (79% of syllabi) and access to care (79%). "Health disparities" was the most common emergent theme, with 50% of courses including related content. There was little consistency in how courses approached each topic. For example, the topic "access to care" covered healthcare delivery systems, determinants of health, legislative reform, and advocacy. Dental public health was often taught alongside unrelated content. Recommendations for dental public health competencies should be updated to include new educational priorities, align with current national recommendations, and align with Commission on Dental Accreditation Standards more clearly.

Dental trainees' mental health changes, sources of stress, coping strategies, and suggestions for mental health improvement 1 year into the pandemic

OBJECTIVES

The goal of this study was to assess how the mental health of dental trainees has changed during the pandemic and to identify the most stressful aspects of trainees' programs, stress coping strategies, and suggestions for individual and institution-driven solutions to improve wellness.

METHODS

The study focused on dental trainees at the University of Washington who completed a wellness survey in fall 2020 (n = 126; response rate = 35.5%) and spring 2021 (n = 105; response rate = 29.6%). The survey included self-report measures assessing four mental health outcomes: depression, anxiety, isolation from peers, and burnout. Stressful aspects of the training program, coping strategies, and institution-driven solutions were measured with open-ended survey items. The chi-square test was used to compare mental health outcome measures between fall and spring and open-ended survey responses were inductively coded.

RESULTS

The prevalence of self-reported depression and anxiety did not change between fall 2020 and spring 2021 (17.2% vs. 21.1%, p = 0.473; 22.4% vs. 23.7%, p = 0.818). Isolation from peers and burnout each significantly increased by almost 20% from fall 2020 to spring 2021 (46.8% vs. 64.3%; p = 0.009 and 26.6% vs. 43.9%; p = 0.017). Trainees identified workload as the most stressful aspect of their program and described using exercise and social support to cope with stress. Trainees suggested institution-supported increases in social events and mental health resources.

CONCLUSIONS

One year into the coronavirus disease 2019 pandemic, poor mental health outcomes were common among dental trainees because of high workload and isolation from peers. Dental schools should promote targeted programs and services aimed at improving dental trainees' well-being.

A conceptual model on caregivers' hesitancy of topical fluoride for their children

BACKGROUND

Topical fluoride hesitancy is a well-documented and growing public health problem. Despite extensive evidence that topical fluoride is safe and prevents tooth decay, an increasing number of caregivers are hesitant about their children receiving topical fluoride, leading to challenges in clinical settings where caregivers refuse preventive care.

PURPOSE

To explore the determinants of topical fluoride hesitancy for caregivers with dependent children.

METHODS

In this qualitative study, we interviewed 56 fluoride-hesitant caregivers to develop an inductive conceptual model of reasons why caregivers are hesitant.

RESULTS

The core construct of the conceptual model of topical fluoride hesitancy centered on caregivers "wanting to protect and not mess up their child". Six domains comprised this core construct: thinking topical fluoride is unnecessary, wanting to keep chemicals out of my child's body, thinking fluoride is harmful, thinking there is too much uncertainty about fluoride, feeling pressured to get topical fluoride, and feeling fluoride should be a choice.

CONCLUSIONS

Topical fluoride hesitancy is complex and multifactorial. Study findings provide insight for future efforts to understand and optimize caregivers' preventive care decision making.

The association of food insecurity with tooth decay and periodontitis among middle-aged and older adults in the United States and Korea

INTRODUCTION

Food insecurity is an important social determinant of health, but there is limited understanding of its relationship with adult oral health. This study examined the associations between food insecurity and dental diseases (caries and periodontitis) among middle-aged and older adults in the United States and South Korea.

METHODS

This study focused on middle-aged (40-59 years) and older adults (>59 years) who participated in the 2011-2016 US National Health and Nutrition Examination Surveys (NHANES) or the 2013-2015 South Korean NHANES. The exposure was food insecurity severity (food secure/early-stage food insecurity/middle-stage or severe food insecurity) assessed using the 18-item US Household Food Security Survey Module. The two outcomes were any untreated tooth decay and periodontitis measured using the Modified Community Periodontal Index of Treatment Needs. Covariate-adjusted odds ratios (OR) with 95% confidence intervals (CI) were generated using multivariable logistic regression models.

RESULTS

Middle or severe food insecurity was associated with significantly higher odds of having untreated tooth decay than no food insecurity, but only among middle-aged adults in the United States (OR: 1.4, 95% CI 1.2, 1.9; P = .037) and Korea (OR = 1.8; 95% CI:1.0, 3.2; P = .036) and older adults in the United States (OR: 2.6, 95% CI 1.7, 4.0; P < .001). The associations between food insecurity and periodontitis were inconsistent across age group and country.

CONCLUSION

Differing cultural norms and access to dental services in the United States and South Korea may influence the relationship between food insecurity and oral health. Future research should explore how addressing food insecurity could help to promote the oral health of middle-aged and older adults in diverse sociocultural contexts.

Effects of Adult Medicaid Dental Benefits Elimination on Child Dental Care Use

OBJECTIVE

The objective of this study was to examine the effect of adult dental benefit cuts on child dental use in Washington state Medicaid and determine if cuts affect child demographic subgroups differentially.

RESEARCH DESIGN

The study used an interrupted time-series methodology to measure differences in child dental use after adult dental benefit elimination and reinstatement. Monthly data came from Washington state Medicaid enrollee and dental claim files from January 2008 to December 2015.

SUBJECTS

Medicaid-enrolled children with at least one Medicaid-enrolled adult in the same household were the intervention group, and Medicaid-enrolled children without a Medicaid-enrolled adult in the same household were the control group.

MEASURES

The outcome was the monthly proportion of Medicaid-enrolled children with a dental examination per 10,000 Medicaid-enrolled children.

RESULTS

After adult dental benefits elimination, dental examinations among children with Medicaid-enrolled adults in the same household gradually decreased, corresponding to 65 fewer dental examinations per 10,000 children per year (5.4 fewer dental examinations per 10,000 children per month; 95% confidence interval: -7.7, -3.1; P =0.006). Adult dental benefits had no effect on dental examination for children without a Medicaid-enrolled adult in the same household. Dental examinations for children with a Medicaid-enrolled adult in the same household continued to gradually decrease after adult benefits reinstatement. Children younger than age 6 were the most adversely impacted by changes to adult Medicaid dental benefits.

CONCLUSION

Policymakers should consider the spillover effects and ethical considerations of eliminating adult Medicaid dental benefits on children's access to dental care.

The interactive effects of oral health literacy and acculturation on dental care use among Hispanic adults

Objective

Assess whether there is an interactive effect between oral health literacy and acculturation on dental care use for Hispanic adults.

Methods

Self‐identifying Hispanic adults participated in this observational study (N = 338). Oral health literacy (low vs. high) was measured using the Comprehensive Measure of Oral Health Knowledge (CMOHK). Acculturation (low vs. high) was measured using the Short Acculturation Scale for Hispanics (SASH) and operationalized a second way by the language in which the survey was completed (English or Spanish). The outcome was dental care use in the past year (yes/no). Confounder‐adjusted modified Poisson regression models were run to generate risk ratios (RR) and to test the hypothesis that participants with high oral health literacy and high acculturation would be more likely to have used dental care in the past year than participants with low oral health literacy and low acculturation.

Results

About 65% of participants used dental care in the past year. The final models failed to show that participants with high oral health literacy and high acculturation were more likely to have used dental care than other participants. However, in the language proxy interaction model, participants with high oral health literacy and low acculturation were significantly more likely to have used dental care than participants with low oral health literacy and low acculturation.

Conclusion

There may be an interaction between oral health literacy and acculturation when modeling dental care use for Hispanic adults that should be further explored.

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.

Seasonal variation in added sugar or sugar sweetened beverage intake in Alaska native communities: an exploratory study

Excess added sugar intake contributes to tooth decay risk in Alaska Native communities. The goal of this exploratory study was to determine if there is seasonal variation in total added sugar intake or in the leading sources of added sugars in a Yup'ik population. Data were collected in spring and winter from 2008-2010 using self-reported intake data measured by 24-hour recall and by hair biomarker (carbon and nitrogen stable isotope). Seventy Yup'ik participants ages 14-70 years were recruited from two communities and data were collected twice from a subset of 38 participants. Self-reported added sugar intake (g/day), biomarker-predicted added sugar intake (g/day), and leading sources of added sugar were calculated. Seasonal variation was evaluated using a paired sample t-test. Total added sugar intake was 93.6 g/day and did not significantly differ by season. Sodas and other sugar-sweetened beverages (e.g. Tang, Kool-Aid) were the leading sources and added sugar from these sources did not significantly differ by season (p=.54 and p=.89, respectively). No seasonal variation in added sugar intake was detected by either self-report or biomarker. Dietary interventions that reduce intake of added sugars have the potential to reduce tooth decay in Yup'ik communities.

Effects of Medicaid expansion on self-reported use of dental services in socioeconomically vulnerable subgroups

OBJECTIVE

Research suggests Medicaid expansion led to modest increases in the use of dental services among low-income adults, especially in states with more generous Medicaid dental benefits. We expand upon this research by examining whether the effect of Medicaid expansion differed across important socioeconomic subgroups.

METHODS

Using Behavioral Risk Factor Surveillance System data from 2012 to 2016, we employed a difference-in-differences framework to estimate the effect of Medicaid expansion on annual use of dental services overall and by whether states offered more-than-emergency Medicaid dental benefits. We used generalized linear mixed-effects model trees to estimate effects across socioeconomic subgroups (e.g., age, education, race, income).

RESULTS

The effect of Medicaid expansion varied by state's generosity of Medicaid dental coverage and combinations of socioeconomic subgroups. Overall, there was no significant association between Medicaid expansion and probability of using dental services (-0.1 pp percentage points [pp], p = 0.914). Medicaid expansion was associated with a modest increase in the probability of using dental services in states with more-than-emergency Medicaid dental benefits (2.3 pp, p < 0.001) and with a modest decrease in states with no or emergency-only benefits (-4.3 pp, p < 0.001). Among adults aged 21-35 without a high school diploma, Medicaid expansion was associated with an 8.1 pp (p = 0.003) increase in dental use probability, but there were no associated effects of Medicaid expansion for other subgroups.

CONCLUSIONS

While Medicaid expansion alone is not sufficient to ensure adults receive recommended dental care, some vulnerable subgroups appear to have benefited. Efforts to mitigate barriers to dental care may be needed to increase uptake of dental services by low-income adults.

Preventive oral health care use for children with special health care needs aged 6 through 12 years enrolled in Medicaid: A mixed methods study

BACKGROUND

The authors aimed to assess preventive oral health care (POHC) use for children with special health care needs (CSHCN) aged 6 through 12 years enrolled in Medicaid and identify intervention strategies to improve oral health.

METHODS

In this sequential mixed methods study, the authors analyzed 2012 Medicaid data for children aged 6 through 12 years in Washington state. They used eligibility and claims data to identify special health care needs status (independent variable) and POHC use (outcome variable). They ran modified Poisson regression models to generate prevalence rate ratios. They coded data from 21 key informant interviews deductively using content analytic techniques.

RESULTS

Of the 208,648 children in the study, 18% were identified as CSHCN and 140,468 used POHC (67.3%). After adjusting for confounding variables, the authors found no difference in POHC use by special health care need status (prevalence rate ratio, 1.00; 95% CI, 0.99 to 1.01; P = .91). In the qualitative analysis, the authors identified 5 themes: caries risk depends on a child's specific health condition, caries complicates overall health, having a special need creates a bigger barrier to care, legislation alone is "not going to make much of a dent," and improvements across all fronts are needed to promote the oral health of CSHCN in Medicaid.

CONCLUSIONS

CSHCN enrolled in Medicaid are just as likely as children without special health care needs to use POHC, although barriers to oral health care access persist for CSHCN.

PRACTICAL IMPLICATIONS

Future efforts should focus on comprehensive strategies that address the varying levels of dental disease risk and difficulties accessing oral health care within the diverse group of CSHCN.

A Qualitative Pilot Study to Investigate Caregiver Attitudes on Healthy Lifestyle Discussions During Dental Visits for Children Younger Than Six Years

Purpose: The purpose of this qualitative pilot study was to investigate caregivers' attitudes about healthy lifestyles and weight-related discussions during dental visits. Methods: Twenty-one caregivers of children younger than six years old at two community dental clinics in Washington State-a rural community clinic serving children of seasonal farmworkers and an urban clinic primarily serving children with special health care needs-were interviewed using a semi-structured guide. Interview data were analyzed inductively via thematic content analysis. Results: Three themes emerged from the data: (1) supporting conversations about healthy lifestyles in the dental office; (2) crafting the conversation and identifying next steps; and (3) ensuring that the dentist is perceived as a caregiver ally. Caregivers were supportive of healthy lifestyle conversations with dentists. Concerns about weight-specific discussions were expressed. Conclusion: Caregivers' attitudes indicated support for conversations on healthy lifestyles. A future workaround incorporating healthy lifestyle discussion into pediatric dental visits is warranted.

Plan Type and Opioid Prescriptions for Children in Medicaid

BACKGROUND

Opioids are generally an inappropriate acute pain management strategy in children, particularly because of the risk for diversion and subsequent misuse and abuse.

OBJECTIVES

To examine associations between Medicaid plan type [coordinated care organization (CCO), managed care (MC), fee-for-service (FFS)] and whether a child received an opioid prescription.

RESEARCH DESIGN

Secondary analysis of Oregon Medicaid data (January 1, 2016 to December 31, 2017).

SUBJECTS

Medicaid-enrolled children ages 0-17 (N=200,169).

MEASURES

There were 2 outcomes: whether a child received an opioid prescription from (a) any health provider or (b) from a visit to the dentist. Predictor variables included Medicaid plan type, age, sex, race, and ethnicity.

RESULTS

About 6.7% of children received an opioid from any health provider and 1.2% received an opioid from a dentist visit. Children in a CCO were significantly more likely than children in a MC (P<0.01) or FFS (P=0.02) plan to receive an opioid from any health provider. Children in a CCO were also significantly more likely than children in MC or FFS to receive an opioid from a dentist visit (P<0.01).

CONCLUSIONS

Pediatric opioid prescriptions vary by plan type. Future efforts should identify reasons why Medicaid-enrolled children in a CCO plan are more likely to be prescribed opioids.

Untreated dental disease and lung transplant waitlist evaluation time for individuals with cystic fibrosis

AIMS

Dental clearance is typically part of the evaluation process prior to placement on the lung transplant waiting list. Individuals with cystic fibrosis (CF) are thought to be at low risk for dental disease. We hypothesized that individuals with CF in need of lung transplantation would have lower dental disease prevalence and shorter waitlist evaluation time than individuals with non-CF lung diseases.

METHODS AND RESULTS

We conducted a retrospective study of individuals who received a lung transplant between 2011 and 2017 at the University of Washington (Seattle, WA, USA) (N = 280). Untreated dental disease was assessed by the individual's dentist. Waitlist evaluation time was defined as the time, in days, from the initial evaluation by a transplant pulmonologist to placement on the lung transplant waiting list. We used logistic and linear regression models for hypothesis testing. The prevalence of untreated dental disease did not differ by CF status (p = 0.99). There was no difference in waitlist evaluation time for transplant recipients by CF status (p = 0.78) or by dental disease status (p = 0.93).

CONCLUSIONS

Our findings provide further evidence that individuals with CF are not at low risk for dental disease. Ensuring optimal oral health is important for all individuals with lung diseases.

Dental trainees' mental health and intention to leave their programs during the COVID-19 pandemic

Background

Dental trainees (dental students, graduate students, and postdoctoral residents) are at increased risk of experiencing poor mental health, which can lead to intentions to leave their program, especially during the COVID-19 pandemic.

Methods

The authors invited 355 dental trainees at the University of Washington School of Dentistry to complete an 83-item questionnaire in August and September 2020. The outcome analyzed was intention to leave their programs. There were 4 self-reported predictors: anxiety, burnout, depression, and COVID-19 impact on overall mental health. The authors ran multiple variable logistic regression models to evaluate relationships between each predictor and outcome (α = .05) and reported odds ratios (ORs) and 95% CIs.

Results

The survey response rate was 35.5%. Overall, 12.7% of participants reported any intention to leave. In total, 22.2% and 16.7% of participants endorsed clinically significant anxiety or depression symptomatology, respectively; 28.6% reported 1 or more burnout symptoms; and 69.0% reported that COVID-19 affected their overall mental health. Participants reporting anxiety (OR, 8.87; 95% CI, 1.80 to 43.57; P = .007), depression (OR, 11.18; 95% CI, 1.84 to 67.74; P = .009), or burnout (OR, 8.14; 95% CI, 1.73 to 38.23; P = .008) were significantly more likely to report intention to leave than those not reporting mental health problems. All participants reporting that the COVID-19 pandemic impacted their mental health expressed intention to leave.

Conclusions

Poor mental health is common among dental trainees and is associated with intention to leave their program.

Practical Implications

COVID-19 has exacerbated the prevalence and consequences of poor mental health among dental students, highlighting the importance of providing wellness resources.

Survey and electronic health record-based medication use agreement in children with cystic fibrosis: A retrospective cross-sectional study

BACKGROUND

Medication use is important to collect accurately in medically complex patients in both clinical and research settings.

AIM

We assessed patient-level agreement for medication use between self-reported survey and electronic health record (EHR) for children with cystic fibrosis (CF).

METHODS

Our retrospective cross-sectional study focused on children with CF ages 6-20 years from Seattle Children's Hospital in Washington state, USA (N = 85). A self- or parent-reported survey included questions on current use of specific medications and antibiotic use in the past 2 months. We compared survey data with data abstracted from the individual's EHR and derived Cohen's Kappa statistics to estimate the level of agreement between the two methods.

RESULTS

Self-reported medication use was generally higher in the survey than in the EHR. The level of agreement ranged from slight for probiotics (74.1% agreement; 95% confidence interval [CI]: 64.6%-83.6%; kappa: 0.07), pancreatic enzymes (80% agreement; 95% CI: 71.3%-88.7%; kappa: 0.12), and vitamin D (55.3% agreement; 95% CI: 44.5%-66.1%; kappa: 0.20) to moderate for chronic azithromycin (80% agreement; 95% CI: 7.13%-88.7%; kappa: 0.50), proton pump inhibitors (76.5% agreement; 95% CI: 67.3%-85.7%; kappa: 0.46), and oral antibiotics (70.6% agreement; 95% CI: 60.7%-80.5%; kappa: 0.42).

CONCLUSION

There is considerable heterogeneity in level of agreement in medication use between self-reported survey and EHR data for children with CF. Standardized approaches are needed to improve the accuracy of medication data collected in clinical practice and research.

Oral health behaviours and dental caries in low-income children with special healthcare needs: A prospective observational study

BACKGROUND

Dental caries is a significant public health problem for low-income children with special healthcare needs (CSHCN).

AIM

We evaluated associations between oral health behaviours (eg diet, fluoride, dental care) and dental caries for CSHCN enrolled in Medicaid, a health insurance programme for low-income populations that provides comprehensive dental coverage for children.

DESIGN

We recruited 116 CSHCN ages 7-20 years from Medicaid enrolment files in Washington state, USA. Caregivers completed a 166-item questionnaire, and children received a dental screening. The outcome was dental caries, defined as total pre-cavitated, decayed, missing or filled tooth (PDMF) surfaces. We ran log-linear regression models and generated prevalence rate ratios (PRR).

RESULTS

The mean age of study participants was 12.4 ± 3.1 years, 41.4% were female, and 38.8% were white. The mean PDMF surfaces were 6.4 ± 9.4 (range: 0-49). Only sugar-sweetened beverage intake was significantly associated with dental caries. CSHCN who consumed >4 sugar-sweetened beverages per week were significantly more likely to have dental caries than those who consumed no sugar-sweetened beverages (PRR: 2.58; 95% CI: 1.37, 4.85; P < .01).

CONCLUSION

Sugar-sweetened beverages are an important target for future behavioural interventions aimed at preventing dental caries in low-income CSHCN.

Pediatric Dental Procedure-Related Pain Assessment Practices in A Rural Alaskan Health Care Organization: A Qualitative Study

Purpose: Acute pain experienced during dental procedures can lead to distress, difficulty with behavior guidance, and dental fear/avoidance. The purpose of this study was to explore dental providers' perceptions of pediatric procedure-related pain and acute pain assessment practices. Methods: Fifteen dental providers (53 percent female; nine dentists, three dental therapists, three dental hygienists) currently/formerly employed by a single rural Alaskan health care organization were interviewed using a semi-structured guide. Recorded interviews were transcribed, verified, and coded using inductive qualitative analytic methods. Results: Six providers suggested that pediatric procedure-related pain is rarely encountered. Providers who reported encountering it rely on observation of body language, facial expression, behavior, crying, and verbalization to know whether a child is experiencing procedural pain. Even when available, only four interviewees reported using standardized pain scales. Conclusions: Dental providers have mixed perceptions about whether they encounter pediatric procedure-related pain. There is high variability in how providersassess procedural pain, and approaches often are nonstandardized.

Factors influencing dentists' willingness to treat Medicaid-enrolled adolescents

OBJECTIVES

To identify factors influencing dentists' willingness to treat Medicaid-enrolled adolescents with intellectual and developmental disabilities in Washington state.

DATA SOURCES

Primary data were collected by a survey instrument administered in 2017 to general and pediatric dentists who were Medicaid providers (N = 512).

METHODS

We administered a 40-item survey, which included 20 hypothetical scenarios involving a 12-year-old Medicaid-enrolled adolescent. Based on the characteristics of the potential patient, dentists were asked to rate their willingness to treat (1 = very likely; 5 = very unlikely). We used conjoint analytic techniques to examine the relative importance of six adolescent- and family-level factors (e.g., severity of intellectual and/or developmental disability [IDD], sugar intake, toothbrushing, caregiver beliefs about fluoride, restorative needs, appointment keeping) and state Medicaid reimbursement level (35 percent, 55 percent, 85 percent of usual, customary, and reasonable amount). Analyses focused on data from 178 dentists with complete and varied responses to the scenarios.

RESULTS

The mean age of participants was 53.8 ± 10.5 years and 10.7 percent were pediatric dentists. The holdouts correlation statistics indicated excellent fit for the conjoint model (Pearson's R = 0.99, P < 0.0001; Kendall's tau = 0.89, P < 0.0001). Reimbursement level and appointment keeping were the most important factors in dentists' willingness to treat Medicaid-enrolled adolescents (importance scores of 26.7 and 25.7, respectively). Restorative needs, caregiver beliefs about fluoride, and IDD severity were the next most important (importance scores of 15.4, 10.6, and 8.1, respectively). Sugar intake and toothbrushing behaviors were the least important.

CONCLUSIONS

Reimbursement and appointment keeping were the most important determinants of dentists' willingness to treat Medicaid-enrolled adolescents with IDD.

Supply of care by dental therapists and emergency dental consultations in Alaska native communities in the Yukon-Kuskokwim delta: a mixed methods evaluation

OBJECTIVES

Examine the relationship between supply of care provided by dental therapists and emergency dental consultations in Alaska Native communities.

METHODS

Explanatory sequential mixed-methods study using Alaska Medicaid and electronic health record (EHR) data from the Yukon-Kuskokwim Health Corporation (YKHC), and interview data from six Alaska Native communities. From the Medicaid data, we estimated community-level dental therapy treatment days and from the EHR data we identified emergency dental consultations. We calculated Spearman partial correlation coefficients and ran confounder-adjusted models for children and adults. Interview data collected from YKHC providers (N=16) and community members (N=125) were content analysed. The quantitative and qualitative data were integrated through connecting. Results were visualized with a joint display.

RESULTS

There were significant negative correlations between dental therapy treatment days and emergency dental consultations for children (partial rank correlation = -0.48; p⟨0.001) and for adults (partial rank correlation = -0.18; p=0.03). Six pediatric themes emerged: child-focused health priorities; school-based dental programs; oral health education and preventive behaviors; dental care availability; healthier teeth; and satisfaction with care. There were four adult themes: satisfaction with care; adults as a lower priority; difficulties getting appointments; and limited scope of practice of dental therapy.

CONCLUSIONS

Alaska Native children, and to a lesser extent adults, in communities served more intensively by dental therapists have benefitted. There are high levels of unmet dental need as evidenced by high emergency dental consultation rates. Future research should identify ways to address unmet dental needs, especially for adults.

Interventions Focusing on Indigenous Populations May Improve Oral Health Outcomes

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Reducing indigenous oral health inequalities: a review from 5 nations. Tiwari T, Jamieson L, Broughton J, Lawrence HP, Batliner TS, Arantes R, Albino J. J Dent Res 2018;97(8):869-77.

SOURCE OF FUNDING

None.

TYPE OF STUDY/DESIGN

Literature review.

An Evaluation of Dental Student Experiences with the Medicaid Application Process

Applying for Medicaid can be a barrier to health care services. Most health science students are unaware of the Medicaid application process. First-year students at the University of Washington School of Dentistry (N=170) completed the Washington state Medicaid application as part of an introductory dental public health course and completed a 20-item survey about their experiences. About 54.7% and 41.8% of students encountered some difficulty in understanding the instructions and completing the application, respectively. Students reported lack of Internet access as a significant barrier to completing the online application. Suggested revisions included making it easier to access and submit the application, simplifying instructions, and shortening the application. Most first-year dental students reported difficulties completing the Medicaid application, which underscores the need to simplify the process for potential beneficiaries. Early experiential learning activities have the potential to expose trainees to the barriers to care that vulnerable populations encounter.