Age of first dental visits: A benefit of the pediatric medical home

OBJECTIVE

This retrospective cohort study compared differences in age one dental visit use and age at first dental visit according to fluoride varnish receipt at the pediatric medical home.

METHODS

Enrollment and claims data were used from Partners For Kids, a pediatric accountable care organization covering Medicaid-enrolled children living in 47 of 88 counties in Ohio. The main outcomes were having an age one dental visit and the mean age at first dental visit. Descriptive statistics and bivariate comparisons were applied.

RESULTS

Among 17,675 children, 2.8% had an age one dental visit. The mean age at first dental visit was 4.8 years. Children who received fluoride varnish from their medical home (12% of study population) were significantly younger at their first dental visit (4.1 vs. 4.9 years, p < 0.001).

CONCLUSION

Despite longstanding recommendations for the age one dental visit, very few Medicaid-enrolled children in Ohio had one. The pediatric medical home lowered the age of first dental visit.

Evaluating the type of pediatric dental care use in the context of neighborhood opportunity

BACKGROUND

Increasing evidence supports the influence of neighborhood factors on health care use and outcomes. This study measured the association between area-level social determinants of health (SDH) and type of dental care use among Ohio pediatric Medicaid beneficiaries.

METHODS

A retrospective dental claims analysis was completed for children aged 1 through 5 years enrolled in Ohio Medicaid with a dental visit in 2017. Dental care use was measured from 2017 through 2021 as 1 of 4 visit types: (1) preventive, (2) caries treatment, (3) dental general anesthesia (GA), and (4) dental emergency department. The Ohio Children's Opportunity Index defined area-level SDH at the census tract level. Exploratory analysis included descriptive statistics of area-level SDH for each outcome. Poisson regression models were developed to examine the associations between the number of each dental care use outcome and Ohio Children's Opportunity Index quintiles. Visualizations were facilitated with geospatial mapping.

RESULTS

Fifty-six percent of children (10,008/17,675) had caries treatment visits. Overall area-level SDH were positively associated with preventive (fifth vs first quintile incidence rate ratio [IRR], 1.09; 95% CI, 1.07 to 1.12), caries treatment (fifth vs first quintile IRR, 1.16; 95% CI, 1.08 to 1.24), and dental GA visits (fifth vs first quintile IRR, 2.13; 95% CI, 1.13 to 4.01).

CONCLUSIONS

Children with preventive, caries treatment, and dental GA visits were more likely to live in neighborhoods with better SDH. Future efforts should investigate the mechanisms by which area-level factors influence dental access and use.

PRACTICAL IMPLICATIONS

Neighborhood factors influence pediatric dental care use. Patient home addresses might add value to caries risk assessment tools and efforts by care networks to optimize efficient care use.

Adverse childhood experiences, dental insurance, and developmental disability: Association with unmet dental needs in Ohio

OBJECTIVE

This study investigated whether insurance status and/or developmental disability moderated the association between adverse childhood experiences (ACE) and unmet dental needs among children aged 0 to 17 in Ohio.

METHODS

We utilized cross-sectional data from the 2021 Ohio Medicaid Assessment Survey to assess the dental needs of children. ACE scores, dental insurance status, and developmental disability status were analyzed using multivariable logistic regression to identify their potential association with parental-reported unmet dental needs.

RESULTS

The weighted sample represented 2,752,222 children in Ohio. Over half reported zero ACEs (55.8%) and no dental needs (56.1%). Approximately 1 in 9 lacked dental insurance (11.1%), and 1 in 10 had a developmental disability (9.9%). Children with one to three ACEs had three times the odds of unmet dental needs compared to children with zero ACEs (OR = 3.20; 95%CI [2.10, 4.89]), and children with four or more ACEs had eight times the odds of unmet dental needs (OR = 8.78; 95%CI [5.26, 14.67]). Children lacking dental insurance had over six times higher odds of unmet dental needs compared to children with dental insurance (OR = 6.10; 95%CI [3.92, 9.49]). The presence of developmental disability status did not moderate the presence of unmet dental needs; however, the lack of dental insurance status significantly moderated the association between ACEs and unmet dental needs.

CONCLUSION

Insurance status, not developmental disability, moderated the association between ACEs and unmet dental needs among children in Ohio. Efforts to ensure continuous access to dental insurance are warranted.

Assessing Pediatric Dental Resident Sedation Skills and Confidence with Simulation: A Pilot Study

Purpose: To conduct a pilot study assessing resident performance and self-efficacy during sedation-related simulations. Methods: Residents completed one informed consent and two sedation-related emergency simulations. Performance was measured for each simulation. Self- efficacy (i. e., confidence) was measured via pre- and post-simulation questionnaires. Descriptive and nonparametric statistics were calculated. Results: Twenty-five residents completed the simulations. Second-year residents performed better than first-year residents in both informed consent and emergency simulations; however, only the informed consent simulation was significant (P<0.02). Self-efficacy significantly increased after completing the simulations (18 percent pre-simulation versus 42.7 percent post-simulation, P<0.001). Residents identified communication skills as an area of improvement after the simulations. For the emergency vignettes, residents expressed feeling inadequate knowledge, problem-solving skills, and teamwork during the simulation. Conclusions: Simulations improved resident confidence in obtaining informed consent and managing certain sedation-related emergencies, but residents felt ill-prepared to manage an emergency. Further study is warranted to understand the best-practice frequency of sedation-related emergency simulation to promote skill retention.

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

OBJECTIVES

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

DESIGN

Retrospective claims-based analysis cohort study.

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSIONS

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

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.

Caries and Oral Health Behaviors Among Children With and Without Intellectual and Developmental Disabilities

This study evaluates oral health behaviors and caries in children with and without intellectual and developmental disabilities.

Calibrating Pediatric Dental Faculty: Caries Management in Primary Teeth

PURPOSE

The purpose of this study was to evaluate caries treatment decisions agreement in primary teeth among board-certified pedi- atric dentistry faculty at a single teaching institution.

METHODS

Ten full-time faculty selected a treatment for each of 64 primary teeth in 17 children based on clinical photos and radiographs. Cases were presented under three different social and behavioral scenarios. Descriptive and kappa statistics were calculated.

RESULTS

The interrater reliability was 0.59 for the decision at the surgical versus nonsurgical level and 0.55 for the treatment-specific decision (e. g., crown versus extraction). Surgical treatments were the predominant preference (76 percent of responses). Non- surgical treatments were preferred for early-stage lesions and in nonideal social and behavioral scenarios. Surgical options were unanimously preferred in sedation or general anesthesia.

CONCLUSIONS

Different clinical scenarios highlight different treatment preferences among faculty. Further emphasis should be placed on calibrating the decision-making process for selecting caries treatment in primary teeth among pediatric dentists.

Implementing Standardized Patient Caregivers to Practice Difficult Conversations in a Pediatric Dentistry Course

INTRODUCTION

Standardized patient (SP) methodology has been used in health professional education to help students develop communication, deeper diagnostic reasoning, and critical thinking skills. Few examples demonstrate the use of SPs to practice difficult conversations with pediatric caregivers in the pediatric dentistry literature. The objective of this educational activity was to describe the implementation of three SPs in a pediatric dentistry course for second-year dental students.

METHODS

We developed three SP encounters covering interactions with caregivers of an infant with severe early childhood caries, an adolescent on the path to gender affirmation, and a child with autism and dental caries whose caregiver was resistant to fluoride- and silver-containing dental materials. We describe the case design process, rubric construction and calibration, student debriefing, and pandemic modifications. We evaluated the effectiveness of the implementation by thematic analysis of student reflections following each encounter using a qualitative descriptive framework.

RESULTS

Eighty-three students completed each encounter. Qualitative analysis showed that students preferred a more realistic encounter by having a child or other distraction present. Students relied on different elements of motivational interviewing depending on the objective of each encounter and the age of the patient. Overall, the SP encounters were well received by students and faculty as an alternative or supplement to traditional student evaluation methods.

DISCUSSION

We noted a number of lessons learned about implementing SP methodology in pediatric dental education. With these experiences now in place, future evaluations should measure student performance in the SP encounters against student performance during clinical care.

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

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

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

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

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

Examining Parental Treatment Decisions Within a Contemporary Pediatric Dentistry Private Practice

PURPOSE

The primary objective of this study was to compare relationships between child, parent, and clinical factors with patient-level treatment decisions for early childhood caries. A secondary objective was to describe children that received silver diamine fluoride (SDF) as interim versus long-term treatment.

PATIENTS AND METHODS

Parents of 2-6-year-old children seeking care at a multi-center pediatric dentistry private practice were enrolled in this cross-sectional study. Demographic data and dental anxiety data according to the Modified Corah's Dental Anxiety Scale were collected via questionnaire. A dental visit behavior rating and decayed, missing, and filled tooth (dmft) index were recorded from the child's dental record. The primary outcome was treatment decision categorized into three groups: (1) treatment with SDF (n=25), (2) conventional restorative treatment under local anesthesia (n=32), and (3) restorative treatment under general anesthesia (n=33). Analyses included descriptive statistics, bivariate analysis, and ordered logistic regression.

RESULTS

Child age, parent education level, family income, dental insurance status, dental visit behavior rating, and dmft were significantly different across treatment groups in bivariate comparisons. However, when included in multivariable, ordered logistic regression, child dental anxiety was the only significant covariate associated with treatment decisions (Odds Ratio=5.01, 95% confidence interval: 1.51 to 16.63). In secondary analysis, two distinct subgroups were identified within the SDF group: one as long-term treatment (n=9) and one as interim treatment prior to general anesthesia (n=16). The long-term group was younger (mean=3.2 versus 3.7), had lower dmft (mean=4 versus 11.1), and had lower frequency of very high dental anxiety (0% versus 15%).

CONCLUSION

The present study identified child dental anxiety as the primary factor associated with treatment decisions at this private practice. The characterization of two subgroups of children treated with SDF has meaningful implications for studies evaluating the economic and public health impacts of SDF.

Cohort Profile: ZOE 2.0-A Community-Based Genetic Epidemiologic Study of Early Childhood Oral Health

Early childhood caries (ECC) is an aggressive form of dental caries occurring in the first five years of life. Despite its prevalence and consequences, little progress has been made in its prevention and even less is known about individuals' susceptibility or genomic risk factors. The genome-wide association study (GWAS) of ECC ("ZOE 2.0") is a community-based, multi-ethnic, cross-sectional, genetic epidemiologic study seeking to address this knowledge gap. This paper describes the study's design, the cohort's demographic profile, data domains, and key oral health outcomes. Between 2016 and 2019, the study enrolled 8059 3-5-year-old children attending public preschools in North Carolina, United States. Participants resided in 86 of the state's 100 counties and racial/ethnic minorities predominated-for example, 48% (n = 3872) were African American, 22% white, and 20% (n = 1611) were Hispanic/Latino. Seventy-nine percent (n = 6404) of participants underwent clinical dental examinations yielding ECC outcome measures-ECC (defined at the established caries lesion threshold) prevalence was 54% and the mean number of decayed, missing, filled surfaces due to caries was eight. Nearly all (98%) examined children provided sufficient DNA from saliva for genotyping. The cohort's community-based nature and rich data offer excellent opportunities for addressing important clinical, epidemiologic, and biological questions in early childhood.

Introducing legislative advocacy into the dental school curriculum: A mixed-methods evaluation

The aim of this project was to evaluate a legislative advocacy exercise in pediatric dentistry at 1 North American dental school. A mixed-methods approach was employed using focus groups and questionnaires. All third-year dental students (n = 84) participated in an exercise as part of the pediatric dentistry course. Participation in the program evaluation was voluntary. Questionnaires were administered to assess students' advocacy beliefs, behaviors, self-efficacy, and knowledge 1 week before and 1 week after the exercise. Six months later, a focus group with questionnaire non-respondents (n = 9) was conducted to explore participants' attitudes and beliefs about oral health advocacy within the dental school curriculum. The focus group followed a semi-structured guide, and transcripts were analyzed using thematic content analysis. Questionnaires were returned from 27 students before (33% response rate) and 23 students (28% response rate) following the advocacy exercise. Students' advocacy beliefs, behaviors, and knowledge showed no change, whereas self-efficacy improved following the advocacy exercise. Students enjoyed the advocacy exercise and viewed it as a positive addition to the curriculum; however, they requested more exposure to advocacy across the curriculum. Students described the power of their collective voice rather than a single person as a major driver of policy change. These findings suggest that curricular changes should incorporate experiential advocacy activities more frequently to help students learn about and gain advocacy skills.

Dentists' Adoption of Silver Diamine Fluoride among 1- to 5-Year-Old Children in North Carolina

BACKGROUND

A natural experiment was conducted to observe the adoption of silver diamine fluoride (SDF) by Medicaid-enrolled dentists in North Carolina (NC). The purpose of this study was to describe the sociocontextual and community health characteristics where dentists adopted SDF, determine the association between SDF use and general anesthesia (GA) use, and examine the changes in GA utilization following implementing SDF reimbursement.

METHODS

NC Medicaid initiated SDF reimbursement in 2016 for children ages 1 to 5 y. This cross-sectional time series study used aggregate NC Medicaid claims, including geographic data, from 2014 to 2018. All dentists who provided GA and/or SDF to children ages 1 to 5 y were included. County health ranking data described social and community health indicators. Descriptive statistics, spatial data techniques, and multivariable methods were used.

RESULTS

From 2016 to 2018, the number of dentists using SDF increased from 35 to 258, or 637%, whereas the number of dentists using GA increased from 179 to 211, or 17%. SDF utilization spread outward from areas of good social and health indicators to areas of poorer indicators. SDF utilization increased from 0.35 to 0.65 per 1,000 children, whereas GA utilization decreased from 2.57 to 2.47 per 1,000 children. GA utilization was positively associated with SDF utilization and poorer county health ranking but did not change before and after SDF implementation.

CONCLUSION

Early adopters of SDF in NC practiced in areas with positive social and community health indicators. Over time, SDF was adopted in resource-poor communities. It remains too early to determine the public health impacts of SDF treatment on GA utilization.

KNOWLEDGE TRANSFER STATEMENT

Policy makers and clinicians can use the results of this study to develop geographically targeted interventions that could lead to clinically and cost-effective public health programs.

Pre-doctoral special healthcare needs education: Lost in a crowded curriculum

We explored academicians' experiences with pre-doctoral special healthcare needs (SHCN) education using one-on-one interviews with academic leaders. We assessed their personal experience with SHCN, the current state of SHCN education at their institution, and their opinions about SHCN education in the pre-doctoral curriculum. Interviews were transcribed verbatim and analyzed using a qualitative descriptive framework to identify emerging themes. Twelve faculty members were interviewed from 10 institutions. All participants acknowledged that the bulk of their training and experience treating patients with SHCN occurred during residency. Participants identified inconsistent pre-doctoral SHCN curricular experiences attributed to time constraints imposed by an increasingly crowded curriculum. Questions remain regarding the place of SHCN education in future pre-doctoral curricula, as well as how to create sustainable systems and programs for dental graduates to gain this experience.

The Effect of Physician Oral Health Services on Dental Use and Expenditures under General Anesthesia

BACKGROUND

Despite early evidence touting the effectiveness of physician-provided oral health services (POHS), recent evidence suggests these services might have little impact on caries-related outcomes in children. General anesthesia (GA) is often used to treat early childhood caries and may be considered the most extreme utilization outcome. We sought to assess the impact of POHS utilization on dental GA utilization and expenditures.

METHODS

We used the Medicaid claims of a birth cohort of children born in 2008 in North Carolina (N = 32,558) to determine the impact of POHS on dental utilization and expenditures under GA for individual children. Children were followed until their eighth birthday. We analyzed the association of the number of prior POHS visits with visit-specific outcomes of dental treatment under GA using population-averaged models fit with generalized estimating equations with exchangeable working correlation structure.

RESULTS

Children with 2 or more previous POHS visits had reduced odds of GA (odds ratio [OR] = 0.93; confidence interval [CI], 0.87-0.99; P = 0.029) and expenditures ($114; CI,-$152.61 to -$75.19; P < 0.001) compared to those without physician-provided oral health visits, adjusting for age, sex, race/ethnicity, and geographic residence. Dental expenditures did not differ between POHS and non-POHS subjects at non-GA visits.

CONCLUSIONS

POHS decreased the odds of having dental GA treatment and dental expenditures at GA visits. The role of physicians in oral health care can reduce the impact on the most severe outcome-treatment under general anesthesia.

KNOWLEDGE TRANSFER STATEMENT

The results of this study have important financial implications for state Medicaid programs and disease management programs trying to mitigate the costs of treating early childhood caries under general anesthesia. Children who receive physician oral health care are less likely to use and more likely to save money on general anesthesia to complete dental treatment.

Development and testing of a patient-centered dental home assessment for low-income families

OBJECTIVES

The purpose of this study was to develop an instrument in English (ENG) and Spanish (SPA) for use in assessing perceptions of dental home characteristics among low-income adults.

METHODS

An expert panel selected 21 items from a pool of 81 items mapped to domains in the American Academy of Pediatrics' medical home. Pilot testing with mothers (n = 795) of children in Early Head Start (EHS) resulted in an expanded 36-item scale, which was field-tested in interviews with ENG- (N_ENG = 665) and SPA-speakers (N_SPA = 116). An exploratory factor analysis of 23 usable items was carried out in an EHS reference group (N_ENG-EHS = 272). The selected model was evaluated by confirmatory factor analysis (CFA) in two other subgroups (N_ENG-NonEHS = 393; N_SPA = 116). We tested measurement and structural invariances using a multiple-group approach. Known-groups validity was examined by testing factor mean differences between two groups defined by whether or not the mother used a single dental office.

RESULTS

A three-factor CFA model with 10 items was retained for its close fit for all three subgroups. Invariance tests found the two ENG subgroups to be homogenous and were combined. Several item and factor parameters in the SPA group differed from the combined ENG group. The proposed dental home measure demonstrated good known-group validity in that people who used the same dental office reported better dental care experiences.

CONCLUSIONS

An instrument to measure the dental home concept among low-income adults was developed with three domains (accessible-comprehensive, compassionate, and health literate care) that demonstrated good validity and reliability.

Protocols, Methods, and Tools for Genome-Wide Association Studies (GWAS) of Dental Traits

Oral health and disease are known to be influenced by complex interactions between environmental (e.g., social and behavioral) factors and innate susceptibility. Although the exact contribution of genomics and other layers of "omics" to oral health is an area of active research, it is well established that the susceptibility to dental caries, periodontal disease, and other oral and craniofacial traits is substantially influenced by the human genome. A comprehensive understanding of these genomic factors is necessary for the realization of precision medicine in the oral health domain. To aid in this direction, the advent and increasing affordability of high-throughput genotyping has enabled the simultaneous interrogation of millions of genetic polymorphisms for association with oral and craniofacial traits. Specifically, genome-wide association studies (GWAS) of dental caries and periodontal disease have provided initial insights into novel loci and biological processes plausibly implicated in these two common, complex, biofilm-mediated diseases. This paper presents a summary of protocols, methods, tools, and pipelines for the conduct of GWAS of dental caries, periodontal disease, and related traits. The protocol begins with the consideration of different traits for both diseases and outlines procedures for genotyping, quality control, adjustment for population stratification, heritability and association analyses, annotation, reporting, and interpretation. Methods and tools available for GWAS are being constantly updated and improved; with this in mind, the presented approaches have been successfully applied in numerous GWAS and meta-analyses among tens of thousands of individuals, including dental traits such as dental caries and periodontal disease. As such, they can serve as a guide or template for future genomic investigations of these and other traits.

Measurement of Early Childhood Oral Health for Research Purposes: Dental Caries Experience and Developmental Defects of the Enamel in the Primary Dentition

Epidemiological investigations of early childhood oral health rely upon the collection of high-quality clinical measures of health and disease. However, ascertainment of valid and accurate clinical measures presents unique challenges among young, preschool-age children. The paper presents a clinical research protocol for the conduct of oral epidemiological examinations among children, implemented in ZOE 2.0, a large-scale population-based genetic epidemiologic study of early childhood caries (ECC). The protocol has been developed for the collection of information on tooth surface-level dental caries experience and tooth-level developmental defects of the enamel in the primary dentition. Dental caries experience is recorded using visual criteria modified from the International Caries Detection and Assessment System (ICDAS), and measurement of developmental defects is based upon the modified Clarkson and O'Mullane Developmental Defects of the Enamel Index. After a dental prophylaxis (toothbrushing among all children and flossing as needed), children's teeth are examined by trained and calibrated examiners in community locations, using portable dental equipment, compressed air, and uniform artificial light and magnification conditions. Data are entered directly onto a computer using a custom Microsoft Access-based data entry application. The ZOE 2.0 clinical protocol has been implemented successfully for the conduct of over 6000 research examinations to date, contributing phenotype data to downstream genomics and other "omics" studies of ECC and DDE, as well as traditional clinical and epidemiologic dental research.

Pharmacologic management for pediatric dental patients in the 21st century

Most children are able to cooperate during conventional, in-office dental treatment using traditional, communicative behavior guidance techniques that are carefully selected and applied to the developmental needs of a particular child. Children who are unable to cooperate during conventional treatment due to a lack of psychological or emotional maturity and/or the existence of a mental, physical, or medical disability may require pharmacologic techniques such as procedural sedation or general anesthesia to complete rehabilitative dental treatment. Patient safety dictates that careful preparation and robust case selection processes guide clinical decision-making related to pharmacologic behavior guidance. Before using these techniques, the sedation provider must demonstrate an adequate understanding of these techniques, from definitions and best practices to case selection and patient safety. This article presents essential information-with an emphasis on best practices and patient safety-for dentists who are considering pharmacologic behavior guidance for the children they treat.

An Algorithm-Based Approach for Behavior and Disease Management in Children

Pharmacologic behavior management for dental treatment is an approach to provide invasive yet compassionate care for young children; it can facilitate the treatment of children who otherwise may not cooperate for traditional in-office care. Some recent highly publicized procedural sedation-related tragedies have drawn attention to risks associated with pharmacologic management. However, it remains widely accepted that, by adhering to proper guidelines, procedural sedation can assist in the provision of high-quality dental care while minimizing morbidity and mortality from the procedure. The purpose of this paper was to propose an algorithm for clinicians to consider when selecting a behavior and disease management strategy for early childhood caries. This algorithm will not ensure a positive outcome but can assist clinicians when counseling caregivers about risks, benefits, and alternatives. It also emphasizes and underscores best-safety practices.

Dental Treatment and Expenditures Under General Anesthesia Among Medicaid-Enrolled Children in North Carolina

PURPOSE

Many studies reporting dental utilization under general anesthesia (GA) are dated. The purpose of this study was to provide contemporaneous data about children receiving dental GA by: (1) determining trends in utilization and associated expenditures; and (2) examining the effects of provider distribution.

METHODS

This time series cross-sectional study of Medicaid-eligible children ages zero to eight years old in North Carolina used aggregate Medicaid claims from State Fiscal Years (SFY) 2011 to 2015 to collect demographic and dental treatment information. Descriptive statistics were stratified by age and year to examine trends over time. Panel analysis techniques were used to explore regional effects of provider distribution on dental GA utilization.

RESULTS

For SFY 2011 to 2015, the overall dental utilization rate was 517.1 per 1,000 (total enrolled equals 632,941 children/year), and the dental GA utilization rate was 15.8 per 1,000. Total dental expenditures averaged $113 million per year, and dental GA averaged $16.7 million per year. The dental GA proportion of expenditures increased over time (P<.001). Provider distribution did not affect dental GA utilization rate (P=.178) but did increase the number of children receiving dental GA (P<.001).

CONCLUSIONS

Utilization and expenditures associated with dental treatment under general anesthesia continue to increase. While this reflects increased access to care, interventions should be examined to provide preventive care earlier in a child's life.

"They Told Me to Take Him Somewhere Else": Caregivers' Experiences Seeking Emergency Dental Care for Their Children

PURPOSE

The purpose of this mixed-methods study was to examine pediatric emergency dental trends in two safety net clinics and care-seeking experiences of young children's caregivers.

METHODS

Administrative data were used to describe and compare emergency first visits of children ages zero to six years in a community-based (CC) and a University-based (UC) safety net clinic from 2010 to 2014. In-person interviews were conducted with 11 caregivers of children ages zero to six presenting for nontrauma-related emergency visits at the UC from January to August 2016. Interviews were transcribed verbatim, coded, and analyzed inductively using Atlas. ti.7.5.9.

RESULTS

The UC experienced significantly more emergency first visits (33 percent) than the CC (five percent, P<0.001), and the majority of these UC visits were referrals. Caregivers were dissatisfied with the experienced barriers of access to care and lack of child-centeredness, specifically the referral out of the dental home for emergency dental care.

CONCLUSIONS

A considerable proportion of children's first visits at dental safety net clinics was emergency related. Children's caregivers voiced issues related to access to care and lack of child-centered care. Discordance was apparent between how professional organizations define the dental home and how caregivers experience it in the context of emergency care.

Workers' compensation and injury duration: evidence from a natural experiment

This paper examines the effect of workers' compensation on time out of work. It introduces a "natural experiment8 approach of comparing individuals injured before and after increases in the maximum weekly benefit amount. The increases examined in Kentucky and Michigan raised the benefit amount for high-earnings individuals by approximately 50 percent, while low-earnings individuals, who were unaffected by the benefit maximum, did not experience a change in their incentives. Time out of work increased for those eligible for the higher benefits and remained unchanged for those whose benefits were constant. The estimated duration elasticities are clustered around 0.3-0.4.

High sodium bicarbonate and acetate hemodialysis: double-blind crossover comparison of hemodynamic and ventilatory effects

The superiority of bicarbonate dialysis (Bi HD) over acetate dialysis (Ac HD) using a high sodium dialysate has not been established to our knowledge. We compared to Bi HD to Ac HD over 6 weeks each in ten stable patients using a double-blind crossover design and a dialysate sodium concentration of 140 mEq/liter. The dialyzer, delivery system, and disalysate constituents were identical except for the substitution of Bi or Ac. Interdialytic weight gain, pre- and post-HD blood pressures, and heart rates were also comparable in the two protocols. Beginning of the week pre-HD serum Bi was greater during Bi HD than Ac HD (19.1 +/- 0.9 vs. 15.1 +/- 0.8 mEq/liter, P less than 0.001); post-HD Bi values were also higher during Bi HD. Similarly, pre-HD pH was also greater with Bi HD 7.40 +/- 0.012 vs. 7.35 +/- 0.001 U, P less than 0.01). The number of adverse symptoms and signs were similar during each protocol (2.0 +/- 0.65 for Bi HD vs. 2.5 +/- 0.5 for Ac HD episodes/patient/6 weeks, NS). However, fewer therapeutic interventions were required during the Bi HD protocol (1.5 +/- 0.43 vs. 3.1 +/- 0.6 treatments/patient/6 weeks, P less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)