Postgraduate education to expand access to dental care: A roadmap to community dental program development

Evidence indicates an increasing shortage of dentists in communities across the United States with potentially significant implications for oral health, as well as overall health and well-being. One strategy to increase access to dental care in rural and underserved communities is community-based postgraduate dental training. However, developing new dental programs requires navigating complex accreditation, financial and community governance, among other, barriers. The Roadmap for Teaching Health Center Dental Program Development presents a framework that guides institutions through the successive steps of developing new postgraduate training programs from identification of need to ultimate maintenance and sustainability. The tool assists programs in anticipating and understanding requirements, reducing time, expense, and uncertainty. While the framework was developed for community-based programs, the steps are applicable to postgraduate programs sponsored by academic institutions as well.

Home Delivery of Water for Caries Prevention in Latinx Children (“Sediento por una Sonrisa,” Thirsty for a Smile): Protocol for a Single-Arm Feasibility Study

Background

Dental caries has significant public health implications afflicting young children. In addition to low social economic status, the most prominent risk factor for early childhood caries is sugar in the diet, particularly sugar-sweetened beverages. Dental treatment for caries in young children is commonly performed under general anesthesia and a significant proportion of children require repeated treatment. Interventions to reduce sugar-sweetened beverage consumption could lead to reduced rates of retreatment for dental caries in young children.

Objective

This protocol describes the rationale, design, and methods of the “Thirsty for a Smile” feasibility study. The aim of the study is to assess the feasibility, acceptability, and appropriateness of a dietary intervention promoting water consumption in lieu of sugar-sweetened beverages among young patients, mostly from Latino heritage.

Methods

This protocol describes a single-arm feasibility study. Twenty-one dyads of children and their caregivers will be recruited. Children between 2 and 9 years old who recently had treatment under general anesthesia for early childhood dental caries will be eligible to participate. The intervention has two components: (1) environmental, in which bottled water is delivered to participants’ homes; and (2) behavioral, in which caregivers will receive patient-centered counseling to increase children’s water intake and reduce sugar-sweetened beverages consumption. Dental caries and anthropometric data will be collected at examination during baseline and final visits. The primary outcome is feasibility and secondary outcomes are acceptability and appropriateness of the intervention.

Results

Funding has been obtained from the National Institute of Dental and Craniofacial Research and the University of Washington approved the study. The feasibility study was conducted from March to November 2019.

Conclusions

This feasibility study will test the study processes prior to a two-arm randomized controlled trial to determine feasibility and acceptability of the intervention and study procedures. This study may provide useful information for other researchers attempting to test similar interventions.

International Registered Report Identifier (IRRID)

RR1-10.2196/37200

Medical-Dental Integration in a Rural Community Health Center: A Qualitative Program Evaluation

BACKGROUND

A community health center (CHC) implemented a medical-dental integration (MDI) program where children were seen at a pediatric medical clinic or women, infants, and children program location by medical and dental providers in the same visit. Our study aims were to elicit the perspectives and experiences of providers and administrators involved in the MDI program to assess the acceptability, feasibility, and success of a CHC integration strategy in Eastern Washington.

METHODS

This is a qualitative study where we conducted semistructured interviews over the phone over a period of 2 months with 12 medical and dental providers and clinical administrators who were involved with the MDI program. Questions addressed perspectives on workflow, patient identification and engagement, leadership support, and barriers and facilitators of the initiative. Qualitative data were analyzed, and emergent themes were identified.

RESULTS

The emergent themes included (a) the MDI program is feasible and acceptable albeit with key considerations regarding the setting, including charting and service integration, progressive leadership and effective communication, and appropriate providers; (b) implementation included structural, systemic, and individual behavior barriers, (c) the program is seen as a benefit to the clinic and patients and a success to date as a way to increase access to quality care.

CONCLUSIONS

Findings from this study helped identify facilitators, such as cultural relevancy and progressive office systems, as well as barriers, such as reimbursement, associated with integrating medical and dental care in a rural CHC setting, is acceptable by providers, and can inform future studies and implementation strategies for others wishing to integrate these services.

Yakima Valley Farm Workers Clinic oral health transformation project

The Yakima Valley Farm Workers Clinic (YVFWC) is one of the largest community health centers in the country with clinics throughout south-central Washington and northern Oregon. Its dental program consists of 14 dental clinics providing general and specialty services to the low-income populations it serves. Modeling itself after the YVFWC medical managed care program; the Dental program recently added value-based metrics to its dental practice after Oregon offered a value-based dental reimbursement plan in 2019. This is the first-step YVFWC's dental program that has taken to prepare for value-based reimbursement and transform its dental practice in order to reduce the disease burden in its patient population. The purpose of this article is to describe the processes YVFWC undertook to prepare itself for the new reimbursement model, which included the development of metrics, a metric validation process, a clinical dashboard, and a method for improving metrics. It also outlines its medical/dental integration improvement brought about by embedding hygienists into the medical primary care teams.

Advancing value in oral health through meaningful measurement

Central to all value-based purchasing (VBP) approaches are value metrics, the measurements used to drive improvement, facilitate payment, and evaluate results of VBP programs. This article outlines approaches for adopting meaningful measurement systems that can be used to support VBP in the near term and identifies systemic changes critical to developing more robust measurement systems to advance VBP in the future.

Addressing disparities in children's oral health: a dental-medical partnership to train family practice residents

Providing oral health care to rural populations in the United States is a major challenge. Lack of community water fluoridation, dental workforce shortages, and geographical barriers all aggravate oral health and access problems in the largely rural Northwest. Children from low-income and minority families and children with special needs are at particular risk. Family-centered disease prevention strategies are needed to reduce oral health disparities in children. Oral health promotion can take place in a primary care practitioner's office, but medical providers often lack relevant training. In this project, dental, medical, and educational faculty at a large academic health center partnered to provide evidence-based, culturally competent pediatric oral health training to family medicine residents in five community-based training programs. The curriculum targets children birth to five years and covers dental development, the caries process, dental emergencies, and oral health in children with special needs. Outcome measures include changes in knowledge, attitudes, and self-efficacy; preliminary results are presented. The program also partnered with local dentists to ensure a referral network for children with identified disease at the family medicine training sites. Pediatric dentistry residents assisted in didactic and hands-on training of family medicine residents. Future topics for oral health training of family physicians are suggested.

Situation-specific child control: a visit to the dentist

This paper describes the development of the Child Dental Control Assessment (CDCA), a situationally-specific measure of control strategies for school-age children visiting the dentist. A pilot proceeded two definitive studies. In the pilot, the instructions and a battery of items were pretested. The first study was with 180 children and gathered data in a classroom setting to establish the psychometric characteristics of the instrument. Factor analysis, accounting for over 50% of the variance, suggested five scales: Dentist-Mediated Control, Active Coping, Cognitive Withdrawal, Reassurance, and Physical Escape. Internal consistency of the scales constructed from the factors ranged from 0.5 to 0.7. The highest standardized scale scores were for Reassurance and Dentist-Mediated Control. Younger children reported a greater need for Active Coping. In the second study in a clinical setting, children completed an assessment battery and were trained to use a signalling device. Higher CDCA scores for the Active Coping scale, but not the other scales, were associated with the use by subjects of a device to signal the dentist. The proposed measure allows assessment of individual differences among children of the same age as well as developmental differences between age groupings of children.

Results of a promising open trial to prevent baby bottle tooth decay: a fluoride varnish study

One hundred thirty-three farm worker children with an average age of 17 months participated in a study of a fluoride varnish in WIC programs in the Yakima Valley of Central Washington. After parents were interviewed, the child was examined and a fluoride varnish applied to the maxillary incisors. At the six-month recall 62 children and their parents returned. Results indicated a significant decrease in decalcification from 35 percent to 21 percent and an increase in decay from 3 percent to 16 percent. The rate of decay was lower than the 30 percent found in this age-group in this population. Of 130 sound teeth at baseline, 13 percent were decayed or decalcified in six months; of 73 decalcified teeth at baseline, 51 percent were found to be sound in six months. Additional experimentation with fluoride varnish is warranted.

White spots caries in Mexican-American toddlers and parental preference for various strategies

One hundred and thirty Mexican-American children ages nine to thirty-four months (Mean = 17.1 months), and their parents/caretakers were studied at a farmworkers clinic in rural Washington. Parents/caretakers participated in a bilingual interview; then each child received a dental examination, and a cotton swab was used to collect plaque for a caries activity test (Cariostat). Results showed that 7 percent had at least one maxillary incisor decayed and 30.4 percent had at least one incisor with a white spot lesion. The Cariostat was related to dental age, but not to disease. Forty percent of the parents/caretakers whose children had disease were aware of the problem. Immediate substitution of cup for bottle and the elimination of extra nighttime feedings were the least likely interventions endorsed by the subjects. Other interventions, including periodic visits for fluoride applications were much more likely.

Mexican-American parents with children at risk for baby bottle tooth decay: pilot study at a migrant farmworkers clinic

Treatment of severe BBTD in very young children often requires the use of general anesthetic. In 1987, the cost was estimated at $700-$1,000; add another $1,000, if hospitalization is needed. Informal surveys of dentists across the country indicate that in 1991-1992, the cost of treatment has increased substantially.

Dental decay rates among children of migrant workers in Yakima, WA

The literature documents a significant decline in the prevalence of dental caries among children. Unfortunately, dental decay rates of children of migrant workers remain high. This study collected data from 885 migrant children in central Washington. This community is in the west coast migrant stream. The area is served by a health center funded through the community and migrant health center program. There is an active dental program provided through the health center. The children were found to have a high rate of dental decay. However, there was a high rate of treatment of this decay and a rate of sealants (a preventive measure) nearly three times the rate in the general population. Although dental decay remains a serious problem in the migrant community, the migrant health centers appear to be making a positive impact on the dental health of the children.