Gastrointestinal distress as a potential mediator between stress and periodontal inflammation

OBJECTIVES

Periodontal disease is multifactorial in its aetiology, which encompasses biopsychosocial contributors, including psychological stress. Gastrointestinal distress and dysbiosis have been associated with several chronic inflammatory diseases yet have rarely been investigated with respect to oral inflammation. Given the implications of gastrointestinal distress on extraintestinal inflammation, this study aimed to evaluate the potential role of such distress as a mediator between psychological stress and periodontal disease.

METHODS

Utilizing a cross-sectional, nationwide sample of 828 adults in the USA generated via Amazon Mechanical Turk, we evaluated data collected from a series of validated self-report psychosocial questionnaires on stress, gut-specific anxiety around current gastrointestinal distress and periodontal disease, including periodontal disease subscales targeted at physiological and functional factors. Structural equation modelling was used to determine total, direct and indirect effects, while controlling for covariates.

RESULTS

Psychological stress was associated with gastrointestinal distress (ß = .34) and self-reported periodontal disease (ß = .43). Gastrointestinal distress also was associated with self-reported periodontal disease (ß = .10). Gastrointestinal distress likewise mediated the relation between psychological stress and periodontal disease (ß = .03, p = .015). Given the multifactorial nature of periodontal disease(s), similar results were demonstrated using the subscales of the periodontal self-report measure.

CONCLUSIONS

Associations exist between psychological stress and overall reports of periodontal disease as well as more specific physiological and functional components. Additionally, this study provided preliminary data supporting the potential mechanistic role that gastrointestinal distress plays in connecting the gut-brain and the gut-gum pathways.

Recruitment and Enrollment of Low-income, Minority Residents of Urban Public Housing into Research

Research participation among vulnerable populations is often limited by the same socioeconomic factors that contribute to poor health. Identifying best practices for inclusion is critical to addressing health disparities. Urban public housing communities bear a disproportionate burden of chronic disease and may represent an opportunity to directly engage historically vulnerable populations in research designed to ultimately reduce that burden. We used mixed-method data to analyze recruitment effectiveness among a random sample of households (N = 380) across two public housing developments in Boston, MA who were approached for participation in a pre-COVID oral health study. Quantitative data from detailed recruitment tracking methods was analyzed to assess the relative efficiency of the methods employed. Field journals of study staff were qualitatively analyzed to identify community-specific recruitment barriers and facilitators. The participation rate among randomly sampled households was 28.6% (N = 131), with participation from primarily Hispanic (59.5%) or Black (26%) residents. Door-to-door knocking with response yielded the highest participation (44.8%), followed by responses to informational study flyers (31%). Primary barriers to enrollment included references to unemployment and employment variations, shift work, childcare responsibilities, time demands, and managing multiple appointments and social services. This study finds active, door-to-door knocking and return visits resolved barriers to participation, and reduced safety concerns and historic distrust. It's time to consider how best to adapt effective pre-COVID recruitment practices for utilization under current and future exposure conditions as effective recruitment of populations such as urban public housing residents into research is only becoming more important.

Preconception Periodontitis and Risk of Spontaneous Abortion in a Prospective Cohort Study

Few studies have evaluated the association between periodontitis and spontaneous abortion (SAB), and all had limitations. We used data from the Pregnancy Study Online (PRESTO), a prospective preconception cohort study of 3,444 pregnancy planners in the United States and Canada (2019-2022), to address this question. Participants provided self-reported data on periodontitis diagnosis, treatment, and symptoms of severity (i.e., loose teeth) via the enrollment questionnaire. SAB (pregnancy loss at <20 weeks' gestation) was assessed via bimonthly follow-up questionnaires. Participants contributed person-time from the date of a positive pregnancy test to the gestational week of SAB, loss to follow-up, or 20 weeks' gestation, whichever came first. We fitted Cox regression models with weeks of gestation as the time scale to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs), and we used inverse probability of treatment weighting to account for differential loss to follow-up. We used probabilistic quantitative bias analysis to estimate the magnitude and direction of the effect of exposure misclassification bias on results. In weighted multivariable models, we saw no appreciable association between preconception periodontitis diagnosis (HR = 0.97, 95% CI: 0.76, 1.23) or treatment (HR = 1.01, 95% CI: 0.79, 1.27) and SAB. A history of loose teeth was positively associated with SAB (HR = 1.38, 95% CI: 0.88, 2.14). Quantitative bias analysis indicated that our findings were biased towards the null but with considerable uncertainty in the bias-adjusted results.

Perceived racism associated with declines in self-rated oral health among U.S. Black women

PURPOSE

Racial disparities in oral health are well-documented. Stress has been associated with both perceived racism and oral health, yet little research has directly investigated the association between perceived racism and oral health.

METHODS

We used data from the Black Women's Health Study, a longitudinal cohort study that includes a geographically diverse sample of Black women across the United States. Perceived exposure to racism was assessed via two scales, one assessing lifetime exposure and one everyday exposure. Self-rated oral health was subsequently assessed over multiple time points. We used Cox proportional hazard models to calculate adjusted incidence rate ratios estimating the association between higher levels of perceived racism and incident "fair" or "poor" oral health, and explored potential effect measure modification using stratified models.

RESULTS

The adjusted incidence rate ratios (n = 27,008) relating perceived racism to incident fair or poor oral health were 1.50 (95% confidence interval 1.35, 1.66) comparing the highest quartile of everyday racism to the lowest and 1.45 (95% confidence interval 1.31, 1.61) for the highest score of lifetime racism compared to the lowest. We did not see evidence of effect modification.

CONCLUSIONS

Higher levels of perceived racism documented in 2009 were associated with declines in self-rated oral health from 2011 to 2019.

Effect of being overweight and obese on periodontal treatment costs

BACKGROUND

Obesity can increase a person's risk of developing periodontal disease, and patients with obesity have greater health care costs. However, the effect of obesity on periodontal treatment costs has not been examined.

METHODS

This retrospective cohort study used data from the electronic dental records of adult patients examined from July 1, 2010, through July 31, 2019 at a US dental school. Primary exposure was body mass index, which was categorized as obese, overweight, or normal. Periodontal disease was categorized using clinical probing measures. Fee schedules and procedure codes were used to compute the primary outcome, which was total periodontal treatment costs. A generalized linear model with gamma distribution was used to examine the relationship between body mass index and periodontal costs after controlling for initial periodontal disease severity and other confounding variables. Parameter coefficients and mean ratios with 95% CIs were estimated.

RESULTS

The study sample included 3,443 adults, of whom 39% were normal weight, 37% were overweight, and 24% were obese. Mean (SD) total periodontal treatment costs for patients who were obese were considerably higher ($420 [$719]) than those for patients who were overweight ($402 [$761]) and patients who were normal weight ($268 [$601]). After controlling for covariates and disease severity, patients who were obese had 27% higher periodontal treatment costs than patients who were normal weight. The additional periodontal treatment costs attributable to obesity were greater than those attributable to either diabetes or smoking.

CONCLUSIONS

The study results suggest that among patients at a dental school, those who were obese incurred substantially higher periodontal treatment costs than patients who were normal weight, independent of initial periodontal disease severity.

PRACTICAL IMPLICATIONS

The study findings have important implications for clinical guidelines and dental benefit design and coverage policies.

Effect of Overweight and Obesity on Periodontal Treatment Intensity

INTRODUCTION

Obesity is associated with greater utilization of medical resources, but it is unclear if a similar relationship exists for dental care.

OBJECTIVES

This retrospective cohort study compared periodontal disease treatment among obese, overweight, and normal-weight patients attending an urban US dental school clinic.

METHODS

Periodontal, demographic, and medical history data for 3,443 adult patients examined between July 1, 2010, and July 31, 2019, were extracted from electronic health records. Body mass index (BMI) was computed from self-reported height and weight and categorized as obese (≥30 kg/m²), overweight (25-29.9 kg/m²), or normal (18-24.9 kg/m²). Periodontal disease was categorized using clinical probing measures. Procedure codes defined treatment type (surgical, nonsurgical, local chemotherapeutics, or none). Logistic regression models controlling for initial periodontal disease severity, age, gender, tobacco use, history of diabetes, dental insurance type, and follow-up (log of days) estimated odds ratios (ORs) and 95% confidence intervals (CIs) of any treatment among obese and overweight relative to normal-weight patients. The association between BMI and a periodontal treatment intensity score, based on treatment type, number of teeth treated, and number of visits, was evaluated with multivariable negative binomial regression.

RESULTS

Mean age at baseline was 44 ± 15 y, and severe periodontal disease was present in 32% of obese, 31% of overweight, and 21% of normal-weight patients. Average follow-up was 3.9 ± 1.6 y. Obese and overweight patients were more likely to have nonsurgical scaling and root planing or surgical procedures than normal-weight patients. Adjusted odds of any treatment were higher among obese (OR = 1.34; 95% CI, 1.14-1.72) and overweight (OR = 1.18; 95% CI, 0.97-1.42) relative to normal weight. Obese and overweight patients had 40% and 24% higher treatment intensity scores, respectively, than normal-weight patients.

CONCLUSION

These results indicate obese and overweight individuals require more intensive periodontal treatment compared to normal-weight individuals, independent of initial disease severity.

KNOWLEDGE OF TRANSFER STATEMENT

The results of this study can be used by dental providers and policymakers to better understand patient characteristics that influence the variability in frequency and length of periodontal treatment. Knowledge of a patient's body mass index may be useful in identifying patients who possibly will have a poorer periodontal prognosis.

Periodontitis is associated with an increased hazard of mortality in a longitudinal cohort study over 50 years

AIM

To evaluate the association between periodontal disease and all-cause mortality in a longitudinal cohort study over 50 years.

MATERIALS AND METHODS

Participants (N = 1156) in the Veterans Affairs Dental Longitudinal Study, aged 25-85 years at enrollment in 1968, received comprehensive medical and oral exams approximately every 3 years through 2007. Periodontal status was defined using person-level, mean whole-mouth radiographic alveolar bone loss (ABL) scores using a five-point Schei ruler, each unit representing 20% increments of ABL. Time-varying Cox regression models estimated hazard ratios (HRs) for the association between continuous and categorical ABL and mortality, adjusting for covariates.

RESULTS

Each one-unit increase in mean ABL score was associated with a 14% increase in the hazard of mortality (adjusted HR = 1.14, 95% confidence interval [CI] 1.02, 1.27). When assessed categorically, HRs for average scores of 2 to <3 and 3 to ≤5 showed increasing associations with hazard of mortality, relative to 0 to <1 (adjusted HR = 1.17, 95% CI 0.94, 1.46; and HR = 1.65, 95% CI 0.94, 2.85, respectively). By contrast, we observed null associations for average scores of 1 to <2 relative to 0 to <1 (adjusted HR = 1.00, 95% CI 0.86, 1.17).

CONCLUSIONS

Time-varying periodontal status assessed using radiographic ABL was positively associated with all-cause mortality even after confounder adjustment.

Edentulism is associated with increased risk of all-cause mortality in adult men

BACKGROUND

Prior reports of positive associations between edentulism and all-cause mortality have been limited by onetime assessments of edentulism and inadequate control of known confounding variables. The authors aimed to assess the association between edentulism and mortality using a longitudinal clinical oral health cohort.

METHODS

The authors used data from the Department of Veterans Affairs Dental Longitudinal Study, an ongoing, closed-panel cohort study from 1968 through 2019 (N = 1,229). Dentition status was evaluated through triennial clinical examinations. Mortality was assessed via the National Death Registry. The authors used Cox regression models to estimate the association between edentulism and all-cause mortality after covariate adjustment. Furthermore, the authors calculated propensity scores and assessed hazard ratios (HRs) in a trimmed, matched, and inverse probability weighted sample.

RESULTS

Participants who were edentulous (N = 112) had 1.24 (95% CI, 1.00 to 1.55) times the hazard of all-cause mortality compared with those who were nonedentulous, after adjustment with time-varying covariates. Use of propensity scores in the model resulted in slightly elevated HRs compared with the standard Cox model, regardless of propensity score method; adjusted HRs were 1.35 (95% CI, 1.01 to 1.80) after matching, 1.26 (95% CI, 1.00 to 1.59) after trimming, and 1.29 (95% CI, 1.18 to 1.42) after inverse probability weighting.

CONCLUSIONS

Edentulism was associated with an increased risk of all-cause mortality in a cohort that captured incident edentulism. This association was consistent after multiple methods to account for confounding.

PRACTICAL IMPLICATIONS

The findings of this study suggest that edentulism is associated with an increase in risk of mortality, after accounting for salient confounding variables using multiple approaches. Efforts to improve equitable access to tooth-preserving treatments are critical.

Dental service utilization and immigrant family structure

OBJECTIVES

To determine the patterns and time trends of dental services received and access to dental care among immigrant and US-born children living in the United States.

METHODS

We analyzed the nationally representative Medical Expenditure Survey data for 2007-2015. Survey weighted mean and frequency were calculated for all the years and for each year for the complete cohort and for the four subgroups of children categorized based on the child's and parents' birthplace (United States or Foreign). These groups were compared to detect differences in dental service received.

RESULTS

Overall 34,482 children aged <18 years were included in the analysis representing the weighted sample size of 564,255,643. Utilization of preventive dental services increased from 37.2 percent in 2007 to 44.4 percent in 2015 overall (P < 0.0001), with similar trend seen within all subgroups. Immigrant children compared to US-born children had higher numbers of surgical and restorative procedures (17 versus 16 per 100-person years, P = 0.03), fewer had at least one preventive dental visit in a year (32.8 percent versus 43.0 percent, P < 0.0001) and were less likely be unable to access dental care (3.0 percent versus 1.7 percent, P = 0.005). Fewer children had delayed access to dental care in recent years (2.0 percent in 2007 to 1.5 percent in 2015) and the decline was consistent in all the subgroups.

CONCLUSION

Stratification into the different subgroups allowed for improved understanding of dental procedure utilization and dental services utilization in all subgroups increased over time. Immigrant children had lower utilization of preventive procedures and higher utilization of surgical and restorative procedures.

Breastfeeding and Early Childhood Caries: Findings from the National Health and Nutrition Examination Survey, 2011 to 2018

Purpose: Childhood caries is a highly prevalent disease that is intricately connected to diet and other social and behavioral factors. While it has been established that breastfeeding confers many health benefits for children, previous research found no consensus on the relationship between breastfeeding and caries. The purpose of this study was to examine the relationship between early childhood caries (ECC) and the length of time breastfeeding using the National Health and Nutrition Examination Survey (NHANES). Methods: Four cycles of NHANES (2011 to 2018) were analyzed, including 3,234 children ages two to five years. The association between breastfeeding duration and incidence of ECC and severe earlychildhood caries (S-ECC) was evaluated using logistic regression, adjusting for age, ethnicity, education, income, last dental visit, and sugar-sweetened beverages. Results: In the study population, 16.9 percent had ECC and 12.2 percent had S-ECC. Breastfeeding six months to one year, one to two years, or over two years was not associated with higher odds of ECC or S-ECC than breastfeeding for zero to six months after adjusting for covariates. Conclusions: There was no statistically significant relationship between breastfeeding and early childhood caries, and breastfeeding duration was not associated with increased caries risk. More research from well-controlled analytical studies is needed to establish or refute a relationship between breastfeeding and ECC.

Medicaid adult dental benefits and oral health of low-income older adults

BACKGROUND

Older adults are keeping their natural teeth longer, spurring calls for dental coverage under Medicare. Although Medicare dental coverage would benefit all older adults, the poorest among them are already eligible for dental benefits through Medicaid. The authors examine the association between states' Medicaid adult dental benefits and dental care use and tooth loss among low-income older adults.

METHODS

Using the Behavioral Risk Factor Surveillance System data from 2014, 2016, and 2018, the authors examined adults 65 years or older. The outcomes examined included annual dental visit and partial and complete tooth loss. Poisson regressions were used to obtain risk ratios after adjusting for covariates.

RESULTS

States' Medicaid adult dental benefits were significantly associated with dental care use, with low-income older adults in states with no coverage having the lowest probability of visiting a dentist (risk ratio [RR], 0.83; 95% CI, 0.74 to 0.94), followed by emergency-only coverage (RR, 0.91; 95% CI, 0.84 to 0.98) and limited benefits (RR, 0.91; 95% CI, 0.85 to 0.98) relative to states with extensive benefits. There were no significant differences in either partial or complete tooth loss.

CONCLUSIONS

States' Medicaid adult dental benefits are significantly associated with dental visits among low-income seniors. Providing comprehensive dental benefits under Medicaid can improve access to dental care among low-income older adults.

PRACTICAL IMPLICATIONS

As the older adult patient population grows, the poorest older adults may face barriers to dental care in the absence of dental coverage. Dental professionals must engage in advocating for comprehensive dental coverage, especially for vulnerable populations.

Third-Molar Status and Risk of Loss of Adjacent Second Molars

The prophylactic removal of asymptomatic third molars is a common but controversial procedure often rationalized as necessary to prevent future disease on adjacent teeth. Our objective in this retrospective cohort study of adult men was to examine whether second-molar loss differed by baseline status of the adjacent third molar, taking into account the individual's overall state of oral hygiene, caries, and periodontitis. We analyzed data from participants of the VA Dental Longitudinal Study who had at least 1 second molar present at baseline and 2 or more triennial dental examinations between 1969 and 2007. We classified second molars by third-molar status in the same quadrant: unerupted, erupted, or absent. Tooth loss and alveolar bone loss were confirmed radiographically. Caries and restorations, calculus, and probing depth were assessed on each tooth. We estimated the hazards of second-molar loss with proportional hazards regression models for correlated data, controlling for age, smoking, education, absence of the first molar, and whole-mouth indices of calculus, caries, and periodontitis. The analysis included 966 men and 3024 second molar/first molar pairs. Follow-up was 22 ± 11 y (median 24, range 3-38 y). At baseline, 163 third molars were unerupted, 990 were erupted, and 1871 were absent. The prevalence of periodontitis on the second molars did not differ by third-molar status. The prevalence of distal caries was highest on the second molars adjacent to the erupted third molars and lowest on the second molars adjacent to the unerupted third molars. Relative to the absent third molars, adjusted hazards of loss of second molars were not significantly increased for those adjacent to erupted (hazard ratio [HR] = 0.96, 95% confidence interval [CI] = 0.79-1.16) or unerupted (HR = 1.25, 95% CI = 0.91-1.73) third molars. We found similar results when using alveolar bone loss as the periodontitis indicator. Our findings suggest that retained third molars are not associated with an increased risk of second-molar loss in adult men.

Geographic variations in dental sealant utilization by Medicaid enrollees

OBJECTIVE

To investigate geographical variations and their relationship to race/ethnicity in dental sealant utilization for first molars among Wisconsin Medicaid enrollees from 2010 to 2013.

METHODS

Wisconsin Medicaid dental claims for sealants in children aged 6-16 years were analyzed. County-level population density, urban influence code, presence of dental health professional shortage areas, and population-per-dentist ratio were considered as geographic predictors. Descriptive statistics and mixed effects Poisson regression models were used to examine the effect of county level covariates on the number of dental sealants received per person-year (PY) of eligibility adjusting for patient-level characteristics. Over-dispersion was modeled by a random residual effect, and all models adjusted for single-year age and gender interaction and race/ethnicity main effect.

RESULTS

Medicaid claims for sealants on first permanent molars for 2010-2013 totaled 288,019 over 1,130,000 PY. The age- and gender-standardized rate of first molar sealant applications per 100 PY were 27.9, 25.7, and 16.6 for White, Hispanic, and Black children, respectively. County-specific rates ranged from a low of 8.9 per 100 PY to a high of 62.6 per 100 PY. In the multivariate analysis after adjusting for geography, compared to Whites, Hispanics had highest rates (rate ratio (RR) = 1.33, 95% CI = 1.30-1.37) of dental sealant utilization followed by Blacks (RR = 1.25, 95% CI = 1.21-1.29). Population density was the only significant geographic predictor (RR = 0.56 per 10-fold increase, 95% CI = 0.45-0.69).

CONCLUSIONS

Substantial geographic variability in the utilization of sealants for first molars was identified. Lower population density was the main geographical predictor of high sealant utilization.

Trends in use of dental care provider types and services in the United States in 2000-2016: Rural-urban comparisons

BACKGROUND

The authors conducted a study to assess recent trends in dental care provider mix (type of dental professionals visited) and service mix (types of dental procedures) use in the United States and to assess rural-urban disparities.

METHODS

Data were from the 2000 through 2016 Medical Expenditure Panel Survey. The sample was limited to respondents who reported at least 1 dental visit to a dental professional in the survey year (N = 138,734 adults ≥ 18 years). The authors estimated rates of visiting 3 dental professionals and undergoing 5 dental procedures and assessed the time trends by rural-urban residence and variation within rural areas. Multiple logistic regression was used to assess the association between rural and urban residence and service and provider mix.

RESULTS

A decreasing trend was observed in visiting a general dentist, and an increasing trend was observed in visiting a dental hygienist for both urban and rural residents (trend P values < .001). An increasing trend in having preventive procedures and a decreasing trend in having restorative and oral surgery procedures were observed only for urban residents (trend P values < .001). The combined data for 2000 through 2016 showed that rural residents were less likely to receive diagnostic services (adjusted odds ratio [AOR], 0.82; 95% confidence interval [CI], 0.72 to 0.93) and preventive services (AOR, 0.87; 95% CI, 0.78 to 0.96), and more likely to receive restorative (AOR, 1.11; 95% CI, 1.02 to 1.21) and oral surgery services (AOR, 1.23; 95% CI, 1.11 to 1.37).

CONCLUSIONS

Although preventive dental services increased while surgical procedures decreased from 2000 through 2016 in the United States, significant oral health care disparities were found between rural and urban residents.

PRACTICAL IMPLICATIONS

These results of this study may help inform future initiatives to improve oral health in underserved communities. By understanding the types of providers visited and dental services received, US dentists will be better positioned to meet their patients' oral health needs.

Survey of Dental Researchers' Perceptions of Sexual Harassment at AADR Conferences: 2015 to 2018

The American Association for Dental Research (AADR) is committed to providing a collegial, safe, and welcoming environment for all. As part of this effort, we assessed perceptions and experiences related to sexual, gender-based, and non-gender-based harassment among registrants at AADR annual meetings from 2015 to 2018 (n = 10,495); examined demographic factors associated with reported experiences; and identified facilitators and potential solutions concerning these types of harassment. Registrants were emailed an invitation to an anonymous online survey. Demographics were assessed categorically, and response distributions to close-ended survey items were evaluated by these variables. Bivariate analyses of participant demographics were conducted with 8 types of perceived harassment. To determine the demographic distribution of reporters, along with bivariate associations among them, restricted analyses were performed among individuals reporting any type of harassment. Qualitative data analysts conducted content analysis of the open-ended responses to questions asking participants to reflect on the topic. Peer debriefing was used to refine the coding schema. A total of 824 responses were received, of which 172 individuals reported experiencing ≥1 of the 8 types of harassment surveyed. Among those, reports of condescending remarks occurred most frequently (70%). Reported harassment of a more sexual nature was less common by comparison. Reporters of harassment were more likely to be women, members of the AADR/CADR (Canadian Association for Dental Research) divisions, and/or frequent meeting attendees. A total of 229 respondents answered at least 1 of the open-ended questions. While the majority of survey respondents reported no personal experience with harassment at AADR meetings, the fact that 1 in 5 did should be cause for concern. In 2018, AADR introduced a "Professional Conduct at Meetings Policy" delineating unacceptable behaviors, including intimidating or harassing speech and actions. Results of this survey form an important baseline from which its impact may be monitored to ensure that future AADR meetings are respectful, supportive, and safe environments for all.

Complex Systems Model of Dynamic Mechanisms of Early Childhood Caries Development

Early childhood caries (ECC) is a largely preventable condition that occurs when children develop caries in their primary teeth before the age of six. National trends of ECC indicate that prevalence is decreasing, but disparities between various sociodemographic groups may be increasing, despite intervention efforts. Dynamic mechanisms in caries development are hypothesized to be responsible for the observed population distributions of disease. Agent-based models (ABMs) have been utilized to explore similar hypotheses in many areas of health research. Therefore, we developed an ABM of ECC development mechanisms and examined population outcomes of hypothetical preventive intervention scenarios. We found that risk-based targeting had minimal impact on population averages or disparities and was largely due to the strength of the dynamic mechanisms among those considered to be at high caries risk. Universally increasing intervention access reduced population caries prevalence, but increased disparities between different groups of caries risk profiles. We show that population distributions of ECC can emerge as a result of dynamic mechanisms that have been shown to drive disease development. Understanding the effectiveness of a proposed intervention in relation to the hypothesized mechanism(s) that contributes to the outcome of interest is critical to future efforts to address population disparities in ECC.

Trends of children being given advice for dental checkups and having a dental visit in the United States: 2001-2016

INTRODUCTION

The objectives of this study were to describe trends of children being given dental checkup advice by primary care providers (PCPs) and having dental visits and to assess factors associated with being given dental checkup advice and having a dental visit.

METHODS

Data were from the annual, cross-sectional Medical Expenditure Panel Survey (MEPS) from 2001 to 2016. The sample included 126,773 children ages 2-17 years. We used predictive margins to estimate the probability of being given dental checkup advice and having a dental visit. We examined time trends of the proportion of children being given dental checkup advice from PCPs, as well as trends in the proportion of children having a dental visit from 2001 to 2016. Multiple logistic regression was used to assess the association between being given dental checkup advice and having a dental visit.

RESULTS

Overall, the proportion of children being given dental checkup advice increased from 31.4% in 2001 to 51.8% in 2016 (Trend P < 0.001). No significant increasing trend was found for having a dental visit among those being given dental checkup advice (Trend P > 0.05). Children being given dental checkup advice were more likely to have a dental visit (AOR = 1.54, P < 0.001).

CONCLUSIONS

Although there was an increase in the proportion of children being given advice to have dental checkups by PCPs from 2001 to 2016, there was no significant increase in having a dental visit among children being given the advice. More research is needed to better understand how dental care advice from a PCP can effectively motivate and facilitate dental care for children.

Predictors of self-reported oral health in the Black Women's Health Study

OBJECTIVES

To describe the self-reported oral health of participants in the Black Women's Health Study (BWHS), a national cohort of 59,000 Black women, and to assess factors associated with this self-report.

METHODS

Annual follow-up of the BWHS cohort occurs via surveys. The 2011 questionnaire included oral health self-report items, on which 38,573 respondents had complete data. Sample characteristics were summarized using descriptive statistics. We assessed correlations with several covariates by estimating odds ratios using multivariable-adjusted logistic regression models.

RESULTS

Those who reported fair or poor oral health were more likely to report current smoking, recent tooth loss, diabetes or hypertension diagnoses, lower education levels, obesity, and higher parity. Few factors were related to self-reported gum disease with bone loss.

CONCLUSIONS

The oral health of US Black women is poorly understood. Correlates of oral health in the BWHS are largely consistent with what has been observed in other populations.

Challenges and Solutions for Improved Oral Health: Examples from Motivational Interviewing Trials

KNOWLEDGE TRANSFER STATEMENT

Irrespective of country, socially disadvantaged children experience greater levels of preventable dental disease than their more socially advantaged peers. Motivational interviewing (MI) is recognized as a potential intervention tool for reducing prevalence of child dental disease. The challenges of implementing MI in 4 trials involving socially vulnerable children are highlighted in this commentary, with some potential solutions offered.

A storytelling intervention reduces childhood caries risk behaviors among American Indian and Alaska Native mothers in Northern California

OBJECTIVES

To evaluate a storytelling intervention targeting the oral health beliefs, knowledge, and behaviors of AIAN pregnant women and mothers.

METHODS

Fifty-three adult AIAN women from three tribal communities in Northern California participated. The intervention story delivered oral health messaging using a traditional storytelling format. The effect of the intervention on self-reported oral health behaviors, dental knowledge, and beliefs was assessed using a pretest-posttest design, with an additional six-month follow-up. Tests of repeated measures using Generalized Linear Models were conducted to assess changes in oral health knowledge, beliefs, and behaviors.

RESULTS

Knowledge and beliefs significantly increased as a result of the intervention and persisted after six months. A consistent, significant increase in positive oral health behaviors from baseline to six-months was also observed.

CONCLUSIONS

The results of this intervention study suggest promise for traditional storytelling to increase oral health-related knowledge, beliefs, and behaviors among self-identified AIAN pregnant women and mothers.

Simulation study of misclassification bias in association studies employing partial-mouth protocols

AIM

To simulate the exposure misclassification bias potential in studies of perio-systemic disease associations due to the use of partial-mouth recording (PMR) protocols.

METHODS

Using data from 640 participants in the Dental Longitudinal Study, we evaluated distributions of clinical periodontitis parameters to simulate hypothetical outcome probabilities using bootstrap sampling. Logistic regression models were fit using the hypothetical outcome as the dependent variable. Models were run for exposure classifications based on full-mouth recording (FMR) and PMR protocols over 10,000 repetitions.

RESULTS

The impact of periodontitis exposure misclassification was dependent on periodontitis severity. Per cent relative bias for simulated ORs of size 1.5, 2 and 4 ranged from 0% to 30% for the effect of severe periodontitis. The magnitude and direction of the bias was dependent on the underlying distribution of the clinical parameters used in the simulation and the size of the association being estimated. Simulated effects of moderate periodontitis were consistently biased towards the null.

CONCLUSION

Exposure misclassification bias occurring through the use of PMR protocols may be dependent on the sensitivity of the classification system applied. Using the CDC-AAP case definition, bias in the estimated effects of severe disease was small, on average. Whereas effects of moderate disease were underestimated to a larger degree.

Using Storytelling to Address Oral Health Knowledge in American Indian and Alaska Native Communities

INTRODUCTION

We conducted a qualitative analysis to evaluate the acceptability of using storytelling as a way to communicate oral health messages regarding early childhood caries (ECC) prevention in the American Indian and Alaska Native (AIAN) population.

METHODS

A traditional story was developed and pilot tested among AIAN mothers residing in 3 tribal locations in northern California. Evaluations of the story content and acceptability followed a multistep process consisting of initial feedback from 4 key informants, a focus group of 7 AIAN mothers, and feedback from the Community Advisory Board. Upon story approval, 9 additional focus group sessions (N = 53 participants) were held with AIAN mothers following an oral telling of the story.

RESULTS

Participants reported that the story was culturally appropriate and used relatable characters. Messages about oral health were considered to be valuable. Concerns arose about the oral-only delivery of the story, story content, length, story messages that conflicted with normative community values, and the intent to target audiences. Feedback by focus group participants raised some doubts about the relevance and frequency of storytelling in AIAN communities today.

CONCLUSION

AIAN communities value the need for oral health messaging for community members. However, the acceptability of storytelling as a method for the messaging raises concerns, because the influence of modern technology and digital communications may weaken the acceptability of the oral tradition. Careful attention must be made to the delivery mode, content, and targeting with continual iterative feedback from community members to make these messages engaging, appropriate, relatable, and inclusive.

Oral Health Disparities Across the Life Span

Despite improvements in the oral health status of the US population as a whole, a disproportionately higher burden of oral diseases and disorders are borne by those individuals from low-income and racial and ethnic minority groups. These differences in health status, health outcomes, or health care use between distinct socially disadvantaged and advantaged groups are well documented and known as health disparities. It is vital that members of the dental profession understand the distribution of oral health and disease across different populations and the life span and participate in developing innovative and sustainable approaches to eliminate oral health disparities.

An Experimental Test of the Two-Dimensional Theory of Cultural Sensitivity in Health Communication

Based on a theoretical framework describing culturally sensitive (CS) health communication, this experiment tested the relative contributions of surface structure and deep structure in the recall of oral health information from pamphlets varied in written message and images. Using a 2 × 2 factorial design, Spanish-speaking Mexican heritage mothers of children under six (n = 160) were randomly assigned to read one of four 12-page pamphlets containing the same oral health information in Spanish: (1) standard written message/standard images; (2) standard written message/CS images; (3) CS written message/standard images; and (4) CS written message/CS images. Participants completed a 22-item oral health knowledge questionnaire before and after reading the pamphlet. Controlling for the effects of pretest scores, acculturation, and educational level on information recall, findings showed significant positive main effects for CS images (F(1, 152) = 5.03, p = .026, partial ŋ² = .032) and CS written message (F(1, 152) = 5.21, p = .024, partial ŋ² = .033). There was no interaction. These results support the two dimensions of CS and their independent effects. They should be applicable to a variety of health communication channels. Further research is needed to investigate the causal mechanism behind the observed effects.

Validity and reliability of a Turkish pediatric oral health-related quality of life measure

Purpose

This study aimed to develop Turkish measures for Pediatric Oral Health-related Quality of Life (POQL) and evaluate their reliability and validity for use in Turkish children aged 8–14 years (Child Self-Report measure; CSR) and their caregivers (Parent Report-on-Child measure; PRC).

Materials and methods

The English POQL was translated into Turkish, adapted for the Turkish culture, and tested in 149 children and their caregivers attending the Çukurova University Pediatric Dentistry clinics to assess the reliability, internal consistency, and discriminant and convergent validity of the Turkish version.

Results

The internal consistency of the Turkish POQL evaluated using Cronbach’s alpha was 0.905 for CSR and 0.887 for PRC. To determine the test–retest reliability, the Turkish POQL was administered to a sub-sample (n=16) a second time 2 weeks after the first survey administration. Intraclass correlation coefficient values of the individual items were 0.895 for CSR and 0.992 for PRC. For total scores, there was a significant difference based on clinical caries status and perceived oral health in both CSR and PRC.

Conclusion

The Turkish POQL is a valid and reliable measure of the perceived impact of oral conditions on children’s lives.

Oral health beliefs, knowledge, and behaviors in Northern California American Indian and Alaska Native mothers regarding early childhood caries

OBJECTIVES

To assess the oral health beliefs, knowledge, and behaviors related to early childhood caries (ECC) risk in a convenience sample of American Indian and Alaska Native (AIAN) mothers residing in rural Northern California communities.

METHODS

Fifty-three mothers of young children were recruited from three tribal communities in Northern California with the assistance of the California Rural Indian Health Board, Inc. and its California Tribal Epidemiology Center and Dental Support Center. Trained study staff administered questionnaires to obtain basic socio-demographic information, to survey participants on their oral health beliefs, knowledge, and behaviors as related to ECC risk, and to identify possible barriers to their accessing professional oral health care. Analyses of covariance were used to explore associations between socio-demographic indicators and oral health behaviors, after controlling for knowledge, beliefs and barriers to care.

RESULTS

Overall, 53 percent of participants reported their oral health as "fair" or "poor." Mothers' education (high) and being employed were positively associated with better oral health behavior scores. Additionally, 72 percent of mothers reported having one or more barriers to oral health care including access. There was a significant relation (P = 0.03) between high number of reported barriers to oral health care and low oral health behavior scores.

CONCLUSIONS

Despite generally high-level oral health knowledge, perceptions of self and child oral health remains low in this sample of AIAN mothers. Factors identified as being associated with oral health behaviors in this sample were similar to those found in other health disparities populations.

Healthy Futures: Engaging the oral health community in childhood obesity prevention - Conference summary and recommendations

Childhood obesity is a major public health problem. An association between obesity and dental caries, the most prevalent disease of childhood, has been identified. One explanation for the association is that consumption of sugar-sweetened beverages and frequent snacking on carbohydrate-rich foods are common risk factors for development of both obesity and caries. The Robert Wood Johnson Foundation (RWJF) has been at the forefront of national efforts to promote healthy weight in children. As part of these efforts, RWJF sponsored the Healthy Futures: Engaging the Oral Health Community in Childhood Obesity Prevention National Conference, held on November 3-4, 2016, at Georgetown University in Washington, DC. The aim of the conference was to increase awareness of evidence-based recommendations; identify strategies; and promote collaborative efforts that oral health professionals, oral-health-related organizations, and others can employ to prevent childhood obesity. This report summarizes the findings presented at the conference and discusses their implications. The report also reviews recommendations made in the areas of research, education, and policy that resulted from the conference.

A Clinical Validation of Self-Reported Periodontitis Among Participants in the Black Women's Health Study

BACKGROUND

There is a paucity of data on the validity of self-report of periodontal disease in African Americans. The Black Women's Health Study (BWHS), a United States national cohort study of 59,000 black women followed via mailed questionnaires since 1995, offered the opportunity to clinically validate self-reported periodontitis among a sample of participants.

METHODS

Oral health questionnaires were sent to study participants residing in Massachusetts. Respondents living in the Boston metro area were invited for clinical examination. Self-reports were compared with clinical data obtained from the 77 women (mean age: 59 years) who were examined. The authors examined the predictive ability of individual and combined questionnaire items with respect to clinical periodontal disease severity. Validation parameters were calculated for each question, and receiver operating characteristic statistics were generated to compare questionnaire items.

RESULTS

Periodontitis prevalence in the validation sample was 24% for severe periodontitis and 61% for moderate disease. Performance of individual questionnaire items with respect to predicting periodontitis was better for severe compared with moderate disease. Combinations of questionnaire items improved the predictive ability with respect to severe disease beyond that of individual questionnaire items.

CONCLUSIONS

Prevalence of severe periodontitis was similar to other age-comparable populations, without regard for race or sex, whereas prevalence of total periodontitis (moderate and severe) among women of similar age and/or race was much higher. Predictive ability of questionnaire items assessed in the BWHS was similar to that in other studies.

The basic research factors questionnaire for studying early childhood caries

BACKGROUND

We describe development of the Early Childhood Caries (ECC) Basic Research Factors Questionnaire (BRFQ), a battery of measures assessing common potential predictors, mediators, and moderators of ECC. Individual-, family-, and community-level factors that are linked to oral health outcomes across at-risk populations are included. Developing standard measures of factors implicated in ECC has the potential to enhance our ability to understand mechanisms underlying successful prevention and to develop more effective interventions.

METHODS

The Early Childhood Caries Collaborating Centers (EC4), funded by National Institute of Dental and Craniofacial Research, developed the BRFQ, which was used across four randomized trials to develop and test interventions for reducing ECC in at-risk populations. Forty-five investigators from across the centers and NIDCR were involved in the development process. Eight "measures working groups" identified relevant constructs and effective measurement approaches, which were then categorized as "essential" or "optional" common data elements (CDEs) for the EC4 projects.

RESULTS

Essential CDEs include 88 items, with an additional 177 measures categorized as optional CDEs. Essential CDEs fell under the following domains: oral health knowledge, oral health behavior, utilization/insurance and cost, parent/caregiver dental self-efficacy, quality of life, caregiver and family characteristics, and child characteristics.

CONCLUSIONS

The BRFQ makes available a battery of measures that support efforts to understand population risk factors for ECC and to compare oral health outcomes across populations at risk. The BRFQ development process may be useful to other clinical research networks and consortia developing CDEs in other health research fields.

TRIAL REGISTRATION

All the trial that used the BRFQ were registered at Clinicaltrial.gov NCT01116726 , April 29, 2010; NCT01116739 , May 3, 2010; NCT01129440 , May 21, 2010; and NCT01205971 , September 19, 2010.

Absence of Fluoride Varnish-Related Adverse Events in Caries Prevention Trials in Young Children, United States

Introduction

Fluoride varnish is an effective prevention intervention for caries in young children. Its routine use in clinical care is supported by meta-analyses and recommended by clinical guidelines, including the US Preventive Services Task Force (B rating). This report is the first prospective systematic assessment of adverse events related to fluoride varnish treatment in young children.

Methods

We determined the incidence of adverse events related to fluoride varnish treatment in 3 clinical trials on the prevention of early childhood caries, conducted under the auspices of the Early Childhood Caries Collaborating Centers, an initiative sponsored by the National Institute of Dental and Craniofacial Research. Each trial incorporated use of fluoride varnish in its protocol and systematically queried all children’s parents or legal guardians about the occurrence of acute adverse events after each fluoride varnish treatment.

Results

A total of 2,424 community-dwelling, dentate children aged 0 to 5 years were enrolled and followed for up to 3 years. These children received a cumulative total of 10,249 fluoride varnish treatments. On average, each child received 4.2 fluoride varnish treatments. We found zero fluoride varnish–related adverse events.

Conclusion

Fluoride varnish was not associated with treatment-related adverse events in young children. Our findings support its safety as an effective prevention intervention for caries in young children.

Impact of Wisconsin Medicaid Policy Change on Dental Sealant Utilization

BACKGROUND

In September 2006, Wisconsin Medicaid changed its policy to allow nondentists to become certified Medicaid providers and to bill for sealants in public health settings.

OBJECTIVE

This study examined changes in patterns of dental sealant utilization in first molars of Wisconsin Medicaid enrollees associated with a policy change.

DATA SOURCE

The Electronic Data Systems of Medicaid Evaluation and Decision Support for Wisconsin from 2001 to 2009.

STUDY DESIGN

Retrospective claims data analysis of Wisconsin Dental Medicaid for children aged 6-16 years.

PRINCIPAL FINDINGS

A total of 479,847 children followed up for 1,441,300 person-years with 64,546 visits were analyzed. The rate of visits for sealants by dentists increased significantly from 3 percent per year prepolicy to 11 percent per year postpolicy, and that of nondentists increased from 18 percent per year to 20 percent after the policy change, but this was not significant. Non-Hispanic blacks had the lowest visit rates for sealant application by dentists and nondentists pre- and postpolicy periods.

CONCLUSIONS

The Wisconsin Medicaid policy change was associated with increased rates of visits for dental sealant placement by dentists. The rate of visits with sealant placements by nondentists increased at the same rate pre- and postpolicy change.

Retention strategies for health disparities preventive trials: findings from the Early Childhood Caries Collaborating Centers

OBJECTIVES

To identify successful strategies for retention of participants in multiyear, community-based randomized controlled trials (RCTs) aiming to reduce early childhood caries in health disparities populations from diverse racial/ethnic backgrounds and across diverse geographic settings.

METHODS

Four RCTs conducted by the Early Childhood Caries Collaborating Centers (EC4), an initiative of the National Institute of Dental and Craniofacial Research, systematically collected information on the success of various strategies implemented to promote participant retention in each RCT. The observational findings from this case series of four RCTs were tabulated and the strategies rated by study staff.

RESULTS

Participant retention at 12 months of follow-up ranged from 52.8 percent to 91.7 percent, and at 24 months ranged from 53.6 percent to 85.9, across the four RCTs. For the three RCTs that had a 36-month follow-up, retention ranged from 53.6 percent to 85.1 percent. Effectiveness of different participant retention strategies varied widely across the RCTs.

CONCLUSIONS

Findings from this case series study may help to guide the design of future RCTs to maximize retention of study participants and yield needed data on effective interventions to reduce oral health disparities.

Development of the Teen Oral Health-Related Quality of Life Instrument

OBJECTIVE

The aim of this study was to develop the Teen Oral Health-Related Quality of Life instrument (TOQOL) and demonstrate its validity and reliability in a diverse sample of 13-18-year-old adolescents.

METHODS

A total of 363 adolescents aged 13-18 years participated in this cross sectional study. Oral screening examinations were conducted to collect oral health status data. Adolescents completed the TOQOL and a generic measure of health-related quality of life, the PedsQL. The psychometric properties of the TOQOL were evaluated in terms of face, content, convergent, concurrent and discriminant validity in addition to internal reliability.

RESULTS

The 16-item TOQOL covers five domains: Physical functioning, Role functioning, Social functioning, Oral problems, and Emotional functioning. The total scale and subscales showed satisfactory reliability with Cronbach alpha ranging from 0.75 to 0.92. TOQOL scores showed significant associations with perceived oral health status and the PedsQL (convergent validity) and discriminated well between adolescents with caries and adolescents who were caries free (discriminate validity).

CONCLUSION

The TOQOL is a valid and reliable oral health-related quality of life measurement that can be recommended for self-report in adolescents aged 13-18 years.

Integration of Oral Health Into the Well-Child Visit at Federally Qualified Health Centers: Study of 6 Clinics, August 2014-March 2015

INTRODUCTION

Early childhood caries, the most common chronic childhood disease, affects primary dentition and can impair eating, sleeping, and school performance. The disease is most prevalent among vulnerable populations with limited access to pediatric dental services. These same children generally receive well-child care at federally qualified health centers. The objective of this study was to identify facilitators and barriers to the integration of oral health into pediatric primary care at health centers to improve problem recognition, delivery of preventive measures, and referral to a dentist.

METHODS

We collected and analyzed background data and data from structured observations and 39 interviews with administrators and staff at 6 clinics in 2 states, Maryland and Massachusetts.

RESULTS

Participants valued oral health across professional roles but cited limited time, lack of training and expertise, low caregiver literacy, and lack of shared medical and dental electronic records as barriers to cooperation. Facilitators included an upper-level administration with the vision to see the value of integration, designated team leaders, and champions. An administration's vision, not structural determinants, patient characteristics, or geographic location, predicted the level of integration. Interviewees generated multilevel recommendations to promote delivery of oral health preventive measures and services during a well-child visit.

CONCLUSION

Poor oral health contributes to health care disparities. Barriers to integrating dental care into pediatric medical practice at health centers must be overcome to improve oral health for children living in poverty, with a disability, at a rural address, or any combination of these. Implementation will require adapting delivery systems to support multidisciplinary collaboration. Strategies suggested here may point the way to enhancing children's oral health.

Metabolic Syndrome and Periodontal Disease Progression in Men

Metabolic syndrome, a cluster of 3 or more risk factors for cardiovascular disease, is associated with periodontal disease, but few studies have been prospective in design. This study's aim was to determine whether metabolic syndrome predicts tooth loss and worsening of periodontal disease in a cohort of 760 men in the Department of Veterans Affairs Dental Longitudinal Study and Normative Aging Study who were followed up to 33 y from 1981 to 2013. Systolic and diastolic blood pressures were measured with a standard mercury sphygmomanometer. Waist circumference was measured in units of 0.1 cm following a normal expiration. Fasting blood samples were measured in duplicate for glucose, triglyceride, and high-density lipoprotein. Calibrated periodontists served as dental examiners. Periodontal outcome events on each tooth were defined as progression to predefined threshold levels of probing pocket depth (≥5 mm), clinical attachment loss (≥5 mm), mobility (≥0.5 mm), and alveolar bone loss (≥40% of the distance from the cementoenamel junction to the root apex, on radiographs). Hazards ratios (95% confidence intervals) of tooth loss or a periodontitis event were estimated from tooth-level extended Cox proportional hazards regression models that accounted for clustering of teeth within individuals and used time-dependent status of metabolic syndrome. Covariates included age, education, smoking status, plaque level, and initial level of the appropriate periodontal disease measure. Metabolic syndrome as defined by the International Diabetes Federation increased the hazards of tooth loss (1.39; 1.08 to 1.79), pocket depth ≥5 mm (1.37; 1.14 to 1.65), clinical attachment loss ≥5 mm (1.19; 1.00 to 1.41), alveolar bone loss ≥40% (1.25; 1.00 to 1.56), and tooth mobility ≥0.5 mm (1.43; 1.07 to 1.89). The number of positive metabolic syndrome conditions was also associated with each of these outcomes. These findings suggest that the metabolic disturbances that comprise the metabolic syndrome may play a role in the development or worsening of periodontitis.

Examination criteria and calibration procedures for prevention trials of the Early Childhood Caries Collaborating Centers

OBJECTIVES

To summarize diagnostic criteria and examiner training and calibration of the National Institute of Dental and Craniofacial Research-funded Early Childhood Caries Collaborating Centers (EC4) and report examiner calibration results from 2010 to 2014. The EC4 at Boston University, University of Colorado, and University of California San Francisco are performing randomized controlled early childhood caries (ECC) prevention trials with caries as the main outcome measure.

METHODS

The EC4 with University of Iowa consultants developed standardized tooth and tooth surface status examination criteria for use in field conditions, examiner training materials, and examiner calibration and re-calibration methodologies. Calibration and re-calibration were performed with 1- to 5-year-old children in the San Francisco Mission District in which assessments from each examiner to be calibrated were compared with those from a single gold standard examiner from 2010 to 2014. Cohen's kappa statistic was used to determine inter-examiner agreement.

RESULTS

A total of seven examiners were successfully (re)calibrated during that period, examining a total of 231 children. Overall unweighted Cohen's kappas for 10 surface conditions exceeded the criterion of 0.70. However, separate agreement for assessment of noncavitated lesions, as in other studies, was lower.

CONCLUSIONS

An experienced multidisciplinary and multi-institutional team was able to develop criteria and training materials to anticipate situations and field conditions the main trials would encounter. Examiners were successfully trained and (re)calibrated.

Dental service utilization and neighborhood characteristics in young adults in the United States: a multilevel approach

OBJECTIVE

To investigate the association between neighborhood level factors and dental visits in young adults in the United States after adjusting for individual level factors.

METHODS

The National Longitudinal Study of Adolescent Health Wave 1 (1994-1995) to Wave III (2001-2002) was analyzed. The primary outcome of having had at least one dental visit in the previous 12 months was analyzed via a multilevel random-effects logistic model accounting for geographic clustering in Wave III and survey design clustering from Wave I. Neighborhood level covariates were defined at the census tract level.

RESULTS

Overall rate of dental visits was 57 percent, highest among 18-20 year olds (65 percent) and lowest in 23-26 year olds (52 percent). Increased proportion of African-Americans (≤5 percent to ≥20 percent) and Hispanics (≤5 percent to ≥20 percent) in a neighborhood corresponded with a decrease in dental visits (60 percent versus 52 percent) and (58 percent versus 51 percent), respectively. Neighborhoods with a high proportion of college-educated residents had a higher percentage of dental visits. Similar differences were found when comparing the lowest and highest tertiles defined by poverty level and unemployment with dental visits. Neighborhood education was significantly associated with dental service utilization after adjustment for individual level factors and dental utilization in adolescence (Waves I and II) in the random effects model.

CONCLUSIONS

This study demonstrates that the education level of residents within a neighborhood was associated with dental service utilization in young adults in the United States.

Recruitment for health disparities preventive intervention trials: the early childhood caries collaborating centers

BACKGROUND

Four trials of interventions designed to prevent early childhood caries are using community-engagement strategies to improve recruitment of low-income, racial/ethnic minority participants. The trials are being implemented by 3 centers funded by the National Institute of Dental and Craniofacial Research and known as the Early Childhood Caries Collaborating Centers (EC4): the Center for Native Oral Health Research at the University of Colorado, the Center to Address Disparities in Children's Oral Health at the University of California San Francisco, and the Center for Research to Evaluate and Eliminate Dental Disparities at Boston University.

COMMUNITY CONTEXT

The community contexts for the EC4 trials include urban public housing developments, Hispanic communities near the US-Mexican border, and rural American Indian reservations. These communities have a high prevalence of early childhood caries, suggesting the need for effective, culturally acceptable interventions.

METHODS

Each center's intervention(s) used community-based participatory research approaches, identified community partners, engaged the community through various means, and developed communication strategies to enhance recruitment.

OUTCOME

All 3 centers have completed recruitment. Each center implemented several new strategies and approaches to enhance recruitment efforts, such as introducing new communication techniques, using media such as radio and newspapers to spread awareness about the studies, and hosting community gatherings.

INTERPRETATION

Using multiple strategies that build trust in the community, are sensitive to cultural norms, and are adaptable to the community environment can enhance recruitment in underserved communities.

The influence of prevalent cohort bias in the association between periodontal disease progression and incident coronary heart disease

PURPOSE

In longitudinal studies, the onset of the index condition (e.g. exposure) does not always coincide with the start of a study's observation period, leading to the possibility of bias in estimation that derives from studying prevalent exposure rather than new exposure. We investigate the possible role of this bias in the relationship between periodontitis progression and coronary heart disease (CHD) among a cohort of men participating in the Veterans Administration Dental Longitudinal Study.

METHODS

At baseline, there were 298 men with existing (i.e., prevalent) periodontitis. During follow-up, routine dental inspection identified 163 new (i.e., incident) cases of periodontitis. Change in mean alveolar bone loss score (MBLS) served as the measure of disease progression. Tabular analyses were performed to obtain crude, stratified, and adjusted measures of the association for periodontitis cases overall and separately for prevalent and incident cases. Potential bias was evaluated by comparing estimates across these subcohorts.

RESULTS

Among all periodontitis cases, increasing MBLS was associated with increasing risk of CHD event. Subdividing periodontal cases into new and prevalent cases revealed that the relationship was most pronounced among incident periodontitis cases (incident rate ratio for MBLS change >0.5 = 5.4), compared with prevalent cases (incident rate ratio for MBLS change >0.5 = 2.5).

CONCLUSIONS

Studying prevalent cases of periodontitis underestimates the association between incidence periodontitis and CHD.

Health disparities and the multicultural imperative

Providing culturally and linguistically appropriate care is a crucial step toward the elimination of oral health disparities in the United States.

BACKGROUND

Health disparities, coupled with rapidly changing demographic trends, continue to plague healthcare, the health care workforce and population health. Consequently, there is still more work indicated to ensure individuals, regardless of race or ethnicity, receive quality health care at an affordable price. The purpose of this paper is to increase the awareness of oral health care practitioners about the causes and consequences of oral health disparities and to highlight promising strategies aimed at improving effective communication between health care providers and the patients they serve.

METHODS

A narrative utilizing key publications will explain the concept of the multicultural imperative, and its direct relationship to the elimination of health disparities including oral health disparities.

CONCLUSIONS

It is essential that oral health professionals strive to become culturally and linguistically proficient in communicating with and caring for all our patients. Members of professional organizations and academic institutions can also work to ensure that both students and current practitioners have access to a curriculum and continuing education with the intended outcome of increased cultural proficiency.