Trends in dental caries in children and adolescents according to poverty status in the United States from 1999 through 2004 and from 2011 through 2014

Pandemic-driven shift: increase in silver diamine fluoride utilization among Medicaid-enrolled children during the COVID-19 public health emergency

Introduction

Untreated dental caries remains a significant public health issue, particularly among children and adolescents from low-income families, where disparities persist. The COVID-19 public health emergency (PHE) changed dental care practices, leading to an increased focus on minimally aerosolizing treatments such as silver diamine fluoride (SDF). This study aimed to describe the temporal changes in SDF utilization among Medicaid-enrolled children across the United States before and during the first half of the COVID-19 PHE. Additionally, the study examined the impact of demographics and state-level policies on SDF utilization.

Methods

We conducted a multiyear cross-sectional study using enrollment and claims data from the Transformed Medicaid Statistical Information System (T-MSIS) for 2019, 2020, and 2021. The study population included Medicaid and Children's Health Insurance Program (CHIP) beneficiaries aged <21 years. We analyzed SDF utilization rates and compared them with other dental services, stratifying the data by age, sex, race/ethnicity, and rurality. Multilevel logistic regression models were used to identify significant predictors of SDF utilization.

Results

The study included approximately 39 million children each year. SDF utilization per 1,000 enrollees increased from 9.10 in 2019 to 16.81 in 2021, with the most significant increases observed in children aged 0-6 years, those living in rural areas, and American Indian/Alaskan Native children. The state-level reimbursement policy for SDF was the most significant predictor, with children in states with such policies being 10.5 times more likely to receive SDF treatment.

Conclusion

The COVID-19 PHE significantly impacted SDF utilization among Medicaid-enrolled children, highlighting the importance of state-level policies. The findings can be used to develop targeted approaches for clinicians to improve access to SDF treatment to address oral health disparities.

Secondary Smoking and Early Childhood Caries: A Systematic Review and Meta-Analysis

OBJECTIVE

This study aimed to systematically review the relationship between secondary smoking and early childhood caries (ECC) among preschool children.

METHOD

Two independent reviewers systematically searched English publications with keywords in PubMed, Web of Science, Medline, Scopus, and Embase to identify publications reporting on secondary smoking and ECC for children under 71 months. Observational studies, including cohort studies, case-control studies, and cross-sectional surveys, were included. The reviewers screened the titles and abstracts to remove duplicate records, reviews, and irrelevant studies. They performed meta-analyses to investigate the prevalence of ECC in children exposed to secondary smoking.

RESULTS

This study identified 1243 publications and included 16 publications. Twelve publications were cross-sectional studies. A meta-analysis of 11 of them revealed that children with secondary smoking exposure had an odds ratio of 1.77 in caries risk (P < .001), whereas one cross-sectional study found no increase in caries risk without data reporting. Two cohort studies with low and very low quality were combined into a meta-analysis, which found children from infancy with secondary smoking exposure had a relative risk of 1.45 in caries incidence (P < .001). Two case-control studies with moderate and low quality were combined into a meta-analysis, which found that children exposed to secondary smoking had an odds ratio of 4.46 in caries prevalence (P < .001).

CONCLUSION

The literature has reported that preschool children with secondary smoking exposure have a higher risk of caries; however, the number and quality of these studies are limited.

Unravelling the Relationship: Oral Protozoans, Periodontitis and Systemic Non-Communicable Diseases

Oral protozoans, specifically Entamoeba gingivalis and Trichomonas tenax, have been identified in the oral cavity of individuals with periodontitis, frequently known as gum disease. Periodontitis is characterised by inflammation and degradation of the periodontal tissues and has been associated with the aggravation of systemic noncommunicable diseases. Although the importance of oral protozoans in periodontitis progression is often overlooked, their occurrence in individuals with periodontitis has reportedly been linked to the same modifiable risk factors contributing to numerous systemic noncommunicable diseases (NCDs). This article aims to provide a comprehensive overview of the occurrence patterns and potential connections among oral protozoans, periodontitis, and systemic NCDs while presenting the existing methods for the detection and identification of E. gingivalis and T. tenax.

Bridging oral health and nutrition: Assessing produce prescription programs in pediatric dental clinics serving low-income communities

OBJECTIVES

This study assesses the needs and feasibility of conducting a produce prescription (produce Rx) program in a pediatric dental clinic setting serving low-income patients.

METHODS

We conducted a cross-sectional quantitative survey examining several household characteristics including demographics, benefits received, fruit and vegetable intake patterns, food security, feasibility of a produce Rx program, and respondents' answers to questions based on social cognitive theory constructs. The survey was administered at the University of Nebraska Medical Center (UNMC) pediatric dental clinic, a pediatric dental residency clinical training site. One hundred adult respondents with low income completed a 36-item questionnaire during their child's dental appointment.

RESULTS

Almost half of respondents reported experiencing food insecurity (45%). Respondents who were food insecure experienced higher levels of nutrition insecurity (p = 0.012), less confidence in choosing fruits and vegetables (FVs) (p = 0.026), difficulty in purchasing FVs in their neighborhood (p = 0.012), and more concern that FVs cost too much (p < 0.001) when compared to respondents who were food secure. Notwithstanding the barriers they face, almost all respondents reported that they eat FVs because of health benefits (95%) and to set a good example for their family (91%). Additionally, most respondents expressed an interest in produce Rx programs (80%) and nutrition education activities (81%).

CONCLUSIONS

This study demonstrated the potential for produce Rx program uptake in a pediatric dental clinic setting through positive caregiver-reported need and interest. Future studies should explore how produce Rx programs can be adapted most effectively in this novel setting.

Dental Caries and Preventive Dental Visits Among Children in the U.S.: The Impact of Race/Ethnicity and Immigration

Introduction

National data on dental caries and dental service use among immigrant children in U.S. are limited. It is not known whether race/ethnicity would interact with immigration status to increase these disparities. Using a nationally representative sample, this study assessed the interaction effects of immigrant generation status and race/ethnicity on dental caries and dental visits among children in the U.S.

Methods

Data were from the 2020 and 2021 National Survey of Children's Health. All data were self-reported by parents/guardians. The 2 outcomes were (1) dental caries (yes/no) in the past 12 months and (2) preventive dental visits (yes/no) in the past 12 months. Racial/ethnic groups included non-Hispanic White, Black, Hispanics, and Asian Americans. The analytical sample included 66,167 children aged 2-17 years, including 1,243 first-generation immigrant children; 11,017 second-generation immigrant children; and 53,907 nonimmigrant children. Study authors ran separate multiple logistic regression models for the 2 outcome variables. All analyses accounted for the survey design of National Survey of Children's Health.

Results

First-generation immigrant children were more likely to have dental caries than nonimmigrant children (AOR=1.44). The interaction of race/ethnicity and immigrant generation status was significant (p=0.04) in the preventive dental visits model, indicating increased challenges in getting dental visits among minority immigrant children in comparison with that among non-Hispanic White immigrant children, especially among first-generation immigrant children of Asian Americans (AOR=0.41) and non-Hispanic Black immigrant children (AOR=0.37).

Conclusions

First-generation immigrant children were less likely to see a dentist and more likely to have dental caries than nonimmigrants. Moreover, first-generation immigrant children from minority racial/ethnic groups were the least likely to seek dental services. To further reduce disparities in oral health and dental use among children in the U.S., culturally sensitive health promotion is warranted to improve oral health literacy and reduce barriers to dental care for immigrants, especially immigrant children of the minority groups.

Association between flavonoids intake and dental caries in children and adolescents: a cross-sectional study from the NHANES database

BACKGROUND

Worldwide, dental caries is a bacterial biofilm-mediated condition with a high morbidity in children and adolescents. Flavonoids are a class of active natural products with antibacterial and anti-inflammatory effect. In vivo and in vitro studies have shown that they can promote tooth mineralization and reduce inflammation. However, the association of flavonoids intake and dental caries in children and adolescents remain unclear.

AIM

This study was to evaluated the association of flavonoid and its subclass intake and dental caries in children and adolescents.

METHODS

Data of participants aged 2-17 years were extracted from the National Health and Nutrition Examination Survey (NHANES) database (2017-2018). Dental caries was measured via the decayed or filled surfaces in primary teeth or permanent teeth (dfs/DFS) index. The weighted univariable and multivariable logistic regression models were utilized to explore the association of flavonoids intake with dental caries in children and adolescents, with odds ratios (ORs) with 95% confidence intervals (CIs). Subgroups analyses based on age, and overweight/obesity were further assessed the association. Subgroup analysis were further performed to explore whether the association between subclasses of anthocyanidins and catechins with dental caries was robust stratified by age and individual with overweight/obesity.

RESULTS

Among totally 1,818 children and adolescents, 786 (43.2%) had dental caries. High intake of anthocyanidins (OR=0.69, 95%CI: 0.52-0.92) and catechins (OR=0.64, 95%CI: 0.44-0.92) were associated with lower odds of dental caries. Similar results were discovered in individuals aged ≥6 years (anthocyanidins, OR=0.62, 95%CI: 0.43-0.90; catechins, OR=0.62, 95%CI: 0.40-0.96), and without overweight/obesity (anthocyanidins, OR=0.58, 95%CI: 0.37-0.90; catechins, OR=0.51, 95%CI: 0.31-0.84). Further investigation found that high intake of cyanidin, petunidin, malvidin, peonidin, (+)-Catechin, (-)-Epigallocatechin, and (-)-epicatechin were associated with lower odds of dental caries in children and adolescents.

CONCLUSION

High intake of anthocyanidins and catechins were associated with lower odds of dental caries in children and adolescents and are a promising intervention to be further explored in children and adolescents.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT03385629.

The Longitudinal Reciprocal Relationships of Tooth Brushing Behaviors Between Underserved Children and Their Caregivers

BACKGROUND

Tooth brushing is effective in preventing early childhood caries. However, it is unclear how children's and caregiver's tooth brushing are reciprocally related.

PURPOSE

The current study investigated whether the longitudinal relationships between children and caregiver tooth brushing are moderated by a caregiver-targeted child oral health intervention and caregiver depression.

METHODS

Secondary analysis of a randomized clinical trial that tested whether caregiver-targeted oral health text messages (OHT) outperformed child wellness text messages (CWT) on pediatric dental caries and oral health behaviors (n = 754, mean child age = 2.9 years, 56.2% Black, 68.3%

RESULTS

Within-participants analyses revealed that caregiver tooth brushing at Months 4 and 12 positively predicted their child's tooth brushing at Months 12 and 24 for caregivers in the OHT condition with low depressive symptoms (i.e., moderation by depressive symptoms and condition). Similarly, children's tooth brushing at Month 4 positively predicted caregiver tooth brushing at Month 12 for caregivers in the OHT condition with low depressive symptoms. There were no significant associations among participants in the CWT condition, regardless of depressive symptoms.

CONCLUSIONS

Child and caregiver tooth brushing have reciprocal influences, but only for those in the OHT condition with low depressive symptoms.

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Key Words

• Child health
• Depressive symptoms
• Family health
• Oral health

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MESH Headings

• Child
• Humans
• Child, Preschool
• Toothbrushing
• Caregivers
• Dental Caries
• Oral Health
• Child Health

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Grants

• UH3DE025492 National Institute for Dental and Craniofacial Research

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Affiliation(s)

Romano Endrighi Center for Behavioral Science Research, Department of Health Policy & Health Services Research, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
Michelle Henshaw Office of Global & Population Health and Department of Health Policy & Health Services Research, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
William G Adams Department of Pediatrics, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
Erin Montion Center for Behavioral Science Research, Department of Health Policy & Health Services Research, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
Hannah Park Center for Behavioral Science Research, Department of Health Policy & Health Services Research, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
Belinda Borrelli Center for Behavioral Science Research, Department of Health Policy & Health Services Research, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA

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Psychosocial Risk Exposure Limits Routine Pediatric Oral Health Care

Introduction

This study aimed to identify social, psychological, and contextual factors that influenced attendance at routine oral health visits in a cohort of 189 preschool children who were followed over a 2-year period.

Methods

Generalized estimating equation was used to examine the association between clinic attendance and the predictors. ORs and 95% CIs were reported in the multiple logistic regression models. The study was conducted in Rochester, New York, between February 2016 and February 2021.

Results

Prior to the COVID-19 pandemic declaration, the rate of canceled and no-show appointments was greater for routine clinic visits (20% and 24%, respectively) than for research visits (14% and 9%, respectively) for the same participants; these rates increased during the pandemic. After adjusting for sociodemographic factors, the likelihood of a canceled or no-show appointment was associated with parental depression (OR=1.06, CI=1.03, 1.09), regardless of the type or occurrence of the visit.

Conclusions

Findings from this study demonstrate that attendance to oral health care in young children is reliably reduced with parental depression and that this may provide one mechanism for early emerging health inequalities of oral health.

Combined effect of dietary calcium consumption and physical activity on dental caries in children and adolescents: a study of the NHANES database

BACKGROUND

Calcium (Ca) is a nutritional factor that associated with dental caries. A recent study showed that in the case of adequate Ca intake, a higher level of physical activity may contribute to bone mass accumulation. However, the combined effect between Ca intake and physical activity on caries experience is unclear. Herein, we aimed to explore the above combined effect on dental caries in children and adolescents.

METHODS

Data of 5,917 children and adolescents were extracted from the National Health and Nutrition Examination Surveys (NHANES) database in 2015-2020 in this cross-sectional study. The NHANES assessed the dietary Ca intake through the 24-hour dietary recalls, and the physical activity level was self-reported using the questionnaires. Also, the dental caries was diagnosed according to the Decayed, Missing and Filled Teeth/Surfaces (DMFT/S) index. Weighted univariate and multivariate logistic regression analyses were utilized to screen the covariates and to investigate the associations of dietary Ca intake and physical activity with dental caries, respectively, and assess the combined effect between dietary Ca intake and physical activity on dental caries. The evaluation indexes were odd ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses of age, obesity, and total sugar intake were also performed.

RESULTS

Among the eligible participants, 2,687 had caries experience. After adjusting for the covariates, we found that children and adolescents who not reach the recommendation level of Ca intake combined with physical activity less than 7 time in 1 week seemed to have higher odds of dental caries [OR = 1.77, 95%CI: (1.38-2.27)], compared with those who reached the standards. In addition, this potential combined effect was also found in age < 12 years old [OR = 1.62, 95%CI: (1.23-2.14)], non-obesity [OR = 1.88, 95%CI: (1.49-2.35)], and total sugar intake (all P < 0.05) subgroups.

CONCLUSIONS

Ca intake and physical activity had a potential combined effect on dental caries in children and adolescents, but the causal relationships between them needed further clarification.

Systems mapping of multilevel factors contributing to dental caries in adolescents

Dental caries is a prevalent chronic disease among adolescents. Caries activity increases significantly during adolescence due to an increase in susceptible tooth surfaces, immature permanent tooth enamel, independence in pursuing self-care, and a tendency toward poor diet and oral hygiene. Dental caries in permanent teeth is more prevalent among adolescents in low-income families and racial/ethnic minority groups, and these disparities in adolescent dental caries experience have persisted for decades. Several conceptual and data-driven models have proposed unidirectional mechanisms that contribute to the extant disparities in adolescent dental caries experience. Our objective, using a literature review, is to provide an overview of risk factors contributing to adolescent dental caries. Specifically, we map the interactive relationships of multilevel factors that influence dental caries among adolescents. Such interactive multilevel relationships more closely reflect the complex nature of dental caries experience among the adolescent population. The methods that we use are two-fold: (1) a literature review using PubMed and Cochrane databases to find contributing factors; and (2) the system dynamics approach for mapping feedback mechanisms underlying adolescent dental caries through causal loop diagramming. The results of this study, based on the review of 138 articles, identified individual, family and community-level factors and their interactions contributing to dental caries experience in adolescents. Our results also provide hypotheses about the mechanisms underlying persistence of dental caries among adolescents.

Conclusions

Our findings may contribute to a deeper understanding of the multilevel and interconnected factors that shape the persistence of dental caries experience among adolescents.

The Evolving Microbiome of Dental Caries

Dental caries is a significant oral and public health problem worldwide, especially in low-income populations. The risk of dental caries increases with frequent intake of dietary carbohydrates, including sugars, leading to increased acidity and disruption of the symbiotic diverse and complex microbial community of health. Excess acid production leads to a dysbiotic shift in the bacterial biofilm composition, demineralization of tooth structure, and cavities. Highly acidic and acid-tolerant species associated with caries include Streptococcus mutans, Lactobacillus, Actinomyces, Bifidobacterium, and Scardovia species. The differences in microbiotas depend on tooth site, extent of carious lesions, and rate of disease progression. Metagenomics and metatranscriptomics not only reveal the structure and genetic potential of the caries-associated microbiome, but, more importantly, capture the genetic makeup of the metabolically active microbiome in lesion sites. Due to its multifactorial nature, caries has been difficult to prevent. The use of topical fluoride has had a significant impact on reducing caries in clinical settings, but the approach is costly; the results are less sustainable for high-caries-risk individuals, especially children. Developing treatment regimens that specifically target S. mutans and other acidogenic bacteria, such as using nanoparticles, show promise in altering the cariogenic microbiome, thereby combatting the disease.

Household, dietary, and clinical characteristics of childhood caries and overweight progression-A prospective cohort study

BACKGROUND

Childhood caries and obesity are complex chronic diseases with negative health outcomes.

AIM

This study sought a risk profile for childhood caries and overweight.

DESIGN

Children were recruited into a longitudinal prospective cohort study. Caries and overweight characteristics were obtained at baseline, 6, 12, and 18 months. Sequential data modeling steps determined a disease risk profile.

RESULTS

At baseline, 50% of the children (n = 194, 3.0 to 6.9 years) had caries; 24% were overweight, of whom 50% had caries. Correlation analysis separated child characteristics from household circumstances. Principal component modeling separated child snacking from meal-eating patterns, and household smoking from parent education variables. Baseline caries and overweight were not associated, but they grouped together in the modeling of composite features. Forty-five percent of children showed caries progression, 29% overweight progression, and 10% progression of both diseases. The strongest predictors of progression were disease presence, household-based characteristics, and sugary drinks. Children with caries and overweight progression shared multiple child- and household-based features.

CONCLUSION

Individually, caries and overweight were not associated. Children with progression of both conditions shared a profile and multiple risk characteristics suggesting these findings could be useful in assessing the risk for the most extreme cases of caries and overweight.

Screening and Preventive Interventions for Oral Health in Children and Adolescents Aged 5 to 17 Years: US Preventive Services Task Force Recommendation Statement

Importance

Oral health is fundamental to health and well-being across the lifespan. Oral health conditions affect the daily lives of school-age children and adolescents, leading to loss of more than 51 million school hours every year. Untreated oral health conditions in children can lead to serious infections and affect growth, development, and quality of life.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate screening and preventive interventions for oral health conditions in children and adolescents aged 5 to 17 years.

Population

Asymptomatic children and adolescents aged 5 to 17 years.

Evidence Assessment

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral health conditions (eg, dental caries) performed by primary care clinicians in asymptomatic children and adolescents aged 5 to 17 years. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions for oral health conditions (eg, dental caries) performed by primary care clinicians in asymptomatic children and adolescents aged 5 to 17 years.

Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening performed by primary care clinicians for oral health conditions, including dental caries, in children and adolescents aged 5 to 17 years. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions performed by primary care clinicians for oral health conditions, including dental caries, in children and adolescents aged 5 to 17 years. (I statement).

The Patient Protection and Affordable Care Act and Pediatric Medical Clinicians' Application of Fluoride Varnish

Importance

Fluoride varnish reduces children's tooth decay, yet few clinicians provide it. Most state Medicaid programs have covered this service during medical visits for children aged 1 to 5 years, but private insurers began covering it only in 2015 due to the Patient Protection and Affordable Care Act (ACA) mandate that they cover a set of recommended preventive services without cost-sharing. Evidence on clinicians' behavior change postmandate is limited.

Objective

To examine monthly changes in fluoride varnish applications among pediatric clinicians following the ACA mandate.

Design, Setting, and Participants

Using all-payer claims data from Massachusetts, this cohort study applied an interrupted time-series approach with linear regression models comparing changes in monthly clinician-level outcomes before and after the mandate. Participants included clinicians who billed at least 5 well-child visits for patients aged 1 to 5 years and were observed at least once premandate. Adjusted for clinician fixed effects, models were assessed overall and separately for clinicians categorized by their monthly share of well-child visits paid by private insurers before the mandate: mostly private (>66% of visits paid by private insurers), mostly public (<33% of visits paid by private insurers), or mixed (33%-66% of visits paid by private insurers) insurance types. Analysis was performed from June 1, 2022, to July 31, 2023.

Exposure

Preenactment and postenactment of the ACA mandate for private insurers to cover fluoride varnish applications without cost-sharing.

Main Outcomes and Measures

Clinician-month measures of whether fluoride varnish was provided during at least 1 well-child visit and the share of such visits, analyzed separately for clinicians who did and did not apply fluoride varnish premandate.

Results

The sample included 2405 clinicians, with 107 841 clinician-months. Premandate, 10.48% of the visits included fluoride varnish applications. Two years postmandate, the likelihood of ever applying fluoride varnish was 13.64 (95% CI, 10.97-16.32) percentage points higher. For clinicians providing fluoride varnish premandate, the share of visits with fluoride varnish increased by 9.22 (95% CI, 5.41-13.02) percentage points. This increase was observed in clinicians who treated children with insurance that was mostly mixed and mostly private; no substantial change was observed among those treating children with mostly public insurance.

Conclusions and Relevance

In this cohort study of pediatric primary care clinicians, an association between the ACA mandate and an increase in fluoride varnish application was observed, especially among clinicians primarily treating privately insured patients and those applying it premandate. However, application remains infrequent, suggesting persistent barriers.

Oral Health of Women and Children: Progress, Challenges, and Priorities

INTRODUCTION

Tooth decay remains the most prevalent chronic disease in children and adults, even though it is largely preventable. Studies show that mothers' oral and overall health is linked to children's oral health and pregnancy outcomes. This paper examines achievements during the last 20 years, assesses current challenges, and discusses future priorities.

ORAL HEALTH STATUS

Data show a modest improvement in children's oral health during the last 20 years; however, tooth decay still affects more than half of adolescents. According to national survey data, about 26% of working-age adults had untreated tooth decay. Overall, significant oral health disparities by race/ethnicity and income persist.

DENTAL SERVICE UTILIZATION

The annual dental visit rate for children in the 2015 Medical Expenditure Panel Survey was 48%. Among children enrolled in Medicaid, dental visit rates increased from 18% in 1993 to nearly 50% in 2018. About 46% of women are estimated to receive teeth cleaning during pregnancy. Over the years, race or ethnicity and income-level differences in dental visits observed in the early 2000s have narrowed substantially in children but not among pregnant women.

DISCUSSION

Many effective interventions are available at the community and individual levels but are underutilized. Lack of integration of oral health into the overall health care system and programs, community conditions, poverty, and limited health literacy make it difficult for families to engage in healthy habits, use preventive interventions, and access treatment promptly.

CONCLUSION

To further improve oral health, policy and system reforms are needed to address the factors mentioned above. Therefore, we urge the federal Maternal and Child Health Bureau to take steps to convene a workshop to develop a framework for future actions.

A Prospective Longitudinal Study of Early Childhood Caries Onset in Initially Caries-Free Children

INTRODUCTION

Early childhood caries (ECC) is a complex oral disease that is prevalent in US children.

OBJECTIVES

The purpose of this 2-y prospective cohort study was to examine baseline and time-dependent risk factors for ECC onset in initially caries-free preschool children.

METHODS

A cohort of 189 initially caries-free children aged 1 to 3 y was recruited. At each 6-mo study visit, children were examined using the ICDAS index; salivary samples were collected to assess mutans streptococci (MS), lactobacilli, Candida species, salivary cortisol (prior and after a stressor), and salivary IgA. Diet and oral health behavior were assessed from parent report. Child and family stress exposure was assessed from measures of psychological symptoms, stressful life event exposure, family organization and violence exposure, and social support. Sociodemographic factors were also considered. A Kaplan-Meier estimator of survival function of time to ECC and a Cox proportional hazards model were used to identify predictors of ECC onset.

RESULTS

Onset of ECC was associated with high salivary MS levels at baseline (log-rank test, P < 0.0001). Cox proportional hazards regression showed that the risk of dental caries significantly increased with salivary MS in log scale over the 6-mo period (hazard ratio, 1.08; P = 0.01). Other risk factors in the model did not reach statistical significance.

CONCLUSION

Our results provide prospective evidence that an increase in salivary MS predicts ECC onset in young, initially caries-free children, confirming that a high salivary MS count likely plays a causal role in ECC onset, independent of covariates.

KNOWLEDGE TRANSFER STATEMENT

These results suggest that we must focus on reducing salivary MS counts in young children and preventing or delaying MS colonization in infants and young children determined to be at risk for ECC.

Socioeconomic and Clinical Demography of Dental Missed Care Opportunities

INTRODUCTION

Missed care opportunities (MCOs) contribute to poor health outcomes, and pediatric dental patients are particularly vulnerable; identifying associated patient characteristics will help inform development of targeted interventional programs.

OBJECTIVE

To assess socioeconomic and demographic disparities associated with MCOs among children in an urban pediatric hospital's dental clinic. MCOs lead to a lack of continuous care and increased emergent needs, so understanding MCOs is required to achieve equitable pediatric dental health.

METHODS

A retrospective 2-y (2019-2020) cohort of MCOs in children 1 to 17 y old, with scheduled dental visits. MCOs were defined as appointments not attended or canceled and not rescheduled prior to initial scheduled visit. Multivariable mixed-effects logistic regression models with patient-level clustering assessed the associations of demographics, neighborhood-level socioeconomic factors (using social vulnerability index [SVI]), and clinic characteristics with MCOs.

RESULTS

Of 30,095 visits, 30.9% were MCOs. Multivariable logistic regression estimated increased likelihood of MCOs in Black/non-Hispanic (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.09-1.32) and Hispanic (OR, 1.18; 95% CI, 1.06-1.31) patients, patients with public insurance (OR, 1.25; 95% CI, 1.15-1.36) or no insurance (OR, 1.46; 95% CI, 1.15-1.85), patients with complex chronic conditions (OR, 1.11; 95% CI, 1.03-1.19), visits scheduled during the COVID-19 pandemic (OR, 9.48; 95% CI, 8.89-10.11), appointments with wait days over 21 d (OR, 4.07; 95% CI, 3.49-4.74), and children from neighborhoods of high social vulnerability (75th percentile SVI) (OR, 1.08; 95% CI, 1.01-1.16).

CONCLUSIONS

Children with highest dental MCOs were from neighborhoods with high SVI, had public insurance, and were from marginalized populations. MCOs contribute to inequities in overall health; hence, interventions that address barriers related to characteristics associated with pediatric dental MCOs are needed.

KNOWLEDGE TRANSFER STATEMENT

Missed care opportunities contribute to poor health outcomes; identifying associated patient characteristics will help inform development of targeted interventional programs. Providing these findings to stakeholders will better impart understanding access barriers and drive research and program development. Dissemination of this information in the form of altering appointment practices will better accommodate specific patient population needs.

L-serine combined with carboxymethyl chitosan guides amorphous calcium phosphate to remineralize enamel

The aim of this study is to investigate a robust and stable calcium-phosphorus system to remineralize human early enamel caries lesions with nanocomplexes of carboxymethyl chitosan/L-serine/amorphous calcium phosphate (CMC-Ser-ACP) to develop an effective method for mimicking the amelogenin (AMEL) mineralization pattern through ACP assembly. A CMC-Ser-ACP nanocomplex solution was first synthesized by a chemical precipitation method, and then 1% sodium hypochlorite (NaClO) was added to induce ACP phase formation. The morphologies of the nanocomplexes were characterized by transmission electron microscopy (TEM), and zeta potential analysis and Fourier transform infrared spectroscopy (FTIR) were performed to detect surface charge and functional group changes. The subtle changes of the demineralized enamel models induced by the remineralization effect were observed by scanning electron microscopy (SEM) and X-ray diffraction (XRD). The CMC-Ser-ACP nanocomplex solution could be preserved without any precipitation for 45 days. After the application of NaClO and through the guidance of Ser, ACP nanoparticles transformed into relatively orderly arranged hydroxyapatite (HAP) crystals, generating an aprismatic enamel-like layer closely integrated with the demineralized enamel, which resulted in enhanced mechanical properties for the treatment of early enamel caries lesions. The CMC-Ser-ACP nanocomplex solution is a remineralization system with great solution stability, and when NaClO is added, it can rapidly regenerate an aprismatic enamel-like layer in situ on the demineralized enamel surface. This novel remineralization system has stable chemical properties and can greatly increase the therapeutic effects against early enamel caries.

Feedback on audit and action planning for dental caries control: a qualitative study to investigate the acceptability among interdisciplinary pediatric dental care teams

Introduction

American Indian and Alaska Native children suffer from the poorest oral health of all populational groups in the United States. Evidence-based practices (EBP) for caries control are well established, but systematically implementing such practices have proven difficult. Audit and feedback with goal setting, and action planning to implement these EBPs have not been tested or adapted for Alaska Native healthcare settings. The aim of this study was to investigate acceptability and perceived feasibility of an audit and feedback intervention for pediatric dental caries control among dental providers and patient stakeholders.

Methods

The pilot program was implemented in two dental clinics from a tribal healthcare consortium in Alaska. Key-informant interviews were conducted to investigate the contextual, organizational, and behavioral facilitators and barriers to the implementation and expansion of the program. Interview transcripts were analyzed by two researchers using thematic analysis.

Results

Eight key informants were interviewed twice (during and after the intervention period), and one once, for a total of 17 interviews. Patient stakeholders were not interviewed due to COVID-19 pandemic clinic closures and social isolation mandates. Three principal themes emerged: a positive organizational climate and culture fostered the acceptability of the program, the positive impacts of the program observed in the pediatric dental teams and the organization, and the challenges to implement the program including understanding the data reports, trusting the accuracy of the data, and competing priorities.

Conclusions

The intervention of audit and feedback with goal setting and action planning was well accepted and perceived as feasible by the study participants given the financial and human resources provided by the research project. This qualitative study can inform the design and evaluation of process-oriented implementation strategies geared towards decreasing health inequities and improving health outcomes, such as dental caries in American Indian and Alaska Native children and adolescents.

A Social Media Intervention for Promoting Oral Health Behaviors in Adolescents: A Non-Randomized Pilot Clinical Trial

Poor oral hygiene and excessive consumption of soda are among the main drivers of systemic health issues in adolescents in the United States. This non-randomized pilot clinical trial focused on the effects of a health text message system and smartphone-based intervention on adolescent tooth-brushing behavior and dietary choices, with a convenience sample of 94 participants aged 12 to 14 years old. A group of 75 participants agreed to use a tooth-brushing app and received a health text message; the other group of 15 agreed to use the tooth-brushing app, but did not receive a health text message. Saliva specimens were collected directly before and at the end of each experiment; changes in the salivary presence of cariogenic bacteria over the duration of the study were evaluated and compared with the demographics and behavioral variables. Within the text message group, 5% of participants increased the frequency of daily tooth brushing. Within the non-intervention group, 29% of participants increased the frequency of their daily tooth brushing. There were reductions in the total salivary bacteria and total streptococci in both groups (p < 0.001), but no change in the presence of cariogenic Mutans streptococci. Raising adolescents' consciousness of oral health behavior resulted in marginal to moderate improvements to oral hygiene and dietary choices, as well as reductions in total salivary bacteria.

Racial/ethnic disparities in preventive dental services use and dental caries among children

OBJECTIVE

To assess disparities in preventive dental service use in four major racial/ethnic groups and assess whether racial/ethnic and income-related disparities among children were reduced from 2016 to 2020.

METHODS

Data were from the 2016 and 2020 National Survey of Children's Health (NSCH). The outcomes of interest were having dental sealants, fluoride treatment, and dental caries in the past 12 months. Racial/ethnic groups included non-Hispanic (NH) whites, blacks, Hispanics, Asians, and others. Family income level was categorized as below or above the 200% federal poverty level (low-income vs. high-income). Children ages 2-17 were included (N = 161,539). All data were self-reported by parents/guardians. We estimated the trends of racial/ethnic disparities in having fluoride treatment, dental sealants, and dental caries from 2016 to 2020 and tested two 2-way interactions (i.e., year by race/ethnicity, year by income) and one 3-way interaction (year by income by race/ethnicity) to assess the change in disparities from 2016 to 2020.

RESULTS

Overall, no significant trends in receipt of fluoride treatment, dental sealants, or having dental caries were found from 2016 to 2020 among the racial/ethnic groups, except for a decreasing trend in dental sealants for Asian American children (p = 0.03). Overall, NH white children were more likely to have received preventive dental services than children from minority groups (all p < 0.05); Asian American children (AOR = 1.31) were more likely to have dental caries than NH white children.

CONCLUSION

Disparities in receipt of evidence-based preventive services by children persisted. Continuous efforts are needed to promote the use of preventive dental services among children of minority populations.

Pediatric Dental Emergencies during the COVID-19 Pandemic in Romania: A Retrospective Study

Pediatric dental emergencies can occur as a result of untreated dental caries, or can be caused by trauma or periodontal issues. The lockdown imposed during the COVID-19 pandemic reduced the number of centers authorized to deliver dental services in Romania, with only a small number of dentists delivering dental emergency treatments. The aim of this study was to investigate the demographic characteristics of children and adolescent patients who were treated in the dental emergency department of Oradea, Romania and to compare the patients who were treated in the dental emergency department in the pre-lockdown (2019), lockdown (2020) and post-lockdown year (2021). All patients who were treated in the dental emergency department were included in the study except for adults and medical files that did not contain all relevant information. Several variables were investigated (age, gender, living environment, location of affected teeth, type of emergency). In 2019, 257 children and adolescents were treated, in 2020, 198, and in 2021, 136. Most patients were aged 7-12 years in all investigated years (2019-47.9%; 2020-50.5%; 2021-43.4%), and the most affected teeth were located in the lower posterior arch (2019-53.3%; 2020-53%; 2021-48.5%). The most frequent emergencies were pulpitis (2019-40.5%; 2020-43.9%) and acute apical periodontitis (2021-42.6%). It was observed that in 2019, patients aged between 0 and 6 years were more frequently associated with trauma (p < 0.001), and in 2019 and 2020, patients aged between 7 and 12 years were more frequently associated with periodontal emergencies (p < 0.001). In 2020, patients from rural areas were more frequently associated with pulpitis (p = 0.025), and in 2021, patients from rural areas were more frequently associated with pulpitis or acute apical periodontitis, and patients from urban areas were associated more frequently with periodontal emergencies (p = 0.042). Pediatric patients with ages between 7 and 12 years old, who lived in an urban environment were most affected. Teeth located in the lower and upper posterior dental arches were most affected, and pulpitis or acute apical periodontitis were the most common pathologies.

Mother's Experience of Conflict Within Their Family Social Network when Advocating for Children's oral Health

OBJECTIVES

Examine whether mothers perceived that child oral health was a source of conflict in family relationships.

METHODS

This cross-sectional qualitative study consisted of 126 semi-structured interviews with mothers of 3-5 year-old children from West Virginia and Pittsburgh, Pennsylvania. Interviews consisted of open-ended questions on the mother's social relationships that affected child dental visits, oral hygiene, and diet. The data were analyzed using template analysis.

RESULTS

Over 85% (n = 111/126) of mothers reported interpersonal conflict in their familial relationships related to child oral health. Most (78%) mothers reported conflict with their partners and 58% of mothers reported conflict with the child's grandparents. Conflicts primarily centered around keeping a consistent oral hygiene routine for the child and the promotion of a low-cariogenic diet.

CONCLUSIONS FOR PRACTICE

Mothers perceived child oral health promotion as a source of conflict in the family. This study suggests that identifying effective strategies to reduce conflict with caretakers are indicated. Oral health professionals can take an active role not only in communicating with the mother, but also with other caretaking adults in the family to promote oral health practices that benefit all children.

Predicting Flossing through the Application of the Multi-Theory Model (MTM) of Health Behavior Change among Minority Adolescents in the United States

Adolescents from minority groups are particularly susceptible to poor oral hygiene behaviors, including lack of daily flossing. This cross-sectional study aimed to conduct an exploratory behavioral research to identify evidence-based (theory-based) approaches to promote flossing behavior among African American/Black and Latinx/Hispanic (minority) adolescents. A 39-item psychometrically valid web-based questionnaire was used to collect responses from a nationwide sample of minority adolescents aged 10-17 years residing in the United States. The data were analyzed using bivariate and multivariate statistical methods. Of 520 minority adolescents (260 African American/Black and 260 Latinx/Hispanic adolescents), the proportion of flossing was nearly equally split in the sample. A significantly higher proportion of minority adolescents who were flossing had access to floss as opposed to those who were not flossing (86.8% vs. 69.8%, p < 0.001). A significantly higher proportion of minority adolescents who were not flossing did not visit the dentist over the past year as opposed to those who floss (25.2% vs. 14.7%, p < 0.001). Among the participants who were not flossing, gender, grade level, instruction in school regarding flossing, and multi-theory model (MTM) of health behavior change constructs were the significant predictors (p < 0.001) of initiating and sustaining flossing. The findings of this study will serve as baseline data for developing and evaluating effective evidence-based interventions using the MTM.

Dental Care Differences Among the Behavioral Health Population in an Accountable Care Organization: A Retrospective Cohort

OBJECTIVE

To compare dental utilization and expenditures between children with and without behavioral health (BH) diagnoses in an accountable care organization.

METHODS

This retrospective cohort study used enrollment and claims data of Medicaid-enrolled children in Ohio. Children with 7 years of continuous enrollment from 2013 to 2019 were included. We calculated 5 dental utilization outcomes: 1) Diagnostic only visits, 2) Preventive visits, 3) Treatment visits, 4) Treatment visits under general anesthesia (GA), and 5) Orthodontic visits. Total 7-year cumulative expenditures were calculated for each outcome. Multivariable logistic regression models were run for each outcome adjusting for demographics and medical comorbidities.

RESULTS

Among 77,962 children, 23% had ≥1 BH diagnosis. No utilization differences were noted between children with and without BH for diagnostic only visits, treatment visits, and orthodontic visits. BH status modified the likelihood of having a preventive visit and dental GA visits based on medical comorbidity. For example, children with BH diagnoses had significantly lower odds of a preventive visit (eg, non-complex chronic comorbidity: odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.85-0.89), and significantly higher odds of a dental treatment under general anesthesia visit (eg, non-chronic comorbidity: OR = 3.69, 95% CI: 3.26-4.18). The total cumulative dental expenditures were $10.5M greater for children with BH.

CONCLUSIONS

Children with BH diagnoses were significantly less likely to have preventive visits and more likely to have dental GA visits, which was expensive. Early identification and intervention could alter treatment approaches, improve care, reduce risk of harm, and achieve cost-savings within a pediatric accountable care organization.

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.

Are We Getting Any Better? A Critical Analysis of Selected Healthy People 2020 Oral Health Indicators in 1999-2004 and 2013-2016, USA

Oral health disparities are prevalent in the American population and are influenced by various social determinants. This study aimed to analyze oral health disparities in the US between 1999-2004 and 2013-2016 according to sociodemographic characteristics. This analytic cross-sectional study analyzed five oral health indicators from Healthy People 2020. A binomial test was used to compare proportions between baseline and follow-up. Only the indicator for non-treated cavities among children reached its goal. White children had the greatest decrease (-15.4%; p = 0.0428) in dental caries. Higher income determined better outcomes for adolescents (-27.54%; p = 0.00032 dental caries) and adults (-15.96%; p = 0.0143 tooth extractions). However, adults 35-44 years with the highest income had a significant increase (40.74%, p = 0.0258) in decayed teeth. This study provides evidence to suggest that some progress has been made towards reducing oral health disparities in the US, primarily among children. However, trends for certain indicators remain disparate between different racial/ethnic and income groups. Applications for the findings of this study should address the intersectional nature of social determinants of health and should center on improving the equity of services offered by public oral healthcare.

Assessment of caries diagnostic thresholds of DMFT, ICDAS II and CAST in the estimation of caries prevalence rate in first permanent molars in early permanent dentition-a cross-sectional study

Background

The actual burden of dental caries prevalence varies with the caries assessment tool used. Therefore, the present study evaluated the caries diagnostic potentials of Decayed, Missing and Filled Teeth (DMFT); International Caries Detection and Assessment System (ICDAS) II and Caries Assessment Spectrum and Treatment (CAST) indices in estimating the caries prevalence rate of first permanent molar (FPM) in Saudi male children aged 7–9 years.

Methods

This descriptive, cross-sectional study included 390 children by multistage stratified cluster sampling method in Al-Jouf Province, Saudi Arabia. The prevalence rates of FPM caries were determined by DMFT, ICDAS II and CAST indices at various diagnostic cut-off points. Intra- and inter-examiner reliability was determined.

Results

The prevalence rates of FPM caries determined by DMFT (decayed), ICDAS II (codes 1–6) and CAST (codes 3–7) were 64.4% (61.6–67.2), 71.5% (69.2–73.2) and 71.0% (68.7–73.3), respectively. The prevalence rates of FPM caries determined by ICDAS II at various diagnostic cut-offs were as follows: ‘sound’ (code ‘0’), 28.5% (26.3–30.8); ‘enamel caries’ (codes 1–3), 57.2% (54.7–59.7) and ‘dentinal caries’ (codes 4–6), 14.3% (12.6–16.1). Similarly, the prevalence rates estimated by CAST at different diagnostic cut-off points were: ‘healthy’ (scores 0–2), 28.1% (25.9–30.4); ‘premorbid’ (score 3, enamel carious), 56.5% (54.0–59.0); ‘morbid’ (scores 4–5, cavitated carious dentin), 7.9% (6.6–9.3); ‘severe morbidity’ (scores 6–7, pulp exposure/fistula/abscess), 6.6% (5.4–8.1) and ‘mortality’ (score 8, lost), 0.8% (0.4–1.4).

Conclusion

Enamel caries lesions were found in more than half of the FPMs investigated in the current study. CAST index is preferable because it detects the complete spectrum of caries. ICDAS II at codes 1–6 and CAST at codes 3–7 projected similar caries prevalence rates in FPMs.

Variation in Current Guidelines for Fluoride Varnish Application for Young Children in Medical Settings in the United States

Background

The United States Preventive Services Task Force recommends that medical providers apply fluoride varnish (FV) to the teeth of all children under 6 years of age, but fewer than 10% of eligible children receive FV as recommended. Prior studies suggest that variation in clinical guidelines is associated with low uptake of other evidence-based health-related interventions, but consistency of national guidelines for the delivery of FV in medical settings is unknown.

Methods

Eligible guidelines for application of FV in medical settings for children under 6 years of age were published in the past 10 years by national pediatric or dental professional organizations or by national public health entities. Guidelines were identified using the search terms fluoride varnish + [application; guidelines, or recommendations; children or pediatric; American Academy of Pediatrics (AAP); American Academy of Pediatric Dentistry] and a search of Guideline Central. Details of the guidelines were extracted and compared.

Results

Ten guidelines met inclusion criteria. Guidelines differed in terms of periodicity recommendations and whether FV was indicated for children with a dental home or level of risk of dental caries.

Conclusion

Numerous recommendations about FV delivery in medical settings are available to pediatric medical providers. Further study is warranted to determine whether the variation across current guidelines detected in this study may contribute to low FV application rates in medical settings.

Prospective association between maternal bonding disorders and child toothbrushing frequency: A cross-sectional study of the Japan Environment and Children's Study

BACKGROUND

Daily toothbrushing prevents early childhood caries, but reinforcement depends on facilitative parenting behaviours. Mother-to-infant bonding, the maternal affection towards the infant, is an environmental factor that strongly influences parenting.

AIM

This study examined the association between maternal bonding and children's daily toothbrushing frequency.

DESIGN

The sample consisted of 83 954 mother-infant pairs at two years postpartum, derived from the initial sample of JECS (cohort study), which included 104 062 foetuses. Maternal bonding disorders were assessed using the Mother-to-Infant Bonding Scale (MIBS). After multiple imputation for missing data, a multinomial logistic regression analysis was conducted with adjustments for several maternal (eg, age at delivery) and child-related (eg, self-performed toothbrushing) variables.

RESULTS

The odds ratio (95% confidence interval) for the association of maternal bonding disorders with the low (once per day) and the very low child toothbrushing frequency (<1 per day) was 1.12 (1.07-1.17) and 1.23 (0.91-1.66), respectively, after covariate adjustments. Furthermore, the univariate general linear model showed that the mean MIBS scores significantly decreased as the daily child toothbrushing frequency increased.

CONCLUSIONS

The prevalence of maternal bonding disorders at one year postpartum was prospectively associated with a lower frequency of child toothbrushing at two years of age.

Davidson KW, Barry MJ, Mangione CM, Cabana M, Caughey AB, Davis EM, Donahue KE, Doubeni CA, Kubik M, Li L, Ogedegbe G, Pbert L, Silverstein M, Stevermer J, Tseng CW, Wong JB. Screening and Interventions to Prevent Dental Caries in Children Younger Than 5 Years: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Dental caries is the most common chronic disease in children in the US. According to the 2011-2016 National Health and Nutrition Examination Survey, approximately 23% of children aged 2 to 5 years had dental caries in their primary teeth. Prevalence is higher in Mexican American children (33%) and non-Hispanic Black children (28%) than in non-Hispanic White children (18%). Dental caries in early childhood is associated with pain, loss of teeth, impaired growth, decreased weight gain, negative effects on quality of life, poor school performance, and future dental caries.

OBJECTIVE

To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review on screening and interventions to prevent dental caries in children younger than 5 years.

POPULATION

Asymptomatic children younger than 5 years.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that there is a moderate net benefit of preventing future dental caries with oral fluoride supplementation at recommended doses in children 6 months or older whose water supply is deficient in fluoride. The USPSTF concludes with moderate certainty that there is a moderate net benefit of preventing future dental caries with fluoride varnish application in all children younger than 5 years. The USPSTF concludes that the evidence is insufficient on performing routine oral screening examinations for dental caries by primary care clinicians in children younger than 5 years and that the balance of benefits and harms of screening cannot be determined.

RECOMMENDATION

The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B recommendation) The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children younger than 5 years. (I statement).

Screening and Interventions to Prevent Dental Caries in Children Younger Than 5 Years: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

A 2014 review for the US Preventive Services Task Force (USPSTF) found that oral fluoride supplementation and topical fluoride use were associated with reduced caries incidence in children younger than 5 years.

OBJECTIVE

To update the 2014 review on dental caries screening and preventive interventions to inform the USPSTF.

DATA SOURCES

Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to September 2020); surveillance through July 23, 2021.

STUDY SELECTION

Randomized clinical trials (RCTs) on screening, preventive interventions, referral to dental care; cohort studies on screening and referral; studies on diagnostic accuracy of primary care oral examination or risk assessment; and a systematic review on risk of fluorosis included in prior USPSTF reviews.

DATA EXTRACTION AND SYNTHESIS

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality.

RESULTS

Thirty-two studies (19 trials, 9 observational studies, and 4 nonrandomized clinical intervention studies [total 106 694 participants] and 1 systematic review [19 studies]) were included. No study evaluated effects of primary care screening on clinical outcomes. One study (n = 258) found primary care pediatrician examination associated with a sensitivity of 0.76 (95% CI, 0.55 to 0.91) and specificity of 0.95 (95% CI, 0.92 to 0.98) for identifying a child with cavities, and 1 study found a risk assessment tool associated with sensitivity of 0.53 and specificity of 0.77 (n = 697, CIs not reported) for a child with future caries. No new trials of dietary fluoride supplementation were identified. For prevention, topical fluoride compared with placebo or no topical fluoride was associated with decreased caries burden (13 trials, n = 5733; mean caries increment [difference in decayed, missing, and filled teeth or surfaces], -0.94 [95% CI, -1.74 to -0.34]) and likelihood of incident caries (12 trials, n = 8177; RR, 0.80 [95% CI, 0.66 to 0.95]; absolute risk difference, -7%) in higher-risk populations or settings, with no increased fluorosis risk. Evidence on other preventive interventions was limited (education, xylitol) or unavailable (silver diamine fluoride), and no study directly evaluated primary care dentistry referral vs no referral.

CONCLUSIONS AND RELEVANCE

There was no direct evidence on benefits and harms of primary care oral health screening or referral to dentist. Dietary fluoride supplementation and fluoride varnish were associated with improved caries outcomes in higher-risk children and settings.

Current Novel Caries Diagnostic Technologies: Restorative Dentists' Attitude and Use Preferences

Early detection of caries lesions is key to a successful restorative dental treatment plan. The aim of this study was to investigate the preferences and attitude of graduate restorative dentistry residents (RDRs) regarding novel caries diagnostic technologies (NCDT) and to provide a brief overview of available technologies for both specialized and general dental practice. This cross-sectional study used an online questionnaire (17 questions) concerning RDRs’ attitude, preferences, and insights regarding five available NCDTs. It was distributed among twenty RDRs at a local government dental school following a review session about NCDTs. Collected responses were analyzed statistically using one-way analysis of variance (ANOVA), chi-squared with Bonferroni correction, and Kruskal-Wallis tests at a 0.05 significance level. Sixty-five percent of RDRs reported an interest in NCDTs as a discussion topic and almost half of them were positive towards their use, however, sixty percent of respondents were hesitant to diagnose caries solely using NCDTs. Fiber-optic-transillumination (FOTI) systems were ranked the best overall and with regard to all the investigated criteria (p < 0.05). Chosen reasons for FOTI included price followed by ease of use. In general, high price rated as the most perceived reason for not choosing a given NCDT followed by low practical applicability. Meanwhile, ease of use followed by relevant application ranked as the main reported reasons to choose an NCDTs.

A wider role for general dental practice?

The role of general dental practice within the NHS is limited to the direct practice of dentistry. Pandemic situations have identified the capability of dentists to take a wider role in patient care, which has been recognised by the FDI World Dental Federation. With the UK government's intention to re-structure primary healthcare to recognise lifestyle elements as the important feature of a new prevention emphasis, could and should the unique position of general dental practice play an important and integral role in promoting overall health and wellbeing?

Comprehensive, School-Based Preventive Dentistry: Program Details and Students' Unmet Dental Needs

BACKGROUND

In this paper, we describe the design, program details, and baseline demographics and oral health of participants in ForsythKids, a regional, comprehensive, school-based mobile caries prevention program.

METHODS

We solicited all Massachusetts elementary schools with greater than 50% of students receiving free or reduced-price meals. Six schools initially elected to participate, ultimately followed by over 50 schools. Interventions were based on systematic reviews and randomized controlled caries prevention trials. Participating students received semiannual dental examinations, followed by comprehensive preventive care. Summary statistics regarding oral health indicators were derived from individual tooth- and surface-level data.

RESULTS

Over a 6-year period, data were collected on 6927 children. The number of students per school ranged from 58 to 681. The overall participation rate was 15%, ranging from 10% to 29%. Overall, 57% of the children were younger than 8 years at baseline. Approximately, 54% of children experienced dental decay on any tooth at baseline; 32% had untreated decay on any tooth, 29% had untreated decay on primary teeth, and 10% untreated decay on permanent teeth.

CONCLUSIONS

Untreated dental decay was double the national average, even in schools within several blocks of community dental clinics. These data demonstrate the need for caries prevention beyond the traditional dental practice.

Ten-year changes in children's oral health disparities: Findings from the 3rd and 4th oral health surveys in Beijing, China

Objectives

Little is known about children's oral health disparities and their changes in developing countries. This study aimed to measure rural‐urban and maternal education‐related disparities in dental visits and untreated caries among Chinese children, and to describe their changes between 2005 and 2015.

Methods

The 12‐year‐old children's oral health data were from the 3rd (2005) and 4th (2015) oral health surveys in Beijing, China. Rural‐urban disparities and maternal education‐related disparities in dental visits and untreated caries were measured. The slope index of inequality (SII) and a relative index of inequality (RII) were applied to reflect the absolute and relative disparities respectively. These were estimated using a generalized linear regression model.

Results

Data were analysed from 388 children in 2005 and 1926 children in 2015. The proportion of 12‐year‐old schoolchildren who visited the dentist was 24.0% in 2005 and 36.0% in 2015. Untreated caries prevalence in 2005 and 2015 was 20.9% and 16.2% respectively. Rural‐urban disparities in dental visits narrowed between 2005 and 2015 (SII: −10.75 to −3.30, RII: 0.55 to 0.87), and maternal education‐related disparities in dental visits also decreased during this decade (SII: −18.52 to −8.49, RII: 0.38 to 0.65). These changes were statistically significant. For disparities in untreated caries, only maternal education‐related disparities in untreated caries in 2015 were found. The SII and RII were 6.39% (95% CI: 1.65, 11.13) and 1.57 (95% CI: 1.13, 2.20) respectively. The change in disparities in untreated caries was not statistically significant for rural‐urban disparities (P = .319) or maternal education‐related disparities (P = .501).

Conclusions

These findings indicate that in Beijing, China, disparities in children's dental visits narrowed between 2005 and 2015. However, maternal education‐related disparities in dental visits and in untreated caries were still apparent, suggesting that policies to improve children's oral healthcare utilization equality should target the children with less‐educated mothers.

Training dental hygienists to place interim therapeutic restorations in a school-based teledentistry program: Oregon's virtual dental home

OBJECTIVES

The objectives of this study on Oregon's virtual dental home were to: 1) demonstrate the feasibility of pilot project training of existing Expanded Practice Dental Hygienists (EPDHs) to perform interim therapeutic restorations (ITRs) in the community settings after diagnosis by the supervising dentist via teledentistry and 2) evaluate satisfaction of parents/guardians of children participating in a pilot program that provides school-based/on-site preventive dental care services utilizing expanded scope EPDHs to conduct dental screenings and place ITRs.

METHODS

This demonstration project was a 4-years longitudinal cohort study (2016-2019) in the school/community-based settings focusing on children in kindergarten to 3rd grade. EPDHs and dentists from a Dental Care Organization were trained to utilize teledentistry and EPDHs were trained to place ITRs, the latter provided onsite dental care. Data was collected regarding child's demographics and oral health status; and parents reported level of satisfaction from services received by their children. Data analysis included descriptive statistics and logistic regression analysis to assess the relative importance of demographic and clinical factors on caries status.

RESULTS

Onsite dental care was provided to 759 children. Of repeat patients (n = 377), 201 (53.3%) children had untreated decay at their first visit. Of these, 13% saw improvements in oral health status at their most recent visit (MRV). There were 162 ITRs planned out of which 50 patients received 99 ITRs. No adverse events were experienced. Of the repeat children receiving ITRs (n = 43), 28% saw improvement in their caries status at their MRV. Parents reported very high levels of satisfaction with the dental care program.

CONCLUSION

Oregon's virtual dental home project was successful in training EPDHs to perform ITRs safely in school settings after caries diagnosis by the supervising dentist via teledentistry and in integrating this component into a regular school-based preventive dental program.

Impacts of innovation in dental care delivery and payment in Medicaid managed care for children and adolescents

Background

We evaluated a 14-county quality improvement program of care delivery and payment of a dental care organization for child and adolescent managed care Medicaid beneficiaries after 2 years of implementation.

Methods

Counties were randomly assigned to either the intervention (PREDICT) or control group. Using Medicaid administrative data, difference-in-difference regression models were used to estimate PREDICT intervention effects (formally, “average marginal effects”) on dental care utilization and costs to Medicaid, controlling for patient and county characteristics.

Results

Average marginal effects of PREDICT on expected use and expected cost of services per patient (child or adolescent) per quarter were small and insignificant for most service categories. There were statistically significant effects of PREDICT (p < .05), though still small, for certain types of service:

Expected number of diagnostic services per patient-quarter increased by .009 units;

Expected number of sealants per patient-quarter increased by .003 units, and expected cost by $0.06;

Total expected cost per patient-quarter for all services increased by $0.64.

These consistent positive effects of PREDICT on diagnostic and certain preventive services (i.e., sealants) were not accompanied by increases in more costly service types (i.e., restorations) or extractions.

Conclusion

The major hypothesis that primary dental care (selected preventive services and diagnostic services in general) would increase significantly over time in PREDICT counties relative to controls was supported. There were small but statistically significant, increases in differential use of diagnostic services and sealants. Total cost per beneficiary rose modestly, but restorative and dental costs did not. The findings suggest favorable developments within PREDICT counties in enhanced preventive and diagnostic procedures, while holding the line on expensive restorative and extraction procedures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06549-3.

What is the association between income loss during the COVID-19 pandemic and children's dental care?

BACKGROUND

The degree to which children experience unmet need for dental care during the COVID-19 pandemic and its association with pandemic-related household job or income loss are unknown.

METHODS

The authors performed a cross-sectional household survey of 348 families in Pittsburgh, Pennsylvania, from June 25 through July 2, 2020. Unmet need for child dental care and pandemic-related household job or income loss were assessed using caregiver self-report.

RESULTS

Caregivers reported that the greatest unmet child health care need during the COVID-19 pandemic was dental care (16%), followed by medical care for a well visit or vaccination (5%). Approximately 40% of caregivers reported job loss or a decrease in household income due to the COVID-19 pandemic. The authors found a significant association between the probability of unmet child dental care and pandemic-related household job or income loss (P = .022). Losing a job or experiencing a decrease in income due to the COVID-19 pandemic was associated with unmet child dental care (relative risk, 1.77; 95% confidence interval, 1.08 to 2.88).

CONCLUSIONS

In this sample, 3 times as many households reported unmet dental care for a child compared with unmet medical care. Unmet child dental care was more common in households where pandemic-related job or income loss occurred.

PRACTICAL IMPLICATIONS

If unmet dental care continues as a result of the COVID-19 pandemic, nontraditional strategies for delivering dental care can be considered to improve access to dental care for children, such as teledentistry and oral health prevention services in primary care settings.

Randomized trial of a photography-aided behavioural intervention to reduce risk factors for caries and malocclusion in high-risk infants

OBJECTIVE

To assess the efficacy of a photography-aided behavioural intervention in reducing risk factors for dental caries and malocclusion in high-risk infants.

MATERIALS AND METHODS

In this randomized trial conducted in a maternity hospital, 55 mothers of recently born infants at high risk of developing oral diseases were allocated to either the intervention (n = 28) or usual care (n = 27). The intervention arm received the same usual care plus an enhanced, behaviour-oriented, photography-aided, two-stage (0 and +6 months) educational programme addressing nutritional, behavioural, lifestyle and familial factors that affect child's oral health. The primary outcome was the proportion of children classified as being at a 'low risk' of developing dental caries at the age of 12 months using a modified score based on the Caries-risk Assessment Form of the American Academy of Pediatric Dentistry. Secondary outcomes included risk factors for malocclusion, such as duration of exclusive breastfeeding, pacifier use and bottle-feeding and/or sippy cup usage.

RESULTS

At 12 months, the proportion of children considered at low risk for dental caries was significantly higher in the intervention group compared to usual care (71% vs 15%, respectively, relative risk = 4.82, 95% confidence interval = 1.89-12.3, p < 0.001). The median duration of exclusive breastfeeding in the intervention group was 1.7 times higher than in the control arm (5 months vs 3 months, p = 0.03).

CONCLUSION

Altogether, our findings provide evidence that a low-cost, two-stage preventive strategy using photographs to deliver a stronger visual impact might significantly reduce the incidence of risk factors for dental caries and malocclusion in 12-month-old children.

Identifying Gaps in Oral Care Knowledge, Attitudes, and Practices of Latinx Parents/Caregivers of Children With and Without Autism Spectrum Disorders

Purpose: This pilot study used data from a survey to examine the knowledge, attitudes, and practices about oral care of Latinx parents/caregivers of children with or without autism spectrum disorder (ASD) to identify gaps to focus future intervention.

Methods: Sixty English-speaking Latinx parents/caregivers who had a child between 4 and 14 years with or without ASD (n=31 ASD, n=29 typically developing [TD]) completed a questionnaire on oral health knowledge, practices, access to care, and demographics. Caregiver responses were compared, and gaps in knowledge and practices were identified.

Results: There were no significant differences in parent age, child age, income, insured status, or overall knowledge scores, only a significant difference in education (p=0.02), with the ASD group reporting less. Scores for knowledge, attitudes, access and practice were all nonsignificantly positively correlated, as was attitudes with access and practice. However, knowledge and attitudes were significantly negatively correlated. Additional significant findings were parents who had lower income and education, had lower oral knowledge scores, decreased frequency of dental visits, increased feelings of being discriminated against, children with increased fear of the dentist, and decreased ease of finding a dentist.

Conclusion: Factors such as income, education, ethnicity, and having a child with ASD can influence what Latinx parents and caregivers know about oral health and how their children experience receiving dental care. Latinx parents/caregivers of children with and without ASD report barriers to dental care, including difficulty attending visits or feeling stigmatized by their dental provider due to their ethnicity. Fear of the dentist is significantly correlated with ASD diagnosis and lower social demographics of the parent, and may contribute to a reduction in preventative oral care visits as well. Health care providers should consider these perspectives when providing care to this population to mitigate further oral health inequities.

Dental caries thresholds among adolescents in England, Wales, and Northern Ireland, 2013 at 12, and 15 years: implications for epidemiology and clinical care

BACKGROUND

Dental caries is the most prevalent condition globally. Despite improvements over the past few decades, there remains a significant disease burden in childhood. Epidemiological surveys provide insight to disease patterns and trends, and have traditionally focused on obvious decay which are inconsistent with contemporary clinical criteria. This study examined the distribution of dental caries in 12- and 15-year-olds in England, Wales and Northern Ireland, by severity threshold, at surface, tooth and child level and explored its association with socioeconomic, psychological and behavioural factors.

METHODS

Data from 12- and 15-year-olds in the 2013 Children's Dental Health Survey (CDHS 2013) were analysed at three levels, taking account of dental caries thresholds which involved recording both clinical decay [visual enamel caries (AV) and above] and obvious decay [non-cavitated dentine lesions (2V) and above]. Negative binomial regression was used to identify factors associated with dental caries experience at both thresholds.

RESULTS

The prevalence and severity of dental caries experience was higher among 15-year-olds at all levels. Visual change in enamel (AV) was by far the most common stage of caries recorded in both ages. The average number of surfaces with obvious decay experience, which has been the traditional epidemiological threshold, in 12- and 15-year-olds was 2.3 and 3.9 respectively. The corresponding values under the clinical decay threshold were higher, at 3.9 and 5.9 respectively. Visualisation of the distribution of dental caries at surface/tooth-level exhibited horizontal symmetry and to a lesser extent vertical symetry. In the adjusted models for both ages, country/region, school type, area deprivation, high frequency sugar consumption and irregular dental attendance were associated with greater caries experience in both groups. Dental anxiety was inversely associated with caries experience among 15-year-olds.

CONCLUSION

This research highlights the importance of recognising dental caries patterns by surface, tooth and child-level amongst adolescents and the value of reporting dental caries distribution by threshold in epidemiological surveys, including its relevance for clinical care. Inclusion of enamel caries reveals the extent of caries management required at a point when non-invasive care is possible, emphasising the importance of prevention through contemporary primary care, which includes supporting self-care.

Community-based sugar-sweetened beverage intervention associated with short-term improvements in self-rated oral health

OBJECTIVES

To assess the efficacy of a community-based childhood obesity prevention intervention targeting Sugar-sweetened beverage (SSB) consumption on self-rated oral health among children and their parents/caregivers.

METHODS

This study is a secondary analysis of data from a pilot site-randomized intervention (H₂ GO!) targeting SSB consumption and obesity risk among children. The 6-week SSB behavioural intervention was implemented in two Massachusetts Boys and Girls Club sites that were matched for size and racial/ethnic composition. Children ages 9-12 years and their parents/caregivers were eligible to participate. Data on self-rated oral health and sociodemographics were obtained via self-report surveys at baseline, 2 and 6 months. Generalized linear mixed regression models were used to estimate 2- and 6-month change in oral health associated with the intervention.

RESULTS

Data are from 100 child participants (46% female; 38% Black, 20% Hispanic, 13% White, 12% Multiracial, 11% Asian) and 87 parent participants (78.2% female; 37.9% Hispanic, 29.9% Black, 14.9% Asian, 10.3% White). At baseline, 47% of child participants rated their oral health as good, followed by very good (32%), fair (11%) and excellent (10%). Among parents, 46.3% rated their oral health as good, followed by very good (29.3%), excellent (9.8%), fair (9.7%) and poor (4.9%). The intervention was associated with 2- and 6-month improvements in child participants' mean self-rated oral health scores (β = 0.78; 95% CI: 0.48, 1.087; P < .001; β = 0.98; 95% CI: 0.61, 1.34; P < .001, respectively) and with 2-month improvements in parent participants' mean self-rated oral health (β = 0.42; 95% CI: 0.016, 0.82; P = .042).

CONCLUSION

Short-term improvements in oral health among children and their parents/caregivers were observed among those participating in a SSB behavioural intervention. Community-based behavioural programmes targeting SSB consumption may be a promising approach to promote oral health as well as prevent childhood obesity.

The health care utilization model: Application to dental care use for Black and Hispanic children

OBJECTIVES

To explore the pathway associated with dental service use among Hispanic and non-Hispanic Black children, applying Andersen's model of health care service utilization.

METHODS

Samples of Hispanic (n = 5,055) and non-Hispanic (NH) Black (n = 2,695) children aged 2-17 years from the 2016 National Survey of Children's Health (NSCH) were included in this study. We used structural equation modeling (SEM) to examine the path of the relationship between dental care visits and the three groups of characteristics in Andersen's behavioral model.

RESULTS

In the models for Hispanic and non-Hispanic Black children, parents' educational attainment directly and positively affected income and having insurance. Also, insurance (Hispanic children: β = 0.17, P ≤ 0.01; NH Black children: β = 0.25, P ≤ 0.01) and age of the child (Hispanic children: β = 0.14, P ≤ 0.01; NH Black: β = 0.21, P ≤ 0.01) directly and positively affected dental care use. However, there was no direct effect of the need factor on dental care use in either model.

CONCLUSIONS

Children may receive dental services that eliminate acute dental problems, probably as a result of the ACA and CHIP coverage. The patterns of findings suggest the need for policy changes to improve pediatric dental coverage and promote professional recommendations for effective dental hygiene.

Household food insecurity and children's oral health: Findings from the 2016-2018 National Survey of Children's Health

OBJECTIVES

The purpose of the present study is to examine the association between household food insecurity and oral health problems among US children, and the role that socioeconomic, insurance, and oral health care utilization variables play in this association.

METHODS

A large, nationally representative sample of children from the 2016-2018 National Survey of Children's Health (NSCH) was employed in the present study (N = 99,962). Logistic regression and negative binomial regression were used to assess the influence of household food insecurity on diverse oral health problems and unmet oral health care needs. The Karlson-Holm-Breen (KHB) method was used to examine the attenuating roles of socioeconomic, insurance, and oral health care utilization variables.

RESULTS

Children in food-insecure households exhibited significantly greater odds of all examined oral health problems as well as unmet oral health care needs. These associations were a) most pronounced in the case of moderate-to-severe food insecurity and b) partly explained by a subset of socioeconomic and insurance-related variables.

CONCLUSIONS

Household food insecurity is a potent risk factor for oral health problems and unmet oral health care needs among US children. Programmatic efforts to address household food insecurity may yield collateral benefits for the oral health of children. Furthermore, because socioeconomic status and insurance-related variables explain part of the association, targeted interventions to improve these factors may improve oral health among at-risk children.

Oral Health Considerations of Children: Grandparent Caregiver Perceptions, Behaviors, and Knowledge

INTRODUCTION

In the United States, approximately 2.7 million grandparents have permanent custody of their grandchildren. Prevalence of primary dental caries has remained steady for those living in poverty, and among children of color. Children in the care of their grandparents frequently live in socioeconomically disadvantaged households, where dental disparities continue to exist. Research regarding the grandfamily dynamic as it relates to oral health, is limited. The purpose of this study was to investigate oral health perceptions, behaviors, and knowledge of grandparents raising/caring for their grandchildren; and explore how a grandparent caregiver's oral health knowledge influences their perceptions/behaviors regarding their grandchild's oral health.

METHODS

This descriptive, cross-sectional survey research used non-probability sampling strategies to recruit grandparents who were the primary caregiver of their grandchildren, aged birth to eighteen years. A validated questionnaire was employed, both in-person and electronically.

RESULTS

A total of 75 grandparents participated and answered 52% (SD = 27%) of oral health knowledge questions correctly. The study showed a correlation between low-income grandparents (M = 3.94, SD = 1.02) having higher pediatric oral health knowledge. Additionally, results indicated the greater the knowledge, the more positive intent to assist grandchildren with routine brushing and in checking their teeth for cavities.

CONCLUSIONS

This study demonstrated that regardless of socioeconomic status, grandparent caregiver's oral health knowledge can positively affect their oral health-related behaviors and values, which could influence their grandchildren's' oral health. Further research regarding grandparent caregiver utilization of public health pediatric services and dental education programs, and the potential influence of these programs on pediatric oral health, should be explored.

Income-Based Disparities in a Yearly Dental Visit in United States Adults and Children: Trend Analysis 1997 to 2016

OBJECTIVE

To determine how income-based disparities in a yearly dental visit (the Healthy People 2020 Leading Health Indicator for Oral Health) changed since legislation to expand dental coverage and to compare disparity trends in children and adults.

METHODS

We analyzed Medical Expenditure Panel Survey 1997 to 2016 to determine yearly dental visit rates for US children and adults by family income. We determined measures of income disparity, including the Slope Index of Inequality and the Relative Index of Inequality and examined trends in yearly dental visit, Slope Index of Inequality, and Relative Index of Inequality using joinpoint regression.

RESULTS

Income-based disparities, absolute and relative, narrowed over time for children. Steady upward trends in yearly dental visit rates were observed for poor and low-income/poor children and no joinpoint was identified that corresponded to legislation expanding dental care coverage for lower income children. Relative income-based disparities in yearly dental visit rates widened for adults over 20 years. After declining for 14 years, yearly dental visit rate increased for poor adults from 2013 to 2016 suggesting a possible positive effect in adult dental care use trends following enactment of the Affordable Care Act.

CONCLUSIONS

In 1997, US children and adults had similar levels of income-based disparity in yearly dental visits, but by 2016, they differed markedly. Trends in income-based disparities in yearly dental visit rate narrowed for children but widened for adults. There are lessons from the expansion of dental care coverage for children that could be applied to improve access to dental care for adults.

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

Background: Dental caries in pediatric patients are noted to have broad impacts on systemic health and well-being. Thus, utilizing an effectiveness-implementation hybrid I design, the Pediatric Providers Against Cavities in Children's Teeth (PACT) trial is investigating multi-level interventions at the practice (incorporation of oral health in electronic medical record [EMR]) and provider levels (theory-based didactic and skills training to communicate oral health facts to parent/caregiver, give a prescription to see a dentist and a list of area dentists) to increase dental utilization among 3 to 6 year old Medicaid-enrolled children attending well-child visits (WCV). The formative and pilot work for the larger main trial are presented. Methods: Formative work-Focus groups with 26 participants (Community leaders, providers, parent/caregivers); and key informant interviews with practice leadership (n = 4). Topics discussed were: core oral health (OH) information to communicate at WCVs and study logistics. Transcripts were coded and analyzed using Atlas.ti; Pilot study was refined using the formative findings and was conducted at two pediatric practices to test the implementation of: the provider didactic and skills training curriculum; EMR incorporation of four OH questions; logistics of incorporating OH activities at a WCV; and parent/caregiver recruitment. Results: Formative work showed that providers and parent/caregivers required knowledge of dental caries, and a list of area Medicaid-accepting dentists. Providers and practice leadership advised on the logistics of incorporating oral health into WCVs. All groups suggested asking parent/caregivers their preferred method of contact and emphasizing importance of OH to motivate participation. Utilizing these findings, the curriculum and protocol was revised. The pilot study in two practices successfully implemented the protocol as follows: all seven providers were trained in two 45 min didactic education and skills session; incorporation of OH questions into practices EMR; recruited 86 child-parent dyads (95% participation) at the WCV; providers delivered the OH intervention to parent/caregivers in <2 min and 90% completed EMR documentation of OH questions. These findings were instrumental in finalizing the main PACT trial in 18 practices. The RE-AIM framework is used in the main trial to collect effectiveness and implementation measures at baseline and follow-up visits. Conclusions: The formative and pilot findings were instrumental in refining the OH intervention and protocol which has resulted in successful implementation of the main trial. Trial Registration: Clinical trials.gov, Registered 9 November 2017, NCT03385629.