Longitudinal caries prevalence in a comprehensive, multicomponent, school-based prevention program

Integrating silver diamine fluoride into school-based oral health programs: A pilot study

Objective

Current approaches to school-based caries prevention can increase access to oral healthcare, but are often limited by costs and other logistical challenges. Evidence from large pragmatic trials support the use of silver diamine fluoride (SDF) to prevent and control caries in school dental programs. In this pilot, we developed implementation strategies and integrated SDF into an existing school-based dental program, Smiles For Students (SFS).

Methods

This was a single-group observational pilot. Using a school-based SDF implementation toolkit, SFS clinicians received training in clinical protocols as well as ongoing interactive technical assistance to support SDF integration. SDF was then implemented into existing clinical workflows.

Results

Following training and implementation, the Smiles For Students program saw a 23 % increase in the number of patients served, a 53 % decrease in the per-child treatment time, a 45 % decrease in labor costs despite increased enrollment, and a 24 % decrease in supply costs. Qualitative feedback indicated strong support for simplified clinical protocols, reduction in cumbersome supplies and materials, and increased flexibility with space and resources.

Conclusions

In a pilot implementation project in which SDF was integrated into an existing school-based dental program serving 16 schools, multiple logistical and economic challenges were mitigated and program clinicians utilized both sealants and SDF to meet the needs of participating children.

Caries Incidence in School-Based Prevention Programs in the Presence of Interval Censoring

BACKGROUND/OBJECTIVES

School-based caries prevention can increase access to critical dental services and reduce oral health inequities. However, little is known regarding the incidence of dental caries in children participating in school caries prevention, and caries diagnosis is often interval censored.

METHODS

In this paper, we used data from a longitudinal, school-based, randomized clinical trial of minimally invasive treatments for dental caries to estimate the per-visit incidence rate and compare the hazard of dental caries in children receiving either silver diamine fluoride or glass ionomer dental sealants. To account for interval censoring, we used semiparametric transformation models for univariate failure time data and imputed caries incidence using G-imputation.

RESULTS

There were 3040 children that met inclusion criteria for analysis, 1516 (49.9%) of which were randomly assigned to receive silver diamine fluoride and 1524 (50.1%) were assigned to receive glass ionomer dental sealants and atraumatic restorations. There were no differences in the hazard of caries between treatments (HR = 0.99, 95% CI = 0.72, 1.24), while children with caries at baseline had a significant increase in the hazard of new caries (HR = 2.54, 95% CI = 2.26, 2.83) compared to those that were caries free. The per-visit caries incidence ranged from 4.8 to 11.1 at the individual level and increased with each successive study observation.

CONCLUSIONS

School-based caries prevention can positively affect caries incidence, and the results can be used to inform future program design and implementation.

The effectiveness of medical nurses in treating children with silver diamine fluoride in a school-based caries prevention program

BACKGROUND

The sustainability of school-based oral health programs depends on the utilization of effective, efficient treatments and the availability of a trained clinical workforce. The objective of this study was to determine whether registered nurses are comparable to dental hygienists in the application and effectiveness of silver diamine fluoride (SDF) and fluoride varnish (FV) for the prevention of dental caries.

METHODS

CariedAway was a school-based study of SDF and FV versus dental sealants and atraumatic restorations. Within the SDF + FV arm, participants were treated by either a licensed dental hygienist or a registered nurse, both under the supervision of a paediatric dentist. Although initial treatment assignment in CariedAway was randomized, assignment to provider was not. The proportion of children who remained caries free after 2 years was assessed for non-inferiority using two-group proportion tests, adjusting for the clustering effect of schools.

RESULTS

A total of 417 children with no untreated caries at baseline were analysed including 298 treated by hygienists and 119 by nurses. The proportion of children who remained caries free after 2 years was 0.81 and 0.80 for those treated by hygienists and nurses, respectively, for a difference of 0.01 (95% CI = -0.07, 0.098) and within the pre-determined non-inferiority margin.

CONCLUSIONS

Nurses may be effective in treating children with silver diamine fluoride and other fluoride varnishes in school-based oral health programs.

School-based caries prevention using silver diamine fluoride: A pragmatic randomized trial in low-income rural children

Background

Dental caries is the world's most prevalent noncommunicable disease, disproportionately affecting children from low-income families and rural geographic areas.

Methods

The CariedAway 3.0 study was a cluster-randomized pragmatic non-inferiority trial comparing silver diamine fluoride (SDF) to sealants and atraumatic restorations (ART) for the prevention and control of dental caries. All participants also received fluoride varnish. Analysis consisted of mixed-effects logistic regression for caries prevalence and weighted least squares and mixed-effects negative binomial regression for caries incidence. A non-inferiority margin of 10% for the difference between groups was used. Dental caries was defined as an ICDAS score of four or greater.

Results

A total of 3345 children were enrolled across 35 schools; however there was a large proportion of children who were noncompliant and received external dental care over the course of the trial. In adjusted analyses of compliant participants (n=1083; 543 in the SDF group and 540 in the sealant and ART group), there was no difference in the weighted risk difference between treatment groups (B=0.003, 95% CI = -0.0001, 0.0008). The odds of caries prevalence was elevated in the SDF group in longitudinal analyses (OR = 1.35, 95% CI = 0.86, 2.11) but was not significant and was below the non-inferiority margin. There were no significant differences between groups for caries incidence in adjusted models (IRR = 1.19, 95% CI = 0.81, 1.74). Results for intent to treat analyses were similar to that of per-protocol.

Discussion

In this school-based clinical trial, the prevalence of dental caries in children treated with SDF and fluoride varnish was non-inferior compared to those treated with sealants, ART, and fluoride varnish, although the overall risk was slightly higher. Unfortunately, a high rate of dropout and participant noncompliance was observed, likely due to the impacts of COVID-19 on study procedures. As a result, observed effects may be unreliable beyond the short-term.

Trial Registration

NCT03448107.

Unmet Dental Needs in Children Following Suspension of School-Based Oral Health Services Due to COVID-19

BACKGROUND

Dental caries (tooth decay) is the world's most prevalent noncommunicable disease and can lead to pain, infection, and edentulism. Many children with caries lack access to traditional dental services. School-based caries prevention can increase access to care and reduce health inequities. Disruptions in school-based care due to pandemic control policies may result in children losing access to their primary dental care option.

METHODS

The CariedAway project was a school-based caries prevention program in operation from 2019 to 2023 in urban schools with a high proportion of low-income, minority students. Program operations were suspended for 2 years due to the COVID-19 pandemic. We estimated the prevalence of untreated decay, swelling, fistula, and pulpal involvement in participants at baseline and again after restrictions were lifted.

RESULTS

A total of 2998 children between the ages of 5 and 13 years were enrolled and received preventive care prior to pandemic shutdowns, and 1398 (47%) completed a follow-up observation after 2 years. At baseline, approximately 30% had untreated caries on any dentition, 11% of children presented with evidence of dental sealants, and no participants had swelling, fistula, or pulpal involvement. After 24 months, 12% of participants had swelling fistula, or pulpal involvement that was not treated during the pandemic period.

CONCLUSION

There are considerable unmet dental needs in high-risk children that may be further exacerbated by a lack of access to care during disease outbreaks.

Noninferiority of Silver Diamine Fluoride vs Sealants for Reducing Dental Caries Prevalence and Incidence: A Randomized Clinical Trial

Importance

Dental caries is the world's most prevalent noncommunicable disease and a source of health inequity; school dental sealant programs are a common preventive measure. Silver diamine fluoride (SDF) may provide an alternative therapy to prevent and control caries if shown to be noninferior to sealant treatment.

Objective

To determine whether school-based application of SDF is noninferior to dental sealants and atraumatic restorative treatment (ART) in the prevalence of dental caries.

Design, Setting, and Participants

The Silver Diamine Fluoride Versus Therapeutic Sealants for the Arrest and Prevention of Dental Caries in Low-Income Minority Children (CariedAway) study was a pragmatic noninferiority cluster-randomized clinical trial conducted from February 2018 to June 2023 to compare silver diamine fluoride vs therapeutic sealants for the arrest and prevention of dental caries. Children at primary schools in New York, New York, with at least 50% of the student population reporting as Black or Hispanic and at least 80% receiving free or reduced lunch were included. This population was selected as they are at the highest risk of caries in New York. Students were randomized to receive either SDF or sealant with ART; those aged 5 to 13 years were included in the analysis. Treatment was provided at every visit based on need, and the number of visits varied by child. Schools with preexisting oral health programs were excluded, as were children who did not speak English. Of 17 741 students assessed for eligibility, 7418 were randomized, and 4100 completed follow-up and were included in the final analysis.

Interventions

Participants were randomized at the school level to receive either a 38% concentration SDF solution or glass ionomer sealants and ART. Each participant also received fluoride varnish.

Main Outcomes and Measures

Primary study outcomes were the prevalence and incidence of dental caries.

Results

A total of 7418 children (mean [SD] age, 7.58 [1.90] years; 4006 [54.0%] female; 125 [1.7%] Asian, 1246 [16.8%] Black, 3648 [49.2%] Hispanic, 153 [2.1%] White, 114 [1.5%] multiple races or ethnicities, 90 [1.2%] other [unspecified], 2042 [27.5%] unreported) were enrolled and randomized to receive either SDF (n = 3739) or sealants with ART (n = 3679). After initial treatment, 4100 participants (55.0%) completed at least 1 follow-up observation. The overall baseline prevalence of dental caries was approximately 27.2% (95% CI, 25.7-28.6). The odds of decay prevalence decreased longitudinally (odds ratio [OR], 0.79; 95% CI, 0.75-0.83) and SDF was noninferior compared to sealants and ART (OR, 0.94; 95% CI, 0.80-1.11). The crude incidence of dental caries in children treated with SDF was 10.2 per 1000 tooth-years vs 9.8 per 1000 tooth-years in children treated with sealants and ART (rate ratio, 1.05; 95% CI, 0.97-1.12).

Conclusions and Relevance

In this school-based pragmatic randomized clinical trial, application of SDF resulted in nearly identical caries incidence compared to dental sealants and ART and was noninferior in the longitudinal prevalence of caries. These findings suggest that SDF may provide an effective alternative for use in school caries prevention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03442309.

The Development and Implementation of a School-Based Dental Sealant Program for Hawaii Public Schools

BACKGROUND

School-based dental sealant programs are noted to increase sealant uptake among children, especially those from low-income families and those living in rural and underserved areas. However, nationally school-based dental sealant programs are substantially underutilized. This paper describes a partnership approach to a school-based dental sealant program for Title 1 public schools in Hawaii.

METHODS

The Hawaii Keiki: Healthy and Ready to Learn program partnered with the Hawaii Dental Service to develop and implement an interprofessional, school-based sealant program (SBSP). This article describes the development of key factors, such as partnerships, an interprofessional team, team roles, policies, and marketing tools to optimize program success.

RESULTS

The SBSP has completed over 3 academic years of implementation in Hawaii public schools. In its initial year (school year [SY] 2019-2020), which presented challenges due to the COVID-19 pandemic, it served 6 schools (106 students screened) on 1 island. It expanded to 14 schools on 1 island (193 students screened) in its second year (SY 2020-2021), 28 schools on 3 islands (653 students screened) in its third year (SY 2021-2022), and during the Fall of the fourth year, the program reached 50 schools on 3 islands (1821 students screened) and is projected to reach over 70 schools by the end of SY 2022-2023.

CONCLUSION

Taking advantage of strategic partnerships and key interprofessional team members, a school-based dental sealant program can help to improve the oral health of children in public schools by helping to decrease barriers to care.

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.

Effect of Silver Diamine Fluoride on Caries Arrest and Prevention: The CariedAway School-Based Randomized Clinical Trial

IMPORTANCE

Dental caries is the most common global childhood disease. To control caries, the Centers for Disease Control and Prevention recommends school-based caries prevention, and the World Health Organization lists glass ionomer cement and silver diamine fluoride as essential medicines for oral disease.

OBJECTIVE

To determine the noninferiority of silver diamine fluoride with fluoride varnish vs traditional glass ionomer sealants with fluoride varnish after 2 years when provided to children via a school-based health care program.

DESIGN, SETTING, AND PARTICIPANTS

The CariedAway study is an ongoing single-blind, cluster randomized, noninferiority trial conducted between February 1, 2019, and June 1, 2023, among 2998 children in 47 New York City primary schools. Children aged 5 to 13 years of any race and ethnicity were recruited from block-randomized schools. Inclusion criteria for schools were a student population of at least 50% Hispanic or Latino or Latina ethnicity and/or Black race and at least 80% of students receiving free or reduced-cost lunch. Statistical analysis is reported through March 2022.

INTERVENTIONS

Children received a single application of silver diamine fluoride with fluoride varnish or an active comparator of glass ionomer sealants and atraumatic restorations with fluoride varnish.

MAIN OUTCOMES AND MEASURES

Primary outcomes were caries arrest and incidence after a 2-year follow-up, assessed using mixed-effects multilevel models and clustered 2-sample proportion tests. The noninferiority margin was 10%. Intention-to-treat analysis was performed using multiple imputation.

RESULTS

A total of 2998 children (1566 girls [52.2%]; mean [SD] age at baseline, 6.6 [1.2] years; 1397 Hispanic or Latino or Latina children [46.6%]; 874 [29.2%] with untreated dental caries) were recruited and treated from September 16, 2019, to March 12, 2020. Follow-up observations were completed for 1398 children from June 7, 2021, to March 2, 2022. The mean (SE) proportion of children with arrested caries was 0.56 (0.04) after experimental treatment and 0.46 (0.04) after control treatment (difference, -0.11; 95% CI, -0.22 to 0.01). The mean (SE) proportion of patients without new caries was 0.81 (0.02) after experimental treatment and 0.82 (0.02) after control treatment (difference, 0.01; 95% CI, -0.04 to 0.06). Analysis of imputed data for the full sample did not deviate from per-protocol analyses. There were no adverse events.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, silver diamine fluoride with fluoride varnish was noninferior to sealants and atraumatic restorations with fluoride varnish for caries arrest and prevention. Results may support the use of silver diamine fluoride as an arresting and preventive agent in school-based oral health programs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03442309.

The Impact of Dental Care Programs on Individuals and Their Families: A Scoping Review

BACKGROUND

Despite significant global improvements in oral health, inequities persist. Targeted dental care programs are perceived as a viable approach to both improving oral health and to address inequities. However, the impacts of dental care programs on individual and family oral health outcomes remain unclear.

OBJECTIVES

The purpose of this scoping review is to map the evidence on impacts of existing dental programs, specifically on individual and family level outcomes.

METHODS

We systematically searched four scientific databases, MEDLINE, EMBASE, CINAHL, and Sociological Abstracts for studies published in the English language between December 1999 and November 2021. Search terms were kept broad to capture a range of programs. Four reviewers (AG, VD, AE, and KKP) independently screened the abstracts and reviewed full-text articles and extracted the data. Cohen's kappa inter-rater reliability score was 0.875, indicating excellent agreement between the reviewers. Data were summarized according to the PRISMA statement.

RESULTS

The search yielded 65,887 studies, of which 76 were included in the data synthesis. All but one study assessed various individual-level outcomes (n = 75) and only five investigated family outcomes. The most common program interventions are diagnostic and preventive (n = 35, 46%) care, targeted children (n = 42, 55%), and delivered in school-based settings (n = 28, 37%). The majority of studies (n = 43, 57%) reported a significant improvement in one or more of their reported outcomes; the most assessed outcome was change in dental decay (n = 35).

CONCLUSIONS

Dental care programs demonstrated effectiveness in addressing individual oral health outcomes. However, evidence to show the impact on family-related outcomes remains limited and requires attention in future research.

"The pediatric dentist is different": A qualitative study of young children's caregivers' experiences of oral health care in the Galapagos Islands

BACKGROUND

Little is known about factors influencing children's access to and use of oral healthcare services in the Galapagos Islands, a resource-limited setting.

AIM

We sought to understand caregivers' experiences and factors influencing their children's use of dental services on San Cristobal Island in the Galapagos Archipelago.

DESIGN

A community-based qualitative interview study was carried out among 25 caregivers of children aged 6 months to 10 years. Participants were recruited via a random walk door-to-door approach in 10 neighborhoods, and interviews were conducted by a trained research assistant who is native of the Galapagos Islands. We employed a grounded theory-based qualitative data analysis based on inductive coding to identify and report major emerging themes and illustrative participant quotes.

RESULTS

Two major themes emerged related to children's oral health care. Participants expressed their preference for care provided by paediatric versus general dentists and recognized the important role of school-based dental care programs, acknowledging their strengths and weaknesses.

CONCLUSIONS

Participants' lived experiences were informative and helped improve our understanding of factors influencing children's use of dental services in the Galapagos Islands. Above and beyond their local relevance, these themes and insights are likely applicable to other global communities that experience similar barriers of access to oral healthcare services.