Disparities in oral health status between older adults in a multiethnic rural community: the rural nutrition and oral health study

Mechanisms of the Native American pain inequity: predicting chronic pain onset prospectively at 5 years in the Oklahoma Study of Native American Pain Risk

ABSTRACT

A pain inequity exists for Native Americans (NAs), but the mechanisms are poorly understood. The Oklahoma Study of Native American Pain Risk (OK-SNAP) addressed this issue and recruited healthy, pain-free NAs and non-Hispanic Whites (NHWs) to attend 2 laboratory visits and assessed mechanisms consistent with the biopsychosocial model of pain: demographics, physical variables, psychosocial factors, and nociceptive/pain phenotypes. Then participants were surveyed every 6 months to assess for chronic pain onset. Results at the 2-year follow-up found that NAs were ∼3x more likely than NHWs to develop chronic pain. Moreover, psychosocial factors (discrimination, stress, pain-related anxiety), cardiometabolic load (higher body mass index and blood pressure, lower heart rate variability), and impaired inhibition of spinal nociception partly mediated the pain inequity. The present study examined mechanisms of chronic pain at the 5-year follow-up for OK-SNAP. Results found that the NA pain inequity worsened-NAs were 4x more likely to develop chronic pain (OR = 4.025; CI = 1.966, 8.239), even after controlling for baseline age, sex assigned at birth, income, and education. Moreover, serial mediation models replicated paths from the 2-year follow-up that linked psychosocial variables, cardiometabolic load, and impaired inhibition of spinal nociception to chronic pain onset. Further, 2 new significant paths were observed. One linked discrimination, stress, sleep problems, and facilitated pain perception to increased pain risk. The other linked discrimination with higher spinal nociceptive threshold and pain risk. These results provide further evidence for a NA pain inequity and identify multiple psychosocial, cardiometabolic, and pronociceptive targets for primary interventions.

Trends in North Carolina's Oral Health Workforce

Work remains in North Carolina to effectively increase access to oral health care and address the maldistribution of the dental workforce. This study provides updated data on the oral health workforce (from 2000 to 2022) in response to the recommendations outlined in the North Carolina Institute of Medicine Oral Health Transformation Task Force report.

Self-rated oral and general health among Aboriginal adults in regional South Australia

BACKGROUND

In Australia, Aboriginal adults experience higher levels of poor oral and general health than the non-Aboriginal population. This study compared self-rated oral and general health among Aboriginal adults in regional South Australia with participants in the National Survey of Adult Oral Health (NSAOH).

METHODS

Data were obtained from the Indigenous Oral Health Literacy Project (IOHLP) based in South Australia. Three sub-populations from the NSAOH were utilised for comparison: National Aboriginal, National non-Aboriginal and South Australian Regional Non-Aboriginal adults. All data were standardised by age group and sex, utilising Census data.

RESULTS

Just over 70% of South Australian Regional Aboriginal participants gave a rating of 'excellent, very good or good' for general health, more than 17% lower than each of the other groups. Just over 50% rated their oral health highly, 20% fewer than the proportion for each other group. Stratifying by key socio-demographic factors did not account for all differences.

CONCLUSIONS

Proportionally fewer South Australian Regional Aboriginal adults had high ratings of oral and general health than the Aboriginal and non-Aboriginal adults from the national survey, indicating that national-level data might underestimate the proportion of regional Aboriginal Australians with poor oral health.

Psychosocial and cardiometabolic predictors of chronic pain onset in Native Americans: serial mediation analyses of 2-year prospective data from the Oklahoma Study of Native American Pain Risk

ABSTRACT

Chronic pain results in considerable suffering, as well as significant economic and societal costs. Previous evidence suggests that Native Americans (NAs) have higher rates of chronic pain than other U.S. racial or ethnic groups, but the mechanisms contributing to this pain disparity are poorly understood. The Oklahoma Study of Native American Pain Risk was developed to address this issue and recruited healthy, pain-free NAs and non-Hispanic Whites. Cross-sectional analyses identified several measures of adversity (eg, trauma and discrimination), cognitive-affective factors (perceived stress and pain-related anxiety/catastrophizing), and cardiometabolic factors (eg, body mass index, blood pressure, and heart rate variability) that were associated with pronociceptive processes (eg, central sensitization, descending inhibition, and hyperalgesia). Every 6-months after enrollment, eligible participants (N = 277) were recontacted and assessed for the onset of chronic pain. This study examines predictors of chronic pain onset in the 222 participants (80%) who responded over the first 2 years. The results show that NAs developed chronic pain at a higher rate than non-Hispanic Whites (OR = 2.902, P < 0.05), even after controlling for age, sex, income, and education. Moreover, serial mediation models identified several potential pathways to chronic pain onset within the NA group. These paths included perceived discrimination, psychological stress, pain-related anxiety, a composite measure of cardiometabolic risk, and impaired descending inhibition of spinal nociception (assessed from conditioned pain modulation of the nociceptive flexion reflex). These results provide the first prospective evidence for a pain disparity in NAs that seems to be promoted by psychosocial, cardiometabolic, and pronociceptive mechanisms.

Oral Health in America

Background

Important, but insufficient, gains have been achieved in access to and delivery of oral health care since the 2000 US surgeon general’s report on oral health in America. Access to care has increased for children and young adults, but considerable work remains to meet the oral health care needs of all people equitably. The National Institutes of Health report, Oral Health in America: Advances and Challenges, reviews the state of the US oral health care system, achievements made since 2000, and remaining challenges. In this article, the authors highlight key advances and continuing challenges regarding oral health status, access to care and the delivery system, integration of oral and systemic health, financing of oral health care, and the oral health workforce.

Results

Public insurance coverage has increased since 2000 but remains limited for many low-income, minority, and older adult populations. The oral health care workforce has expanded to include new dental specialties and allied professional models, increasing access to health promotion and preventive services. Practice gains made by women and Asian Americans have not extended to other minority demographic groups. Oral health integration models are improving access to and delivery of patient-centered care for some vulnerable populations.

Conclusions and Practical Implications

Coordinated policies and additional resources are needed to further improve access to care, develop dental insurance programs that reduce out-of-pocket costs to lower-income adults, and improve the integration of oral and medical health care delivery targeting a common set of patient-centered outcomes. Dental care professionals need to fully participate in meaningful and system-wide change to meet the needs of the population equitably.

Variation in dental services by rurality among privately insured adults in the United States

OBJECTIVES

Rurality is associated with reduced dental access and worse oral health outcomes. It is unknown whether there is variation in dental services received by rural adults who visit a dentist.

METHODS

This was a retrospective analysis of claims data from a large private insurer. All individuals who had at least one dental visit in 2018 were included. Patient demographics, whether or not a patient's ZIP code was rural as defined by the Federal Office of Rural Health Policy, as well as ZIP code demographics were collected. Differences in the frequency of dental services received were evaluated using χ² tests. Multilevel logistic regressions were used to evaluate the individual and ZIP code-level correlates of receiving a preventive dental procedure, a tooth extraction, or a denture-related dental procedure.

RESULTS

Rates of preventive, oral and maxillofacial surgery, and denture-related procedures were higher among rural adults. Accounting for individual age and gender, and ZIP code average income and dentist density, rural dwellers were more likely to receive a preventive procedure [odds ratio (OR) 1.15, P < 0.0001] or tooth extraction (OR 1.08, P < 0.0001), and less likely to have a denture-related procedure (OR 0.94, P = 0.015) compared to nonrural dwellers. Female gender was the strongest predictor of receiving a preventive procedure (OR 1.30, P < 0.0001).

CONCLUSIONS

Even among privately insured individuals with known access to dental care, rurality was associated with significant differences in the frequency of various dental procedures. Rural dental patients may have higher needs for oral surgical procedures, even when they have access to preventive care.

Dental Care Utilization and Service Needs Among American Indian/Alaska Native/Native Hawaiian Elders: 2008 to 2017

Objective: This study describes trends in self-reported dental care utilization and services needed among American Indian/Alaska Native/Native Hawaiian (AI/AN/NH) elders 2008 to 2017, including demographic and socioeconomic variability. Method: Researchers utilized data from the Survey of Elders administered by the National Resource Center on Native American Aging, representing all regions of the United States and 262 tribes. Data were analyzed comparing means over time and between/within groups. Results: Between April 2008 and March 2017, there was a statistically significant (p < .001) increase in the proportion of older adults who visited a dentist and an increase in need for treatment. A smaller proportion of older adults reported need for treatment among those who were privately insured, high income, had no tobacco use, were employed, and had visited a dental professional in the last year. Discussion: These findings highlight current dental needs among tribal elders while also identifying elders at greater risk of poor oral health.

Racial Differences in the Oral Microbiome: Data from Low-Income Populations of African Ancestry and European Ancestry

Increasing evidence indicates the significant racial difference in gut, vaginal, and skin microbiomes. However, little is known regarding the racial difference in the oral microbiome. In this study, deep sequencing of 16S rRNA genes was utilized to assess the oral microbiome in mouth rinse samples of 1,058 African-Americans (AAs) and 558 European-Americans (EAs) from the Southern Community Cohort Study. Generally, AAs had a higher species richness than EAs, with P = 5.28 × 10-14 (Wilcoxon rank sum test) for Faith's phylogenetic diversity index. A significant difference in overall microbiome composition was observed between AAs and EAs, with P = 5.94 × 10-4 (MiRKAT) for the weighted UniFrac distance matrix. We also found 32 bacterial taxa showing a significant differential abundance or prevalence between the two racial groups at a Bonferroni-corrected P < 0.05 in linear or logistic regression analyses. Generally, AAs showed a higher abundance of Bacteroidetes and a lower abundance of Actinobacteria and Firmicutes Interestingly, four periodontal pathogens, Porphyromonas gingivalis, Prevotella intermedia, Treponema denticola, and Filifactor alocis, were more prevalent among AAs than among EAs, with Bonferroni-corrected P values of 5.23 × 10-6, 4.47 × 10-6, 1.08 × 10-3, and 4.49 × 10-5, respectively. In addition, all of these 32 taxa were significantly correlated with the percentage of genetic African ancestry. These findings call for research to understand how the racial difference in oral microbiome influences the health disparity.IMPORTANCE In this systemic investigation of racial differences in the oral microbiome using a large data set, we disclosed the significant differences in the oral microbial richness/evenness, as well as in the overall microbial composition, between African-Americans and European-Americans. We also found multiple oral bacterial taxa, including several preidentified oral pathogens, showing a significant different abundance or prevalence between African-Americans and European-Americans. Furthermore, these taxa were consistently found to be associated with the percentage of genetic African ancestry. Our findings warrant further research to understand how the racial difference in the oral microbiome influences the health disparity.

Oral health status of adults in North Carolina assisted living facilities

OBJECTIVES

The specific aims of this study were to describe the baseline oral health status of persons residing in North Carolina assisted living facilities and determine how identified oral health problems vary according to resident and facility demographic variables.

METHODS

This cross-sectional descriptive epidemiologic study used a statewide random sample of 40 assisted living facilities and a convenience sample of 854 assisted living residents. Dental hygienists and dentists conducted oral screenings on residents using the Association of State and Territorial Dental Director's Basic Screening Survey for Older Adults tool.

RESULTS

Nearly one-third of participants were younger than 65. Overall, poorer oral health was noted for non-Hispanic black residents, Medicaid recipients, residents of small facilities (20-60 beds), and residents of facilities located in the Coastal Plains region of the state. Oral health also worsened with increasing length of residence yet seemed to improve with age. The overall rate of edentulism was 29 percent, half of whom did not have complete dentures. Nearly half (48.6 percent) of residents had untreated decay.

CONCLUSIONS

There is a need for policy and public health programming that addresses the broad racial and socioeconomic factors that contribute to disparities among the institutionalized. Furthermore, the oral health disparities between institutionalized and community-dwelling older adults reflect the need for policy that requires and ensures access to a minimum level of oral health care throughout the duration of a resident's stay. Programming to support such policy should include development of an oral health workforce that is competent in geriatric oral health care.

Oral Health and Dental Care in Older Asian Americans in Central Texas

OBJECTIVES

To examine factors associated with dental health insurance, self-rated oral health, and use of preventive dental care services in older Asian Americans.

DESIGN

Cross-sectional survey.

SETTING

The Asian American Quality of Life Survey was conducted with 2,614 Asian Americans living in central Texas using questionnaires available in English and six Asian languages.

PARTICIPANTS

Asian American Quality of Life Survey participants aged 60 and older (N = 533; mean age = 69.4 ± 6.9).

MEASUREMENTS

Participants were asked whether they had insurance that covered the cost of any dental visit, how they would rate their overall oral health status, and whether they had visited a dental clinic for a routine examination in the past 12 months. Information was also collected on sociodemographic and immigration-related variables.

RESULTS

More than 61% of the sample had no dental health insurance, 45% reported that their oral health was fair or poor, and 44% had not used preventive dental care services. A series of logistic regression analyses identified factors posing a significant risk to oral health and dental care. For example, those with limited English proficiency were 3.5 times as likely to lack dental health insurance and 3.2 times as likely to rate their oral health as fair or poor. The odds of not using preventive dental care services were 6.4 times as great in those without dental health insurance.

CONCLUSION

The overall findings call attention to efforts to promote oral health and dental care in older Asian Americans.

Associação entre resiliência e qualidade de vida relacionada à saúde bucal em idosos

OBJETIVO: Avaliar a associação entre resiliência e qualidade de vida relacionada à saúde bucal, por meio de uma abordagem hierárquica baseada em um modelo teórico conceitual em uma coorte de idosos do Rio Grande do Sul. MÉTODOS: Foi conduzido um estudo transversal aninhado a um estudo de coorte, em 2008. Foram avaliados 498 idosos de Carlos Barbosa, Rio Grande do Sul. As medidas avaliadas foram sociodemográficas, comportamentos de saúde, qualidade de vida relacionada à saúde bucal, medida pelo Oral Health Impact Profile (OHIP-14), Escala de Resiliência e CPOD. A associação entre o potencial de resiliência e os impactos na percepção de saúde bucal relacionados à qualidade de vida foi verificada por meio de regressão binomial negativa. Razões das médias (RM) são apresentadas com seus intervalos de confiança de 95% (IC95%). RESULTADOS: Maiores médias do OHIP foram encontradas entre mulheres (6,7 ± 6,3; p = 0,011), moradores da zona rural (7,3 ± 6,7; p = 0,004) e solteiros (8,0 ± 6,3; p = 0,032). O modelo final da análise multivariada mostrou que ser morador da zona rural (RM = 1,32; IC95% 1,06 - 1,65) e casado (RM = 1,36; IC95% 1,07 - 1,72) foram variáveis independentemente associadas à qualidade de vida relacionada à saúde bucal. Não houve associação entre resiliência e qualidade de vida relacionada à saúde bucal. CONCLUSÃO: Os resultados sugerem que variáveis sociodemográficas estão associados à qualidade de vida relacionada à saúde bucal. A hipótese de que a resiliência pudesse exercer um papel importante no desfecho não foi confirmada.

Social stratification and tooth loss among middle-aged and older Americans from 1988 to 2004

OBJECTIVES

Tooth retention has improved over the past few decades, but it is not known whether these trends have been observed across all demographic/socioeconomic subgroups. We examined number of missing teeth among dentate individuals (n = 9,113) as well as edentulism and systematically modeled their trends over time by using clinical examination data.

METHODS

We investigated the association between social stratification and trends in tooth retention among adults ages 50+ from 1988 to 2004, using four waves of the National Health and Nutrition Examination Surveys (NHANES) (n = 11,812).

RESULTS

The prevalence of edentulism declined from 24.6% in NHANES III (1988-1994) to 17.4% in 2003-2004, and the mean number of missing teeth declined from 8.19 to 6.50. Older participants, Blacks, the less educated and those with lower income were higher on both edentulism and number missing teeth. Both edentulism and number of missing teeth declined over time, but their patterns varied. For edentulism, age and socioeconomic related disparities decreased over time due to more decline among older and low-income participants. For missing teeth, there was less decrement among older and low-income participants, resulting in increased age and socioeconomic related disparities.

CONCLUSIONS

Our study found disparities in trends of tooth loss across demographic/socioeconomic strata. Findings suggest that racial/ethnic disparities are partially explained by socioeconomic status. Interventions designed to improve oral health for older adults, particularly those with low levels of income, need special attention.

Racial disparities in trajectories of dental caries experience

OBJECTIVES

This study charted the trajectories of dental caries, including decayed teeth, missing teeth and filled teeth among older Americans over a 5-year period. In particular, it focused on racial differences in the levels of and rates of change in dental caries experience.

METHODS

Data came from the Piedmont Dental Study. The sample included 810 older Americans who were dentate at the baseline with up to 4 repeated observations between 1988 and 1994. Hierarchical linear models were employed in depicting intrapersonal and interpersonal differences in dental caries experience.

RESULTS

Different measures of caries outcomes exhibited distinct trajectories. On average, the number of decayed teeth decreased over time, whereas missing teeth increased. In contrast, the number of filled teeth remained stable during a 5-year period. Relative to their white counterparts, older black Americans had more decayed teeth and missing teeth but fewer filled teeth. Blacks and whites differed in the levels of dental caries but not in their rates of change except for missing teeth. Even when demographic and socioeconomic attributes were adjusted, racial variations in dental caries experience remained significant.

CONCLUSIONS

Although significantly correlated, various dental caries outcomes move along different paths over time. In view of the persistent racial disparities in dental caries trajectories, future interventions to minimize such variations among older Americans in the levels of and the rates of change in dental caries experience are clearly warranted.

Examining the perceptions, preferences, and practices that influence healthy aging for African American older adults: an ecological perspective

This study explored the healthy aging and health promotion perceptions, preferences, and practices of a purposive sample of African American older adults who resided in two communities in the south. An ecological framework was used to capture environmental factors, perceptions regarding access to health promotion resources, and health behavior preferences and practices. A mixed-method approach was used. Health supporting amenities were mapped, focus groups were conducted, and demographic information was obtained. The data were merged to create consolidated themes. The results indicated that health promotion amenities were available, but with some limitations. Convenient access to transportation strongly affected ability to use resources. Older adults were interested in preserving their health and independence, but some had difficulty staying motivated to maintain a healthy lifestyle. They wanted easier access to amenities. Implications for best practice include attention to culturally responsive outreach, motivating with social support and incentives, and developing community-based culturally compatible programming.

Sex/Gender differences in tooth loss and edentulism: historical perspectives, biological factors, and sociologic reasons

This review highlights what is known regarding differences in tooth loss by sex/gender, and describes: gender-related tooth ablation (the deliberate removal of anterior teeth during life) found in skulls from history and prehistory; potential mediators of the relationship between sex/gender and tooth loss; the current epidemiology of gender differences in tooth loss (limited to North America); and risk factors for tooth loss in the general population and in women.

Dental care utilization among North Carolina rural older adults

OBJECTIVES

This analysis delineates the predisposing, need, and enabling factors that are associated with regular and recent dental care in a multiethnic sample of rural older adults.

METHODS

A cross-sectional, comprehensive, oral-health survey conducted with a random, multiethnic (African American, American Indian, white) sample of 635 community-dwelling adults aged 60 years and older was completed in two rural southern counties. Logistic regression models assessed the simultaneous associations of dental care with predisposing, enabling, and need factors.

RESULTS

Almost no edentulous rural older adults received dental care; 27.1 percent of dentate rural older adults had received regular dental care, and 36.7 percent had received recent dental care. Predisposing (less than high-school education, dental anxiety), enabling (no regular place for dental care), and need factors (no filled teeth) reduced the odds of regular dental, while predisposing (dental anxiety), enabling (no regular place for dental care), and need factors (no filled teeth) reduced the odds of recent dental care. Having excellent, very good, or good self-rated oral health increased the odds of receiving regular and recent dental care.

CONCLUSIONS

Regular and recent dental care are infrequent among rural older adults. Contrary to expectations, those not receiving dental care are those who most need care; this has been referred to as the Paradox of Dental Need. Community access to dental care and the ability of older adults to pay for dental care must be addressed by public-health policy to improve the health and quality of life of older adults in rural communities.

Edentulism trends among middle-aged and older adults in the United States: comparison of five racial/ethnic groups

OBJECTIVES

This study examined edentulism trends among adults aged 50 and above in five ethnic groups in the United States: Asians, African Americans, Hispanics, Native Americans, and non-Hispanic Caucasians.

METHODS

Data came from the National Health Interview Surveys between 1999 and 2008. Respondents included 616 Native Americans, 2,666 Asians, 15,295 African Americans, 13,068 Hispanics, and 86,755 Caucasians.

RESULTS

In 2008, Native Americans had the highest predicated rate of edentulism (23.98%), followed by African Americans (19.39%), Caucasians (16.90%), Asians (14.22%), and Hispanics (14.18%). Overall, there was a significant downward trend in edentulism rates between 1999 and 2008 (OR = 0.97, 95% CI: 0.96, 0.98). However, compared with Caucasians, Native Americans showed a significantly less decline of edentulism during this period (OR = 1.10, 95% CI: 1.02, 1.19).

CONCLUSIONS

While there was a downward trend in edentulism between 1999 and 2008, significant variations existed across racial/ethnic groups. Innovative public health programs and services are essential to prevent oral health diseases and conditions for minority populations who lack access to adequate dental care. Additionally, given the increasing numbers of adults retaining their natural teeth, interventions designed to assist individuals in maintaining healthy teeth becomes more critical.

Diabetes Effects on Dental Implant Survival

The goal of this review is to critically appraise the clinical evidence guiding our application of dental implant therapy relative to glycemic control for patients with diabetes. Our initial searches of the literature identified 129 publications relevant to both dental implants and diabetes. These were reduced to 17 clinical studies for inclusion. Reported implant failure rates in these 17 reports ranged from 0 to 14.3% for patients with diabetes. Unfortunately, the majority of these reports lacked sufficient information relative to glycemic control to allow the application of the findings toward clinical care. However, clinical evidence is emerging from several investigations that diabetes and glycemic control are important considerations that may require modifications to therapeutic protocols, but may not be contraindications to implant therapy in diabetes patients. Also, a potentially important role for implant therapy to support oral function in diabetes dietary management remains to be determined.

A critical review of diabetes, glycemic control, and dental implant therapy

OBJECTIVES

To systematically examine the evidence guiding the use of implant therapy relative to glycemic control for patients with diabetes and to consider the potential for both implant therapy to support diabetes management and hyperglycemia to compromise implant integration.

MATERIAL AND METHODS

A systematic approach was used to identify and review clinical investigations directly assessing implant survival or failure for patients with diabetes. A MEDLINE (PubMED) database search identified potential articles for inclusion using the search strategy: (dental implants OR oral implants) AND (diabetes OR diabetic). Inclusion in this review required longitudinal assessments including at least 10 patients, with included articles assessed relative to documentation of glycemic status for patients.

RESULTS

Although the initial search identified 129 publications, this was reduced to 16, for inclusion. Reported implant failure rates for diabetic patients ranged from 0% to 14.3%. The identification and reporting of glycemic control was insufficient or lacking in 13 of the 16 studies with 11 of these enrolling only patients deemed as having acceptable glycemic control, limiting interpretation of findings relative to glycemic control. Three of the 16 studies having interpretable information on glycemic control failed to demonstrate a significant relationship between glycemic control and implant failure, with failure rates ranging from 0% to 2.9%.

CONCLUSIONS

Clinical evidence is lacking for the association of glycemic control with implant failure while support is emerging for implant therapy in diabetes patients with appropriate accommodations for delays in implant integration based on glycemic control. The role for implants to improve oral function in diabetes management and the effects of hyperglycemia on implant integration remain to be determined.

Dental anxiety and oral health outcomes among rural older adults

OBJECTIVES

The objective of this study is to determine the degree to which rural older adults are able to complete a measure of dental anxiety and to assess the prevalence, as well as the demographic and oral health characteristics, of individuals reporting high dental anxiety.

METHODS

A population-based sample of 635 African American, American Indian and White older adults (age ≥ 60 years) completed an in-home survey, and 362 dentate participants completed an oral examination. Dental anxiety was measured using the four-item Corah's Dental Anxiety Scale (DAS). Gender, ethnicity, age, education, and oral health outcomes were compared between those who completed all four DAS questions (completers) and those who did not (noncompleters) as well as, among completers, those with high versus low DAS scores.

RESULTS

There were 94 (14.8%) noncompleters. Noncompletion was associated with older age, lower education, being edentulous, and having gingival recession. 12.4% of DAS completers had high DAS scores, which was more common among those aged 60-70 years, women, and those with oral pain and sore or bleeding gums. In logistic regression analysis, only sore and bleeding gums had a significant association with a high DAS score (odds ratio = 2.40, 95% confidence interval 1.09-5.26).

CONCLUSIONS

About one in eight rural older adults have high dental anxiety, which is associated with poor oral health outcomes. Identifying new approaches to measure dental anxiety among a population with limited interaction with dental care providers is needed.

Wisconsin Medicaid enrollees' recurrent use of emergency departments and physicians' offices for treatment of nontraumatic dental conditions

BACKGROUND

Medicaid enrollees experience a number of barriers that prevent them from seeking care in dental offices, leading some to repeatedly seek treatment for nontraumatic dental conditions (NTDCs) in emergency departments (EDs) and physicians' offices (POs). The authors examined the rate of return visits to EDs and POs for treatment of NTDCs among Wisconsin Medicaid enrollees and sought to characterize frequent and typical users of such care in this population.

METHODS

The authors conducted a retrospective analysis of all Wisconsin Medicaid dental claims for NTDCs to EDs and POs from 2001 through 2003. They used finite mixture models, allowing for covariate dependence, to model separate rates of return for NTDC-related visits corresponding to typical and frequent users of EDs and POs.

RESULTS

Overall, 23,999 enrollees had made NTDC-related visits to EDs and POs, with 6.5 percent estimated to be frequent users of such care. Typical and frequent users had a mean (± standard error) rate of return visits of 0.2 ± 0.01 and 4.0 ± 0.08 per year, respectively. Male enrollees and people aged 19 to 42 years were more likely to be frequent users, with African American and Hispanic enrollees having lower odds of being frequent users than did white enrollees. The effect of living in an area with a shortage of dental health care professionals did not affect the likelihood of being a frequent user of EDs and POs for such care.

CONCLUSIONS

Male and middle-aged enrollees were significantly more likely to be frequent users of EDs and POs for treatment of NTDCs. Compared with white enrollees, African American and Hispanic enrollees were less likely to be frequent users and had lower rates of recurrent visits for NTDCs among typical users.

CLINICAL IMPLICATIONS

Improved access to dental care for Medicaid enrollees that is best managed by dental care providers should reduce the rates of recurrent NTDC-related visits to EDs and POs.

Ethnic variation in oral health and social integration among older rural adults

This analysis examines the associations of oral health with social integration among ethnically diverse (African American, American Indian, White) rural older adults. Data are from a cross-sectional survey of 635 randomly selected community-dwelling adults aged 60+. Measures include self-rated oral health, number of teeth, number of oral health problems, social engagement, and social network size. Minority elders have poorer oral health than do White older adults. Most rural elders have substantial social engagement and social networks. Better oral health (greater number of teeth) is directly associated with social engagement, whereas the relationship of oral health to social network size is complex. The association of oral health with social engagement does not differ by ethnicity. Poorer oral health is associated with less social integration among African American, American Indian, and White elders. More research on the ways oral health affects the lives of older adults is warranted.

Dry mouth and dietary quality in older adults in north Carolina

OBJECTIVES

To quantify prevalence of dry mouth, association between dry mouth and beverage intake and dietary quality, and association between dry mouth and self-reported dietary accommodations to oral health deficits.

DESIGN

Cross-sectional study; data from self-reports.

SETTING

Rural North Carolina counties with substantial African-American and American Indian populations.

PARTICIPANTS

Six hundred twenty-two participants aged 60 and older.

MEASUREMENTS

Data included the 11-item Xerostomia Inventory (higher scores connote greater effect from dry mouth), a food frequency questionnaire (converted into Health Eating Index-2005 scores), and survey items on foods modified before consumption or avoided because of oral health problems.

RESULTS

Dry mouth was associated with being female, lower education, and income below the poverty level. Although overall beverage consumption did not vary with dry mouth, consumption of certain sugar-sweetened beverages was positively associated with dry mouth. Overall dietary quality did not differ with dry mouth, but more-severe dry mouth was associated with lower intake of whole grains and higher intakes of fruits. Dry mouth was strongly associated with self-reported modification and avoidance of foods. Those in the highest tertile of dry mouth were more likely to modify several foods than those in the lowest tertile and were more likely to avoid three or more foods.

CONCLUSION

Older adults appear to modify foods or selectively avoid foods in response to perceived dry mouth. Despite these behaviors, dry mouth does not result in poorer dietary quality.

Oral health among white, black, and Mexican-American elders: an examination of edentulism and dental caries

OBJECTIVES

To examine racial/ethnic disparities in oral health among older Americans.

METHODS

Differences in frequency of edentulism and number of decayed, missing, and filled teeth were assessed in 2,679 non-Hispanic white, 742 non-Hispanic black, and 934 Mexican-American individuals aged 60 and older from the National Health and Nutrition Examination Survey (1999-2004).

RESULTS

Controlling for potential confounding variables, blacks and Mexican-Americans had significantly higher numbers of decayed teeth but fewer numbers of filled teeth than whites. Although blacks had a lower likelihood of being edentulous than whites, dentate blacks had a higher number of missing teeth. Compared with whites, Mexican-Americans were less likely to be edentulous, and dentate Mexican-Americans had fewer missing teeth. Our study also showed that blacks and Mexican-Americans had less frequent dental checkups than whites.

CONCLUSIONS

Oral health disparities are persistent across racial/ethnic groups for older Americans despite the fact that the differences between groups typically diminish when socioeconomic, health-related, and behavioral factors are considered in the models. Our study suggests that reducing racial/ethnic oral health disparities requires multiple clinical approaches.

A review of the experience, epidemiology, and management of pain among American Indian, Alaska Native, and Aboriginal Canadian peoples

Substantial literature suggests that diverse biological, psychological, and sociocultural mechanisms account for differences by race and ethnicity in the experience, epidemiology, and management of pain. Many studies have examined differences between Whites and minority populations, but American Indians (AIs), Alaska Natives (ANs), and Aboriginal peoples of Canada have been neglected both in studies of pain and in efforts to understand its biopsychosocial and cultural determinants. This article reviews the epidemiology of pain and identifies factors that may affect clinical assessment and treatment in these populations. We searched for peer-reviewed articles focused on pain in these populations, using PubMed, CINAHL, Cochrane, and the University of New Mexico Native Health Database. We identified 28 articles published 1990 to 2009 in 3 topic areas: epidemiology of pain, pain assessment and treatment, and healthcare utilization. A key finding is that AI/ANs have a higher prevalence of pain symptoms and painful conditions than the U.S. general population. We also found evidence for problems in provider-patient interactions that affect clinical assessment of pain, as well as indications that AI/AN patients frequently use alternative modalities to manage pain. Future research should focus on pain and comorbid conditions and develop conceptual frameworks for understanding and treating pain in these populations.

PERSPECTIVE

We reviewed the literature on pain in AI/ANs and found a high prevalence of pain and painful conditions, along with evidence of poor patient-provider communication. We recommend further investigation of pain and comorbid conditions and development of conceptual frameworks for understanding and treating pain in this population.

Impact of denture usage patterns on dietary quality and food avoidance among older adults

This study categorizes older adults living in rural areas by denture status, assesses the frequency of wearing dentures during meals, and determines whether denture status or use is associated with dietary quality or the number of foods avoided. A multi-ethnic population-based sample of adults ≥60 years (N = 635) in the rural United States was interviewed. Survey included denture use, removing dentures before eating, and foods avoided due to oral health problems. Dietary intakes were converted into Healthy Eating Index-2005 scores. Sixty percent wore removable dentures of some type; 55% never, 27% sometimes, and 18% always removed dentures when eating. More frequent removal was associated with lower dietary quality and more foods avoided. Those with severe tooth loss had the lowest dietary quality and avoided the most foods. Many rural older adults wear dentures. Learning how they adapt to denture use will offer insight into their nutritional self-management and help explain differences in dietary quality.

A comparison of surgery and family medicine residents' perceptions of cross-cultural care training

The need for physicians formally trained to deliver care to diverse patient populations has been widely advocated. Utilizing a validated tool, Weissman and Betancourt's Cross-Cultural Care Survey, the aim of this current study was to compare surgery and family medicine residents' perceptions of their preparedness and skillfulness to provide high quality cross-cultural care. Past research has documented differences between the two groups' reported impressions of importance and level of instruction received in cross-cultural care. Twenty surgery and 15 family medicine residents participated in the study. Significant differences were found between surgery and family medicine residents on most ratings of the amount of training they received in cross-cultural skills. Specifically, family medicine residents reported having received more training on: 1) determining how patients want to be addressed, 2) taking a social history, 3) assessing their understanding of the cause of illness, 4) negotiating their treatment plan, 5) assessing whether they are mistrustful of the health care system and÷or doctor, 6) identifying cultural customs, 7) identifying how patients make decisions within the family, and 8) delivering services through a medical interpreter. One unexpected finding was that surgery residents, who reported not receiving much formal cultural training, reported higher mean scores on perceived skillfulness (i.e. ability) than family medicine residents. The disconnect may be linked to the family medicine residents' training in cultural humility - more knowledge and understanding of cross-cultural care can paradoxically lead to perceptions of being less prepared or skillful in this area.

Association between dietary quality of rural older adults and self-reported food avoidance and food modification due to oral health problems

OBJECTIVES

To quantify the association between food avoidance and modification due to oral health problems, to examine the association between food practices and dietary quality, and to determine foods associated with these self-management behaviors.

DESIGN

Cross-sectional.

SETTING

Rural North Carolina.

PARTICIPANTS

Six hundred thirty-five community-dwelling adults aged 60 and older.

MEASUREMENTS

Demographic and food frequency data and oral health assessments were obtained during home visits. Avoidance (0, 1-2 foods, 3-14 foods) and modification (0-3 foods, 4-5 foods) due to oral health problems were assessed for foods representing oral health challenges. Food frequency data were converted into Healthy Eating Index-2005 (HEI-2005) scores. Linear regression models tested the significance of associations between HEI-2005 measures and food avoidance and modification.

RESULTS

Thirty-five percent of participants avoided three to 14 foods, and 28% modified four to five foods. After adjusting for age, sex, ethnicity, poverty, education, and tooth loss, total HEI-2005 score was lower (P<.001) for persons avoiding more foods and higher for persons modifying more foods (P<.001). Those avoiding three to 14 foods consumed more saturated fat and energy from solid fat and added sugar and less nonhydrogenated fat than those avoiding fewer than three foods. Those who modified four to five foods consumed less saturated fat and solid fat and added sugar but more total grains than those modifying fewer than four foods.

CONCLUSION

Food avoidance and modification due to oral health problems are associated with significant differences in dietary quality. Approaches to minimize food avoidance and promote food modification by persons having eating difficulties due to oral health conditions are needed.