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Cardoso MZ, Lana TMSD, Collares K, Bervian J, Lopes MWP, Signor GR, Ardenghi TM, Borba M. School type and oral conditions associated with school performance and absenteeism in adolescents: A multilevel analysis. Int J Paediatr Dent 2024; 34:202-210. [PMID: 37203265 DOI: 10.1111/ipd.13090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 05/04/2023] [Accepted: 05/12/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Investigations assessing how oral health status affects school performance and attendance considering individual and community variables are lacking. AIM To analyze the association of school contextual factors and oral conditions with school performance and absenteeism in early adolescence. DESIGN This cross-sectional study was carried out with 593 12-year-old students from 20 schools in Passo Fundo, a southern city in Brazil. The caregivers provided sociodemographic information by means of a questionnaire. Oral health status was clinically examined for dental caries and gingival bleeding. Students answered the CPQ11-14 questionnaire to assess the oral health-related quality of life (OHRQoL). Information on contextual factors was obtained from the schools' administrators. "School performance" was measured by Portuguese and Mathematic tests' scores, and "school absenteeism" by the number of school days missed. Descriptive statistics was conducted, followed by unadjusted and adjusted multilevel linear regression. RESULTS At the individual level, low OHRQoL was associated with lower school performance and higher absenteeism. At the contextual level, students from private schools had higher school performance and lower mean of school days missed. CONCLUSIONS The type of school and OHRQoL were associated with school performance and attendance of adolescents.
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Affiliation(s)
- Moisés Zacarias Cardoso
- Graduate Program in Dentistry, Dental School, University of Passo Fundo, Passo Fundo, Brazil
| | | | - Kauê Collares
- Graduate Program in Dentistry, Dental School, University of Passo Fundo, Passo Fundo, Brazil
| | - Juliane Bervian
- Graduate Program in Dentistry, Dental School, University of Passo Fundo, Passo Fundo, Brazil
| | | | | | - Thiago Machado Ardenghi
- Graduate Program in Dental Science, Dental School, Federal University of Santa Maria, Santa Maria, Brazil
| | - Márcia Borba
- Graduate Program in Dentistry, Dental School, University of Passo Fundo, Passo Fundo, Brazil
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Giles E, Relins S, Gray-Burrows K, Baker SR, Day PF. Dental caries and school readiness in 5-year-olds: A birth cohort data linkage study. Community Dent Oral Epidemiol 2024. [PMID: 38679802 DOI: 10.1111/cdoe.12968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 03/13/2024] [Accepted: 04/15/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE To describe the association between dental caries and school readiness in 5-year-old children taking part in the Born in Bradford (BiB) birth cohort, UK. METHODS The Early Years Foundation Stage Profile (EYFSP) assesses the school readiness of young children and is strongly predictive of future academic attainment. Children are recorded as 'emerging' (below expected), 'expected', or 'exceeding' in five key learning areas. The Oral Health Survey of 5-year-olds (OHS5) is undertaken biennially in England, assessing caries experience at a dentine threshold (d3mft). EYFSP and OHS5 were available for a proportion of children participating in BiB. Odds ratios and confidence intervals for caries experience were established, and odds ratios adjusted for significant sociodemographic variables. RESULTS EYFSP and OHS5 data were available for 2.5% (n = 346) BiB participants. Nearly half (45.2%) had caries. A measure of socio-economic status, receiving free school meals, was the only demographic variable strongly related to caries experience (OR: 2.8, 95% CI: 1.6-4.9). After adjustment, children 'emerging' in EYFSP learning areas had 1.6- to 2.2-fold (95% CI: 1.0-3.8) higher odds of experiencing caries. Children 'exceeding' EYFSP learning areas had 2.3- to 4-fold (95% CI: 0.1-0.9) lower odds of caries experience. CONCLUSION This is the first study to explore the association between caries experience and school readiness using a holistic assessment tool. The association was found across different learning areas and was comparable to and independent of socio-economic status. The findings indicate oral health-related absenteeism is not a causative factor. EYFSP shows potential to enhance the targeting of preventive interventions at a child, class or school level.
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Affiliation(s)
- Erin Giles
- Department of Paediatric Dentistry, School of Dentistry, University of Leeds, Leeds, UK
| | - Samuel Relins
- Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Bradford, UK
| | - Kara Gray-Burrows
- Department of Paediatric Dentistry, School of Dentistry, University of Leeds, Leeds, UK
| | - Sarah R Baker
- Unit of Oral Health, Dentistry and Society, School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Peter F Day
- Department of Paediatric Dentistry, School of Dentistry, University of Leeds, Leeds, UK
- Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Bradford, UK
- Community Dental Service, Bradford District Care NHS Foundation Trust, Bradford, UK
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Patel N, Griffin SO, Linabarger M, Lesaja S. Impact of school sealant programs on oral health among youth and identification of potential barriers to implementation. J Am Dent Assoc 2022; 153:970-978.e4. [PMID: 35953306 DOI: 10.1016/j.adaj.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND School sealant programs (SSPs) increase sealant prevalence among children lacking access to oral health care. SSPs, however, are substantially underused. From 2013 through 2018, the Centers for Disease Control and Prevention funded 18 states for SSP activities in high-need schools (≥ 50% free and reduced-price meal program participation). From 2019 through 2020, the authors assessed SSPs' impact in reducing caries and how states expanded SSPs. The authors also discuss potential barriers to expansion. METHODS For Aim 1, the authors used a published methodology and SSP baseline screening and 1-year retention data to estimate averted caries over 9 years attributable to SSPs. For Aim 2, the authors used state responses to an online survey, phone interviews, and annual administrative reports. RESULTS Using data for 62,750 children attending 18.6% of high-need schools in 16 states, the authors estimated that 7.5% of sound, unsealed molars would develop caries annually without sealants and placing 4 sealants would prevent caries in 1 molar. Fourteen states reported SSP expansion in high-need schools. The 2 most frequently reported barriers to SSP expansion were levels of funding and policies requiring dentists to be present at assessment or sealant placement. CONCLUSIONS The authors found that SSPs typically served children at elevated caries risk and reduced caries. In addition, the authors identified funding levels and policies governing supervision of dental hygienists as possible barriers to SSP expansion. PRACTICAL IMPLICATIONS Increasing SSP prevalence could reduce caries. Further research on potential barriers to SSP implementation identified in this study could provide critical information for long-term SSP sustainability.
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Lipton BJ, Decker SL, Stitt B, Finlayson TL, Manski RJ. Association Between Medicaid Dental Payment Policies and Children’s Dental Visits, Oral Health, and School Absences. JAMA Health Forum 2022; 3:e223041. [PMID: 36218932 PMCID: PMC9463610 DOI: 10.1001/jamahealthforum.2022.3041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Question Are increases in the ratio of Medicaid payment rates to dentist charges for an index of services associated with improvements in children’s outcomes? Findings This cross-sectional study used a difference-in-differences analysis to evaluate 15 738 Medicaid-enrolled and 16 867 privately insured children aged 6 to 17 years who participated in the 2016-2019 National Survey of Children’s Health. Increasing the Medicaid fee ratio was associated with significant but modest improvements in children’s dental visits and oral health and had no significant association with school absences. Meaning More generous Medicaid dental payment policies are associated with improvements in children’s outcomes. Importance Although all state Medicaid programs cover children’s dental services, less than half of publicly insured children receive recommended care. Objective To evaluate the association between the ratio of Medicaid payment rates to dentist charges for an index of services (fee ratio) and children’s preventive dental visits, oral health, and school absences. Design, Setting, and Participants In this cross-sectional study, a difference-in-differences analysis was conducted between September 2021 and April 2022 of 15 738 Medicaid-enrolled children and a control group of 16 867 privately insured children aged 6 to 17 years who participated in the 2016-2019 National Survey of Children’s Health. Exploratory subgroup analyses by sex and race and ethnicity were also performed. A 2-sided P < .05 was considered significant. Main Outcomes and Measures Past-year preventive dental visits (at least 1 and at least 2), parent-reported excellent oral health, and number of days absent from school (at least 4 days and at least 7 days). Results The Medicaid-enrolled sample included a weighted estimate of 51.20% boys and 48.80% girls (mean age, 11.24 years; Black, 21.65%; Hispanic, 37.75%; White, 31.45%). By weighted baseline estimates, 87% and 48% of Medicaid-enrolled children had at least 1 and at least 2 past-year dental visits, respectively, and 29% had parent-reported excellent oral health. Increasing the fee ratio by 1 percentage point was associated with percentage point increases of 0.18 in at least 1 dental visit (95% CI, 0.07-0.30), 0.27 in at least 2 visits (95% CI, 0.04-0.51), and 0.19 in excellent oral health (95% CI, 0.01-0.36). Increases in at least 2 visits were larger for Hispanic children than for White children. By weighted baseline estimates, 28% and 15% of Medicaid-enrolled children had at least 4 and at least 7 past-year school absences, respectively. Regression estimates for school absences were not statistically significant for the full sample but were estimated to be significantly reduced among girls. Conclusions and Relevance This cross-sectional study found that more generous Medicaid payment policies were associated with significant but modest increases in children’s preventive dental visits and excellent oral health. Further research is needed to understand the potential association between policies that improve access to dental care and children’s academic success.
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Affiliation(s)
- Brandy J. Lipton
- Division of Health Management and Policy, School of Public Health, San Diego State University, California
- Center for Health Economics and Policy Studies, San Diego State University, California
| | - Sandra L. Decker
- Division of Research and Modeling, Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Brittney Stitt
- Division of Health Management and Policy, School of Public Health, San Diego State University, California
| | - Tracy L. Finlayson
- Division of Health Management and Policy, School of Public Health, San Diego State University, California
| | - Richard J. Manski
- Division of Research and Modeling, Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland
- School of Dentistry, University of Maryland, Baltimore, Maryland
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Mohamed SAS, Baker SR, Deery C, Vettore MV. Are oral health conditions associated with schoolchildren's performance and school attendance in the Kingdom of Bahrain? A life-course perspective. Int J Paediatr Dent 2022; 32:127-143. [PMID: 33971047 DOI: 10.1111/ipd.12803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 04/19/2021] [Accepted: 04/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The link between oral diseases and school performance and school attendance remains unclear among Middle Eastern children. AIM To investigate the relationship of oral conditions with schoolchildren's school performance and attendance using the life-course approach. DESIGN A cross-sectional study was conducted with 466 schoolchildren aged 7-8 years from Kingdom of Bahrain (KoB) and their parents. Questionnaire data on children's current and at-birth environmental characteristics were completed by their parents. Children's oral health measures, including ICDAS (International Caries Detection and Assessment System), PUFA (pulp, ulcer, fistula, abscess), and DDE (developmental defects of enamel) indices, were the exposure variables. School performance and school attendance data obtained from the school register were the outcome variables. The data were analysed using multivariate ordinal logistic regression. RESULTS The odds of excellent school performance were significantly lower for children with untreated dentinal caries (OR = 0.98; 95% CI: 0.96-0.99). Children with caries-treated teeth showed greater odds of excellent school performance (OR = 1.41; 95% CI: 1.15-1.74). Disease Control and PreventionNone of the dental conditions were significantly associated with children's school attendance. A permissive parental style was associated with poor school attendance (OR = 2.63; 95% CI: 1.08-6.42). CONCLUSION Dental caries was associated with poor school performance but not with school attendance. Treated caries was associated with good school performance.
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Affiliation(s)
- Seham A S Mohamed
- Unit of Oral Health, Dentistry and Society, School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Sarah R Baker
- Unit of Oral Health, Dentistry and Society, School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Christopher Deery
- Unit of Oral Health, Dentistry and Society, School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Mario V Vettore
- Department of Health and Nursing Sciences, University of Agder, Kristiansand, Norway
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Aldosari MA, Bukhari OM, Ruff RR, Palmisano JN, Nguyen H, Douglass CW, Niederman R, Starr JR. Comprehensive, School-Based Preventive Dentistry: Program Details and Students' Unmet Dental Needs. J Sch Health 2021; 91:761-770. [PMID: 34389994 DOI: 10.1111/josh.13063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 01/28/2021] [Accepted: 02/03/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Muath A Aldosari
- Assistant Professor, , Department of Periodontics and Community Dentistry, College of Dentistry, 3094 King Saud University, Riyadh 12372-7224, Saudi Arabia; Lecturer, Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115., USA
| | - Omair M Bukhari
- Assistant Professor, , Department of Preventive Dentistry, Umm Al-Qura University Faculty of Dentistry, 2275 Al Awali District, Mecca, Saudi Arabia
| | - Ryan Richard Ruff
- Associate Professor, , Department of Epidemiology & Health Promotion, New York University College of Dentistry and College of Global Public Health, 433 First Avenue, 7th Floor, New York, NY, 10044., USA
| | - Joseph N Palmisano
- Director, , Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, 85 East Newton Street, M921, Boston, MA, 02118., USA
| | - Helen Nguyen
- Public Health Dentist, , Forsyth Institute, 245 First Street, Cambridge, MA 02142; Lecturer, Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA, 02115., USA
| | - Chester W Douglass
- Professor Emeritus, , Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115; Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA, 02115., USA
| | - Richard Niederman
- Professor, , Department of Epidemiology & Health Promotion, New York University College of Dentistry, 433 First Avenue, 7th Floor, New York, NY, 10044., USA
| | - Jacqueline R Starr
- Director of Strategic Initiatives, , Channing Division of Network Medicine, Brigham and Women's Hospital, 181 Longwood Avenue, Boston, MA 02115; Lecturer, Department of Medicine, Harvard Medical School, Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine., USA
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Kearney J, Fitzgerald R, Burnside G, Higham S, Flannigan N, Halford JCG, Boyland EJ. Television advertisements for high-sugar foods and beverages: effect on children's snack food intake. Br J Nutr 2021; 125:591-7. [PMID: 32746948 DOI: 10.1017/S0007114520003116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Energy-dense food advertising affects children's eating behaviour. However, the impact of high-sugar food advertising specifically on the intake of sweet foods is underexplored. This study sought to determine whether children would increase their intake of sugar and total energy following high-sugar food advertising (relative to toy advertising) and whether dental health, weight status and socio-economic status (SES) would moderate any effect. In a crossover, randomised controlled trial, 101 UK children (forty male) aged 8-10 years were exposed to high-sugar food/beverage and toy advertisements embedded within a cartoon. Their subsequent intake of snack foods and beverages varying in sugar content was measured. A dental examination was performed, and height and weight measurements were taken. Home postcode provided by parents was used to assign participants to SES quintiles. Children consumed a significantly greater amount of energy (203·3 (95 % CI 56·5, 350·2) kJ (48·6 (95 % CI 13·5, 83·7) kcal); P = 0·007) and sugar (6·0 (95 % CI 1·3, 10·7) g; P = 0·012) following food advertisements compared with after toy advertisements. This was driven by increased intake of the items with most sugar (chocolate and jelly sweets). Children of healthy weight and with dental caries had the greatest intake response to food advertising exposure, but there were no differences by SES. Acute experimental food advertising exposure increases food intake in children. Specifically, high-sugar food and beverage advertising promotes the consumption of high-sugar food items. The debate around the negative health effects of food advertising on children should be widened to include dental health as well as overall dietary health and obesity.
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Lipton BJ. Adult Medicaid benefit generosity and receipt of recommended health services among low-income children: The spillover effects of Medicaid adult dental coverage expansions. J Health Econ 2021; 75:102404. [PMID: 33291015 DOI: 10.1016/j.jhealeco.2020.102404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/08/2020] [Accepted: 09/09/2020] [Indexed: 06/12/2023]
Abstract
Low-income children are less likely to receive recommended health services than their high-income counterparts. This paper examines whether the design of parental Medicaid benefit packages could serve as a mechanism for reducing income-based disparities in unmet health care needs, considering dental benefits as a case study. Leveraging state-level changes to adult dental benefits over time, I find that coverage is associated with increases of 14 and 5 percentage points, respectively, in the likelihood of a recent dental visit among parents and children directly exposed to the policy. Child effects appear to be concentrated among younger children under age 12.
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Affiliation(s)
- Brandy J Lipton
- San Diego State University, School of Public Health, 5500 Campanile Drive, San Diego, CA 92182, United States.
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Jackson DB, Testa A. Household food insecurity and children's oral health: Findings from the 2016-2018 National Survey of Children's Health. J Public Health Dent 2020; 81:150-161. [PMID: 33251647 DOI: 10.1111/jphd.12431] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/28/2020] [Accepted: 11/19/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Dylan B Jackson
- Department of Population, Family, and Reproductive Health, Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alexander Testa
- College for Health, Community, and Policy, The University of Texas at San Antonio, San Antonio, TX, USA
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Testa A, Jackson DB. Parental incarceration and children's oral health in the United States: Findings from the 2016-2018 National Survey of Children's Health. Community Dent Oral Epidemiol 2020; 49:166-175. [PMID: 33219566 DOI: 10.1111/cdoe.12588] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/27/2020] [Accepted: 10/09/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study aimed to examine the association between parental incarceration and children's oral health in the United States and assess the degree to which household socioeconomic factors, children's healthcare insurance and oral healthcare utilization/preventive care explain this association. METHODS Using data from the 2016-2018 National Survey of Children's Health (NSCH; N = 99 962), a series of logistic regression models were used to investigate the association between parental incarceration and a variety of children's oral health conditions. The Karlson-Holm-Breen method was used to assess the degree to which household socioeconomic factors, children's healthcare insurance and oral healthcare utilization/preventive care visits reduced the association between parental incarceration and children's oral health. RESULTS Results from logistic regression analyses demonstrated that net of control variables, children of incarcerated parents have significantly worse oral health including poor or fair teeth condition (OR = 2.71, 95% CI = 2.23-3.29), toothaches (OR = 1.72, 95% CI = 1.36-2.18), gum bleeding (2.12, 95% CI = 1.52-2.94), cavities/tooth decay (OR = 1.50, 95% CI = 1.26-1.77) and are more likely to have unmet dental care needs (OR = 1.78, 95% CI = 1.28-2.46). Attenuation analyses demonstrated this relationship is partially explained by household material hardship and children's health insurance. CONCLUSIONS Parental incarceration is associated with worse oral health and unmet dental care needs. Household material hardship and children's health insurance partially attenuate this association. Efforts to expand oral health literacy to incarceration-exposed parents, and policies that buffer against material hardship and inadequacies in children's health insurance may be useful for improving oral health of children whose parents have been incarcerated.
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Fukuya Y, Matsuyama Y, Isumi A, Doi S, Ochi M, Fujiwara T. Toothbrushing and School Refusal in Elementary School: A Longitudinal Study. Int J Environ Res Public Health 2020; 17:ijerph17207505. [PMID: 33076373 PMCID: PMC7602552 DOI: 10.3390/ijerph17207505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/01/2020] [Accepted: 10/10/2020] [Indexed: 11/25/2022]
Abstract
The aim of this study was to examine the association between toothbrushing frequency and school refusal among elementary school children. We used data from the Adachi Child Health Impact of Living Difficulty (A-CHILD) longitudinal study conducted between 2015 and 2016 in Adachi City, Tokyo, Japan. A questionnaire was distributed to all first-grade children aged 6 to 7 years (N = 3697, follow-up rate: 86.2%). Propensity score (PS) matching was applied to collapse the known covariates on toothbrushing frequency in grade 1 on the association with school refusal in grade 2. Among the followed children, 2.4% showed school refusal in grade 2 (89 children) and 23.5% (870 children) brushed their teeth once or less than once daily in grade 1. After propensity score matching, children with toothbrushing once or less than once daily in grade 1 were 2.25 (95% CI: 1.25–4.05) times more likely to show school refusal in grade 2, compared with those with toothbrushing twice or more a day. Our findings suggest that toothbrushing once or less than once daily is an independent risk factor for school refusal among children. Oral health promotion to recommend toothbrushing more than once a day could prevent school refusal. Further intervention studies investigating the mechanism and causality are warranted.
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Affiliation(s)
- Yoshifumi Fukuya
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; (Y.F.); (Y.M.); (A.I.); (S.D.)
| | - Yusuke Matsuyama
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; (Y.F.); (Y.M.); (A.I.); (S.D.)
| | - Aya Isumi
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; (Y.F.); (Y.M.); (A.I.); (S.D.)
- Japan Society for the Promotion of Science, Tokyo 102-0083, Japan
| | - Satomi Doi
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; (Y.F.); (Y.M.); (A.I.); (S.D.)
- Japan Society for the Promotion of Science, Tokyo 102-0083, Japan
| | - Manami Ochi
- National Institute of Public Health, Department of Health and Welfare Services, Saitama 351-0104, Japan;
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; (Y.F.); (Y.M.); (A.I.); (S.D.)
- Correspondence: ; Tel.: +81-3-5803-5187
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Ghafari M, Bahadivand-Chegini S, Nadi T, Doosti-Irani A. The global prevalence of dental healthcare needs and unmet dental needs among adolescents: a systematic review and meta-analysis. Epidemiol Health 2019; 41:e2019046. [PMID: 31778605 PMCID: PMC6883027 DOI: 10.4178/epih.e2019046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/27/2019] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Access to dental healthcare services is a major determinant of dental health in communities. This meta-analysis was conducted to estimate the global prevalence of dental needs and of unmet dental needs in adolescents. METHODS PubMed, Web of Science, and Scopus were searched in June 2018. The summary measures included the prevalence of met and unmet dental needs. A meta-analysis was performed using the inverse variance method to obtain pooled summary measures. Out of 41,661 retrieved articles, 57 were ultimately included. RESULTS The pooled prevalence of orthodontic treatment needs was 46.0% (95% confidence interval [CI], 38.0 to 53.0), that of general treatment needs was 59.0% (95% CI, 42.0 to 75.0), that of periodontal treatment needs was 71.0% (95% CI, 46.0 to 96.0), and that of malocclusion treatment needs was 39.0% (95% CI, 28.0 to 50.0). The pooled prevalence of unmet dental needs was 34.0% (95% CI, 27.0 to 40.0). CONCLUSIONS The highest and lowest prevalence of unmet dental needs were found in Southeast Asia and Europe, respectively. The prevalence of dental needs was higher in the countries of the Americas and Europe than in other World Health Organization (WHO) regions. The prevalence of unmet dental needs was higher in Southeast Asia and Africa than in other WHO regions.
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Affiliation(s)
- Mahin Ghafari
- Department of Public Health, School of Health, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Samira Bahadivand-Chegini
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Tayebeh Nadi
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Amin Doosti-Irani
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran.,Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
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Ruff RR, Senthi S, Susser SR, Tsutsui A. Oral health, academic performance, and school absenteeism in children and adolescents: A systematic review and meta-analysis. J Am Dent Assoc 2018; 150:111-121.e4. [PMID: 30473200 DOI: 10.1016/j.adaj.2018.09.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/25/2018] [Accepted: 09/27/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND The authors conducted a systematic review and meta-analysis to provide a summary estimate of the association between oral health and academic performance. TYPES OF STUDIES REVIEWED The authors conducted a systematic search of PubMed, Embase, and Google Scholar for studies on oral health, school absence, and academic achievement published in English from January 1945 through December 2017. Exposures included subjectively or objectively measured caries, oral pain, and periodontitis. Outcomes included school absence and school achievement. RESULTS The authors screened a total of 2,041 studies, from which they extracted data from 14 studies of 139,989 children (12 cross-sectional studies, 1 case-control study, and 1 longitudinal study). Five studies had school absence as the primary outcome, and 7 studies had student achievement as the primary outcome. Three studies included both outcomes. The authors found no studies for periodontitis. The average modified Newcastle-Ottawa Scale score was 3.93. The authors rated 10 studies as having a low risk of bias and 4 as having a high risk of bias. Qualitative synthesis suggested that poor oral health may have negative effects on student absenteeism and achievement, but study quality was highly variable. Results from meta-analyses indicated that poor oral health was significantly associated with increased odds of poor academic performance (pooled odds ratio, 1.52; 95% confidence interval, 1.20 to 1.83) and absenteeism (pooled odds ratio, 1.43; 95% confidence interval, 1.24 to 1.63). CONCLUSIONS AND PRACTICAL IMPLICATIONS Increased focus on the broader implications of improvements in oral health for children, such as educational or socioemotional development, is of further interest to practicing dentists owing to the greater connection between oral health and general health. The authors of this study found that caries or tooth pain had a negative association with academic achievement and school absenteeism. However, study quality was limited by inconsistent exposure and outcome definitions and a predominance of cross-sectional designs. Thus, causal conclusions are not supported.
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Rebelo MAB, Rebelo Vieira JM, Pereira JV, Quadros LN, Vettore MV. Does oral health influence school performance and school attendance? A systematic review and meta-analysis. Int J Paediatr Dent 2018; 29:138-148. [PMID: 30367538 DOI: 10.1111/ipd.12441] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/28/2018] [Accepted: 09/25/2018] [Indexed: 12/15/2022]
Abstract
AIM To examine the evidence on the influence of oral health status on school performance and school attendance in children and adolescents. DESIGN A systematic review was performed in accordance with PRISMA included epidemiological studies that assessed concomitantly oral health measures, participants' school performance and/or school attendance. Electronic search was conducted on MEDLINE, SCOPUS, Web of Science, ScienceDirect, and LILACS. Studies published up to May 2018 in any language were eligible. The risk of bias was assessed using the Newcastle-Ottawa Scale. Meta-analysis was used to obtain pooled estimates between oral health measures and school performance and school attendance. RESULTS Eighteen studies were included. Of them, fifteen studies were used for the meta-analyses. Most studies were assessed as moderate quality. Children with one or more decayed teeth had higher probability of poor school performance (OR = 1.44 95%CI: 1.24-1.64) and poor school attendance (OR = 1.57 95%CI: 1.08-2.05) than caries-free children. Poor parent's perception of child's oral health increased the odds of worse school performance (OR = 1.51 95%CI: 1.10-1.92) and poor school attendance (OR = 1.35 95%CI: 1.14-1.57). CONCLUSIONS Children and adolescents with dental caries and those reporting worse oral health experience poor school performance and poor school attendance.
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Affiliation(s)
| | | | | | | | - Mario Vianna Vettore
- Unit Oral Health, Dentistry and Society, School of Clinical Dentistry, University of Sheffield, Sheffield, UK
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Lee I, Monahan S, Serban N, Griffin PM, Tomar SL. Estimating the Cost Savings of Preventive Dental Services Delivered to Medicaid-Enrolled Children in Six Southeastern States. Health Serv Res 2018; 53:3592-3616. [PMID: 29194610 PMCID: PMC6153169 DOI: 10.1111/1475-6773.12811] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To quantify the impact of multiyear utilization of preventive dental services on downstream dental care utilization and expenditures for children. DATA SOURCES/STUDY SETTING We followed 0.93 million Medicaid-enrolled children who were 3-6 years old in 2005 from 2005 to 2011. We used Medicaid claims data of Alabama, Georgia, Mississippi, North Carolina, South Carolina, and Texas. STUDY DESIGN We clustered each state's study population into four groups based on utilization of topical fluoride and dental sealants before caries-related treatment using machine learning algorithms. We evaluated utilization rates and expenditures across the four groups and quantified cost savings of preventive care for different levels of penetration. DATA EXTRACTION METHOD We extracted all dental-related claims using CDT codes. PRINCIPAL FINDINGS In all states, Medicaid expenditures were much lower for children who received topical fluoride and dental sealants before caries development than for all other children, with a per-member per-year difference ranging from $88 for Alabama to $156 for Mississippi. CONCLUSIONS The cost savings from topical fluoride and sealants across the six states ranged from $1.1M/year in Mississippi to $12.9M/year in Texas at a 10 percent penetration level. Preventive dental care for children not only improves oral health outcomes but is also cost saving.
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Affiliation(s)
- Ilbin Lee
- School of BusinessUniversity of AlbertaEdmontonABCanada
| | - Sean Monahan
- Fraud Strategy and AnalysisCapital One Financial CorporationArlingtonVA
| | - Nicoleta Serban
- School of Industrial and Systems EngineeringGeorgia Institute of TechnologyAtlantaGA
| | - Paul M. Griffin
- Regenstrief Center for Healthcare EngineeringPurdue UniversityWest LafayetteIN
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Abstract
The World Federation of Public Health Associations' Oral Health Working Group (WFPHA OHWG) carried out a survey to establish the extent of global dental public health (DPH) capacity. Senior stakeholders in DPH completed 124 surveys, covering 73 countries and all WHO regions. The survey evaluated DPH workforce within the country, funding, education, current services, and integration between public health and DPH in countries across the world. In 62 per cent of countries, DPH is only partially integrated in the public health system, while in 25 per cent of countries it has not yet been formally integrated. DPH programs at Masters level are available in 44 per cent of countries. Over half of countries have 0 to 10 trained DPH professionals. Because both poor oral and general health share several common risk factors, DPH must be integrated into national health systems and budgets, with an emphasis on having trained DPH specialists available in every country to collaborate in healthcare policy and provision.
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Affiliation(s)
- Marta Lomazzi
- World Federation of Public Health Associations, Geneva, Switzerland
| | - Valerie Wordley
- King's College London, Centre for International Child Oral Health, 26-29 Drury Lane, Rooms 329-331, London, UK
| | - Raman Bedi
- King's College London, Centre for International Child Oral Health, 26-29 Drury Lane, Rooms 329-331, London, UK.
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Griffin SO, Naavaal S, Scherrer C, Patel M, Chattopadhyay S. Evaluation of School-Based Dental Sealant Programs: An Updated Community Guide Systematic Economic Review. Am J Prev Med 2017; 52:407-415. [PMID: 27865653 PMCID: PMC5870866 DOI: 10.1016/j.amepre.2016.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/21/2016] [Accepted: 10/05/2016] [Indexed: 11/18/2022]
Abstract
CONTEXT A recently updated Community Guide systematic review of the effectiveness of school sealant programs (SSPs) still found strong evidence that SSPs reduced dental caries among schoolchildren. This follow-up systematic review updates SSP cost and benefit information from the original 2002 review. EVIDENCE ACQUISITION Using Community Guide economic review methods, the authors searched the literature from January 2000 to November 20, 2014. The final body of evidence included 14 studies-ten from the current search and four with cost information from the 2002 review. Nine studies had information on SSP costs; six on sealant benefit (averted treatment costs and productivity losses); four on SSP net cost (cost minus benefit); and three on net cost to Medicaid of clinically delivered sealants. The authors imputed productivity losses and discounted costs/outcomes when this information was missing. The analysis, conducted in 2015, reported all values in 2014 U.S. dollars. EVIDENCE SYNTHESIS The median one-time SSP cost per tooth sealed was $11.64. Labor accounted for two thirds of costs, and time to provide sealants was a major cost driver. The median annual economic benefit was $6.29, suggesting that over 4 years the SSP benefit ($23.37 at a 3% discount rate) would exceed costs by $11.73 per sealed tooth. In addition, two of four economic models and all three analyses of Medicaid claims data found that SSP benefit to society exceeded SSP cost. CONCLUSIONS Recent evidence indicates the benefits of SSPs exceed their costs when SSPs target schools attended by a large number of high-risk children.
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Affiliation(s)
- Susan O Griffin
- Division of Oral Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.
| | - Shillpa Naavaal
- Division of Oral Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Christina Scherrer
- Systems and Industrial Engineering, Kennesaw State University, Kennesaw, Georgia
| | - Mona Patel
- Office of Public Health Preparedness and Response, CDC, Atlanta, Georgia
| | - Sajal Chattopadhyay
- Community Guide Branch, Division of Public Health Information Dissemination, CDC, Atlanta, Georgia
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Griffin S, Naavaal S, Scherrer C, Griffin PM, Harris K, Chattopadhyay S. School-Based Dental Sealant Programs Prevent Cavities And Are Cost-Effective. Health Aff (Millwood) 2016; 35:2233-2240. [PMID: 27920311 PMCID: PMC5870880 DOI: 10.1377/hlthaff.2016.0839] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Untreated cavities can have far-reaching negative consequences for people's ability to eat, speak, and learn. By adolescence, 27 percent of low-income children in the United States will have untreated cavities. School-based sealant programs typically provide dental sealants (a protective coating that adheres to the surface of molars) at little or no cost to students attending schools in areas with low socioeconomic status. These programs have been shown to increase the number of students receiving sealants and to prevent cavities. We analyzed the cost-effectiveness of school sealant programs using data (from school programs in fourteen states between 2013 and 2014) on children's cavity risk, including the effects of untreated cavities on a child's quality of life. We found that providing sealants in school programs to 1,000 children would prevent 485 fillings and 1.59 disability-adjusted life-years. School-based sealant programs saved society money and remained cost-effective across a wide range of reasonable values.
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Affiliation(s)
- Susan Griffin
- Susan Griffin is a health economist in the Division of Oral Health, Centers for Disease Control and Prevention (CDC), in Atlanta, Georgia
| | - Shillpa Naavaal
- Shillpa Naavaal is an assistant professor in pediatric dentistry at Virginia Commonwealth University, in Richmond
| | - Christina Scherrer
- Christina Scherrer is a professor in the Department of Systems and Industrial Engineering at Kennesaw State University, in Georgia
| | - Paul M Griffin
- Paul M. Griffin is a professor in the School of Industrial and Systems Engineering, Georgia Institute of Technology, in Atlanta
| | - Kate Harris
- Kate Harris is a health communications specialist in the Center for Surveillance, Epidemiology, and Laboratory Services at the CDC
| | - Sajal Chattopadhyay
- Sajal Chattopadhyay is an economist in the Center for Surveillance, Epidemiology, and Laboratory Services at the CDC
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Shaikh S, Siddiqui AA, Aljanakh M. School Absenteeism due to Toothache among Secondary School Students Aged 16-18 Years in the Ha'il Region of Saudi Arabia. Pain Res Treat 2016; 2016:7058390. [PMID: 26989510 DOI: 10.1155/2016/7058390] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/31/2016] [Indexed: 10/26/2022]
Abstract
Objective. This study assessed the impact of toothache on school attendance among secondary school students in the Ha'il Region, Saudi Arabia. Methods. A cross-sectional, paper based survey was conducted among 16-18-year-old students of public sector secondary schools in the Ha'il Region, Saudi Arabia. Results. Of the 510 students selected from the participating schools, 480 were analyzed (94.1%). Of the sample, 50.4% were boys. Among the participants in the study, 86 students reported school absence due to toothache in the six months prior to the survey. Consequently, the prevalence of absenteeism due to toothache in this study was of 18%. Conclusion. The prevalence of school absenteeism due to toothache among students in the Ha'il Region was low. Yet, still, missed school days due to toothache may have implications for students also in the Ha'il Region, Saudi Arabia, as school absenteeism leads to missed opportunities for learning and academic advancement.
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Neves ÉTB, Firmino RT, de França Perazzo M, Gomes MC, Martins CC, Paiva SM, Granville-Garcia AF. Absenteeism among preschool children due to oral problems. J Public Health (Oxf) 2015. [DOI: 10.1007/s10389-015-0697-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Grund K, Goddon I, Schüler IM, Lehmann T, Heinrich-Weltzien R. Clinical consequences of untreated dental caries in German 5- and 8-year-olds. BMC Oral Health 2015; 15:140. [PMID: 26538196 PMCID: PMC4634920 DOI: 10.1186/s12903-015-0121-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 10/19/2015] [Indexed: 11/10/2022] Open
Abstract
Background About half of all carious lesions in primary teeth of German 6- to 7-year-old children remain untreated, but no data regarding the clinical consequences of untreated dental caries are available. Therefore, this cross-sectional observational study aimed to assess the prevalence and experience of caries and odontogenic infections in the primary dentition of 5- and 8-year-old German children. Methods Dental examinations were performed in 5-year-old pre-school children (n = 496) and in 8-year-old primary school children (n = 608) living in the Westphalian Ennepe-Ruhr district. Schools and preschools were selected by sociodemographic criteria including size, area, ownership, socio-economic status. Caries was recorded according to WHO criteria (1997). The Lorenz curves were used to display the polarisation of dental caries. Caries pattern in 5-year-olds was categorized by Wyne’s (1997) definition of early childhood caries (ECC). Odontogenic infections as clinical consequence of untreated dental caries were assessed by the pufa index. The ‘untreated caries-pufa ratio’ was calculated, and the Spearman’s rank correlation coefficient (ρ) was used for evaluating the correlation between dmft and pufa scores. Categorical data were compared between groups using the chi-square test and continuous data were analysed by t-test. Results Caries prevalence and experience in the primary dentition was 26.2 %/0.9 ± 2.0 dmft in 5-year-olds and 48.8 %/2.1 ± 2.8 dmft in 8-year-olds. ECC type I (22 %) was the prevalent caries pattern in 5-year-olds. About 30 % of the tooth decay was treated (5y: 29.7 %/8y: 39.3 %). The Lorenz curves showed a strong caries polarisation on 20 % of the children. Pufa prevalence and experience was 4.4 %/0.1 ± 0.5 pufa in 5-year-olds and 16.6 %/0.3 ± 0.9 pufa in 8-year-olds. In 5-year-olds 14.2 % and in 8-year-olds 34.2 % of the d-component had progressed mainly to the pulp. A significant correlation between dmft and pufa scores exists in both age groups (5y: ρ = 0.399; 8y: ρ = 0.499). First deciduous molars were most frequently affected by odontogenic infections, presenting virtually all pufa scores (>95 %). Conclusions Prevalence and experience of odontogenic infections and the untreated caries-pufa ratio were increasing from the younger to the elder children. Dmft and pufa scores in primary teeth predict a higher caries risk in permanent teeth. The pufa index highlights relevant information for decision makers to develop effective oral health care programs for children at high risk for caries.
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Affiliation(s)
- Katrin Grund
- Department of Preventive and Paediatric Dentistry, Jena University Hospital, Bachstr. 18, D-07743, Jena, Germany.
| | - Inka Goddon
- Department of Social Services and Health, Health Services for Children and Adolescents Schwelm, Hauptstr. 92, D-58332, Schwelm, Germany.
| | - Ina M Schüler
- Department of Preventive and Paediatric Dentistry, Jena University Hospital, Bachstr. 18, D-07743, Jena, Germany.
| | - Thomas Lehmann
- Department of Medical Statistics and Epidemiology, Jena University Hospital, Bachstr. 18, D-07743, Jena, Germany.
| | - Roswitha Heinrich-Weltzien
- Department of Preventive and Paediatric Dentistry, Jena University Hospital, Bachstr. 18, D-07743, Jena, Germany.
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