Behavioral Outcomes of a Pragmatic Early Childhood Caries Management Trial

OBJECTIVES

To evaluate a preventative behavioral intervention for managing early childhood caries (ECC) in a cohort of high-risk children.

METHODS

This pragmatic trial of the MySmileBuddy Program (MSB) evaluated preventive behavioral outcomes in a 1-y community health worker-delivered intervention to prevent ECC progression. Pre-/postintervention surveys assessed parent-reported child engagement in therapeutic toothbrushing (i.e., adult-assisted brushing with fluoridated toothpaste twice daily) and caries-related dietary behaviors and barriers. Generalized linear model with identity link for continuous variables and logit link for dichotomous outcomes evaluated pre-/postintervention comparisons and generalized estimating equations accounted for within-participant correlation (α = 0.05).

RESULTS

Among 1,130 children with postintervention data, the average age was 3.97 y, 99% were Medicaid insured, and 88% were Hispanic. Most parents (95%) were mothers/grandmothers, married or in a committed partnership (75%), unemployed (62%), and with modest education (80% high school degree or less). The odds of reported therapeutic brushing nearly doubled (n = 864; odds ratio [OR] = 1.79, 95% confidence interval [CI] = 1.46, 2.20, P < 0.001); day and night bottle/sippy cup frequencies dropped 0.29 units (n = 871; 95% CI = -0.37, -0.33, P < 0.001) and 0.22 units (n = 1,130; 95% CI = -0.30, -0.15, P < 0.001); nighttime breastfeeding reduced 0.15 units (n = 870; 95% CI = -0.21, -0.10, P < 0.001); sharing utensils reduced 0.30 units (n = 572; 95% CI = -0.39, -0.21, P < 0.001); not using sugary foods to calm child improved 0.37 units (n = 664; 95% CI = 0.31, 0.44, P < 0.001); odds of eating meals and snacks at a table increased (n = 572; OR = 1.57, 95% CI = 1.28, 1.93, P < 0.001; n = 572; OR = 1.80, 95% CI = 1.50, 2.15, P < 0.001) respectively; and reducing barriers to behaviors improved 0.38 units for toothbrushing (n = 666; 95% CI = 0.31, 0.44, P < 0.001) and 0.33 units for diet (n = 668; 95% CI = 0.29, 0.38, P < 0.001).

CONCLUSION

Despite limitations inherent to pragmatic trials, significant behavioral changes suggest that MSB yielded an important salutary impact. Forthcoming mediation analyses will explore causal pathways. Findings support integration of MSB's behavior change program in caries management initiatives.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians, public health leaders, and researchers to inform the development and implementation of community-based, preventative behaviorally focused early childhood caries prevention programs. Study findings may enhance the understanding of the impact of behavioral interventions that engage parents of young children and could lead to more effective prevention for populations at high-risk of caries.

The dental caries pandemic and disparities problem

Understanding caries etiology and distribution is central to understanding potential opportunities for and likely impact of new biotechnologies and biomaterials to reduce the caries burden worldwide. This review asserts the appropriateness of characterizing caries as a "pandemic" and considers static and temporal trend reports of worldwide caries distribution. Oral health disparities within and between countries are related to sugar consumption, fluoride usage, dental care, and social determinants of health. Findings of international and U.S. studies are considered in promoting World Health Organization's and others' recommendations for science-based preventive and disease management interventions at the individual, clinical, public health, and public policy levels.

An analysis of dental visits in U.S. children, by category of service and sociodemographic factors, 1996

PURPOSE

Data from the 1996 Medical Expenditure Panel Survey were analyzed to determine the distribution of diagnostic and preventive, surgical, and other dental visit types received by U.S. children, aged 0-18 years.

METHODS

Weighted point estimates and standard errors were generated using SUDAAN and stratified by age, sex, race/ethnicity, and poverty status.

RESULTS

Overall, 39.3% of children had a diagnostic or preventive visit, 4.1% had a surgical visit, and 16.2% had a visit for a restorative/other service. Diagnostic and preventive services were most common, across age categories. For all types of service, utilization was higher among white and non-poor children, but there were no differences by gender. Age-specific associations were mixed, with diagnostic and preventive service and surgical service utilization having a different distribution than other service type. Poverty status was generally not associated with service-specific utilization among African-American children.

CONCLUSIONS

There are profound disparities in the level of dental services obtained by children, especially among minority and poor youth. Findings suggest that Medicaid fails to assure comprehensive dental services for eligible children. Improvements in oral health care for minority and poor children are necessary if national health objectives for 2010 are to be met successfully.

The impact of insurance coverage on children's dental visits and expenditures, 1996

BACKGROUND

Health insurance coverage has been shown to relate positively with the use of dental services. The purpose of the authors' study was to describe the level of dental coverage among U.S. children and to assess the impact of dental coverage on children's use of dental services and expenditures for dental care.

METHODS

The focus of these analyses is on dental care coverage, use and expenditures for U.S. children during 1996. National estimates are provided for the population with dental coverage, the population with a dental visit, and mean total expenditure for each of several socioeconomic and demographic categories during 1996 using data from the Medical Expenditure Panel Survey.

RESULTS

Fifty-two percent of children younger than 18 years of age had private dental coverage during 1996. Approximately 56 percent of children in families with a poverty status level of 133 percent of the federal poverty level or below were covered by Medicaid during 1996. Fifty-six percent of children with private coverage had made at least one dental visit, compared with 28 percent of noncovered children. Twenty-eight percent of children covered by Medicaid had made at least one dental visit compared with 19 percent of noncovered children.

CONCLUSION

Medicaid dental coverage seems to have had a lesser effect on the likelihood of a child's having a dental visit than had private coverage. Improving oral health for poorer children may depend partly on improving the design of Medicaid dental coverage programs.

PRACTICE IMPLICATIONS

By understanding these analyses, practitioners, advocates and policymakers will be better positioned to provide care, improve access and better meet the needs of all American children.

Access to dental care for Head Start enrollees

OBJECTIVES

The objectives of this review are to characterize the oral health and dental access of Head Start children, describe barriers to their care, advance strategies to address those barriers, and consider how Head Start Performance Standards can be utilized to maximize oral health and access to dental care.

METHODS

Published, programmatic, and solicited data describing oral health status and dental service utilization are reviewed together with reports of conferences exploring access barriers. Head Start performance measures for child health and development services, child health and safety, family partnerships, and community partnerships are individually evaluated for their potential to improve oral health.

RESULTS

Head Start children, like all low-income children, enjoy the highest rates of dental coverage (because of Medicaid and the State Child Health Insurance Program), yet these children also experience the highest rates of tooth decay, the most unmet dental care needs, the highest rates of dental pain, and the fewest dental visits. Getting children the dental care they need is problematic because of: multiple barriers associated with public and private dental delivery systems, Medicaid program funding and administration, dental workforce sufficiency and distribution, and issues of culture and communication that stand between parents, children, and caregivers.

CONCLUSIONS

To move beyond screening and to access necessary dental care requires integration between medical and dental care, recognition and elimination of barriers to care, an understanding of dental provider types and their capacities, a formally structured referral process, and regular monitoring to ensure that complete care is obtained. Action steps are suggested that can maximize the effectiveness of Head Start Performance Standards. Head Start holds tremendous potential to actively develop and implement policies that can markedly improve both access to needed dental services and the oral health status of young disadvantaged children.

Health care savings from microbiological caries risk screening of toddlers: a cost estimation model

OBJECTIVES

Modeling new biomedical technologies and determining their expected cost is necessary before initiating formal clinical trials. This paper estimates an economic model for the potential cost impact of microbiological screening of toddlers for caries risk compared to the traditional method of managing pediatric caries.

METHODS

Potential cost savings were calculated based on screening test properties (sensitivity and specificity) derived from a population of 1,180 children aged 1 to 3 years with a caries prevalence of 15 percent. An algorithm was then developed to allocate prevalent and anticipate incident caries, treatment effectiveness assumptions, and existing regional treatment costs.

RESULTS

The cost analysis model conservatively predicts savings of 7.3 percent from screening and early intervention. Cumulative dental treatment costs for a child at age 4 years are $367.90 if the child has been screened and $396.70 otherwise. The model further predicts that cost savings increase significantly as caries prevalence increases.

CONCLUSIONS

Microbiologic risk assessment for pediatric caries may be an example of a preventive public health screening technique that results in both clinical benefits and cost savings. If the model is validated by randomized clinical trials, microbiologic screening could be used by pediatric primary care providers to identify toddlers who require early referral to dentists for further risk assessment and early caries management.

Public and clinical policy considerations in maximizing children's oral health

Although children's oral health in the US has improved over recent decades, a subset of children continues to suffer extensive disease that is severe enough to constitute a public health problem with considerable individual consequences. Disparities in oral health are wide and growing. Dental caries prevalence may be increasing with shifts in child demographics. Policy approaches to maximizing children's oral health and pediatricians' roles in promoting effective policies are discussed.

The age one dental visit: information on the web

As consumers increasingly turn to the Internet as a health resource it is likely that parents may seek information on the recommended age for a first dental visit. A meta-search engine was used to determine whether a parent would find available, accessible, and authoritative information when seeking this recommendation. Of 47 "hits" on the phrase "first dental visit", only 2 were associated with major national health professional associations. Information obtained through this search technique was readily available and accessible but not authoritative. Individual searches on sites of leading dental and pediatric organizations revealed that all major dental organizations that provide consumer information and the Bright Futures consortium of child healthcare providers site all advocate the age 1 visit. The American Academy of Pediatrics, however suggests age 3 for the first visit. Information obtained from selected sites is available and authoritative but not particularly accessible unless the names of leading organizations are known.

Pediatric dental visits during 1996: an analysis of the federal Medical Expenditure Panel Survey

Pediatric health policy articulated by the government, health professions, and child advocates is concerned with eliminating health disparities among children and increasing access to essential pediatric health services. National data are widely available on dental health status and associated disparities by income and race, but little data have been reported on dental service utilization by children. Data from the 1996 federal Medical Expenditure Panel Survey were analyzed to determine the percentage of children who obtained a dental visit and the number of visits children experienced by age, sex, ethnic/racial background, family income, and parental education. Overall, 43% of all children ages birth through 18 obtained at least one dental visit in 1996. Among children who see a dentist, the average number of visits during 1996 was 2.7. Low income, low education, and minority status are all associated with both lower odds of having a dental visit and lower number of visits per utilizer. Children under 6 had less than half the dental visit rate of older children and had fewer visits per person among utilizers.

Case planning and management according to caries risk assessment

Ultimately, the dentist's role is to guide children through their growth and development free of disease. The dentist must recognize each child's unique susceptibility to caries and each parent's interest, competency, and accomplishment in controlling this disease. With this recognition, it is possible to tailor the frequency and content of dental visits necessary to maintain a child caries-free. Similarly, the frequency of examinations, office topical fluoride treatments, radiographs, and other diagnostic or preventive interventions depends upon the dentist's assessment of how intense professional efforts need to be to help parents maintain their children in health. Goldman and Burket summarized the relationship between science and practice and detailed the responsibilities of clinicians with the following words: "The practice of dentistry is an art in which the teachings of dental science are put to their practical application. A patient visits the dentist for consultation on the state of health of the dentition, with the expectation that everything possible will be done not only to repair or help heal by therapeutic correction any disease present but also to prevent disease from occurring, if possible." Treating caries at the level of the disease process to prevent its expression, progression, and ultimate dental destruction is the highest calling and deepest challenge facing dentists who care for young children. Techniques including risk assessment, triage, tailored care, and thoughtful treatment grounded in dental and behavioral science have put that goal within reach of dentists and parents to the great benefit of children.

Dispelling the myth that 50 percent of U.S. schoolchildren have never had a cavity

The erroneous claim that 50 percent of U.S. schoolchildren have never had a cavity has taken on the virtues of truth through frequent and widespread restatement. The 50-percent caries-free statement is an excessively optimistic misrepresentation by the media of the 1986-87 survey of oral health among schoolchildren by the National Institute of Dental Research because it only tells part of the story--it ignores dental disease in the primary dentition. This article documents that numerous public policy papers reflect failure to consider primary tooth caries data. Consequently, a significant disease burden has been overlooked. The article reviews the persistent underreporting of children's caries experience in policy documents and the dental literature, and reviews additional epidemiologic studies of caries reported in U.S. dental literature since 1985. Dental caries remains the single most common disease of childhood that is not self-limiting or amenable to a course of antibiotics. The popular statement that half of U.S. schoolchildren have never experienced tooth decay fails profoundly to reflect the extremity and severity of this still highly prevalent condition of childhood. At a time of extreme pressure on the Medicaid Early and Periodic Screening, Diagnosis, and Treatment budget this uncritically held belief is leading to inappropriate policy and funding decisions that can put the health of children at risk.