Changes in children's dental fear after restorative treatment under different sedation types: Associations with parents' experiences and dental health

BACKGROUND

Dentists often use sedative medications such as nitrous oxide inhaled sedation and general anesthesia (GA) to help decrease patient fear and manage paediatric patients' behavior during treatment.

AIM

The goal of this study was to examine factors associated with dental fear changes after restorative dental treatment under nitrous oxide or GA in children 4-12 years old.

DESIGN

A prospective cohort study of 124 children examined changes in dental fear, number of treatment visits, and parental factors among children receiving restorative dental treatment under nitrous oxide (n = 68) or GA (n = 56) sedation. Data were collected at pretreatment (T1), 16 weeks post-treatment (T2), and at 29-month follow-up (T3).

RESULTS

Dental fear increased slightly, but not significantly, under both forms of sedation between T1 and T3. Children's dental fear was associated with parents' poor dental experiences and oral health, but not with number of treatment visits.

CONCLUSIONS

Progression of children's dental fear seems not dependent solely on the type of sedation used but is likely predicted by factors including pretreatment dental fear and dental needs. Dentists recommending sedation for children's dental care may consider pretreatment dental need, fear levels, and parental factors when determining which type of sedation to use.

Pediatric Dentists' Use of Nonpharmacological Behavior Guidance Techniques and Experiences with Parent / Caregiver Acceptance: A National Survey

Purpose: To determine: (1) which nonpharmacological behavior guidance techniques recommended in the American Academy of Pediatric Dentistry's (AAPD) best practice statement are currently routinely used by pediatric dentists; and (2) their perception of parent/ caregiver acceptance of the techniques. Methods: All active AAPD dentist members were invited to participate in this cross-sectional study. Participants (n equals 518) completed an online questionnaire that queried the use of each nonpharmacological behavior guidance technique outlined in the AAPD best practice statement, the frequency with which parent / caregiver hesitancy/refusal is encountered for each, and practice characteristics and demo- graphics. Data were analyzed using descriptive statistics and tests of group differences. Results: Nearly all participants endorsed routine use of the foundational techniques tell-show-do (98.6 percent), counseling skills to build rapport (97.7 percent), and positive reinforcement (95.6 percent). Fewer endorsed using more complex techniques like desensitization (75.3 percent), memory restructuring (22.6 percent), and cognitive behavioral therapy (4.4 percent). There were significant differences in mean years of clinical experience between those who used and did not use some of the more complex techniques. Of the 26 techniques queried, parent / caregiver hesitancy/refusal was encountered most frequently for parental absence, physical restraints, and voice control, and never to rarely for the others. Conclusions: This first-ever study of all nonpharmacological behavior gui- dance techniques outlined in the AAPD's best practice statement suggests that pediatric dentists routinely use foundational techniques but less frequently use more resource-intensive or complex techniques. With few exceptions, these techniques are well accepted by parents / caregivers.

Nonpharmacological Behavior Guidance for the Pediatric Dental Patient

Purpose: To present evidence-based recommendations on nonpharmacological behavior guidance for the pediatric dental patient. Methods: The work group assessed eight systematic reviews for effectiveness of nonpharmacological behavior guidance techniques in children undergoing preventive care or a dental treatment visit. The key outcomes assessed included cooperative behavior, anxiety, and procedural pain. To formulate the recommendations, the work group used the GRADE framework to obtain consensus on domains such as priority of the problem, certainty of the evidence, balance between desirable and undesirable consequences, patients' values and preferences, acceptability, and feasibility. Results: Overall, the use of basic nonpharmacological behavior guidance techniques resulted in trivial-to-small effect on improvement in behavior or reduction in anxiety. However, for children and adolescents undergoing preventive care, mobile applications and modeling showed large effects in reduction of anxiety. For those undergoing dental treatment, strategies such as modeling, positive reinforcement, biofeedback relaxation, breathing relaxation, animal-assisted therapy, combined tell-show-do, audiovisual distraction, and cognitive behavior therapy showed large reduction in anxiety. For children and adolescents with special health care needs, audiovisual distraction and sensory-adapted dental environment showed large reduction of anxiety. Conclusions: All the formulated recommendations were conditional and were mostly based on very low certainty of evidence. Conditional recommendations imply that different choices or combinations of behavior guidance techniques may be most appropriate for different patients. Clinicians should use techniques consistent with the parent/patient values and preferences. These recommendations are based on the best available evidence to-date and are intended to aid clinical decision making.

Acculturation and Dental Care-Related Anxiety: An Exploratory Assessment from the Hispanic Community Health Study / Study of Latinos

This study aimed to determine the associations between acculturation, dental anxiety, and dental utilization among Hispanics/Latinos living in the US. A proxy measure of dental anxiety was available for 7539 adults who had not visited a dentist within the last year. All completed the Short Acculturation Scale for Hispanics (SASH). Bivariate logistic regression and adjusted multivariable logistic regression analysis were conducted. Approximately 22% of the sample was dentally anxious. Dental anxiety was significantly associated with SASH language scale score (OR 1.09, 95%CI 1.02, 1.18, p = 0.04), years in US (OR 1.53, 95%CI 1.23, 1.91, p < 0.0001), and preferred Spanish language (OR 1.30, 95%CI 1.05, 1.63, p = 0.0192); lower acculturation corresponded to higher dental anxiety. Adjusting for sex, age, education, income, insurance, and oral health status, level of acculturation was associated with dental anxiety (AOR 0.87, 95%CI 0.75, 0.91, p = 0.009), but neither were associated with utilization. Acculturation may be an important predictor of dental anxiety for Hispanics/Latinos living in the US.

Nonpharmacological Behavior Guidance for Children with Special Health Care Needs During Preventive and Treatment Dental Visits: A Systematic Review-Part 3

PURPOSE

To assess the effectiveness of nonpharmacological behavior guidance interventions used for children and youth with special health care needs (CYSHCN) during preventive and dental treatment visits.

METHODS

Databases: Ovid MEDLINE, PsycINFO (EBSCOhost), Embase, and Cochrane Library, were searched from 1946 to February 2022, for randomized clinical trials (RCTs) comparing effectiveness of basic and advanced nonpharmacological techniques rendered during a preventive visit (exam, fluoride application, radiographs, and prophylaxis) or a treat- ment visit (simple surgical treatment, sealants, restorative care with or with local anesthesia) with control or other interventions. The primary outcome measures for the studied interventions were reduction in anxiety, fear, pain, and improvement in cooperative behavior. Eight authors determined the included Randomized Controlled Trials (RCTs), performed data extraction, and assessed the risk of bias (ROB). Standardized Mean Difference calculation and assignment of quality of evidence by Grading of Recommendations Assessment, Development and Evaluation approach were done.

RESULTS

Eleven articles qualified for analysis from 219 screened articles. Included studies evaluate the effectiveness of in office strategies such as modeling, audio-visual distraction, sensory adapted dental environment, and picture exchange communication system. The certainty of evidence ranged from Very low to Low and the magnitude of effect varied from trivial to large change in the desired outcomes.

CONCLUSIONS

Most basic non-pharmacological behavior guidance techniques showed some trivial to small reduction in self-reported anxiety and/ or improvement in behavior, with audiovisual distraction, Sensory Adapted Dental Environment, and Picture Exchange Communication System showing large reduction in anxiety based on some rating scales. Systematic Review Registration Number: PROSPERO: CRD42022314723.

Nonpharmacological Behavior Guidance For Children During Dental Treatment Visits: A Systematic Review and Meta-Analysis-Part 2

'Purpose: To assess the effectiveness of nonpharmacological behavior guidance interventions used for children undergoing dental treatment visits.

METHODS

Databases: Ovid MEDLINE, PsycINFO (EBSCOhost), Embase, and Cochrane Library, were searched from 1946 to February 2022, for randomized clinical trials (RCTs) comparing effectiveness of basic and advanced nonpharmacological techniques rendered during a dental treatment visit including sealants, restorative care, dental local anesthesia, and simple surgical procedures. The primary outcome measures were reduction in anxiety, fear, pain, and improvement in cooperative behavior. Eight authors determined the included RCTs, performed data extraction, and assessed the risk of bias (ROB). Standardized Mean Difference calculation and assignment of quality of evidence by Grading of Recommenda- tions Assessment, Development and Evaluation approach were done.

RESULTS

Forty articles qualified for analysis from 219 screened articles. Included studies evaluated the effectiveness of pre-visit preparation and in office strategies rendered pre-/post- or during treatment such as positive imagery, direct observation/modeling, desensitization, tell-show-do and its modifications, voice control, positive reinforcement, memory restructuring, bio- feedback and breathing relaxation, animal assisted therapy, combined therapies, and cognitive behavior therapy. The certainty of evidence ranged from Very low to high and the magnitude of effect varied from trivial to large change in the desired outcomes.

CONCLUSIONS

Most of the basic non- pharmacological behavior guidance techniques showed trivial to small reduction in self-reported anxiety and/or improvement in behavior, with modeling, positive reinforcement, biofeedback relaxation, breathing relaxation, animal assisted therapy, combined tell-show-do and audiovisual distraction, and cognitive behavior therapy showing large effects in reduction of anxiety based on some scales.

Nonpharmacological Behavior Guidance for Children During Preventive Dental Visits: A Systematic Review-Part 1

PURPOSE

To assess the effectiveness of nonpharmacological behavior guidance interventions used for a child undergoing preventive dental visits.

METHODS

Databases: Ovid MEDLINE, PsycINFO (EBSCOhost), Embase, and Cochrane Library, were searched from 1946 to February 2022, for randomized clinical trials (RCTs) comparing effectiveness of basic and advanced nonpharmacological techniques rendered during a pre- ventive visit including examination, prophylaxis, fluoride application and radiographs. Workgroup (WG) identified moderate-to-high quality system- atic reviews (SRs) published on hypnosis, audiovisual distraction, and parental presence/ absence; and decided to exclude these interventions from current SR to avoid duplication. The primary outcome measures for the studied interventions included reduction in anxiety, fear, pain, and improve- ment in cooperative behavior. Eight authors determined the included RCTs, performed data extraction, and assessed the risk of bias. Standardized Mean Difference calculation and assignment of quality of evidence by Grading of Recommendations Assessment, Development and Evaluation approach were done.

RESULTS

Fifteen articles qualified for analysis from 219 screened articles. WG found studies evaluating effectiveness of pre- visit preparation and in-office strategies rendered pre- or during treatment such as positive imagery, communication, modeling, tell-show-do, magic tricks, mobile applications, positive reinforcement, and sensory adapted dental environment. The certainty of evidence ranged from Very low to Moderate and the magnitude of effect varied from trivial to a large change in the desired outcomes.

CONCLUSIONS

Most basic nonpharmacological behavior guidance techniques showed trivial to small reduction in self-reported anxiety and/or improvement in behavior, with mobile application and modeling showing large effects in reduction of anxiety based on some rating scales. Systematic Review Registration Number: PROSPERO: CRD42022314723.

Using Trainee Failures to Enhance Learning: A Qualitative Study of Pediatric Hospitalists on Allowing Failure

INTRODUCTION

Attendings allow trainee failure when perceived educational benefits outweigh potential patient harm. This strategy has not been explored in pediatrics, where it may be shaped by unique factors. Our objectives were to understand if, when, and how pediatric hospitalists allow trainees to fail during clinical encounters.

METHODS

Using constructivist grounded theory, we conducted semistructured interviews with 21 pediatric hospitalists from a children's hospital in the United States. Iterative, constant comparative analysis took place concurrent with data collection. During regular team meetings, we refined and grouped codes into larger themes.

RESULTS

Nineteen of the 21 participants shared that they intentionally allowed failure as a teaching strategy, acknowledging this strategy's emotional power and weighing the educational benefits against harms to current and future patients, caregivers, and trainees. Participants described a multistep process for allowing failure: 1) initiate an orientation to signal that they prioritize a psychologically safe learning environment; 2) consider factors which influence their decision to allow failure; and 3) debrief with trainees. However, participants did not explicitly alert trainees to this teaching strategy. They also avoided using the word "failure" during debriefs to protect trainees from psychological harm.

CONCLUSIONS

Most pediatric hospitalists in this study allowed failure for educational purposes. However, they did so cautiously, weighing the educational value of the failure against the safety of both current and future patients, the relationship with the caregivers, and the trainees' well-being. Future research should involve trainees to more comprehensively understand the experience and effectiveness of this teaching strategy.

Dissemination and implementation research for oral and craniofacial health: Background, a review of literature and future directions

Oral conditions are highly prevalent globally and have profound consequence on individuals and communities. Clinical (e.g. dental treatments, behavioural counselling) and non-clinical (e.g. community-based programming, water fluoridation, oral health policy) evidence-based interventions have been identified, recommended and applied at the clinic, community and policy levels. Still, the burden of oral conditions persists, with inequitable distribution across populations. A major driver of this lack of progress is poor translation of research findings, which results in an evidence-to-practice gap. Dissemination and implementation science (DIS) has emerged to address this gap. A relatively new field, application of DIS represents an important avenue for achieving good dental, oral and craniofacial health for all. The goal of this introductory article is to provide a brief background on DIS relevant to researchers in dentistry and oral health. The problem of knowledge translation, basic concepts and terminology in DIS, and approaches to doing dissemination and implementation research-including implementation strategies, key outcomes, and implementation theories, models and frameworks-are discussed. Additionally, the article reviews literature applying DIS to dentistry and oral health. Results of published studies and their implications for the field are presented. Drawing on the literature review and contemporary thinking in DIS, current gaps, opportunities and future directions are discussed. Resources for understanding and applying DIS are provided throughout. This article serves as a primer on DIS for dental and oral health researchers of all types working across a range of contexts; it also serves as a call to action for increased application of DIS to address the burden of oral conditions globally.

Perspectives on the future of dissemination and implementation research in oral and craniofacial sciences

Dissemination and implementation science is a field of research that promotes the adoption and maintenance of evidence-based interventions in healthcare delivery and community settings and seeks to understand the processes by which such adoption and maintenance occur. While dissemination and implementation science is an established field in health services research, it is relatively new and making inroads in dental, oral and craniofacial research. This article summarizes the proceedings from a scientific panel on 'Dissemination and Implementation Science for Oral and Craniofacial Health' that was held during the international Behavioral and Social Oral Health Sciences Summit. The panelists were four experts on dissemination and implementation science in dental and non-dental academic settings in the United States and Scotland, with affiliations ranging from schools of dentistry and public health to the National Institutes of Health and a healthcare system with integrated dental services. The panel discussion addressed how dissemination and implementation science can be used to further oral health research. The narrative report presented here aims to describe the panelists' reflections and insights on their current initiatives in dissemination and implementation research to inform future research endeavors within the oral and craniofacial sciences. Specifically, this article focuses on six discussion topics: (1) how organizational determinants can serve as facilitators or barriers to the implementation of evidence-based dental practice; (2) how dentistry can 'de-implement' practices that are not effective; (3) how implementation science can support the delivery of evidence-based dental practice using adaptation; (4) how to get started in implementation science; (5) how the broader environment can support large-scale implementation efforts; and (6) how oral and craniofacial science is well suited for advancing dissemination and implementation research.

Dental trainees' mental health changes, sources of stress, coping strategies, and suggestions for mental health improvement 1 year into the pandemic

OBJECTIVES

The goal of this study was to assess how the mental health of dental trainees has changed during the pandemic and to identify the most stressful aspects of trainees' programs, stress coping strategies, and suggestions for individual and institution-driven solutions to improve wellness.

METHODS

The study focused on dental trainees at the University of Washington who completed a wellness survey in fall 2020 (n = 126; response rate = 35.5%) and spring 2021 (n = 105; response rate = 29.6%). The survey included self-report measures assessing four mental health outcomes: depression, anxiety, isolation from peers, and burnout. Stressful aspects of the training program, coping strategies, and institution-driven solutions were measured with open-ended survey items. The chi-square test was used to compare mental health outcome measures between fall and spring and open-ended survey responses were inductively coded.

RESULTS

The prevalence of self-reported depression and anxiety did not change between fall 2020 and spring 2021 (17.2% vs. 21.1%, p = 0.473; 22.4% vs. 23.7%, p = 0.818). Isolation from peers and burnout each significantly increased by almost 20% from fall 2020 to spring 2021 (46.8% vs. 64.3%; p = 0.009 and 26.6% vs. 43.9%; p = 0.017). Trainees identified workload as the most stressful aspect of their program and described using exercise and social support to cope with stress. Trainees suggested institution-supported increases in social events and mental health resources.

CONCLUSIONS

One year into the coronavirus disease 2019 pandemic, poor mental health outcomes were common among dental trainees because of high workload and isolation from peers. Dental schools should promote targeted programs and services aimed at improving dental trainees' well-being.

The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States

PhenomenonMoral distress, which occurs when someone's moral integrity is seriously compromised because they feel unable to act in accordance with their core values and obligations, is an increasingly important concern for physicians. Due in part to limited understanding of the root causes of moral distress, little is known about which approaches are most beneficial for mitigating physicians' distress. Our objective was to describe system-level factors in United States (U.S.) healthcare that contribute to moral distress among pediatric hospitalist attendings and pediatric residents.ApproachIn this qualitative study, we conducted one-on-one semi-structured interviews with pediatric hospitalist attendings and pediatric residents from 4 university-affiliated, freestanding children's hospitals in the U.S. between August 2019 and February 2020. Data were coded with an iteratively developed codebook, categorized into themes, and then synthesized.FindingsWe interviewed 22 hospitalists and 18 residents. Participants described in detail how the culture of medicine created a context that cultivated moral distress. Norms of medical education and the practice of medicine created conflicts between residents' strong sense of professional responsibility to serve the best interests of their patients and the expectations of a hierarchical system of decision-making. The corporatization of the U.S. healthcare system created administrative and financial pressures that conflicted with the moral responsibility felt by both residents and hospitalists to provide the care that their patients and families needed.InsightsThese findings highlight the critical role of systemic sources of moral distress. These findings suggest that system-level interventions must supplement existing interventions that target individual health care providers. Preventing and managing moral distress will require a broad approach that addresses systemic drivers, such as the corporatization of medicine, which are entrenched in the culture of medicine.

Association Between Mental Health and Oral Health Status and Care Utilization

Studies have shown that mental health and oral health may be correlated, with associations demonstrated between mental health problems and tooth loss, periodontal disease, and tooth decay. The COVID-19 pandemic had alarming implications for individuals' and communities' mental and emotional health. This study examined the associations between mental health status, oral health status, and oral healthcare utilization and highlighted the impact of COVID-19 on mental health. Additionally, this study examines specific sociodemographic factors that may amplify oral health disparities. A nationally representative survey was conducted to capture attitudes, experiences, and behaviors related to oral health, mental health, and unmet oral health needs. Eighteen percent of respondents were categorized as having poor mental health. Visiting the dentist in the last year was more common amongst individuals with good mental health. From the logistic regression model, mental health status, age group, race/ethnicity, education, and last dental visit were all significantly associated with of oral health status. Mental health status, age group, and income groups were all significantly associated with unmet oral health need. Future work should focus on the mental-oral health association, including determining ways to improve oral healthcare utilization and oral health status among people with poorer mental health.

Consensus Statement on Future Directions for the Behavioral and Social Sciences in Oral Health

The behavioral and social sciences are central to understanding and addressing oral and craniofacial health, diseases, and conditions. With both basic and applied approaches, behavioral and social sciences are relevant to every discipline in dentistry and all dental, oral, and craniofacial sciences, as well as oral health promotion programs and health care delivery. Key to understanding multilevel, interacting influences on oral health behavior and outcomes, the behavioral and social sciences focus on individuals, families, groups, cultures, systems, societies, regions, and nations. Uniquely positioned to highlight the importance of racial, cultural, and other equity in oral health, the behavioral and social sciences necessitate a focus on both individuals and groups, societal reactions to them related to power, and environmental and other contextual factors. Presented here is a consensus statement that was produced through an iterative feedback process. The statement reflects the current state of knowledge in the behavioral and social oral health sciences and identifies future directions for the field, focusing on 4 key areas: behavioral and social theories and mechanisms related to oral health, use of multiple and novel methodologies in social and behavioral research and practice related to oral health, development and testing of behavioral and social interventions to promote oral health, and dissemination and implementation research for oral health. This statement was endorsed by over 400 individuals and groups from around the world and representing numerous disciplines in oral health and the behavioral and social sciences. Having reached consensus, action is needed to advance and further integrate and translate behavioral and social sciences into oral health research, oral health promotion and health care, and the training of those working to ensure oral health for all.

Development and Validation of the Oral Health Values Scale

OBJECTIVES

Oral health values, the degree to which one places importance on or demonstrates investment in improving or maintaining one's dental status, are believed to vary across individuals. Research on this construct is in its infancy, so a new Oral Health Values Scale (OHVS) was developed and validated. The aim was to create a multidimensional measure of oral health values that could be used in future epidemiological or behavioural investigations involving determinants of dental treatment-seeking behaviour and/or oral health.

METHODS

The OHVS was developed in three cross-sectional phases. A 45-item pool was developed, and 12 expert raters from various oral health professions rated the items for their representativeness and relevance, as well as specificity and clarity. Based on the expert feedback, an initial 30-item scale was subsequently established and administered to a developmental sample (N = 306) using Amazon's Mechanical Turk (MTurk). The scale was further refined to be 12 items and its structure was confirmed in a validation sample (N = 308), also using MTurk. Correlations among OHVS scores and other oral health-related constructs were examined in the developmental and validation samples.

RESULTS

Expert review of items for the oral health values construct and the OHVS provided initial evidence of content validity. The final 12-item scale exhibited a four-factor structure with good internal consistency, α = 0.84. The psychometric properties of the final scale were confirmed in a second sample using confirmatory factor analysis, although evidence for the OHVS's four-factor structure was mixed. Overall, OHVS scores were consistently related to other oral health constructs in anticipated ways, providing evidence of construct validity.

CONCLUSIONS

The OHVS demonstrated content validity, internal consistency, and construct validity. Results suggest that the OHVS is a psychometrically sound instrument.

Adolescent Dental Fear and Anxiety: Background, Assessment, and Nonpharmacologic Behavior Guidance

Adolescence, the period from 11 to 21 years of age, bridges the chasm between childhood and adulthood. Adolescence can be challenging as bodies, cognition, and personality go through major transformations, but it is also a time of great joy as confident adults with a clear identity develop. Dentists need to be knowledgeable about the developmental characteristics of this group because some of the cognitive and emotional changes make adolescents vulnerable to new fears. Dentists must tailor behavior guidance to this developing psyche in a way that respects independence and promotes confidence to foster lifelong positive views of dentistry.

Longitudinal Analysis of Children's Oral Health-Related Quality of Life After Restorative Dental Treatment

Purpose: To document mid- and long-term changes in oral health-related quality of life (OHRQoL) following dental intervention in a sample of restorative treatment-naïve children receiving different levels of care, with and without general anesthesia (GA). Methods: This prospective cohort study followed 132 children. Parents completed the pediatric OHRQoL instrument (POQL) before, 16 weeks after (i.e., posttreatment), and 18 to 45 (mean equals 29.5) months after (i.e., follow-up) child receipt of treatment. Parents provided child demographic and oral health information. The number of restored surfaces and anesthesia type were abstracted from dental records. The mean differences in POQL scores were compared across groups. Results: The sample was 49 percent female (age range equals four to 12 years; mean±standard deviation equals 5.8±1.8). Overall, from pretreatment to posttreatment, mean POQL scores decreased by 4.5 points (P<0.001), representing improved OHRQoL. Only among children with 10 or more surfaces restored or who received GA did follow-up POQL scores remain significantly lower than pretreatment scores (mean difference equals -7.4 and -8.0, respectively, P<0.01). Overall, follow-up scores were significantly higher than posttreatment scores, representing a decline from the initial improvement. Conclusions: Regardless of disease severity, children experience an immediate improvement in OHRQoL following restorative treatment. Improvements in OHRQoL are sustained over the long-term only among children with more extensive pretreatment needs.

Dental trainees' mental health and intention to leave their programs during the COVID-19 pandemic

Background

Dental trainees (dental students, graduate students, and postdoctoral residents) are at increased risk of experiencing poor mental health, which can lead to intentions to leave their program, especially during the COVID-19 pandemic.

Methods

The authors invited 355 dental trainees at the University of Washington School of Dentistry to complete an 83-item questionnaire in August and September 2020. The outcome analyzed was intention to leave their programs. There were 4 self-reported predictors: anxiety, burnout, depression, and COVID-19 impact on overall mental health. The authors ran multiple variable logistic regression models to evaluate relationships between each predictor and outcome (α = .05) and reported odds ratios (ORs) and 95% CIs.

Results

The survey response rate was 35.5%. Overall, 12.7% of participants reported any intention to leave. In total, 22.2% and 16.7% of participants endorsed clinically significant anxiety or depression symptomatology, respectively; 28.6% reported 1 or more burnout symptoms; and 69.0% reported that COVID-19 affected their overall mental health. Participants reporting anxiety (OR, 8.87; 95% CI, 1.80 to 43.57; P = .007), depression (OR, 11.18; 95% CI, 1.84 to 67.74; P = .009), or burnout (OR, 8.14; 95% CI, 1.73 to 38.23; P = .008) were significantly more likely to report intention to leave than those not reporting mental health problems. All participants reporting that the COVID-19 pandemic impacted their mental health expressed intention to leave.

Conclusions

Poor mental health is common among dental trainees and is associated with intention to leave their program.

Practical Implications

COVID-19 has exacerbated the prevalence and consequences of poor mental health among dental students, highlighting the importance of providing wellness resources.

Moral Distress in Pediatric Residents and Pediatric Hospitalists: Sources and Association With Burnout

OBJECTIVE

Moral distress is increasingly identified as a major problem affecting healthcare professionals, but it is poorly characterized among pediatricians. Our objective was to assess the sources of moral distress in residents and pediatric hospitalist attendings and to examine the association of moral distress with reported burnout.

METHODS

Cross-sectional survey from January through March 2019 of pediatric residents and hospital medicine attending physicians affiliated with 4 free-standing children's hospitals. Moral distress was measured using the Measure of Moral Distress for Healthcare Professionals (MMD-HP). Burnout was measured using 2 items adapted from the Maslach Burnout Inventory.

RESULTS

Respondents included 288 of 541 eligible pediatric residents (response rate: 53%) and 118 of 168 pediatric hospitalists (response rate: 70%; total response rate: 57%). The mean MMD-HP composite score was 93.4 (SD = 42.5). Residents reported significantly higher frequency scores (residents: M = 38.5 vs. hospitalists: M = 33.3; difference: 5.2, 95% confidence interval [CI], 2.9-7.5) and composite scores (residents: M = 97.6 vs hospitalists: M = 83.0; difference:14.6, 95% CI, 5.7-23.5) than hospitalists. The most frequent source of moral distress was "having excessive documentation requirements that compromise patient care," and the most intense source of moral distress was "be[ing] required to work with abusive patients/family members who are compromising quality of care." Significantly higher mean MMD-HP composite scores were observed among participants reporting that they felt burned out at least once per week (M= 114.6 vs M= 82.3; difference: 32.3, 95% CI, 23.5-41.2).

CONCLUSIONS

Pediatric residents and hospitalists report experiencing moral distress from a variety of patient-, team-, and system-level sources, and this distress is associated with burnout.

Pediatric Dental Procedure-Related Pain Assessment Practices in A Rural Alaskan Health Care Organization: A Qualitative Study

Purpose: Acute pain experienced during dental procedures can lead to distress, difficulty with behavior guidance, and dental fear/avoidance. The purpose of this study was to explore dental providers' perceptions of pediatric procedure-related pain and acute pain assessment practices. Methods: Fifteen dental providers (53 percent female; nine dentists, three dental therapists, three dental hygienists) currently/formerly employed by a single rural Alaskan health care organization were interviewed using a semi-structured guide. Recorded interviews were transcribed, verified, and coded using inductive qualitative analytic methods. Results: Six providers suggested that pediatric procedure-related pain is rarely encountered. Providers who reported encountering it rely on observation of body language, facial expression, behavior, crying, and verbalization to know whether a child is experiencing procedural pain. Even when available, only four interviewees reported using standardized pain scales. Conclusions: Dental providers have mixed perceptions about whether they encounter pediatric procedure-related pain. There is high variability in how providersassess procedural pain, and approaches often are nonstandardized.

Supply of care by dental therapists and emergency dental consultations in Alaska native communities in the Yukon-Kuskokwim delta: a mixed methods evaluation

OBJECTIVES

Examine the relationship between supply of care provided by dental therapists and emergency dental consultations in Alaska Native communities.

METHODS

Explanatory sequential mixed-methods study using Alaska Medicaid and electronic health record (EHR) data from the Yukon-Kuskokwim Health Corporation (YKHC), and interview data from six Alaska Native communities. From the Medicaid data, we estimated community-level dental therapy treatment days and from the EHR data we identified emergency dental consultations. We calculated Spearman partial correlation coefficients and ran confounder-adjusted models for children and adults. Interview data collected from YKHC providers (N=16) and community members (N=125) were content analysed. The quantitative and qualitative data were integrated through connecting. Results were visualized with a joint display.

RESULTS

There were significant negative correlations between dental therapy treatment days and emergency dental consultations for children (partial rank correlation = -0.48; p⟨0.001) and for adults (partial rank correlation = -0.18; p=0.03). Six pediatric themes emerged: child-focused health priorities; school-based dental programs; oral health education and preventive behaviors; dental care availability; healthier teeth; and satisfaction with care. There were four adult themes: satisfaction with care; adults as a lower priority; difficulties getting appointments; and limited scope of practice of dental therapy.

CONCLUSIONS

Alaska Native children, and to a lesser extent adults, in communities served more intensively by dental therapists have benefitted. There are high levels of unmet dental need as evidenced by high emergency dental consultation rates. Future research should identify ways to address unmet dental needs, especially for adults.

Gender Inequalities in the Dental Workforce: Global Perspectives

The aim of this review is to investigate the growth of diversity and inclusion in global academic dental research with a focus on gender equality. A diverse range of research methodologies were used to conduct this review, including an extensive review of the literature, engagement of key informants in dental academic leadership positions around the world, and review of current data from a variety of national and international organizations. Results provide evidence of gender inequalities that currently persist in dental academics and research. Although the gender gap among graduating dental students in North America and the two most populous countries in Europe (the United Kingdom and France) has been narrowed, women make up 30% to 40% of registered dentists in countries throughout Europe, Oceania, Asia, and Africa. In academic dentistry around the globe, greater gender inequality was found to correlate with higher ranking academic and leadership positions in the United States, United Kingdom, several countries in European Union, Japan, and Saudi Arabia. Further disparities are noted in the dental research sector, where women make up 33% of dental researchers in the European Union, 35% in North America, 55% in Brazil, and 25% in Japan. Family and societal pressures, limited access to research funding, and lack of mentoring and leadership training opportunities are reported as also contributing to gender inequalities. To continue advancing gender equality in dental academia and research, efforts should be geared toward the collection and public dissemination of data on gender-specific distributions. Such evidence-driven information will guide the selection of future strategies and best practices for promoting gender equity in the dental workforce, which provides a major pipeline of researchers and scholars for the dental profession.

Transmission of dental fear from parent to adolescent in an Appalachian sample in the USA

BACKGROUND

Dental fear/anxiety is associated with numerous negative outcomes. State dental fear is known to be transmitted from parents to their children in the dental setting, but it is not known how trait fear/anxiety might be shared between parents and offspring long term, and especially for adolescents.

AIM

This study aimed to: (a) compare dental fear levels of adolescents and their parents; (b) predict adolescent dental fear based on demographic variables, fear of pain, and parental dental fear; and, (c) determine relative contributions of mothers' and fathers' dental fear to adolescent fear.

DESIGN

In this cross-sectional study, the Dental Fear Survey and Fear of Pain Questionnaire-9 were administered to 350 adolescents (age range 11-17) and 515 of their parents, with t test and ANOVA used to calculate between-group differences; multiple linear regression was used to predict adolescent fear from parent fear.

RESULTS

Adolescents' dental fear was predicted by their own fear of pain and their parents' dental fear, but not their parents' fear of pain nor their own age or gender. When considered together, fathers' but not mothers' dental fear predicted adolescents' dental fear.

CONCLUSIONS

Parents' fears/anxieties about dentistry are associated with adolescents' dental fear in a manner suggestive of intergenerational transmission.

Organizational Readiness to Implement System Changes in an Alaskan Tribal Dental Care Organization

INTRODUCTION

Tribal health care systems are striving to implement internal changes to improve dental care access and delivery and reduce health inequities for American Indian and Alaska Native children. Within similar systems, organizational readiness to implement change has been associated with adoption of system-level changes and affected by organizational factors, including culture, resources, and structure.

OBJECTIVES

The objectives of this study were to assess organizational readiness to implement changes related to delivery of evidence-based dental care within a tribal health care organization and determine workforce- and perceived work environment-related factors associated with readiness.

METHODS

A 92-item questionnaire was completed online by 78 employees, including dental providers, dental assistants, and support staff (88% response rate). The questionnaire queried readiness for implementation (Organizational Readiness for Implementing Change), organizational context and resources, workforce issues, organizational functioning, and demographics.

RESULTS

Average scores for the change commitment and change efficacy domains (readiness for implementation) were 3.93 (SD = .75) and 3.85 (SD = .80), respectively, where the maximum best score was 5. Perceived quality of management, a facet of organizational functioning, was the only significant predictor of readiness to implement change (B = .727, SE = .181, P < .0002) when all other variables were accounted for.

CONCLUSION

Results suggest that when staff members (including dentists, dental therapists, hygienists, assistants, and support staff) from a tribal health care organization perceive management to be high quality, they are more supportive of organizational changes that promote evidence-based practices. Readiness-for-change scores indicate an organization capable of institutional adoption of new policies and procedures. In this case, use of more effective management strategies may be one of the changes most critical for enhancing institutional behaviors to improve population health and reduce health inequities.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians and other leaders implementing changes within dental care organizations. To promote organizational readiness for change and, ultimately, more expedient and efficient adoption of system-level changes by stakeholders, consideration should be given to organizational functioning generally and quality of management practices specifically.

Provider and community perspectives of dental therapists in Alaska's Yukon-Kuskokwim Delta: A qualitative programme evaluation

OBJECTIVES

Dental therapists deliver preventive and basic restorative care and have been practicing since 2006 in Alaska's Yukon-Kuskokwim (YK) Delta. In this qualitative programme evaluation, we documented health providers' and community members' experiences with dental therapy. The goal of the evaluation was to develop a conceptual model of dental care delivery in Alaska Native Communities centred on dental therapists.

METHODS

We developed semi-structured interview scripts and used snowball sampling to recruit 16 health providers with experience providing care in the YK Delta and 125 community members from six YK Delta Communities in 2017 and 2018. The six communities were a stratified convenience sample based on community-level exposure to dental therapists (high, medium and no exposure). Interview data were digitally recorded, transcribed, verified for accuracy and coded inductively into conceptual domains using content analytic methods.

RESULTS

Providers believed individuals living in the YK Delta have benefited from clinic-based restorative care and community-based education provided by dental therapists. The restricted scope of dental therapy practice limits the complexity of care that may be offered to patients. However, community members expressed high satisfaction with the quality of care provided by dental therapists. Community members noted more widespread knowledge and evolving norms about oral health and believed dental therapists are helping to prevent disease and improve quality of life. Participants believed access to dental care for children has improved over the years, but felt that many adults in the YK Delta continue to have unmet needs. A potential barrier to sustained programme effectiveness is low retention of dental therapists in the region, driven primarily by reports that dental therapists feel overworked, stressed and geographically isolated.

CONCLUSIONS

Dental therapists have contributed to the dental care delivery system in Alaska's YK Delta. Future opportunities remain within the system to address the needs of adults, develop strategies to retain dental therapists in the region and incorporate evidence-based, prevention-oriented strategies to improve oral health behaviours and reduce oral diseases.

Alaska Native Children Do Not Prefer Sugar-Sweetened Fruit Drinks to Sugar-Free Fruit Drinks

BACKGROUND

Alaska Native children, including children of Yup'ik descent, consume large volumes of sugar-sweetened fruit drinks, which contain added sugars that contribute to obesity, diabetes, and dental caries. To date, taste preference evaluations have not been conducted on commercially available sugar-free fruit drinks.

OBJECTIVE

The study tested the hypothesis that children would have equal preference for sugar-free and sugar-sweetened fruit drinks.

DESIGN

This was an experimental two-alternative forced-choice paired preference test.

PARTICIPANTS/SETTING

The study focused on a convenience sample of Yup'ik children, aged 7 to 10 years, recruited and enrolled from the Yukon-Kuskokwim Health Corporation dental clinic in Bethel, AK (N=89).

INTERVENTION

Children evaluated four different commercially available sugar-free fruit drinks paired with the sugar-sweetened versions of each flavor. Order of flavor pair presentation was alternated across children, and order of presentation within each of the four pairs was randomized across pairs.

MAIN OUTCOME MEASURES

The outcome was taste preference for the sugar-free versus the sugar-sweetened version of a fruit drink.

STATISTICAL ANALYSES PERFORMED

A test of equivalence was run across all four flavors and separately for each flavor using two one-sided tests.

RESULTS

The data failed to demonstrate equivalence of the sugar-free and sugar-sweetened fruit drinks across all four flavors (P=0.51) or separately for each flavor. However, this was not because of a preference for sugar-sweetened drinks. The preference for sugar-free drinks overall and for each flavor was >50%. Although the lower bounds of the 90% CIs were within the range of equivalence (40% to 60%), the upper bounds were outside the range of equivalence (>60%). According to post hoc analyses, similar preferences were observed for Yup'ik and non-Yup'ik children, boys and girls, and children of different ages.

CONCLUSIONS

Taste preference findings suggest that sugar-free fruit drinks may be a well-tolerated alternative to sugar-sweetened fruit drinks for Yup'ik children in Alaska Native communities.

Assessment of pain-related fear in individuals with chronic painful conditions

Background

Heightened fear and anxiety related to pain may result in emotional and behavioral avoidance responses causing disability, distress, and depression. Fear and anxiety associated with pain can potentially change the course of the pain experience. It is plausible that fear and anxiety related to pain affect the duration and frequency of pain experienced by the patient.

Aim

The study aimed to examine the applicability of the Fear of Pain Questionnaire-III (FPQ-III) in identifying who are likely to report longer duration and greater frequency of pain experience.

Methods

To test this hypothesis, a cross-sectional study was conducted with 579 individuals from a community-based sample living with chronic pain. The factor structure and validity of FPQ-III in the community-based sample were also tested.

Results

The findings suggest higher fear of severe pain but lower fear of medical pain, associated with longer duration and more frequent pain experience. The analysis also confirmed the three-factor structure of FPQ-III, demonstrating good internal consistency for fear of severe pain (0.71) and fear of medical pain (0.73) and acceptable range for fear of minor pain (0.65).

Conclusion

These findings suggest that the FPQ-III can be potentially applied to identify individuals at risk for prolonged continuous pain and as a screening tool to measure fear and anxiety related to pain.

Influence of Fear of Pain and Coping Strategies on Health-Related Quality of Life and Patient-Anticipated Outcomes in Patients With Chronic Pain: Cross-Sectional Study Protocol

Background

Fear of pain and coping strategies are emotional-behavioral responses to pain and are known to play an important role in the development and maintenance of pain. It is highly likely that fear of pain and coping strategies influence each other, potentially affecting the course of chronic pain. To our knowledge, the relationship between pain, fear of pain and coping strategies, and how they influence patient-anticipated outcomes and health-related quality of life, have not been investigated.

Objective

The aims of this study are to test (1) if both fear of pain and/or coping strategies are sufficient causes for maintaining pain; and (2) whether fear of pain influences coping strategies and pain intensity. The study will also examine the impact of fear of pain and coping strategies on health-related quality of life and patient-anticipated outcomes.

Methods

The cross-sectional study will be conducted using an online survey. The Fear of Pain Questionnaire-III (FPQ-III), the Brief Coping Inventory (COPE), and EuroQoL-5d (EQ-5D) validated questionnaires will be used to collect data. Information pertaining to demographic factors, pain-related factors, and patient-anticipated outcomes will also be collected. The study has ethics approval from the Human Research Ethics Committee of the University of Adelaide. Study participants will be individuals aged 18 years and above who are experiencing chronic pain (ie, pain lasting more than 6 months). Effect measure modification technique (EMMM) will be used to examine if fear of pain acts as a moderator or mediator between coping strategies and pain. Simple and multinomial logistic regression analysis will be used to examine the effect of fear of pain and coping strategies on health-related quality of life and patient-anticipated outcomes.

Results

Recruitment began July 2017 and it is anticipated that data collection will be completed by October 2017. Findings from this study will help to extend our understanding of fear of pain and coping strategies, their interaction, and their impact on health-related quality of life and patient-anticipated outcomes.

Conclusions

Fear of pain and coping strategies have significant influence on the experience of chronic pain and its course. This study will help enhance our understanding of the relationship between fear of pain and coping strategies, which may help in developing patient-centered care practices.

Motivational Interviewing as an Adjunct to Cognitive Behavior Therapy for Anxiety Disorders: A Critical Review of the Literature

Cognitive behavior therapy (CBT) is efficaciously and effectively used in the treatment of anxiety disorders; however, as CBT for anxiety routinely utilizes exposure components, clients often experience ambivalence about treatment and their clinicians often must deal with resistance. Motivational Interviewing (MI) is a therapeutic strategy that addresses ambivalence about change in clinical interventions. MI has been applied as an adjunct for treatments such as CBT in order to increase motivation for and commitment to the intervention, especially when components of the treatment may be challenging (e.g., exposure, cognitive restructuring). Though researchers have commented specifically on the use of MI as a supplement to CBT for anxiety disorders, no comprehensive review has systematically assessed the strengths and limitations of extant literature on the topic, nor across anxiety disorders. Findings are summarized from 6 case studies and uncontrolled trials and 11 randomized controlled trials published through March 2016. An integrated critique of this literature also is offered. Limitations and the preliminary nature of the work in this area notwithstanding, it appears that it is feasible to supplement or integrate CBT with MI and that doing so has the potential to improve treatment initiation and engagement, as well as clinical outcomes. A number of directions for future research are addressed, such as determining which MI approaches to implement, with whom, when, and in what contexts.

Fear of Pain Mediates the Association between MC1R Genotype and Dental Fear

Fear of pain is experienced in acute and chronic pain populations, as well as in the general population, and it affects numerous aspects of the orofacial pain experience, including pain intensity, pain-related disability, and pain behavior (e.g., avoidance). A related but separate construct-dental fear-is also experienced in the general population, and it influences dental treatment-seeking behavior and oral and systemic health. Minimal work has addressed the role of genetics in the etiologies of fear of pain and dental fear. Limited available data suggest that variants of the melanocortin 1 receptor (MC1R) gene may predict greater levels of dental fear. The MC1R gene also may be etiologically important for fear of pain. This study aimed to replicate the finding that MC1R variant status predicts dental fear and to determine, for the first time, whether MC1R variant status predicts fear of pain. Participants were 817 Caucasian participants (62.5% female; mean ± SD age: 34.7 ± 8.7 y) taking part in a cross-sectional project that identified determinants of oral diseases at the community, family, and individual levels. Participants were genotyped for single-nucleotide polymorphisms on MC1R and completed self-report measures of fear of pain and dental fear. Presence of MC1R variant alleles predicted higher levels of dental fear and fear of pain. Importantly, fear of pain mediated the relation between MC1R variant status and dental fear (B = 1.60, 95% confidence interval: 0.281 to 3.056). MC1R variants may influence orofacial pain perception and, in turn, predispose individuals to develop fears about pain. Such fears influence the pain experience and associated pain behaviors, as well as fears about dental treatment. This study provides support for genetic contributions to the development/maintenance of fear of pain and dental fear, and it offers directions for future research to identify potential targets for intervention in the treatment of fear of pain and dental fear.

Dental Care-Related Fear and Anxiety: Distress Tolerance as a Possible Mechanism

Distress tolerance, the degree to which one is able to cope with and endure negative emotional states, has been broadly applied to understand and treat a variety of health (including behavioral) problems, but little is known about its role in oral health care and specifically dental care-related fear and anxiety, making it a novel construct in the oral health care literature. This cross-sectional study examined distress tolerance as a possible predictor of dental fear and anxiety among a sample of adults with and without diagnoses of dental phobia, investigated possible differences in levels of distress tolerance between adults with and without dental phobia, and determined possible associations between distress tolerance and fear of pain, anxiety sensitivity, and depression. Using 52 volunteers (n = 31, dental phobia group; n = 21, healthy comparison group), this investigation used self-report measures of distress tolerance, fear of pain, anxiety sensitivity, dental fear, and depression. The Anxiety Disorders Interview Schedule, a semi-structured interview, was used to assess for dental phobia and other psychological disorders. Distress tolerance significantly predicted dental fear and anxiety, even after controlling for age, sex, fear of pain, anxiety sensitivity, and depression. In addition, the dental phobia group had lower distress tolerance than the healthy comparison group. Distress tolerance was significantly associated with fear of pain, anxiety sensitivity, and depression. Findings indicate that low distress tolerance plays a unique and distinct role as a possible mechanism in the genesis of dental care-related fear and anxiety and phobia and may exacerbate the experience of other states, including fear of pain and anxiety sensitivity. Knowledge Transfer Statement: Results indicate that patients who have a lower ability to tolerate emotional and physical distress may have higher levels of dental care-related fear and anxiety and even dental phobia, as well as associated sequelae (e.g., avoidance of dental care). Treatment of highly fearful dental patients may helpfully include a focus on increasing distress tolerance.

Toward a genetic understanding of dental fear: evidence of heritability

OBJECTIVES

Dental fear is a prevalent problem that impacts dental treatment-seeking behavior and thus oral, systemic, and psychological health. Among other important predictors, fear of pain has been shown to be a critical component of dental fear. While learning history (id est, past experience) is known to shape development and maintenance of dental fear and fear of pain, minimal work has addressed genetic etiological variables for these healthcare-related anxieties. With the aim of coming to a more complete conceptualization of dental fear, this study assessed the heritability of dental fear and fear of pain and elucidated the role of genetics in the relation between the constructs.

METHODS

Participants (n = 1370; 827 female), aged 11-74 years (M = 29.2, SD = 12.2), in a family-based cohort study completed measures of dental fear and fear of pain. Heritability and genetic correlation were estimated using likelihood-based methods under the variance components framework.

RESULTS

Dental fear was 30% heritable (P < 0.001) and fear of pain was 34% heritable (P < 0.001). Notably, there was substantial genetic correlation between dental fear and fear of pain, ρ_G = 0.67, suggesting they are genetically related, but likely are distinct phenotypes.

CONCLUSIONS

It is clear that, in addition to environmental factors, genetic influences are important in the etiology of dental fear and anxiety and should be considered in future studies of fear and anxiety associated with dental treatment and, potentially, interventions aimed at reducing distress that is a barrier to dental treatment utilization.

Depression and Rural Environment are Associated With Poor Oral Health Among Pregnant Women in Northern Appalachia

Both oral health problems and depression among pregnant women contribute to maternal-infant health outcomes. Little is known, however, about the potential effects of clinically significant depression on the oral health status of pregnant women. The purpose of the present study was to determine the influence of clinically significant depression and rural- or urban-dwelling status on oral health outcomes among pregnant women. Pregnant women (N = 685) in rural (i.e., West Virginia) and urban (i.e., Pittsburgh, PA) areas of northern Appalachia were assessed by calibrated examiners regarding gingivitis, oral hygiene, and DMFT (decayed, missing, and filled teeth), completed the Center for Epidemiologic Studies-Depression Scale (CES-D) and provided demographics. Participants were categorized based on clinically significant depressive symptoms (CES-D ≥ 16) and rural/urban domicile. Women with depression and those living in rural areas had worse oral health on all three indices than their non-depressed and urban counterparts. Depression, particularly among women in rural areas, affects certain oral health indices and represents a modifiable target for intervention. Moreover, treatments designed specifically for rural populations may be of particular utility. Women who are pregnant or planning to become pregnant may benefit from regular depression screenings from their dental and medical health care providers.

Collecting psychosocial self-report data in oral health research: impact of literacy level and computerised administration

OBJECTIVES

In oral and other health research, participant literacy levels may impact the quality of data obtained through self-report (e.g., degree of data missingness). This study addressed whether computerized administration of a battery of psychosocial instruments used in an oral health disparities research protocol yielded more complete data than paper-and-pencil administration and aimed to determine the role of general literacy in differences in data missingness between administration types.

DESIGN

Oral health data were obtained from 1,652 adolescent and adult participants who were administered a large questionnaire battery via either paper-and-pencil or tablet personal computer. Number of unanswered items for each participant was compared across administration mode. For a subset of 171 participants who were randomized to one of the administration modes, general literacy and satisfaction with the questionnaire experience also were assessed.

RESULTS

Participants assigned to complete the oral health questionnaire battery via tablet PC were significantly more likely than those assigned to the paper-and-pencil condition to have missing data for at least one item (p < .001); however, for participants who had at least one missing item, paper-and-pencil administration was associated with a greater number of items missed than was tablet PC administration (p < .001). Across administration modes, participants with higher literacy level completed the questionnaire battery more rapidly than their lower literacy counterparts (p < .001). Participant satisfaction was similar for both modes of questionnaire administration (p ≥ .29).

CONCLUSIONS

These results suggest that a certain type of data missingness may be decreased through the use of a tablet computer for questionnaire administration.

Patternable nanowire sensors for electrochemical recording of dopamine

Spatially resolved electrochemical recording of neurochemicals is difficult due to the challenges associated with producing nanometer-scale patternable and integrated sensors. We describe the lithographic fabrication and characterization of patternable gold (Au) nanowire (NW) based sensors for the electrochemical recording of dopamine (DA). We demonstrate a straightforward NW-size-independent approach to align contact pads to NWs. Sensors, with NW widths as small as 30 nm, exhibited considerable insensitivity to scan rates during cyclic voltammetry, a nonlinear increase in oxidation current with increasing NW width, and the selectivity to measure submaximal synaptic concentrations of DA in the presence of interfering ascorbic acid. The electrochemical sensitivity of Au NW electrode sensors was much larger than that of Au thin-film electrodes. In chronoamperometric measurements, the NW sensors were found to be sensitive for submicromolar concentration of DA. Hence, the patternable NW sensors represent an attractive platform for electrochemical sensing and recording.

Only male mice show sensitization of handling-induced convulsions across repeated ethanol withdrawal cycles

BACKGROUND

Alcohol abuse, especially when experienced in multiple cycles of chronic abuse and withdrawal, leads to a sensitization of central nervous system hyperexcitability that may culminate in overt expression of seizures. In spite of the growing prevalence of alcohol abuse and dependence in females shown in recent epidemiologic studies, evidence of sexual dimorphism in the expression of alcohol withdrawal-induced seizures and the development of seizure sensitization following multiple cycles of ethanol (EtOH) exposure and withdrawal has not been examined in either animal models or in clinical reports.

METHODS

Subjects in these experiments were male and female C3H/Hecr mice. The female mice were intact or ovariectomized, with ovariectomized mice receiving 17-beta-estradiol or placebo pellets. All mice were exposed to 4 cycles of exposure to 16-hour EtOH vapor, separated by 8-hour withdrawal periods. During each 8-hour withdrawal, hourly assessment of seizure propensity was assessed as handling-induced convulsions. Additional assessments were taken up to 72 hours after the final EtOH withdrawal cycle.

RESULTS

Male and female mice showed similar seizure propensity during an initial withdrawal from chronic EtOH. Across subsequent withdrawal cycles, however, male mice exhibited a robust increase in seizure severity beginning with the third withdrawal cycle. In marked contrast, female mice failed to demonstrate sensitization of seizure severity. The lack of seizure sensitization following up to 4 cycles of alcohol exposure and withdrawal could not be explained by hormonal status (presence or absence of estrogen) or by sex differences in blood alcohol levels.

CONCLUSIONS

Male and female mice exposed to the same number of cycles of EtOH withdrawal demonstrate differences in expression of seizures. Males show the typical sensitization of seizures, or kindling response, which has been reported clinically as well as in animal models, but females do not. The reason for the lack of seizure sensitization in female mice remains to be elucidated, but may be related to sex differences in alcohol effects on excitatory/inhibitory neurotransmission, rather than to hormonal or blood alcohol level differences.

Paroxetine for social anxiety and alcohol use in dual-diagnosed patients

The objective of this study was to compare the efficacy and tolerability of paroxetine to matched placebo in adults with co-occurring social anxiety disorder and alcohol use disorder. Outcome measures included standardized indices of social anxiety and alcohol use. Fifteen individuals meeting DSM-IV criteria for both social anxiety disorder and alcohol use disorder were randomized to treatment. Paroxetine (n = 6) or placebo (n = 9) was given in a double-blind format for 8 weeks using a flexible dosing schedule. Dosing began at 20 mg/d and increased to a target dose of 60 mg/d. There was a significant effect of treatment group on social anxiety symptoms, where patients treated with paroxetine improved more than those treated with placebo on both the Clinical Global Index (CGI) and the Liebowitz Social Anxiety Scale (Ps < or = 0.05). On alcohol use, there was not a significant effect of treatment on quantity/frequency measures of drinking, but there was for the CGI ratings (50% paroxetine patients versus 11% placebo patients were improvers on drinking, P < or = 0.05). This pilot study suggests that paroxetine is an effective treatment for social anxiety disorder in individuals with comorbid alcohol problems, and positive treatment effects can be seen in as little as 8 weeks. Further study is warranted to investigate its utility in helping affected individuals reduce alcohol use.

Alcohol and pregnancy: highlights from three decades of research

The detrimental effects of alcohol on offspring have been alluded to for centuries, although only in the past few decades has the relationship between alcohol and birth defects been shown conclusively. This review article begins with a historical overview of the understanding of alcohol's effects on the offspring, followed by a description of the first clinical reports of fetal alcohol syndrome. The contribution of animal models is highlighted and some possible mechanisms of alcohol's teratogenicity are discussed. Challenges and opportunities for future research are offered.

Gender comparison in alcoholics with concurrent social phobia: implications for alcoholism treatment

The present study compares male and female alcoholics with concurrent social phobia (N = 110) enrolled in an alcohol treatment study. Groups were compared using demographics, social phobia symptoms and severity, and psychiatric variables. Results showed that females reported higher fear ratings than males on some social phobia measures, although for the most part, the genders were more similar than different on social phobia symptoms and severity. There was a high occurrence of psychiatric comorbidity, especially for females. Females also reported more distress than males in family and social functioning. The results are discussed in terms of their implications for treatment for individuals with concurrent alcoholism and social phobia.

Concurrent alcoholism and social anxiety disorder: a first step toward developing effective treatments

BACKGROUND

Social anxiety disorder (also called social phobia) is an anxiety disorder in which affected individuals fear the scrutiny of others. Clinical reports suggest that individuals with social anxiety disorder often use alcohol to alleviate anxiety symptoms, a practice that leads to alcohol abuse and/or dependence in approximately 20% of affected individuals. The present study investigated whether simultaneous treatment of social phobia and alcoholism, compared with treatment of alcoholism alone, improved alcohol use and social anxiety for clients with dual diagnoses of social anxiety disorder and alcohol dependence.

METHODS

The design was a two-group, randomized clinical trial that used 12 weeks of individual cognitive behavioral therapy for alcoholism only (n = 44) or concurrent treatment for both alcohol and social anxiety problems (n = 49). Outcome data were collected at the end of 12 weeks of treatment and at 3 months after the end of treatment.

RESULTS

Results with intent-to-treat analyses showed that both groups improved on alcohol-related outcomes and social anxiety after treatment. With baseline scores covaried, there was a significant effect of treatment group on several drinking measures. Counter to the hypothesis, the group treated for both alcohol and social anxiety problems had worse outcomes on three of the four alcohol use indices. No treatment group effects were observed on social anxiety indices.

CONCLUSIONS

Implications for the staging of treatments for coexisting social phobia and alcoholism are discussed, as well as ways that modality of treatments might impact outcomes.

Cognitive behavioral therapy delays relapse in female socially phobic alcoholics

The present study was conducted to test the hypothesis that socially phobic alcoholics treated with Cognitive Behavioral therapy (CBT) will have better drinking outcomes than those treated with Twelve-Step Facilitation therapy (TSF). Three hundred ninety-seven treatment-seeking alcoholics with concurrent social phobia were compared retrospectively to a matched sample of 397 alcoholics without social phobia. Treatment was delivered in an outpatient setting, and patients were randomized to either CBT, TSF, or Motivational Enhancement therapy (MET). The groups were compared on self-reported drinking measures (e.g., quantity and frequency of drinking, and time-to-event measures) during treatment period and monthly for 1 year following treatment. Survival analyses revealed that female outpatients with social phobia showed delayed relapse to drinking when treated with CBT rather than TSF; the reverse was true for female outpatients without social phobia. Survival analyses in male outpatients with and without social phobia revealed an opposite trend, though it was not statistically significant. These data suggest that Cognitive Behavioral therapy is superior to Twelve-Step Facilitation therapy for the treatment of alcohol problems in specific populations. namely socially phobic women seeking outpatient treatment.

Progesterone and prostaglandin H synthase-2 involvement in alcohol-induced preterm birth in mice

BACKGROUND

Recently, an association between alcohol consumption during pregnancy and shortened gestational length has been reported, but the underlying mechanisms remain unknown. Progesterone (P4) and prostaglandins have been shown to play important roles in parturition in both human and animal models. Recently, it has been suggested that prostaglandin H synthase-2 (PGHS-2) is responsible for prostaglandin changes associated with term and preterm labor. It is possible that alcohol induces preterm birth by altering P4 or PGHS-2 levels. These studies were designed to determine the role of P4 and PGHS-2 in alcohol-induced preterm labor in mice.

METHODS

Experiment 1: Pregnant dams treated with either vehicle or alcohol (6 g/kg, intragastrically) on gestational day (GD) 16 were killed at various times in gestation up to the time of delivery. Plasma P4 levels were measured by radioimmunoassay and uterine PGHS-2 mRNA expression was measured by Ribonuclease Protection Assay. Results indicated that alcohol treatment was associated with an earlier decline in plasma P4 levels and an earlier rise in uterine PGHS-2 mRNA levels during gestation. Experiment 2: Pregnant C57BL/6J females were treated with either P4 (2.0 mg, subcutaneously) or vehicle (sesame oil) 2 hr before receiving either 6 g/kg alcohol (intragastrically) or vehicle (isocaloric sucrose) on gestational day (GD) 16. Results indicate that P4 pretreatment effectively antagonized alcohol-induced preterm delivery. Experiment 3: On GD16, pregnant dams received either 100 mg/kg nimesulide (a specific PGHS-2 inhibitor) or vehicle (saline) subcutaneously, 2 hr before treatment with either 6 g/kg alcohol (given intragastrically) or isocaloric sucrose. Nimesulide was effective in antagonizing alcohol-induced preterm labor.

CONCLUSIONS

Together, these data suggest that both P4 and PGHS-2 may play roles in alcohol-induced preterm birth.

Alcohol plus cocaine prenatally is more deleterious than either drug alone

A C57BL/6J mouse model was used to examine the coteratology of alcohol and cocaine. Plugged female mice were assigned to one of four treatment groups: control, cocaine only, alcohol only, or alcohol-cocaine. Experimental animals were treated from gestation day (GD) 6-18 and were killed the morning of GD 19. Alcohol was administered in a liquid diet containing 25% ethanol-derived calories (25% EDC), and cocaine was administered daily in subcutaneous injections of 60 mg/kg. All groups were pair-fed to the alcohol-cocaine group. The results showed that the cocaine-only and the alcohol-cocaine group had fewer successful pregnancies. The alcohol-only group had the lowest maternal weight gain from GD 1-19. There were no treatment group effects on litter size, sex ratio, or prenatal mortality. Importantly, fetuses in the alcohol-cocaine group weighed less than all other groups and had the greatest occurrence of fetal anomalies. These data confirm the teratogenic effects of alcohol and cocaine and suggest that the combination of the two drugs, if administered chronically, is more deleterious to pregnancy and fetal outcome than either drug alone.

Alcoholics with and without social phobia: a comparison of substance use and psychiatric variables

OBJECTIVE

While alcoholics with social phobia comprise a substantial portion of the alcoholic population, little is known about how they differ from alcoholics without social phobia in their substance use and psychiatric health. The present study was conducted to examine baseline differences between alcoholics with and without social phobia on substance use and psychiatric variables.

METHOD

Alcoholics without social phobia (n = 397) were chosen to match those with social phobia (n = 397) on several variables, including age and gender. All subjects were participants in Project MATCH, a large clinical client-treatment matching study.

RESULTS

Exploratory/Confirmatory analyses revealed that alcoholics with social phobia had higher scores on the alcohol dependence scale and endorsed more dependence symptoms on the SCID, although they did not drink greater amounts or more often than alcoholics without social phobia. They also reported drinking in order to improve sociability and enhance functioning more than did the comparison group. Alcoholics with social phobia were more likely to conform to social norms than alcoholics without social phobia. They also had more symptoms of depression as indicated by higher scores on the Beck Depression Inventory and higher incidence of a major depressive episode from the C-DIS.

CONCLUSIONS

Alcoholics with social phobia enter treatment with some problems that are more severe than those expressed by alcoholics without social phobia. Whether these problems affect treatment efficacy is an important area for future research.

Gender differences in substance use disorders

Despite the fact that the rate of substance abuse and dependence is higher among men than it is among women, the prevalence rates, especially the more recent ones, indicate that a diagnosis of substance abuse is not gender specific. From the emerging literature on gender differences over the past 25 years, male and female substance abusers are clearly not the same. Women typically begin using substances later than do men, are strongly influenced by spouses or boyfriends to use, report different reasons for maintaining the use of the substances, and enter treatment earlier in the course of their illnesses than do men. Importantly, women also have a significantly higher prevalence of comorbid psychiatric disorders, such as depression and anxiety, than do men, and these disorders typically predate the onset of substance-abuse problems. For women, substances such as alcohol may be used to self-medicate mood disturbances, whereas for men, this may not be true. Although these comorbid disorders might complicate treatment for women, women are, in fact, responsive to treatment and do as well as men in follow-up. Gender differences and similarities have significant treatment implications. This is especially true for the telescoping phenomenon, in which the window for intervention between progressive landmarks is shorter for women than for men. This is also true for the gender differences in physical and sexual abuse, as well as other psychiatric comorbidity that is evident in female substance abusers seeking treatment. The barriers to treatment for women are being addressed in many treatment settings to encourage more women to enter treatment, and family and couples therapy are standard therapeutic interventions. Negative consequences associated with substance abuse are different for men and women, and gender-sensitive rating instruments must be used to measure not only the severity of the problem but also to evaluate treatment efficacy. To determine whether gender differences observed over the past 25 years become less demarcated in comparisons of younger cohorts of substance abusers in the future will be interesting. Changing societal roles and attitudes toward women, the increase in women entering the workplace, in general, and into previously male-dominated sports and professions, in particular, may influence not only opportunities to drink but also drinking culture. Some gender differences likely will remain, but other gender differences will probably also emerge. The comparison of male and female substance abusers promises to be a fruitful one for researchers. The translation if the research findings to the treatment community to improve treatment outcome for both sexes will be an equally exciting challenge for the field.

Telescoping of landmark events associated with drinking: a gender comparison

OBJECTIVE

The literature suggests that women exhibit "telescoped" development of (i.e., faster progression to) alcoholism, with fewer years drinking than men. The purpose of this study was to use data gathered in the course of a large clinical trial to further examine this issue.

METHOD

Subjects in this retrospective study were from a pool of 1,307 men and 419 women enrolled in Project MATCH, a multisite alcohol treatment matching study. MATCH subjects were recruited from both outpatient and aftercare settings over a 2-year period. Age-of-onset for landmark events in the development of alcoholism were determined from self-report and clinical interviews given at baseline entry into the study. Gender differences in age-of-onset variables were assessed within both outpatient and aftercare settings. Gender differences in progression times between successive landmarks were also examined. Differences were tested with both multivariate and univariate ANOVA techniques.

RESULTS

Women generally began getting drunk regularly at a later average age than men (26.6 versus 22.7 years, p< or =.001), began experiencing their first drinking problems at a later average age than men (27.5 versus 25.0 years, p< or =.001) and exhibited loss of control over their drinking at a later average age than men (29.8 versus 27.2 years, p< or =.001). However, these gender differences were most pronounced for older individuals and attenuated for younger subjects. Women also progressed faster than men, on average, between first getting drunk regularly and first encountering drinking problems (0.9 versus 2.3 years, p< or =.001) and between first loss of drinking control and onset of worst drinking problems (5.5 versus 7.8 years, p< or =.001). Women also exhibited shorter average progression times between first getting drunk regularly and first seeking treatment (11.6 versus 15.8 years, p< or =.001), although this effect was negligible for younger subjects.

CONCLUSIONS

Telescoping is a relatively robust phenomenon in treatment-seeking alcoholics and indicates that women are more likely to progress faster through the landmark events in the development of alcoholism than are men.