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.

Addition of Povidone-Iodine to Fluoride Varnish for Dental Caries: A Randomized Clinical Trial

INTRODUCTION

Dental caries is the most common chronic childhood disease. Products of metabolism by bacteria populating the tooth surface induce development and progression of cavities.

OBJECTIVES

We sought to determine whether a polyvinylpyrrolidone-iodine (PVP-I; povidone-iodine) and NaF topical varnish was superior to one containing only NaF in prevention of new dental caries lesions in a single-center randomized active-controlled trial based on a double-blind, parallel-group design.

METHODS

The site was Pohnpei State, Federated States of Micronesia. The study population was healthy children 49 to 84 mo old who were enrolled in early childhood education: 284 were randomized (1:1 allocation), and 273 were included in year 1 analysis and 262 in year 2. The test varnish contained 10% PVP-I and 5.0% NaF. The comparator contained only 5.0% NaF but was otherwise identical. Varnishes were applied every 3 mo during 2 y. The primary outcome was the surface-level primary molar caries lesion increment (d_2-4mfs) at 2 y. Caries lesion increments from baseline to year 1 and year 2 were compared between conditions with log-linear regression, adjusting for age and sex and whether the tooth was sound at baseline (free of caries lesions).

RESULTS

At year 1, the caries lesion increment for primary molars sound at baseline was 0.9 surfaces (SD = 1.5) for the test varnish versus 1.8 (SD = 2.2) for the comparator varnish with fluoride alone (adjusted rate ratio, 0.50; 95% CI, 0.31 to 0.81; P = .005). At year 2, the caries lesion increment for primary molars sound at baseline was 2.3 surfaces (SD = 2.8) for the test varnish as compared with 3.3 (SD = 2.7) for the comparator (adjusted rate ratio, 0.74; 95% CI, 0.52 to 1.03; P = .073). Teeth that were already cavitated at baseline did not show a preventive effect. There were no harms.

CONCLUSIONS

A dental varnish containing PVP-I and NaF is effective in the primary prevention of cavities in the primary dentition (NCT03082196).

KNOWLEDGE TRANSFER STATEMENT

This study demonstrates that periodic application of a varnish containing NaF and PVP-I is effective in prevention of caries lesions and useful in assessing the potential of combined treatment.

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.

Comparison of CaOH with MTA for direct pulp capping: a PBRN randomized clinical trial

This practice-based, randomized clinical trial evaluated and compared the success of direct pulp capping in permanent teeth with MTA (mineral trioxide aggregate) or CaOH (calcium hydroxide). Thirty-five practices in Northwest PRECEDENT were randomized to perform direct pulp caps with either CaOH (16 practices) or MTA (19 practices). Three hundred seventy-six individuals received a direct pulp cap with CaOH (n = 181) or MTA (n = 195). They were followed for up to 2 yrs at regular recall appointments, or as dictated by tooth symptoms. The primary outcomes were the need for extraction or root canal therapy. Teeth were also evaluated for pulp vitality, and radiographs were taken at the dentist's discretion. The probability of failure at 24 mos was 31.5% for CaOH vs. 19.7% for MTA (permutation log-rank test, p = .046). This large randomized clinical trial provided confirmatory evidence for a superior performance with MTA as a direct pulp-capping agent as compared with CaOH when evaluated in a practice-based research network for up to 2 yrs.

Immunization of Macaca fascicularis against experimental periodontitis using a vaccine containing cysteine proteases purified from Porphyromonas gingivalis

INTRODUCTION

Periodontitis is a common infectious disease to which Porphyromonas gingivalis has been closely linked, in which the attachment tissues of the teeth and their alveolar bone housing are destroyed. We conducted a study to determine if immunization using a purified antigen could alter the onset and progression of the disease.

METHODS

Using the ligature-induced model of periodontitis in Macaca fascicularis, we immunized five animals with cysteine protease purified from P. gingivalis and used an additional five animals as controls. Alveolar bone loss was measured by digital subtraction radiography.

RESULTS

Immunization induced high titers of specific immunoglobuin G serum antibodies that were opsonic. Total bacterial load, levels of P. gingivalis in subgingival plaque and levels of prostaglandin E(2) in gingival crevicular fluid were significantly reduced. Onset and progression of alveolar bone loss was inhibited by approximately 50%. No manifestations of toxicity were observed.

CONCLUSIONS

Immunization using a purified protein antigen from P. gingivalis inhibits alveolar bone destruction in a ligature-induced periodontitis model in M. fascicularis.

Single-nucleotide polymorphisms and haplotype analysis in beta-defensin genes in different ethnic populations

Beta-defensins are cationic antimicrobial peptides expressed by epithelial cells and exhibit antibacterial, antifungal, and antiviral properties. The defensins are part of the innate host defense network and may have a significant protective role in the oral cavity and other mucosa. Defects or alteration in expression of the beta-defensins may be associated with susceptibility to infection and mucosal disorders. We examined the occurrence of single-nucleotide polymorphisms (SNPs) in the human beta-defensin genes DEFB1 and DEFB2 encoding human beta-defensin-1 and -2 (hBD-1, hBD-2), respectively, in five ethnic populations and defined haplotypes in these populations. Fifteen SNPs were identified in both DEFB1 and DEFB2. Coding region SNPs were found in very low frequency in both genes. One nonsynonymous DEFB1 SNP, G1654A (Val --> Ile), and one nonsynonymous DEFB2 SNP, T2312A (Leu --> His), were identified. Seven sites in each gene exhibited statistically significant differences in frequency between ethnic groups, with the greatest variation in the promoter and in the 5'-untranslated region of DEFB1. DEFB1 displayed 10 common haplotypes, including one cosmopolitan haplotype. Eight common haplotypes were found in DEFB2, including one cosmopolitan haplotype shared among all five ethnic groups. Our results show that genotypic variability among ethnic groups will need to be addressed when performing associative genetic studies of innate defense mechanisms and susceptibility to disease.

The roles of beliefs, catastrophizing, and coping in the functioning of patients with temporomandibular disorders

Pain-related beliefs, catastrophizing, and coping have been shown to be associated with measures of physical and psychosocial functioning among patients with chronic musculoskeletal and rheumatologic pain. However, little is known about the relative importance of these process variables in the functioning of patients with temporomandibular disorders (TMD). To address this gap in the literature, self-report measures of pain, beliefs, catastrophizing, coping, pain-related activity interference, jaw activity limitations, and depression, as well as an objective measure of jaw opening impairment, were obtained from 118 patients at a TMD specialty clinic. Controlling for age, gender, and pain intensity, significant associations were found between (1) pain beliefs and activity interference, depression, and non-masticatory jaw activity limitations, (2) catastrophizing and activity interference, depression, and non-masticatory jaw activity limitations, and (3) coping and activity interference and depression. Controlling for age, gender, pain intensity, and the other process variables, significant associations were found between (1) beliefs and activity interference and depression, and (2) catastrophizing and depression. No process variable was associated significantly with the objective measure of jaw impairment. The results suggest that for patients with moderate or high levels of TMD pain and dysfunction, beliefs about pain play an important role in physical and psychosocial functioning.

Comparisons of Yupik infant growth measurements with NCHS/CDC reference data

The National Center for Health Statistics/Centers for Disease Control and Prevention growth reference is routinely used to monitor Yupik infant growth although Yupiks are ethnically different from the population from which the reference was developed. To clarify interpretation of Yupik infant growth data for clinical practice and public health assessment, Yupik infant growth measurements were compared with this reference. From 1990 through 1992 a convenience survey of 555 Yupik infants was completed in pediatric clinics in the Yukon Kuskokwim Delta region of Alaska. Data was analyzed using Z-score distributions of height-for-age, weight-for-age, and weight-for-height and head circumference-for-age percentiles based on the growth reference. At birth, Yupik neonates had significantly greater height-for-age and weight-for-age than the National Center for Health Statistics/Centers for Disease Control and Prevention reference. Between 1 and 12 months, Yupik infants had significantly greater weight-for-age, weight-for-height, and head circumference-for-age than the growth reference.

Effectiveness of local anesthesia in pediatric dental practice

BACKGROUND

Pain control in dental treatment for children is very important. The purpose of this study is to describe the characteristics of local anesthetic use by pediatric dentists and to examine factors related to its effectiveness in children.

METHODS

The authors observed 361 patients in 17 pediatric dental practices in Washington state while each child received restorative or surgical dental treatment. The authors recorded data concerning local anesthetic use and effectiveness. The children's mean age was 87 months, and 181 (50.1 percent) of the patients were girls. A pediatric dentist observer rated each child's anxiety before the initial injection of local anesthetic and the effectiveness of pain control during restorative treatment. The observing dentist asked the treating dentist about the effectiveness of pain control after completion of treatment.

RESULTS

Forty-two of 361 children (11.6 percent) were observed to experience ineffective pain control. Fourteen of 17 dentists (82.4 percent) were observed to have at least one patient in whom pain control was ineffective. Lidocaine (2 percent with 1:100,000 epinephrine) was used by 15 of 17 dentists (88.2 percent) and in 312 of 361 cases (86.4 percent). The average amount of agent was one cartridge (36 milligrams of lidocaine). Children who were anxious, who had symptoms before treatment, and who underwent more invasive operative and endodontic procedures were more likely to experience ineffective pain control.

CONCLUSIONS

The data suggest that painful treatment is relatively frequent even in specialized pediatric practice. Variability in general practice is likely to be greater.

CLINICAL IMPLICATIONS

The incidence of ineffective pain control may be less if clinicians use methods to reduce anxiety and perioperative infection and symptoms.

Identification of neonatal hearing impairment: hearing status at 8 to 12 months corrected age using a visual reinforcement audiometry protocol

OBJECTIVES

1) To describe the hearing status of the at-risk infants in the National Institutes of Health-Identification of Neonatal Hearing Impairment study sample at 8 to 12 mo corrected age (chronologic age adjusted for prematurity). 2) To describe the visual reinforcement audiometry (VRA) protocol that was used to obtain monaural behavioral data for the sample.

DESIGN

All neonatal intensive care unit infants and well babies with risk factors (including well babies who failed neonatal tests) were targeted for follow-up behavioral evaluation once they had reached 8 mo corrected age. Three thousand one hundred and thirty-four (64.4%) of the 4868 surviving infants returned for at least one behavioral hearing evaluation, which employed a well-defined VRA protocol. VRA thresholds or minimum response levels (MRLs) were determined for speech and pure tones of 1.0, 2.0, and 4.0 kHz for each ear using insert earphones.

RESULTS

More than 95% of the infants were reliably tested with the VRA protocol; 90% provided complete tests (four MRLs for both ears). Ninety-four percent of the at-risk infants were found to have normal hearing sensitivity (MRLs of 20 dB HL) at 1.0, 2.0, and 4.0 kHz in both ears. Of the infants, 2.2% had bilateral hearing impairment, and 3.4% had impairment in one ear only. More than 80% of the impaired ears had losses of mild-to-moderate degree.

CONCLUSIONS

This may be the largest study to attempt to follow all at-risk infants with behavioral audiometric testing, regardless of screening outcome, in an effort to validate the results of auditory brain stem response, distortion product otoacoustic emission, and transient evoked otoacoustic emission testing in the newborn period. It is one of only a few studies to report hearing status of infants at 1 yr of age, using VRA on a clinical population. Successful testing of more than 95% of the infants who returned for the VRA follow-up documents the feasibility of obtaining monaural behavioral data in this population.

An explanatory model of the dental care utilization of low-income children

OBJECTIVES

Factors related to the utilization of dental care by 5- to 11-year-old children from low-income households were investigated using a comprehensive multivariate model that assessed the contribution of structure, history, cognition, and expectations. The influence of dentist-patient interactions, psychosocial and health beliefs, particularly fear of the dentist, on utilization were investigated.

METHODS

Children were chosen randomly from public schools, and 895 mothers were surveyed and their children were interviewed in the home. Utilization was studied during the 1991-1992 school year, including a 6-month follow-up period after the interview.

RESULTS

The overall utilization rate was 63.2%, and the rate for nonemergent (preventive) visits was 59.9%. Utilization was unrelated to actual oral health status. Race and years the guardian lived in the United States were predictive of an episode of care. Preventive medical visits and perceived need were strong predictors of a visit to the dentist, as were beliefs in the efficacy of dental care. Mothers who were satisfied with their own care and oral health and whose children were covered by insurance were more likely to utilize children's dental care. In contrast, child dental fear and absences from school for family problems were associated with lower rates of utilization.

CONCLUSIONS

Mutable factors that govern the use of care in this population were identified. These findings have implications for the design of dental care delivery systems for children and their families.

Dental care satisfaction: the reliability and validity of the DSQ in a low-income population

OBJECTIVES

Studies examining satisfaction with dental health care among the poor are quite rare. This study was done to confirm the internal structure and reliability of the Dental Satisfaction Questionnaire (DSQ), a measure of dental care satisfaction, among a low-income population, and provide normative data regarding dental satisfaction among low-income people.

METHODS

Subjects were 895 mothers of school-aged children who were administered the DSQ as part of a larger study of dental utilization and dental fears in Seattle.

RESULTS

Factor analysis largely confirmed the factor structure of the DSQ. Results also suggested subjects in this sample were less satisfied with pain management than nonpoor people. Self-reported dental health and dental appearance were associated with satisfaction with pain management, quality of care, access to care, and overall satisfaction. Race/ethnicity, education level, marital status, nation of origin, and type of insurance predicted differences in satisfaction with pain management and access.

CONCLUSIONS

Barriers to dental care and quality of care among low-income populations are discussed. Uses and research with the DSQ are suggested.

Smokeless tobacco use: how it affects the performance of major league baseball players

The authors examined the effect of smokeless tobacco use on the athletic performance of major league baseball players during the 1988 season. They evaluated performance records of 158 players on seven major league teams who played or pitched at least 10 games or innings during the 1988 season. ST use, they concluded, is not related to player performance in major league baseball but does place players at significantly increased risk for mucosal lesions and other oral pathology.

The prevalence of dental anxiety in children from low-income families and its relationship to personality traits

The prevalence of dental anxiety and the association between dental anxiety and personality traits were examined in a population-based sample of 895 US urban children, from 5 to 11 years of age, from low-income families. Dental anxiety was reported by the child using the Dental Subscale (DS) of the Children's Fear Survey Schedule, and behavioral problems and personality traits were evaluated by parent report on the Child Behavior Checklist (CBCL). Mean DS scores were 31.1 (SD = 10.3) for boys and 34.3 (SD = 11.0) for girls. CBCL score means were 33.3 (SD = 23.2) for boys and 28.5 (SD = 19.1) for girls. The hypothesized relationship between DS and CBCL scores in this population was not demonstrated.

Origins of childhood dental fear

This study explored Rachman's theory of fear acquisition applied to fear of the dentist in a large sample of low income American primary school children. Children and their mother/guardians were interviewed or completed questionnaires in the home about fear acquisition and related concerns. A multivariate logistic regression model was evaluated in order to explore the relationship of direct conditioning and modeling variables to fear levels. Both direct conditioning and parent modeling factors were significant independent predictors of fear level even when controlling for gender, age and other sociodemographic and attitudinal factors.

Behavior problems in 5- to 11-year-old children from low-income families

OBJECTIVE

The aims of the present study were to survey the Child Behavior Checklist (CBCL) scores (behavioral section) in a nonclinical population of US urban children from low-income families and to compare the distribution and pattern of scores with the normative data in the CBCL manual (1991).

METHOD

The sample consisted of 890 low-income children and a mother or female guardian selected randomly from among Seattle public school students aged 5 to 11 years.

RESULTS

In this sample the total CBCL score as well as all subscale scores were significantly higher than the norms. The proportion of children who scored in the clinical/borderline range was also higher than the norm.

CONCLUSIONS

These findings support previous work showing that poverty is a risk factor for mental distress in children. They also raise questions about the validity of the CBCL norms for screening or research purpose for low-income families.

A three-year clinical trial using a glass ionomer cement for the bonding of orthodontic brackets

Recent clinical studies measuring orthodontic bracket failure, when using glass ionomer cement as an adhesive, have reported a wide range of percentages of bracket failure. The present study recorded bracket failure over a 3-year period, longer than had been previously measured. Seventeen participants were randomly assigned to one of two treatment groups, either using glass ionomer cement or composite resin for bonding. In each group, brackets were bonded to incisors, canines, and premolars. Bracket failure was measured over the duration of comprehensive orthodontic treatment for all participants. Brackets bonded with the glass ionomer cement were more likely to fail (log-rank test; P < or = 0.022). This difference was clinically significant. At the present time, the disadvantage of extra bracket failures appears to outweigh potential advantages when considering glass ionomer cement for the routine bonding of orthodontic brackets.