A scoping review of guidelines on caries management for children and young people to inform UK undergraduate core curriculum development

BACKGROUND

Current evidence in cariology teaching is not consistently reflected in paediatric dentistry in the United Kingdom (UK). Many dental schools are not consistently teaching biological approaches to caries management, with outdated or complex methods being taught outwith the purview of general dental practitioners. This scoping review aimed to map current guidelines on the management of caries in children and young people. This is part of a work package to inform the consensus and development of a UK-wide caries management curriculum for paediatric dentistry.

METHODS

A search of electronic databases for peer reviewed literature was performed using Cochrane Library, MEDLINE via PubMed, TRIP Medical Database and Web of Science. Hand searching was undertaken for grey literature (citations of sources of evidence, websites of global organisations and Google Web Search™ (Google LLC, California, USA). Results from databases were screened independently, concurrently by two reviewers. Full texts were obtained, and reviewers met to discuss any disagreement for both database and hand searching.

RESULTS

This review identified 16 guidelines suitable for inclusion. After quality appraisal, eight were selected for synthesis and interpretation. Key themes included the shift towards selective caries removal and avoidance of complete caries removal unless in specific circumstances in anterior teeth. For "early lesions" in primary and permanent teeth with and without cavitation, several guidelines recommend biological management including site specific prevention and fissure sealants.

CONCLUSIONS

This review mapping current cariology guidelines for children and young people found gaps in the literature including classification of early carious lesions and management of early cavitated lesions. Areas identified for further exploration include integration of biological caries management into treatment planning, selective caries removal and whether pulpotomy is specialist-level treatment, requiring referral. These results will inform consensus recommendations in the UK, using Delphi methods.

Barriers to routine dental care for children with special health care needs

PURPOSE

The aim of this mixed method study was to identify barriers for children with special health care needs (SHCN) to receiving routine preventive dental care following restorative dental care with general anesthesia (GA).

METHODS

Electronic health records were reviewed for inclusion criteria and demographic data. Caregivers of children with SHCN were contacted to participate in qualitative interviews. Interview topics explored child, family, and community level influences to accessing routine dental care. Qualitative analysis identified key themes of barriers and enablers to care.

RESULTS

A total of 1708 children received dental care with GA during the 2-year study period, of which 498 (29.16%) had a diagnosis of a SHCN. The most common type of SHCN was neurodevelopmental disorders (28.51%). The mean age at time of GA was 8.6 years. Fifty caregivers completed interviews. Identified barriers to obtaining routine dental care included child stress/anxiety, finding an accepting provider, dismissive providers, and proximity of provider/transportation to dental care. Enablers to obtaining care included effective behavior management, continuity of provider/care, positive provider attitude, and referral to an accepting provider.

CONCLUSION

Adequately trained and local providers with an accepting attitude are essential to enabling children with SHCN to obtain equitable access to routine dental care.

Impact of the COVID-19 pandemic on pediatric Medicaid dental claims in Arizona

OBJECTIVES

To examine the role COVID-19 had on access to dental services among children in Arizona by comparing paid pediatric dental claims made before and during the pandemic.

METHODS

In a retrospective descriptive study, we examined Medicaid paid claims for dental services among pediatric patients from March through December 2019 and during the outbreak in 2020. Using dental claims data obtained from the Centers for Health Information and Research at Arizona State University (ASU), we analyzed Medicaid (Arizona Health Care Cost Containment System [AHCCCS]) reimbursed dental services.

RESULTS

During the COVID-19 pandemic, paid preventive dental claims for children aged birth to 21 years decreased in 2020 compared to the same time period in 2019. Pediatric patients in Arizona utilized fewer dental services and had less access to credentialed Medicaid dental providers during the pandemic. Further, rural counties had statistically significant fewer preventive, minor restorative, major restorative, and endodontic claims compared to urban counties. Arizona rural counties also had fewer providers who were paid $10,000 or more per year during 2020 than in 2019.

CONCLUSIONS

COVID-19 has had a detrimental impact on pediatric dental service utilization. While dental services were provided during the COVID-19 pandemic, preventive and restorative dental claims dropped for rural Arizona children aged birth to 21 years. This reveals potential negative impacts on oral health. Further research should examine the direct and indirect impact the COVID-19 pandemic has had on dental service utilization and oral health for the general pediatric population.

Investigating the scope and costs of dental treatment provided under general anaesthesia among children with congenital heart disease

AIM

To identify the types of dental treatment provided under general anaesthesia for children diagnosed with congenital heart disease (CHD), quantify the costs within a publicly funded tertiary paediatric hospital setting and identify factors which affect the cost.

METHODS

A retrospective analysis of dental records (July 2015 to June 2019) was conducted for children with CHD who had undergone a dental general anaesthetic procedure at The Children's Hospital at Westmead, Australia. Patient and treatment-related information were collected, and a costing analysis was performed on 89 dental general anaesthetic procedures.

RESULTS

Mean age at the time of the general anaesthetic was 8.15 years. About 27% of children with CHD had a history of dental infection. Dental extractions and restorations comprised the majority of treatments provided, with extractions performed in 86% of procedures. The mean number of days in hospital was 1.43 and the mean cost was $4395.14. The cost was significantly greater when children presented with a facial swelling compared to any other reason.

CONCLUSIONS

Dental extractions are performed in the majority of general anaesthetics. Not only is there an economic burden to the public health system in providing dental treatment under general anaesthesia for children with CHD, the health impacts also appear to be substantial. A considerable proportion required overnight hospitalisation and days in hospital was strongly related to the cost of the dental general anaesthetic. Systematic referral pathways for accessing dental care are an important consideration for children with CHD.

Sociobehavioural Factors Associated With Child Oral Health During COVID-19

OBJECTIVES

The aim of this study was to identify the sociobehavioural factors that influenced children's oral health during the COVID-19 pandemic.

METHODS

The online cross-sectional study was conducted in Al Jouf Province in the northern region of Saudi Arabia. A total of 960 parents of children aged 5 to 14 years were invited by multistage stratified random sampling. Descriptive, multinomial, and multiple logistic regression analyses were performed to estimate odds ratios and determine the relationship between independent and dependent variables. P < .05 was considered statistically significant.

RESULTS

Of the 960 participants, 693 (72.1%) reported that their child had 1 or more untreated dental decay. The children of uneducated parents were 1.6-fold more likely to have 1 or more untreated dental decay (adjusted odds ratio [AOR], 1.66; 95% CI, 0.74-3.73; P < .001). The children of unemployed parents were 4.3-fold more likely to have a financial burden for a child dental visit (AOR, 4.34; 95% CI, 2.73-6.89; P < .001). Parents from a rural area were 26.3-fold more likely to have spent a lag period of over 2 years since their child's last dental visit (AOR, 26.34; 95% CI, 7.48-92.79; P < .001). Nursery-level children were 5.4-fold more likely to need immediate care (AOR, 5.38; 95% CI, 3.01-9.60; P < .001).

CONCLUSIONS

The present study demonstrated a very high prevalence of 1 or more untreated dental decay in our cohort. Children of rural areas, uneducated, unemployed, widow/divorced, low- and middle-income parents and nursery school children were linked to poorly predictive outcomes of child oral health during the pandemic.

Deep Sedation for Dental Care Management in Healthy and Special Health Care Needs Children: A Retrospective Study

BACKGROUND

Very young children, and those with disabilities and extensive oral pathology, who cannot be treated in the dental chair, require deep sedation or general anesthesia for dental treatment.

OBJECTIVE

The aim of this study is to describe and compare the oral health status in healthy and SHCN children and the treatments performed under deep sedation on an outpatient basis with a minimal intervention approach, and their impact on quality of life.

METHODS

A retrospective study between 2006 and 2018 was made. A total of 230 medical records of healthy and SHCN children were included. The data extracted were age, sex, systemic health status, reason for sedation, oral health status before sedation, treatments administered during sedation, and follow-up. The quality of life after deep sedation of 85 children was studied through parental questionnaires. Descriptive and inferential analyses were made.

RESULTS

Of the 230 children, 47.4% were healthy and 52.6% were SHCN. The median age was 7.10 ± 3.40 years (5.04 ± 2.42 in healthy children and 8.95 ± 3.09 in SHCN children). The main reason for sedation was poor handling in the dental chair (99.5%). The most frequent pathologies were caries (90.9%) and pulp pathology (67.8%). Healthy children had more teeth affected by decay and with pulp involvement. Patients aged < 6 years received more pulpectomies and pulpotomies. After treatment, parents stated that children were more rested and less irascible, ate better, increased in weight, and had improved dental aesthetics.

CONCLUSIONS

Differences in treatments carried out did not depend on the general health status or the failure rate but on age, with more pulp treatments in healthy children who were younger, and more extractions near to the age of physiological turnover in children with SHCN who were older. Intervention under deep sedation with a minimally invasive treatments approach met the expectations of parents and guardians, as it improved the children's quality of life.

Practice Patterns Among Dentist Anesthesiologists for Pediatric Patients with Autism Spectrum Disorders

PURPOSE

The purpose of this study was to evaluate practice patterns among dentist anesthesiologists for pediatric patients with autism spectrum disorders (ASD) undergoing sedation for dental procedures.

METHODS

An electronic nationwide survey was delivered to all members of the American Society of Dentist Anesthesiologists. The survey assessed provider training and comfort in treating pediatric patients with ASD, perioperative procedures for children with and without ASD, and preferred educational resources for the perioperative management of pediatric patients with ASD.

RESULTS

Respondents were 114 dentist anesthesiologists and residents (33.3 percent response rate). Respondents indicated a high comfort level for managing pediatric patients with ASD for sedation (mean equals 91.9±14.74 [SD] percent). The average number of patients with ASD who respondents treat per week was 3.48±2.44). Providers reported making scheduling and staffing accommodations for patients with ASD. More than half of respondents reported no difference between patient groups in medication dosing for sedation and medication regimens used intraoperatively; however, only 43.9 percent of providers indicated using equivalent preoperative medication regimens for both patient groups, and providers reported increased usage of preoperative anxiolytic techniques with patients with ASD. Importantly, 87.7 percent of respondents reported the same incidence of adverse events during the perioperative period between groups.

CONCLUSIONS

Findings from this survey suggest there are both similarities and differences in how dentist anesthesiologists practice with pediatric patients with and without autism spectrum disorders. Additional research is warranted to measure the clinical benefits of modified practices for patients with ASD and identify best practices for this vulnerable population.

A Technical Assistance Curriculum for Expanding Sustainable School-Based Oral Health Programs in the Carolinas' Dental Safety Net

PURPOSE

School-based oral health programs (SBOHPs) provide opportunities to address oral health inequities by providing convenient access points for care. No published guidelines on SBOHP implementation existed. Our work describes how philanthropic, public, and academic organizations partnered to support dental safety net providers with designing comprehensive SBOHPs in North and South Carolina.

DESCRIPTION

A multi-sector leadership team was established to manage a new SBOHP philanthropic-funded grant program organized into two phases, Readiness and Implementation, with the former a 6-month planning period in preparation of the latter. Readiness included technical assistance (TA) delivered through coaching and 15 online learning modules organized in four domains: operations, finance, enabling services, and impact. Organizations could apply for implementation grants after successful TA completion. Process evaluation was used including a Readiness Stoplight Report for tracking progression.

ASSESSMENT

Ten Readiness grantees completed the TA. A variety of models resulted, including mobile, portable and fixed clinics. Descriptive analysis was conducted on the readiness stoplight reports. Components of the operation and finance domains required were the most time-intensive, specifically the development of policy manuals, production goals, and financial performance tracking.

CONCLUSION

The program's structure resulted in (a) a two-state learning community, (b) SBOHP practice and policy alignment, and (c) coordinated program distribution. TA improvements are planned to account for COVID-19 threats, including school closures, space limitations, and transmission fears. Telehealth, non-aerosolizing procedures, and improved scheduling and communication can address concerns. Organizations considering SBOHPs should explore similar recommendations to navigate adverse circumstances.

Outcomes Associated With State Policies Enabling Provision of Oral Health Services in Medical Offices Among Medicaid-enrolled Children

BACKGROUND

To increase receipt of preventive oral health services (POHS), all state Medicaid programs have enacted policies to encourage nondental providers to deliver POHS in medical offices. This study examined if these Medicaid policies improved oral health, as measured by reductions in dental visits with treatment and preventable emergency department (ED) visits for nontraumatic dental conditions (NTDC).

METHODS

Using data on children aged 6 months to up to 6 years from 38 state Medicaid programs during 2006-2014, we used a generalized difference-in-differences estimation approach to examine the probability of a child having, in a year, any dental visits with caries-related treatment and any ED visits for NTDC, conditional on length of policy enactment. Models included additional child-level and county-level characteristics, state and year fixed effects, probability weights, and clustered standard errors.

RESULTS

Among a weighted sample of 45,107,240 child/year observations, 11.7% had any dental visits with treatment and 0.2% had any ED visits for NTDC annually. Children in states with and without medical POHS policies had similar odds of having any dental visits with treatment, regardless of length of policy enactment. Children in states with medical POHS policies enacted for one or more years had significantly greater odds of having any ED visits for NTDC (P<0.05).

CONCLUSIONS

State policies making POHS available in medical offices did not affect rates of dental visits with caries-related treatment, but were associated with increased rates of potentially avoidable ED visits for NTDC. Findings suggest that many young Medicaid-enrollees lack access to dentists.

Compliance of Special Health Care Needs and Healthy Pediatric Patients with Preventive Visits after Dental Treatment under General Anesthesia

Purpose: To identify compliance of special health care needs and healthy pediatric patients with preventive dental appointments after treatment under general anesthesia (GA).<br/>Methods: Records of special health care needs (SHCN) patients treated under GA in 2015 and 2016 were reviewed. The control group consisted of randomly selected healthy patients also treated under GA in the same time period and hospital. Patient demographics were compared, and the number of preventive visits was recorded for 24 months after GA.<br/>Results: The sample consisted of 141 SHCN patients and 142 healthy children. The average number of preventive visits post-GA appointment was 2.74 out of a recommended nine visits over two years for the study population. There was a statistically significant difference in the level of compliance based on age and referral source, but there was no difference based on health status.<br/>Conclusion: Compliance with preventive dental visits after treatment under GA among all pediatric patients, regardless of health status, must be improved. Caregivers must be further educated to implement change and barriers to care must be explored.

Monetary incentives for improving smartphone-measured oral hygiene behaviors in young children: A randomized pilot trial

AIMS

To assess feasibility, acceptability, and early efficacy of monetary incentive-based interventions on fostering oral hygiene in young children measured with a Bluetooth-enabled toothbrush and smartphone application.

DESIGN

A stratified, parallel-group, three-arm individually randomized controlled pilot trial.

SETTING

Two Los Angeles area Early Head Start (EHS) sites.

PARTICIPANTS

36 parent-child dyads enrolled in an EHS home visit program for 0-3 year olds.

INTERVENTIONS

Eligible dyads, within strata and permuted blocks, were randomized in equal allocation to one of three groups: waitlist (delayed monetary incentive) control group, fixed monetary incentive package, or lottery monetary incentive package. The intervention lasted 8 weeks.

OUTCOMES

Primary outcomes were a) toothbrushing performance: mean number of Bluetooth-recorded half-day episodes per week when the child's teeth were brushed, and b) dental visit by the 2-month follow-up among children with no prior dental visit. The a priori milestone of 20% more frequent toothbrushing identified the intervention for a subsequent trial. Feasibility and acceptability measures were also assessed, including frequency of parents syncing the Bluetooth-enabled toothbrush to the smartphone application and plaque measurement from digital photographs.

FINDINGS

Digital monitoring of toothbrushing was feasible. Mean number of weekly toothbrushing episodes over 8 weeks was 3.9 in the control group, 4.1 in the fixed incentive group, and 6.0 in the lottery incentive group. The lottery group had 53% more frequent toothbrushing than the control group and 47% more frequent toothbrushing than the fixed group. Exploratory analyses showed effects concentrated among children ≤24 months. Follow-up dental visit attendance was similar across groups. iPhone 7 more reliably captured evaluable images than Photomed Cannon G16.

CONCLUSIONS

Trial protocol and outcome measures were deemed feasible and acceptable. Results informed the study protocol for a fully powered trial of lottery incentives versus a delayed control using the smart toothbrush and remote digital incentive program administration.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03862443.

Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits?

In the United States, state Medicaid programs pay for medical and dental care for children from low-income families and support nondental primary care providers delivering preventive oral health services (POHS) to young children in medical offices ("medical POHS"). Despite the potential of these policies to expand access to care, there is concern that they may replace dental visits with medical POHS. Using Medicaid claims from 38 states from 2006 to 2014, we conducted a repeated cross-sectional study and used linear probability regression to estimate the association between the annual proportion of children in a county receiving medical POHS and the probability that a child received 1) dental POHS and 2) a dental visit in a given year. Models included county and year fixed effects and controlled for child- and county-level factors, and standard errors were clustered at the state level. In a weighted population of 45.1 million child-years (age, 6 mo to <6 y), we found no significant nor substantively important association between the proportion of children in a county receiving medical POHS and the probability that a child received dental POHS or a dental visit. Additionally, we found an almost zero probability (<0.001) that the reduction in dental POHS was at least as large as the expansion in medical POHS (full substitution) and a 0.50 probability that increased medical POHS was associated with an increase in dental POHS of at least 6.6% of the expansion of medical POHS. Results were similar when receipt of dental visits was examined. This study failed to find evidence that medical POHS replaced dental visits for young children enrolled in Medicaid and, in fact, offers evidence that increased medical POHS was associated with increased utilization of dental care. Given lower-than-desired rates of dental visits for this population, delivery of medical POHS should be expanded.

Caregivers' Barriers to Dental Care for Children with Autism Spectrum Disorder

Purpose: To investigate caregivers' perspective on barriers to dental care for children with autism spectrum disorder (ASD).<br/> Methods: A cross-sectional survey assessing perceived barriers to dental care was administered to 46 caregivers who had a child with ASD (study group) and 37 who had children without ASD (control group) but with chronic health issues.<br/> Results: The barriers most frequently reported in the study group were difficulty finding a dentist who would treat their child (32 percent) and the child's uncooperative behavior (39 percent). A significantly higher number of caregivers of children with ASD agreed that their child was uncooperative and that such behavior was a barrier to finding care (chi-square=15.22, P =0.0001). The number of barriers reported by caregivers of children with ASD was greater than that reported by the other caregivers. Caregivers of children with severe ASD perceived having the most barriers to care.<br/> Conclusion: There are many barriers faced by caregivers in getting dental treatment for their children with ASD. Understanding the difficulty caregivers have in securing dental care for their children with ASD may help dentists and agencies work to improve access.

Preventive oral health care use and oral health status among US children: 2016 National Survey of Children's Health

BACKGROUND

Research has identified significant gaps in preventive oral health care among certain subpopulations of US children. The authors of this study sought to estimate children's preventive oral health care use and oral health and investigate associations with child, family, and health care characteristics.

METHODS

Data for this observational, cross-sectional study came from the 2016 National Survey of Children's Health. Children aged 2 through 17 years were included (n = 46,100). Caregiver-reported measures were preventive dental visits, prophylaxis, toothbrushing or oral health care instructions, fluoride, sealants, fair or poor condition of the teeth, and problems with carious teeth or caries. Univariate, bivariate, and multivariable logistic regression analyses were conducted.

RESULTS

As reported by parents or caregivers, 8 in 10 children had a preventive dental visit in the past year but lower rates of specific services: 75% prophylaxis, 46% fluoride, 44% instructions, and 21% sealants. In addition, 12% had carious teeth or caries and 6% had fair or poor condition of the teeth. In adjusted analyses, young children (aged 2-5 years), children with no health insurance, and those from lower-income and lower-educated households had decreased likelihood of a preventive dental visit as well as specific preventive services. Children with preventive health care visits and a personal physician or nurse had increased likelihood of receiving preventive oral health care.

CONCLUSIONS

Preventive oral health services are lagging among young children and children from lower socioeconomic backgrounds. Further studies are needed to identify interventions that encourage use of specific preventive services.

PRACTICAL IMPLICATIONS

Dentists should work with caregivers and primary care providers to promote preventive oral health care, especially among young children and those from lower socioeconomic backgrounds.

The influence of clinical and psychosocial characteristics on children behaviour during sequential dental visits: a longitudinal prospective assessment

PURPOSE

This is the first study to adopt a multilevel approach to assess the impact of the order of dental visits on child's behaviour. The aim was to investigate which factors directly interfere with child's behaviour regardless of the order of sequential dental visits.

METHODS

In this prospective longitudinal study, children aged 7-12 years were invited to participate. Child behaviour was assessed using the Frankl Scale during four sequential dental visits. Chi-square test was used to analyse the effect of dental fear on children's non-cooperative behaviour according to the presence of dental fear. Multilevel mixed logistic regression model was used to assess the association between predictor variables and the outcome (child behaviour) during the sequential dental visits.

RESULTS

Overall, 111 children participated in this study. Maternal dental anxiety, dental pain and complexity of the treatment were associated with the non-cooperative behaviour in children aged 7-12 years. When stratified by dental fear, the complexity of the treatment remained associated with non-cooperative behaviour.

CONCLUSIONS

The results provide evidence that, even with the familiarization of child with the dental environment, maternal dental anxiety, dental pain in the last month, and the complexity of dental treatment negatively affect the children's behaviour aged 7-12 years.

Medicaid caseload for pediatric oral health care

BACKGROUND

The authors' aims were to compare, according to strata, dentists' participation in Medicaid and Medicaid provider-level caseload measured as the number of patients or visits for preventive or restorative care for 2 comparison years.

METHODS

The data sources were the 2012-2013 Medicaid Analytic eXtract claims and 2013 National Plan and Provider Enumeration System data sets. The authors measured Medicaid participation as the proportion of dentists participating in Medicaid among those in the National Plan and Provider Enumeration System. The authors measured provider-level caseload according to the number of patients or visits. The authors stratified oral health care providers according to state; whether practicing in rural, suburban, or urban communities; and provider type.

RESULTS

The differences in participation rates for rural versus suburban and versus urban communities ranged from -4% through 27% and -6% through 37%, respectively. The 2012 state median number of patients per provider for preventive care ranged from 99 through 358. The provider-level caseload increased from rural to urban and from other provider to general dentist to pediatric dentist. The difference in caseload from 2012 to 2013 was not statistically significant except for the pediatric dentist type.

CONCLUSIONS

This study's results suggest that the realized caseload for children enrolled in Medicaid varies according to provider type and urbanicity. The state median caseload for preventive care is lower than the 500:1 patient to provider ratio used as the minimum caseload in access estimates from other studies.

PRACTICAL IMPLICATIONS

This study's results can assist states in gauging the level of oral health care provided to children insured by Medicaid compared with that in other states, with implications for the specification of oral health policies.

Dental Service Utilization Among Children in the Child Welfare System

OBJECTIVE

To examine predisposing, enabling, and need-related factors associated with dental utilization by children involved with the child welfare system (CWS).

METHODS

Data were analyzed from the National Survey of Child and Adolescent Well-Being (NSCAW; Wave II), a national probability sample of children (2-17 years) following a welfare assessment during 2008-2009 (n = 2806). Caregiver-reported child receipt of dental services in the past year was the outcome in weighted logistic regression models.

RESULTS

Two-thirds of children had a recent dental visit. Older children (OR 2.95, 95% CI 2.06,4.21 for ages 6-11; OR 2.47, CI 1.82, 3.37 for ages 12-17, compared to ages 2-5) were more likely to have visited the dentist, as were children of more educated caregivers (OR 1.68; CI 1.20, 2.36 for high school, OR 2.45; CI 1.71, 3.52 for more than high school). Children without a usual source of care (OR 0.50; CI 0.27, 0.94) and those living with non-biological parents had lower odds of a recent visit (OR 0.64; CI 0.43, 0.97). Children with dental problems were twice as likely to have a recent visit (OR 2.02; CI 1.21, 3.38), while children with unmet needs who could not afford care had lower odds of utilizing services (OR 0.28; CI 0.16, 0.46).

CONCLUSIONS FOR PRACTICE

Many children in the CWS, especially younger children (ages 2-5), did not have a reported dental visit in the past year. Cost was a barrier, and caregiver status was associated with the likelihood of obtaining dental care. Health and social service providers should refer these children for dental care.

Dental Team's Role in Maternal and Child Oral Health During and After Pregnancy

For a mother-to-be, pregnancy presents an opportunity to improve not only her health and well being but also that of the immediate family, particularly the newborn infant. The National Consensus Statement of the Oral Health Care During Pregnancy Expert Group together with both governmental and non-governmental guidelines indicate that dental care is both safe and effective during pregnancy. These statements and guidelines may not be widely understood across all healthcare providers that form the perinatal care team, and confusion seems to exist among the general public regarding the safety of and necessity for dental care during pregnancy. Only about half of pregnant patients seek care, even those with dental problems. Previous articles in this series have reviewed appropriateness of dental care during a healthy pregnancy and specific steps to be taken in consideration of the altered physiology brought on by pregnancy and the increased risk associated with oral diseases such as changes in periodontal status, dental caries, and acid erosion; communication through the technique of motivational interviewing with patients who are either planning to become or are pregnant; and collaboration with the perinatal team of providers to ensure improved health outcomes for mother and baby. This final article in the series addresses considerations during and after pregnancy to ensure mother and child may follow a pathway to a future of good oral health.

Acceptance of Preventive Dental Services for Children at a Retail-Based Clinic: A Pilot Study

Purpose: Low-income children with high caries risk are disproportionately affected by poor access to dental care. Retail-based clinics (RBCs) can provide accessible ancillary oral health care. The purposes of this study were: (1) to measure caregivers' acceptance rate of an oral health screening, fluoride varnish (FV) application, and caries risk assessment offered to children on a walk-in basis in an RBC; and (2) to categorize the caries risk and demographics among the participants.<br/> Methods: Screenings and FV applications were provided to children younger than 18 years at a Walgreens Health Care Clinic in Baltimore, Md., USA, from October 2016 to October 2017. The acceptance rate and caries risk using the American Dental Association caries risk assessment form were documented. Descriptive statistics and Fisher's exact test were used to analyze the data.<br/> Results: Eighty-five children and their caretakers were approached and 32 (38 percent) agreed to participate. Most children had high caries risk (84.3 percent) and a dental home (81.2 percent), but only 50 percent reported visiting their dentist in the last year.<br/> Conclusion: Our results demonstrate modest acceptance of FV application for children on a convenience basis. This population had predominantly high caries risk, with poor adherence to follow-up with their dental home. Retail-based dental care should not replace the dental home but could support it by increasing access to preventive dental care in children. (J Dent Child 2019;86(1):40-6)<br/> Received July 2, 2018; Last Revision August 13, 2018; Accepted August 13, 2018.

The Effect of Supplemental Oxygen on Postoperative Nausea and Vomiting in Children Undergoing Dental Work

Administration of 80% intraoperative oxygen has been proposed as being a cheap, safe and effective means reducing postoperative nausea and vomiting (PONV) but no studies have been performed in the high risk paediatr population. We tested whether 80% intraoperative oxygen reduces PONV in well children undergoing electi day-stay dental treatment under general anaesthesia. Ninety-five children received standardized sevoflurane, morphin vecuronium anaesthesia with either 30% or 80% intraoperative oxygen and no antiemetic prophylaxis in a randomize double blind, prospective trial. There was no difference in PONV or in the use of rescue ondansetron between the groups. The total incidence of PONV was 40% in the group that received 30% oxygen and 33% in those that receive 80% oxygen. High inspired intraoperative oxygen was not found to significantly reduce PONV in well children undergoing dental work under general anaesthesia.

Dental Sealants Part 4: Bisphenol A: What dentists should know

Bisphenol A (BPA) is a synthetic chemical resin used worldwide to produce plastic products. It is also a component of the bisphenol A diglycidylether methacrylate (Bis-GMA), which is a monomer found in dental resin-based materials (including resin-based dental sealants, RBSs). The controversy about its possible toxicity begins around the early '30s. Even if the amount of BPA released by dental sealants is well below the limit proposed by the U.S. Environmental Protection Agency and the European Food Safety Authority, we can reduce the risk of exposure, particularly for children, following precautionary measures.

A Cost Analysis of Three Pharmacologic Behavior Guidance Modalities in Pediatric Dentistry

Purpose: The aims of this study was to compare dental treatment costs for three pharmacologic behavior guidance modalities: (1) dental office-based moderate sedation (SED); (2) hospital-based general anesthesia (GA-H); and (3) dental office-based general anesthesia (GA-OFF). Methods: Data were collected for healthy two- to six-year-olds who had full-mouth rehabilitation using GA-H at the University of North Carolina Children's Hospital, Chapel Hill, N.C., USA. Patients served as their own controls to compare costs across the three modalities. Rendered treatments were quantified using relative value units (RVUs). Costs included opportunity costs and administrative data. We relied upon ordinary least squares analyses to examine the relationship between total costs and RVUs. Results: Of 200 consecutive hospital records, 65 met the inclusion criteria. The mean age was 4.4 years old (range equals two to six years old; 41 ASA I, 24 ASA II). Dental treatment using GA-H averaged 118 minutes (range equals 62 to 256 minutes), with a mean of 12 teeth (range equals six to 20) treated. GA-H costs were 4.1 times greater than GA-OFF costs (range equals 1.1 to 4.9), and 4.5 times greater than SED costs (range equals 0.9 to 7.1); GA-OFF costs were 1.1 times greater than SED costs (range equals 0.7 to 1.6). Conclusions: Treatment completed (measured in relative value units) was correlated highest with costs for dental office-based moderate sedation and least for hospital-based general anesthesia. If more than four SED appointments are needed, GA-OFF may provide cost-savings; however, at no point does GA-H offer cost-savings.

Obstructive sleep apnea syndrome in children

Obstructive sleep apnea syndrome (OSAS) in children is defined as a "disorder of breathing during sleep characterized by prolonged partial upper airway obstruction [hypopnea] and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns." OSAS is both prevalent and underdiagnosed in children. OSAS has harmful central nervous system, cardiovascular, and metabolic consequences, which can include an inability to concentrate in school, poor academic performance, behavioral problems, cardiovascular effects, and poor growth and development. Apneas in children are produced by an imbalance between upper airway load and neuromuscular tone. Many factors influence these attributes, but the most important are adenotonsillar hypertrophy and obesity. History and examination are fundamental areas that dentists can use to help diagnose OSAS in pediatric patients. Full-night polysomnography is the gold standard for obtaining a definitive diagnosis. Dental practitioners also can play a crucial role in the treatment and management of this condition.

Preventive dental care use for children with special health care needs in Washington's Access to Baby and Child Dentistry program

BACKGROUND

Preschool-aged children with special health care needs (CSHCN) from low-income households are at increased risk of developing poor oral health. The study goal was to assess preventive dental care use for CSHCN enrolled in Medicaid within Washington state's Access to Baby and Child Dentistry (ABCD) program.

METHODS

The authors analyzed 2012 Medicaid eligibility and claims files for children younger than 6 years in the ABCD program (N = 206,488). The authors used medical diagnosis and eligibility data to identify each child's special needs status (no or yes). The outcome was preventive dental care use (no or yes). The authors used modified Poisson regression models to estimate crude and covariate-adjusted prevalence rate ratios.

RESULTS

Of the 206,488 children in the study, 2.1% were CSHCN, and 114,570 used preventive dental care (55.5%). CSHCN used preventive care at rates similar to those of children without special health care needs (SHCN) (54.7% and 55.5%, respectively; P = .32). After adjustment for confounding variables, CSHCN were significantly less likely to use preventive dental care than were children without SHCN (prevalence rate ratio, 0.91; 95% confidence interval, 0.88 to 0.94; P < .001). Older preschool-aged children were significantly more likely to use preventive dental care than were younger preschool-aged children. A significantly higher proportion of preventive medical care users also used preventive dental care.

CONCLUSIONS

CSHCN who were enrolled in Medicaid in Washington's ABCD program were less likely to use preventive dental care than were children without SHCN who were enrolled in Medicaid.

PRACTICAL IMPLICATIONS

Future intervention research investigators should evaluate ways to improve access to preventive dental care for CSHCN. Additional strategies may be needed to improve oral health behaviors for preschool-aged CSHCN receiving Medicaid.

Access to preventive services after the integration of oral health care into early childhood education and medical care

BACKGROUND

The effect of Early Head Start (EHS) on receipt of preventive oral health services (POHS) from both oral and medical health care providers is not known.

METHODS

The authors compared children enrolled in North Carolina EHS programs with similar children enrolled in Medicaid but not EHS on the use of POHS. They analyzed 4 dependent variables (oral assessment by medical health care provider, oral assessment by oral health care provider, fluoride application by medical health care provider, fluoride application by oral health care provider) by using multivariate logistic regression that controlled for covariates.

RESULTS

Primary caregivers of children enrolled in EHS (n = 479) and Medicaid (n = 699) were interviewed when children were approximately 10 and 36 months of age. An average of 81% of EHS and non-EHS children received POHS from an oral or medical health care provider at follow-up. EHS children had greater odds of receiving an oral health assessment (odds ratio [OR], 2.33; 95% confidence interval [CI], 1.74 to 3.13) and fluoride (OR, 1.53; 95% CI, 1.16 to 2.03) from an oral health care provider than children not enrolled. EHS children had decreased odds (OR, 0.73; 95% CI, 0.54 to 0.99) of receiving fluoride from a medical health care provider.

CONCLUSIONS

Both children enrolled in EHS and community control participants had high rates of POHS, but the source of services differed. EHS children had greater odds of receiving POHS from oral health care providers than non-EHS children. EHS and non-EHS children had equal rates for fluoride overall because of the greater percentage of non-EHS children with medical fluoride visits.

PRACTICAL IMPLICATIONS

The integration of POHS in early education and Medicaid medical benefits combined with existing dental resources in the community greatly improves access to POHS.

Oral Health Problems and Solutions in High-Risk Children and Young Adults

Purpose: The Coordinated Healthcare for Complex Kids (CHECK) project targets publically insured children and young adults with chronic diseases. The CHECK oral health program intervenes at individual, family, and community levels. This paper describes the baseline oral health status of CHECK patients. Methods: CHECK patients older than 18 years of age and caretakers of younger patients were asked about their oral health. Medicaid claims data were used to determine diagnoses and level of risk. Attendance data from the Chicago Public Schools was obtained to assess absenteeism. Results: Of the 5,509 CHECK patients, 1,122 (20.4%) reported some type of oral health problem in the last six months. The most common issue was a history of dental caries (<small>N</small>=753, 13.7%). The odds of oral health problems increased significantly in adolescents (odds ratio [OR]=1.20; 95% confidence interval [CI]=1.02 to 1.40) and young adults (OR=1.55; 95% CI=1.31 to 1.85) compared with children. Males were less likely than females to have oral health problems (OR=0.83, 95% CI=0.73 to 0.95). Worse general health was significantly associated with oral health problems. Conclusion: CHECK is implementing a multilevel comprehensive approach to address oral health problems.