Impact on Dental Utilization of the Integration of Oral Health in Pediatric Primary Care Through Quality Improvement.

OBJECTIVES: To evaluate child-level dental utilization and expenditure outcomes based on if and where children received fluoride varnish (FV) at quality improvement (QI) medical practices, at non-QI medical practices, at dental practices, or those who never received FV from any practice. DESIGN: Retrospective claims-based analysis cohort study. SETTING: Children with Medicaid insurance through an Ohio pediatric accountable care organization. PARTICIPANTS: Children aged 1 to 5 years with 1 or more well-child visits between 2015 and 2017. INTERVENTION: FV receipt versus no FV. Among children who received FV, categorized if FV delivered by a QI-participating medical provider, a non-QI-participating medical provider, and a dental provider. MAIN OUTCOME MEASURE: Dental claims from 2014 to 2019 were collected for preventive dental visits, caries-related treatment visits, dental general anesthesia (GA) visit, and emergency department visit for a dental problem to examine utilization patterns, expenditures, and dental outcomes. RESULTS: The QI group had a significantly higher incidence of preventive dental visits than the dental (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI], 0.91-0.96) or non-QI groups (IRR = 0.86; 95% CI, 0.84-0.88). Compared with the QI group, the non-QI (adjusted odds ratio [aOR] = 2.6; 95% CI, 2.4-2.9) and dental (aOR = 2.9; 95% CI, 2.6-3.3) groups were significantly more likely to have caries-related treatment visits. The dental group children were significantly more likely to have dental treatment under GA than the QI group (aOR = 5.3; 95% CI, 2.0-14.4). CONCLUSIONS: Children seen at QI practices appear to have an increased uptake of preventive dental services, which may explain the lower incidence of dental caries visits and GA treatment.

Contemporary predoctoral paediatric behaviour guidance education in the United States and Canada.

PURPOSE: To determine the contemporary educational experiences of predoctoral dental students in the United States and Canada regarding behaviour guidance (BG) of the child patient and assess trends from a previous study in 2004. METHODS: Data were collected from 32 predoctoral paediatric dentistry programme directors in the United States and Canada via a web-based survey. RESULTS: The didactic curriculum hours devoted to the teaching of BG techniques in 2019 are similar to 2004. A majority (60.7%) of programmes do not have a formal assessment of competency with BG techniques. Lectures (n = 28), clinical experience (n = 28) and observation (n = 26) were the most common techniques implemented to teach BG techniques, and tell-show-do (100%), non-verbal communication (82.1%), positive reinforcement (89.3%) and distraction (82.1%) were the techniques that more than 75% of dental students most commonly have hands-on experience with during their dental education. In 2019, students tended to have more hands-on experience with nitrous oxide/oxygen inhalation and less hands-on experience with aversive techniques and sedation. CONCLUSIONS: The majority of dental schools do not have a formal competency in BG of the child patient. Compared with 2004, nitrous oxide/oxygen is used more by dental students and there is less predoctoral education in aversive BG techniques.

Safety and Efficacy of 3 Pediatric Midazolam Moderate Sedation Regimens.

Our aim was to characterize effectiveness and complications in children receiving oral midazolam alone, nasal midazolam alone, or oral midazolam with other sedatives. Children received oral midazolam alone, nasal midazolam, or oral midazolam in combination with other sedative medications. All subjects received a presedation history and physical examination and were sedated per protocol by any of 28 resident providers under attending supervision. Sedations were rated for success and complications by clinicians. Postoperative complications were assessed by trained staff up to 48 hours postoperatively. Seven hundred and one encounters, completed over 24 months, yielded 650 usable sedations. The majority of children were healthy (469; 68.2%) and 86% (532) weighed between 10 and 25 kg. Sedations were deemed successful in about 80% of cases. Planned treatment was completed in over 85% of encounters. Oral midazolam alone yielded the best behavior. Physical assessment factors of behavior and age were correlated (P = .035) with effectiveness. Hiccups and a positive medical history were significantly related (P = .049). Side effects of either nausea/vomiting, dysphoria, or hiccups occurred in less than 10% of cases. All 3 regimens were effective with minimal postoperative complications.

Evaluating the type of pediatric dental care use in the context of neighborhood opportunity.

BACKGROUND: Increasing evidence supports the influence of neighborhood factors on health care use and outcomes. This study measured the association between area-level social determinants of health (SDH) and type of dental care use among Ohio pediatric Medicaid beneficiaries. METHODS: A retrospective dental claims analysis was completed for children aged 1 through 5 years enrolled in Ohio Medicaid with a dental visit in 2017. Dental care use was measured from 2017 through 2021 as 1 of 4 visit types: (1) preventive, (2) caries treatment, (3) dental general anesthesia (GA), and (4) dental emergency department. The Ohio Children's Opportunity Index defined area-level SDH at the census tract level. Exploratory analysis included descriptive statistics of area-level SDH for each outcome. Poisson regression models were developed to examine the associations between the number of each dental care use outcome and Ohio Children's Opportunity Index quintiles. Visualizations were facilitated with geospatial mapping. RESULTS: Fifty-six percent of children (10,008/17,675) had caries treatment visits. Overall area-level SDH were positively associated with preventive (fifth vs first quintile incidence rate ratio [IRR], 1.09; 95% CI, 1.07 to 1.12), caries treatment (fifth vs first quintile IRR, 1.16; 95% CI, 1.08 to 1.24), and dental GA visits (fifth vs first quintile IRR, 2.13; 95% CI, 1.13 to 4.01). CONCLUSIONS: Children with preventive, caries treatment, and dental GA visits were more likely to live in neighborhoods with better SDH. Future efforts should investigate the mechanisms by which area-level factors influence dental access and use. PRACTICAL IMPLICATIONS: Neighborhood factors influence pediatric dental care use. Patient home addresses might add value to caries risk assessment tools and efforts by care networks to optimize efficient care use.

Age of first dental visits: A benefit of the pediatric medical home.

OBJECTIVE: This retrospective cohort study compared differences in age one dental visit use and age at first dental visit according to fluoride varnish receipt at the pediatric medical home. METHODS: Enrollment and claims data were used from Partners For Kids, a pediatric accountable care organization covering Medicaid-enrolled children living in 47 of 88 counties in Ohio. The main outcomes were having an age one dental visit and the mean age at first dental visit. Descriptive statistics and bivariate comparisons were applied. RESULTS: Among 17,675 children, 2.8% had an age one dental visit. The mean age at first dental visit was 4.8 years. Children who received fluoride varnish from their medical home (12% of study population) were significantly younger at their first dental visit (4.1 vs. 4.9 years, p < 0.001). CONCLUSION: Despite longstanding recommendations for the age one dental visit, very few Medicaid-enrolled children in Ohio had one. The pediatric medical home lowered the age of first dental visit.

Impact of Reduced Operating Room Access on Dental Departments in Children's Hospitals.

Purpose: Access to hospital operating rooms (HORs) for pediatric dental patients worsened with the COVID-19 pandemic. The purpose of this study was to assess the impact of hospital operating room denials for dental patients on service and teaching missions in selected US children's hospitals (CHs). Methods: A 12-question online survey was sent to administrative heads of 34 CH dental departments. Results: Twenty-two surveys were completed. All respondent CHs were engaged in pediatric dentistry training. The majority (68 percent) reported that access to HORs worsened since 2017, resulting in longer wait times for hospital dental service cases (82 percent), decreased ability to achieve and maintain oral health for special needs patients (64 percent), more caries-related emergency department visits (50 percent), and delays in medical surgery for children needing dental clearance (45 percent). A quarter (27 percent) reported HOR availability somewhat affected resident training. Conclusion: Lack of access to hospital operating rooms in training hospitals had a negative impact on the quality and timeliness of care and the quality of training.

Aspiration of an exfoliated primary molar in a child with cerebral palsy: A case report.

Foreign body aspiration is a concern in children which may occur with anything introduced to the oral cavity and can result in significant morbidity and mortality. Food and foreign objects are the most commonly aspirated objects in young children. Aspiration of a normally exfoliated primary tooth is thought to be extremely rare, if not unheard-of. The purpose of this case report is to describe the events occurring to a 10-year-old child with a cerebral palsy presenting with signs and symptoms of respiratory distress due to aspiration of a naturally exfoliated primary molar. Recommendations are provided for delivery of appropriate anticipatory guidance, management of exfoliating primary teeth, and safe clinical practice.

Knowledge and Perceptions of Dental Care During Pregnancy: A Cross-Sectional Survey of Adolescents and Young Adults.

Purpose: To evaluate knowledge, perceptions and current practices regarding care-seeking behaviors and oral health in pregnant and non-pregnant adolescent and young adults, and to assess barriers to dental care during pregnancy.
Methods: An 18-question survey was distributed to patients in three tertiary hospital clinics in Columbus, Ohio, USA. Statistical analyses used chi-square and Fisher's exact tests, with significance at P <0.05.
Results: Of 227 respondents, 197 were female and about 30 percent were pregnant. The mean and median age was 17 years. Almost half were African American, 69 percent had public insurance and over 75 percent had one or two annual dental check-ups. Less than one percent indicated pregnant females should never go to the dentist, although 63 percent of pregnant respondents had not sought dental care while pregnant and less than five percent had been to the dentist in the six months prior to pregnancy. The most reported barrier to seek dental care was the patient being too busy.
Conclusions: Dental care among pregnant adolescents seems to be less utilized than their non-pregnant peers. The importance and safety of dental care during pregnancy are less understood among adolescents and young adults than in older, pregnant women. Most respondents, including males, stated that if a pregnant female has tooth pain, she should go to the dentist, but were unaware if materials used at the dentist were harmful to the baby. Interventions to improve knowledge and reduce barriers to dental care during pregnancy are needed for adolescents and young adults.

Comparison of Spanish-Speaking Parental Understanding Using Two Alternative Consent Pathways.

Purpose: The purpose of this study was to assess the understanding of Spanish-speaking caregivers consenting to dental care using general anesthesia (GA) utilizing two consent-delivery pathways. Methods: Seventy-eight parents of children who never had GA were randomly assigned to one of two groups: (1) interpreter; or (2) video; they completed a survey to evaluate comfort level with GA and comprehension of areas of informed consent. Results: Most parents in both groups understood the risks associated with GA (89 percent in the interpreter group and 90 percent in the video group). The majority of families had difficulty understanding indications for GA (64 percent in the interpreter group versus 60 percent in the video group). Overall, 97 percent of participants believed they sufficiently understood the information presented about GA. The mean score for comfort level with GA was 7.03 for the interpreter group and 6.82 for the video group. Conclusion: Consent pathways used in this study were not significantly different for risk understanding and acquisition of consent-related knowledge.

Safety Training in US Pediatric Dentistry Advanced Education Programs: A Survey of Program Directors.

Purpose: Incorporation of patient safety and quality improvement into the educational framework of all health care trainees, including those in dentistry, is growing. The purpose of this study was to characterize the current state of patient safety training and education in US pediatric dentistry residency programs. Methods: A 19-item web-based survey was emailed to all US pediatric dentistry residency program directors in 2021. The survey collected information regarding program background, safety education, safety protocol and experience, attitudes toward safety, and potential support for safety education. Data were analyzed using descriptive statistics and Fisher's exact test. Results: Seventy-two directors (76 percent response rate) completed the survey. The majority felt safety education was somewhat (11 percent, N equals six) or extremely important (68 percent, N equals 49) for residents. Only six percent (N equals four) reported residents entered their program with an adequate understanding of safety science. Most (74 percent, N equals 53) taught safety science through both didactic seminars and clinical experience. Timeouts under general anesthesia (78 percent, N equals 56) and emergency simulations (72 percent, N equals 52) were more common modes of clinical safety training. Overall, a limited number of program directors had familiarity with many safety tools used to prevent adverse events. Program directors' experience with adverse events was not associated with opinions regarding the importance of safety education. The majority expressed interest in AAPD supporting safety education. Conclusions: Although program directors feel safety education is important, programs do not sufficiently address safety education and look for support to help integrate safety measures into education.

Primary Second Molar Treatment as a Predictor of Repeat General Anesthesia.

Purpose: The purpose of this study was to investigate an association between treatments on the primary second molars (PSMs) under general anesthesia (GA) and odds of repeat GA. Methods: This was a retrospective study of children who received dental treatment under GA between the ages of 24 to 48 months. Descriptive statistics and logistic regression models (P<0.05) were used to test the association between the treatment of PSMs at the first dental GA visit (GA1) and the odds of receiving GA a second time (GA2) within the next 55 months post-GA1. Results: A total of 819 children (53 percent male) with a mean (±SD) age of 36 (±seven SD) months and 3,276 PSMs were included. Only three percent of children with all PSMs covered at GA1 received GA2. The odds of GA2 significantly increased for children with any uncovered PSMs. Among children with four uncovered PSMs, 19 percent (odds ratio [OR] equals 13; 95 percent confidence interval [95% CI] equals 5.8 to 33.5; P<0.001) and among those with unerupted PSMs at GA1, 51 percent received GA2 (OR equals 62.9; 95% CI equals 23.5 to 189.2; P<0.001). In the group that received GA2, 79.1 percent of uncovered PSMs at GA1 eventually received a stainless steel crown at GA2. Conclusions: Restorative treatments other than stainless steel crowns were associated with higher odds of repeat general anesthesia. These findings support the preferential use of full-coverage restorations for the treatment of carious primary molars in young children undergoing GA to minimize the risk of the need for repeat GA.

Oral Health Advocacy Education Impacts Future Engagement: Exploration at a Midwestern US Dental School.

Purpose: With the emergence of COVID-19, and the potential inclusion of dental benefits in Medicare, it is critical that dentists are able to engage in legislative advocacy to support public oral health. Dental education has an opportunity to teach advocacy skills to future dentists, although advocacy training in predoctoral dental education has been largely ignored. The purpose of this study was to evaluate fourth-year dental student's attitudes toward advocacy, identify the type and extent of advocacy experiences during dental school, and assess their future intentions to engage in advocacy. Methods: An electronic questionnaire was administered to fourth-year dental students enrolled in their final semester at Ohio State University. Results: Forty-seven students completed the survey (43% response rate). Most (84%) respondents agreed that advocacy training should be a required experience in accreditation standards for predoctoral dental education. Over half (58%) reported seldom or no exposure to legislative and regulatory processes in oral health policy development in the curriculum. Students who participated in grassroots advocacy efforts while in dental school were more likely to contact legislators regarding dental issues (p = 0.005) or public insurance (p = 0.037), and participate in future lobbying efforts (p = 0.019). Students who contributed to PAC while in dental school were more likely to express intentions to contribute in future (p = 0.005). Conclusions: There is limited exposure to legislative advocacy in predoctoral dental education. Dental students with advocacy experience are more likely to report intentions to participate in advocacy as dentists. Dental education has a critical role in preparing future dentist-advocates.

Denial of Operating Room Access for Pediatric Dental Treatment: A National Survey.

Purpose: U.S. pediatric dentists require access to hospital operating rooms (ORs) to deliver safe and effective dental care to some children but have reported denial of access to ORs for general anesthesia (GA), causing long waiting times, deferral of medically necessary dental care, and unmeasured pain and anxiety for patients. The purpose of this pilot study was to examine the extent and possible underlying causes of operating room access denial. Methods: Public policy advocates (PPAs) of the American Academy of Pediatric Dentistry completed a written or electronic questionnaire about state-specific OR denials during March 2020. Results: Responses from 50 states and the District of Columbia showed 34 PPAs (67 percent) acknowledging OR access problems, with 14 out of 34 (41 percent) reporting a moderate or major problem. Western district PPAs reported the fewest states affected (four out of 11; 36 percent). Hospitals and reimbursement emerged as frequent foci for denials in comment analysis. Conclusions: Operating room access denial is a problem for pediatric dentists in the majority of U.S. states and the District of Columbia; in those states reporting it as a problem, it was considered moderate or major in significance by almost half.

Ohio Dentists' Perceptions on Children School Absenteeism for Dental Care Appointments.

Purpose: This cross-sectional study evaluated knowledge, practices, and beliefs of Ohio dentists treating school-aged children regarding school absenteeism in relation to compliance with dental appointments.
Methods: A 26-item questionnaire was distributed to 7,274 dentists licensed in the state of Ohio in 2019. Eligible participants were pediatric dentists (PDs) and general dentists (GDs) who treated individuals younger than 16 years of age.
Results: A return rate of 13.5 percent (958 total participants) provided a sample consisting of approximately 90 percent of GDs, a mean age of 48.5 years and primarily practicing in suburban locations. Respondents felt parental attitudes had changed over the past five years, with a significantly higher proportion of PDs reporting increased parental concerns about school absences than GDs (59.5 percent versus 31.5 percent; P <0.001). Length of excused absence increased with treatment complexity. PDs were more likely to permit longer absences than GDs and to allow parents to decide the length of absence, particularly for children with special health care needs. PDs were 6.6 times more likely to report that concerns about school absences often negatively affected oral health (P <0.001).
Conclusion: Dentists acknowledged that school absences and school policy affected parental choices regarding dental visits, with PDs consistently stating a greater effect than GDs.

Feasibility and usability study of a pilot immersive virtual reality-based empathy training for dental providers.

PURPOSE: Social determinants of health (SDOH) significantly impact individuals' engagement with the healthcare system. To address SDOH-related oral health disparities, providers must be equipped with knowledge, skills, and attitudes (KSAs) to understand how SDOH affect patients and how to mitigate these effects. Traditional dental school curricula provide limited training on recognizing SDOH or developing empathy for those with SDOH-related access barriers. This study describes the design and evaluation of such a virtual reality (VR)-based simulation in dental training. We hypothesize the simulation will increase post-training KSAs. METHODS: We developed "MPATHI" (Making Professionals Able THrough Immersion), a scripted VR simulation where participants take the role of an English-speaking caregiver with limited socioeconomic resources seeking dental care for a child in a Spanish-speaking country. The simulation is a combination of 360° video recording and virtual scenes delivered via VR headsets. A pilot was conducted with 29 dental residents/faculty, utilizing a pre-post design to evaluate effectiveness in improving immediate and retention of KSAs toward care delivery for families facing barriers. RESULTS: MPATHI led to increased mean scores for cognitive (pre = 3.48 ± 0.80, post = 4.56 ± 0.51, p < 0.001), affective (pre = 4.20 ± 0.4, post = 4.47 ± 0.44, p < 0.001), and skill-based learning (pre = 4.00 ± 0.47, post = 4.52 ± 0.37, p < 0.001) immediately post-training. There was not a significant difference between skills measured immediately post-training and in the 1-month post-training survey (p = 0.41). Participants reported high satisfaction with the content and methods used in this training. CONCLUSIONS: This pilot study supports using VR SDOH training in dental education. VR technology provides new opportunities for innovative content design.

Prenatal dental care: a review.

Good oral health during pregnancy is necessary for the health of both the mother and the baby. Dental care during pregnancy is safe, effective, and recommended, yet many dental professionals delay treatment due to concerns for fetal safety. This article discusses common dental findings and treatment considerations during pregnancy. Oral health professionals should promote the safety of dental care during pregnancy.

A survival analysis of primary second molars in children treated under general anesthesia.

BACKGROUND: The authors examined time to need new treatment of primary second molars in very young children treated under general anesthesia (GA). METHODS: During this retrospective chart review, the authors examined patients aged 2 through 4 years with severe early childhood caries (ECC) who received dental treatment under GA. Primary second molars were tracked in periodic recall visits after GA for 6 through 89 months. Using a random-effects Cox proportional hazards model, the authors compared hazards of teeth requiring new treatment based on treatments received at GA. RESULTS: Of 3,166 primary second molars included in the study, 367 (12%) were not erupted, 77 (2%) received topical fluoride only, 873 (28%) received a pit and fissure sealant, 242 (8%) received a composite restoration, and 1,607 (50%) received a stainless steel crown (SSC) at GA. SSCs had a survival probability of 98% by 84 months after GA, significantly higher than all other groups (P < .0001). The second molars that were not erupted at GA had the highest hazard, especially within the first 24 months after GA. Teeth that received sealant had longer time to need new treatment than nonsealed teeth; however, at 84 months after GA, only 33% of the sealed teeth did not require additional treatment. CONCLUSIONS: Preventive or restorative treatments other than SSCs resulted in need for new treatment in a substantial number of teeth. SSCs had the highest success in this population with severe ECC treated under GA and should be chosen over other restorative options to reduce risk of undergoing repeat dental treatment. PRACTICAL IMPLICATIONS: Aggressive treatment with SCC should be considered for young children with severe ECC especially those who are treated under GA at a young age.

The impact of oral health on the quality of life of young patients with congenital cardiac disease.

The purposes of our study were, first, to determine the prevalence of dental caries in young patients with congenital cardiac disease, second, to determine the effect of oral health in their quality of life, third, to examine parental knowledge about associations between oral health and cardiac health, and fourth, to examine parental perceptions regarding access to dental care. A standardized questionnaire was given to a convenience sample of parents of 43 children with cardiac disease and 43 healthy controls from 12 to 71 months of age. In every patient, we performed a dental examination. Descriptive statistics, the two-tailed t-test, and Fisher's exact test were used for statistical analysis. Of the children with cardiac disease, 17% had caries, compared to 13% of the control group. Almost half of those with cardiac disease had never seen a dentist, compared to 35% of the control subjects. Of the parents of those with cardiac disease, one-fifth did not know whether oral health was important for the heart, compared to one-tenth of controls. Insurance and access to care were not barriers to obtain dental treatment. Statistically significant differences were, first, parents of children with congenitally malformed hearts felt more guilt about their child's oral health than control parents (p = 0.026), second, they were more upset about the dental problems and/or treatments of their children (p = 0.012), and third, they thought that dental problems and/or dental treatment made their children more irritable (p = 0.012). Our findings indicate that it is of paramount importance that cardiologists and their associated staff educate patients and families about oral health and other issues associated with congenital cardiac disease.

Evaluation of the Ability of Five- to 11-Year-Olds to Brush Their Teeth Effectively with Manual and Electric Toothbrushing.

Purpose: This study's purposes were to: (1) correlate toothbrushing effectiveness measured by plaque removal with children's parent- reported ability to perform life tasks and their executive function; and (2) compare plaque removal by children using a manual versus electric toothbrush. Methods: A convenience sample of 120 healthy five- to 11-year-olds was randomly and evenly assigned to manual or electric tooth- brush groups. A questionnaire was developed from items selected from previously validated social science instruments and completed by caregivers. Plaque was measured by calibrated scorers using the Oral Hygiene Index-Simplified before and after children brushed with respective toothbrushes. Statistical significance was established at P<0.05. Results: The type of toothbrush had no effect on brushing effectiveness. Ability to write a complete address, tie shoes independently, cut meat with a knife, and cut out complex shapes were associated with better toothbrushing effectiveness. Increasing ability to play a musical instrument and wash dishes independently were associated with increased plaque removal. Parents were good predictors of a child's readiness to brush, based on plaque removal scores. Conclusions: Certain life skills and quality of performance of tasks were associated with toothbrushing effectiveness in five- to 11-year-olds and may be used to determine a child's readiness to brush independently.

Advocacy training in US advanced pediatric dentistry training programs.

PURPOSE: This study: (1) assessed pediatric dentistry residency program directors' attitudes toward and involvement in advocacy training; and (2) identified types and extent of advocacy training in U.S. pediatric dentistry programs. METHODS: Between October 2005 and February 2006, all 66 pediatric dentistry residency program directors were invited to complete a 62-item online questionnaire. The survey investigated: (1) directors' attitudes toward advocacy training; (2) nature of advocacy training offered during residency; (3) extent of resident involvement in different settings; and (4) directors' involvement in advocacy. RESULTS: Forty-two program directors responded (64%). Overall, respondents agreed that advocacy by pediatric dentists for children beyond the dental office was important and that residency programs should provide advocacy training. Most programs did not routinely offer advocacy opportunities in nonclinical settings. Over half of programs required community outreach clinic rotations for all residents. One third offered didactic curriculum in the legislative process. Over 50% of program directors reported personal involvement in legislative oral health lobbying within 3 years, but fewer than a third were involved with professional political action committees (PACs). CONCLUSIONS: Advocacy is seen as on important in pediatric dentistry but variation in attitudes of program directors and program offerings exists in US training programs.