A Community-Based Oral Health Intervention in Navajo Nation Head Start: Participation Factors and Contextual Challenges.

Successful interventions require consistent participation by intended recipients. We utilized mixed methods to describe participation of 518 parent-child dyads enrolled in a randomized cluster trial of a 2-year oral health intervention for Head Start (HS) families across Navajo Nation delivered by native Community Oral Health Specialists (COHS). We quantitatively assessed factors that contributed to participation and qualitatively examined barriers and strategies. The intervention offered fluoride varnish (FV) and oral health promotion (OHP) activities for two cohorts (enrolled in 2011, N = 286, or 2012, N = 232) of children in the HS classrooms and OHP for parents outside the classroom. Child participation was good: FV: 79.7 (Cohort 1) and 85.3 % (Cohort 2) received at least 3 of 4 applications; OHP: 74.5 (Cohort 1) and 78.4 % (Cohort 2) attended at least 3 of 5 events. Parent participation was low: 10.5 (Cohort 1) and 29.8 % (Cohort 2) attended at least three of four events. Analysis of survey data found significant effects on parent participation from fewer people in the household, Cohort 2 membership, greater external-locus of control, and a greater perception that barriers existed to following recommended oral health behaviors. Qualitative analysis of reports from native field staff, COHS, community members, and the research team identified barriers (e.g., geographic expanse, constraints of a research trial) and suggested strategies to improve parent participation (e.g., improve communication between COHS and parents/community). Many challenges to participation exist when conducting interventions in rural areas with underserved populations. Working with community partners to inform the development and delivery of interventions is critical.

Validation of a pediatric oral health-related quality of life scale in Navajo children.

BACKGROUND: American Indian (AI) children experience the highest rates of early childhood caries (ECC) in the USA, yet no tool has been validated to measure the impact of ECC on their oral health-related quality of life (OHRQoL). OBJECTIVE: To validate a pediatric OHRQoL scale in a preschool, rural, reservation-based AI population. METHODS: In 2011 and 2012, we measured the OHRQoL of AI children attending Head Start in Navajo Nation with the 12-item preschool version of the pediatric oral health-related quality of life (POQL) scale administered to their parents/caregivers. Parents/caregivers also reported their children's subjective oral health status (OHS) and oral health behavior adherence. Concurrently, calibrated dental examiners measured the children's decayed, missing, and filled tooth surfaces (dmfs). Validation was assessed with internal reliability and convergent and divergent validity testing and exploratory factor analyses. RESULTS: We measured the outcomes in 928 caregiver-child dyads. All children were AI and in preschool [mean (SD) child age was 4.1 (0.5) years]. The majority of children had experienced decay [dmfs: 89 %, mean (SD): 21.5 (19.9)] and active decay [any ds: 70 %, mean (SD): 6.0 (8.3)]. The mean (SD) overall POQL score was 4.0 (9.0). The POQL scale demonstrated high internal consistency reliability (Cronbach alpha = 0.87). Convergent validity of the POQL scale was established with highly significant associations between POQL and caries experience, OHS, and adherence to oral health behaviors (all ps < 0.0001). CONCLUSIONS: The POQL scale is a reliable and valid measure of OHRQoL in preschoolers from the Navajo Nation.

Association of Ethnic Identity with Oral Health Knowledge, Attitudes, Behavior, and Outcomes on the Navajo Nation.

American Indians and Alaska Natives (AI/ANs) experience poor oral health. Children and adults living on the Navajo Nation have a particularly high rate of dental decay. The literature suggests that health outcomes are often associated with the strength of one's ethnic identity. We investigated the association of ethnic identity among Native parents with oral health knowledge, attitudes, behavior, and outcomes. Analyses used baseline data from a randomized controlled trial designed to reduce dental decay among AI/AN preschoolers enrolled in the Navajo Nation Head Start Program. Greater perceived importance of ethnic identity was associated with better oral health knowledge and attitudes but was unassociated with oral health behavior and was linked to worse oral health status. Parents who were better able to speak their tribal language had greater confidence in their ability to manage their children's oral health, engaged in better oral health behavior, and reported better parental oral health status.

Validation of the Sense of Coherence Scale in an American Indian population.

This study examined the psychometric properties of the Sense of Coherence (SOC) scale in the context of an oral health-related clinical trial conducted in an American Indian population-specifically, people of the Navajo Nation. Data were derived from baseline evaluations of parents (or caregivers) of Navajo children aged 3-5 from 52 Head Start classes enrolled in a trial of an intervention to prevent early childhood caries (ECC). A 190-item Basic Research Factors Questionnaire, which included the SOC, was administered to 1,016 parents/caregivers. Assessment of internal reliability and convergent validity, and confirmatory factor analyses were conducted. Multiple linear regression analysis was used to examine associations between parents' SOC and other potentially convergent measures. Confirmatory factor analysis was used to examine 1- and 3-factor solutions of the SOC scale. Higher SOC was significantly related to higher parental education and income, employment status, and higher scores for social support, internal Oral Health Locus of Control (OHLOC), self-efficacy, importance of oral health, oral health knowledge and behavior, and children's oral health quality of life. Higher SOC also was related to lower reported distress and lower external OHLOC. Cronbach's α was 0.84 for all SOC items, but lower for each of the 3 SOC subscales. Confirmatory factor analyses suggested a 3-factor solution was superior to a 1-factor solution. The SOC scale had good internal reliability and convergent validity in this American Indian population.

Validation and Impact of Caregivers' Oral Health Knowledge and Behavior on Children's Oral Health Status.

PURPOSE: To validate oral health knowledge and behavior measures from the Basic Research Factors Questionnaire, developed to capture specific themes contributing to children's oral health outcomes and the influence of caregivers. METHODS: Data were collected as part of a randomized clinical trial (n equals 992) aimed at reducing dental caries in young children. Participants were American Indian/Alaska Native caregivers with a three- to five-year-old child enrolled in a Navajo Nation Head Start Center. Caregivers completed the questionnaire at enrollment with concomitant evaluation of children for decayed, missing, and filled tooth surfaces (dmfs). Oral health knowledge and behavior outcomes were compared with convergent measures (participant sociodemographic characteristics, oral health attitudes, and indicators of oral health status). RESULTS: Caregiver oral health knowledge was significantly associated with education, income, oral health behavior, and all but one of the oral health attitude measures. Behavior was significantly associated with several measures of oral health attitudes and all but one measure of oral health status. As the behavior score improved, dmfs scores declined, child/caregiver overall oral health status improved, and pediatric oral health quality of life improved. CONCLUSIONS: Questionnaire measures were valid for predicting specific caregiver factors potentially contributing to children's oral health status.

Characterization of rat parotid and submandibular acinar cell apoptosis in primary culture.

Apoptosis is a highly organized cellular process that is critical for maintaining glandular homeostasis. We have used primary rat salivary acinar cells from the parotid and submandibular glands to investigate the critical regulatory events involved in apoptosis. Caspase-3 activity, cleavage of caspase substrates, and deoxyribonucleic acid (DNA) fragmentation were assayed in cells treated with etoposide, a DNA-damaging agent, or brefeldin A (BFA), a Golgi toxin. Dose-response studies showed that the sensitivity of both cell types to etoposide and BFA was similar, with 150 microM etoposide or 1.5 microM BFA inducing maximal caspase activation. However, BFA induced a more robust activation of caspase and DNA fragmentation in both cell types. Similar results were observed when the caspase cleavage of poly(adenosine 5'-diphosphate ribose) polymerase and protein kinase C delta were analyzed by Western blot. Analysis of the kinetics of apoptosis showed that caspase-3 activation was maximal at 8 h of etoposide or BFA treatment in the parotid cells and at 8-18 h in the submandibular cells. A similar time course was observed when DNA fragmentation was assayed, although maximal DNA fragmentation in BFA-treated cells was two- to threefold higher than that observed in etoposide-treated cells. Despite slight kinetic differences, it would appear that the apoptotic cascade is very similar in both primary parotid and submandibular acinar cells. Although limited in their long-term stability in culture, the use of primary, nonimmortalized salivary acinar cultures will also permit the use of specific transgenic animals to further characterize the molecular events involved in the regulation of salivary gland acinar cell apoptosis.

Modulation of SOD activity in rat submandibular glands.

Reactive oxygen species (ROS) such as superoxide anion (O(2)(*-)), hydrogen peroxide (H(2)O(2)) and hydroxyl radical (*OH) are produced constantly in aerobic organisms. Submandibular glands of rats treated with isoproterenol (ISO) were analysed in respect to the level of superoxide dismutase (SOD), lipoperoxidation, protein oxidation and glutathione (GSH)/GSSG. Although ISO response is very well studied in salivary glands cells, the effect of ISO treatment on ROS productions or on SOD activation is not known. SOD activity increased after isoproterenol subcutaneous injection. In contrast, cycloheximide, a protein synthesis inhibitor, was found to decrease the total SOD activity. The GSH/GSSG ratio and the lipoperoxidation were also found to be increased after isoproterenol injection, while the protein oxidation was not affected by the same treatment. Injection of isoproterenol after cycloheximide treatment resulted in the recovery of the total SOD activity. This increase of activity is related to the amount of MnSOD isoform as shown by Western blot analysis. Our results suggest that the antioxidant protection of SOD may be activated during the salivary glands ISO treatment and that the mitochondrial MnSOD has an important role in the oxidative stress process.

Preventing caries in preschoolers: successful initiation of an innovative community-based clinical trial in Navajo Nation Head Start.

UNLABELLED: Navajo Nation children have the greatest prevalence of early childhood caries in the United States. This protocol describes an innovative combination of community-based participatory research and clinical trial methods to rigorously test a lay native Community Oral Health Specialists-delivered oral health intervention, with the goal of reducing the progression of disease and improving family knowledge and behaviors. METHODS/DESIGN: This cluster-randomized trial designed by researchers at the Center for Native Oral Health Research at the University of Colorado in conjunction with members of the Navajo Nation community compares outcomes between the manualized 2-year oral health fluoride varnish-oral health promotion intervention and usual care in the community (child-caregiver dyads from 26 Head Start classrooms in each study arm; total of 1016 dyads). Outcome assessment includes annual dental screening and an annual caregiver survey of knowledge, attitudes and behaviors; collection of cost data will support cost-benefit analyses. DISCUSSION: The study protocol meets all standards required of randomized clinical trials. Aligned with principles of community-based participatory research, extended interaction between members of the Navajo community and researchers preceded study initiation, and collaboration between project staff and a wide variety of community members informed the study design and implementation. We believe that the benefits of adding CBPR methods to those of randomized clinical studies outweigh the barriers and constraints, especially in studies of health disparities and in challenging settings. When done well, this innovative mix of methods will increase the likelihood of valid results that communities can use.

Factors Associated with Oral Health Status in American Indian Children.

The literature reports psychosocial, environmental, and cultural factors related to Early Childhood Caries (ECC), but few studies have included American Indian/Alaska Native (AI/AN) populations. AI/AN children have the highest prevalence of ECC among any population group in the United States. This study examined socio-demographic characteristics of children and their parents/caregivers and psychosocial characteristics of parents/caregivers as risk factors for baseline oral health status of preschool children in the Navajo Nation, as part of a 3-year cluster randomized clinical trial to evaluate the effectiveness of trained community workers providing a fluoride varnish and oral health promotion intervention to. The study recruited 1,015 children at 52 Head Start Centers. Baseline ECC data were collected by calibrated dental hygienists for 981 of the children ages of 3-5 years, and a Basic Research Factors Questionnaire (BRFQ) was completed by their parents/caregivers. Bivariable analysis revealed that dmfs was higher in older children; in males; in children with male parents/caregivers; and when the parent/caregiver had less education and income, worse oral health behavior in caring for their children's teeth, and higher scores for external powerful others and external chance locus of control, greater perceived susceptibility and barriers, and lower scores for community risky behavior. In a multiple linear regression model, the variables that remained statistically significant were child's age and gender, and oral health behavior score of the parent/caregiver. Intervening to improve parent/caregiver oral health behavior in caring for the teeth of children potentially could in AI/AN children.

Learning from caries-free children in a high-caries American Indian population.

OBJECTIVE: We aimed to identify salutogenic patterns of parental knowledge, behaviors, attitudes, and beliefs that may support resistance to early childhood caries (ECC) among a high caries population of preschool American Indian (AI) children. METHOD: Participants were 981 child-parent dyads living on a Southwestern reservation who completed baseline assessments for an ongoing randomized clinical trial. T-tests were used to assess differences between reported knowledge, behaviors, and beliefs of parents whose children were caries-free (10.7 percent) and those whose children had caries (89.3 percent). Chi-square analyses were used for categorical variables. RESULTS: Although there were no socio-demographic differences, parents of caries-free children viewed oral health as more important and reported more oral health knowledge and adherence to caries-preventing behaviors for their children. Parents of caries-free children were more likely to have higher internal locus of control, to perceive their children as less susceptible to caries, and to perceive fewer barriers to prevention. These parents also had higher sense of coherence scores and reported lower levels of personal distress and community-related stress. CONCLUSIONS: Effective interventions for ECC prevention in high-caries AI populations may benefit from approaches that support and model naturally salutogenic behaviors.

Electrogenic NBCe1 (SLC4A4), but not electroneutral NBCn1 (SLC4A7), cotransporter undergoes cholinergic-stimulated endocytosis in salivary ParC5 cells.

Cholinergic agonists are major stimuli for fluid secretion in parotid acinar cells. Saliva bicarbonate is essential for maintaining oral health. Electrogenic and electroneutral Na(+)-HCO(3)(-) cotransporters (NBCe1 and NBCn1) are abundant in parotid glands. We previously reported that angiotensin regulates NBCe1 by endocytosis in Xenopus oocytes. Here, we studied cholinergic regulation of NBCe1 and NBCn1 membrane trafficking by confocal fluorescent microscopy and surface biotinylation in parotid epithelial cells. NBCe1 and NBCn1 colocalized with E-cadherin monoclonal antibody at the basolateral membrane (BLM) in polarized ParC5 cells. Inhibition of constitutive recycling with the carboxylic ionophore monensin or the calmodulin antagonist W-13 caused NBCe1 to accumulate in early endosomes with a parallel loss from the BLM, suggesting that NBCe1 is constitutively endocytosed. Carbachol and PMA likewise caused redistribution of NBCe1 from BLM to early endosomes. The PKC inhibitor, GF-109203X, blocked this redistribution, indicating a role for PKC. In contrast, BLM NBCn1 was not downregulated in parotid acinar cells treated with constitutive recycling inhibitors, cholinergic stimulators, or PMA. We likewise demonstrate striking differences in regulation of membrane trafficking of NBCe1 vs. NBCn1 in resting and stimulated cells. We speculate that endocytosis of NBCe1, which coincides with the transition to a steady-state phase of stimulated fluid secretion, could be a part of acinar cell adjustment to a continuous secretory response. Stable association of NBCn1 at the membrane may facilitate constitutive uptake of HCO(3)(-) across the BLM, thus supporting HCO(3)(-) luminal secretion and/or maintaining acid-base homeostasis in stimulated cells.