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

OBJECTIVES: Examine the relationship between supply of care provided by dental therapists and emergency dental consultations in Alaska Native communities. METHODS: Explanatory sequential mixed-methods study using Alaska Medicaid and electronic health record (EHR) data from the Yukon-Kuskokwim Health Corporation (YKHC), and interview data from six Alaska Native communities. From the Medicaid data, we estimated community-level dental therapy treatment days and from the EHR data we identified emergency dental consultations. We calculated Spearman partial correlation coefficients and ran confounder-adjusted models for children and adults. Interview data collected from YKHC providers (N=16) and community members (N=125) were content analysed. The quantitative and qualitative data were integrated through connecting. Results were visualized with a joint display. RESULTS: There were significant negative correlations between dental therapy treatment days and emergency dental consultations for children (partial rank correlation = -0.48; p⟨0.001) and for adults (partial rank correlation = -0.18; p=0.03). Six pediatric themes emerged: child-focused health priorities; school-based dental programs; oral health education and preventive behaviors; dental care availability; healthier teeth; and satisfaction with care. There were four adult themes: satisfaction with care; adults as a lower priority; difficulties getting appointments; and limited scope of practice of dental therapy. CONCLUSIONS: Alaska Native children, and to a lesser extent adults, in communities served more intensively by dental therapists have benefitted. There are high levels of unmet dental need as evidenced by high emergency dental consultation rates. Future research should identify ways to address unmet dental needs, especially for adults.

Implementation partnerships in a community-based intergenerational oral health study.

BACKGROUND: University-community partnerships are a common strategy used in implementing community-based health promotion trials, yet few published studies report these interactions in detail. "Baby Smiles" was a five-year intervention study in Oregon, USA. The study involved 400 low-income women during and after pregnancy across four rural counties. In this report, we describe and assess four university-community health partnerships formed to support the intervention. METHODS: A community health partnership advisory group for the study was established in each of the four participating counties. Group membership ranged from 9 to 23 individuals. A survey was administered to the groups five times in a 2.5 year period. The survey asked members' opinions of the intervention's goals, scientific basis and relevance to their organisation. Questions also asked about members' knowledge of oral health, beliefs about access to dental care for low-income pregnant women and children in their county and how their organisation functioned. RESULTS: There was strong overall support by each partnership group despite differences in the groups' structure, foci and turnover in membership during intervention period. Responses to specific survey items indicating misinformation or negative opinions about oral health care were used to address weaknesses in study implementation throughout the conduct of the study. CONCLUSION: Systematic monitoring of community support for a multi-year oral health intervention is feasible and can identify potential barriers to address while the study is underway.

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

INTRODUCTION: Dental caries is the most common chronic childhood disease. Products of metabolism by bacteria populating the tooth surface induce development and progression of cavities. OBJECTIVES: We sought to determine whether a polyvinylpyrrolidone-iodine (PVP-I; povidone-iodine) and NaF topical varnish was superior to one containing only NaF in prevention of new dental caries lesions in a single-center randomized active-controlled trial based on a double-blind, parallel-group design. METHODS: The site was Pohnpei State, Federated States of Micronesia. The study population was healthy children 49 to 84 mo old who were enrolled in early childhood education: 284 were randomized (1:1 allocation), and 273 were included in year 1 analysis and 262 in year 2. The test varnish contained 10% PVP-I and 5.0% NaF. The comparator contained only 5.0% NaF but was otherwise identical. Varnishes were applied every 3 mo during 2 y. The primary outcome was the surface-level primary molar caries lesion increment (d2-4mfs) at 2 y. Caries lesion increments from baseline to year 1 and year 2 were compared between conditions with log-linear regression, adjusting for age and sex and whether the tooth was sound at baseline (free of caries lesions). RESULTS: At year 1, the caries lesion increment for primary molars sound at baseline was 0.9 surfaces (SD = 1.5) for the test varnish versus 1.8 (SD = 2.2) for the comparator varnish with fluoride alone (adjusted rate ratio, 0.50; 95% CI, 0.31 to 0.81; P = .005). At year 2, the caries lesion increment for primary molars sound at baseline was 2.3 surfaces (SD = 2.8) for the test varnish as compared with 3.3 (SD = 2.7) for the comparator (adjusted rate ratio, 0.74; 95% CI, 0.52 to 1.03; P = .073). Teeth that were already cavitated at baseline did not show a preventive effect. There were no harms. CONCLUSIONS: A dental varnish containing PVP-I and NaF is effective in the primary prevention of cavities in the primary dentition (NCT03082196). KNOWLEDGE TRANSFER STATEMENT: This study demonstrates that periodic application of a varnish containing NaF and PVP-I is effective in prevention of caries lesions and useful in assessing the potential of combined treatment.

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

INTRODUCTION: Tribal health care systems are striving to implement internal changes to improve dental care access and delivery and reduce health inequities for American Indian and Alaska Native children. Within similar systems, organizational readiness to implement change has been associated with adoption of system-level changes and affected by organizational factors, including culture, resources, and structure. OBJECTIVES: The objectives of this study were to assess organizational readiness to implement changes related to delivery of evidence-based dental care within a tribal health care organization and determine workforce- and perceived work environment-related factors associated with readiness. METHODS: A 92-item questionnaire was completed online by 78 employees, including dental providers, dental assistants, and support staff (88% response rate). The questionnaire queried readiness for implementation (Organizational Readiness for Implementing Change), organizational context and resources, workforce issues, organizational functioning, and demographics. RESULTS: Average scores for the change commitment and change efficacy domains (readiness for implementation) were 3.93 (SD = .75) and 3.85 (SD = .80), respectively, where the maximum best score was 5. Perceived quality of management, a facet of organizational functioning, was the only significant predictor of readiness to implement change (B = .727, SE = .181, P < .0002) when all other variables were accounted for. CONCLUSION: Results suggest that when staff members (including dentists, dental therapists, hygienists, assistants, and support staff) from a tribal health care organization perceive management to be high quality, they are more supportive of organizational changes that promote evidence-based practices. Readiness-for-change scores indicate an organization capable of institutional adoption of new policies and procedures. In this case, use of more effective management strategies may be one of the changes most critical for enhancing institutional behaviors to improve population health and reduce health inequities. KNOWLEDGE TRANSFER STATEMENT: The results of this study can be used by clinicians and other leaders implementing changes within dental care organizations. To promote organizational readiness for change and, ultimately, more expedient and efficient adoption of system-level changes by stakeholders, consideration should be given to organizational functioning generally and quality of management practices specifically.

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

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

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

OBJECTIVE: The aims of the present study were to survey the Child Behavior Checklist (CBCL) scores (behavioral section) in a nonclinical population of US urban children from low-income families and to compare the distribution and pattern of scores with the normative data in the CBCL manual (1991). METHOD: The sample consisted of 890 low-income children and a mother or female guardian selected randomly from among Seattle public school students aged 5 to 11 years. RESULTS: In this sample the total CBCL score as well as all subscale scores were significantly higher than the norms. The proportion of children who scored in the clinical/borderline range was also higher than the norm. CONCLUSIONS: These findings support previous work showing that poverty is a risk factor for mental distress in children. They also raise questions about the validity of the CBCL norms for screening or research purpose for low-income families.

Statistical issues in periodontal research.

In the past 10 to 12 years, there have been several statistical issues identified in periodontal research which require and have generated non-standard or new statistical approaches. The purpose of this paper is to give an overview of these issues and approaches. Three general categories of issues are described: (i) statistical methods for detecting when disease progression occurs, and biological theories and corresponding statistical models which attempt to describe how the disease progresses; (ii) design issues in studies of therapeutic efficacy; and (iii) analytic issues arising from periodontal data analysis.

Efficiency issues among statistical methods for demonstrating efficacy of caries prevention.

Although repeated tooth-surface-specific information is commonly collected during a longitudinal caries clinical trial, traditional methods often make limited use of the repeated measures. Newer methods of analysis, such as methods based on time-to-event and methods for longitudinal or clustered data, have the potential to increase the efficiency of the statistical analysis. We compare a range of analytical methods from the traditional analysis based only on the number of caries onsets to newer methods that incorporate time at risk and surface-specific information, such as Poisson regression methods for clustered data, with respect to the efficiency of treatment comparisons. Under most circumstances, the greatest gain in efficiency associated with time-to-event methods will be due to the ability of subjects to contribute caries onsets to the analysis until they are lost from the study. Incorporating the number of surfaces at risk, the surface time at risk, and surface-specific characteristics will typically produce only a modest gain in efficiency.

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

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

Between-subject and within-subject statistical information in dental research.

The evaluation of risk factors in dental research frequently uses observations at multiple sites in the same patient. For this reason, statistical methods that accommodate correlated data are generally used to assess the significance of the risk factors (e.g., generalized estimating equations, generalized linear mixed models). In applications of these methods, it is typically assumed (implicitly, if not explicitly) that between-subject and within-subject comparisons will produce the same estimated effect of the risk factor. When between- and within-subject comparisons conflict, the statistical methods can give biased estimates or results that are difficult to interpret. For illustration, we present two examples from periodontal disease studies in which different statistical methods give different estimates and significance levels for a risk factor. Statistical analyses in dental research should assess whether different sources of information give similar conclusions about risk factors or treatments.

Overbite and overjet are not related to self-report of temporomandibular disorder symptoms.

Overbite and overjet, especially high or low values, have been found in some studies to be associated with temporomandibular disorders (TMD). This study evaluates the relationship between overbite/overjet and three TMD self-report measures (pain, joint noises, limited mouth-opening). Subjects were from two population-based cross-sectional studies (3033 subjects). After adjustment for age and gender, high or low values of overbite were not associated with an increased risk of self-reported TMD pain as compared with a reference category of a normal overbite of 2 to 3 mm (-8 to -1 mm, odds ratio = 0.36, 95% confidence interval = 0.05-2.76; 6 to 15 mm, odds ratio = 1.08, 95% confidence interval = 0.68-1.72). Similar non-significant results were found for overjet and TMD pain, and for the association of overjet/overbite and joint noises or limited mouth-opening. This study provides the strongest evidence to date that there is no association between overbite or overjet and self-reported TMD.

The relationship between auditory brainstem response latencies and behavioral thresholds in normal hearing infants and adults.

The relationship between behavioral thresholds and auditory brainstem response (ABR) latencies for 4 and 8 kHz tone pips were examined in normal-hearing 3-month-olds, 6-month-olds and adults. The latencies of waves I and V and the I-V interval of the ABR were analyzed. A linear latency-intensity function was also fit to each subject's latencies for each wave at several levels. The y-intercept of the latency-intensity function was used as a summary measure of latency to examine behavior-ABR correlations. The pattern of age-related change in behavioral threshold was not closely matched by age-related latency reduction for Wave I, Wave V or the I-V interval. However, 3-month-olds with higher behavioral thresholds had longer Wave V latencies and longer I-V intervals than 3-month-olds with lower behavioral thresholds. There was no significant difference in latency between 6-month-olds or adults with higher thresholds and 6-month-olds or adults with lower thresholds. There was also a significant correlation between the Wave V-Wave I latency-intensity intercept difference and behavioral threshold at both 4 and 8 kHz among 3-month-olds. The correlation was not significant among 6-month-olds or adults. These findings suggest that one of the factors responsible for immature behavioral thresholds at 3 months is related to transmission through the auditory brainstem. Because variability in hearing threshold among normal-hearing adults is low, it is not surprising that behavioral threshold is unrelated to ABR latency in this group. However, the lack of such a relationship among 6-month-olds implies that structures central to the auditory brainstem, either sensory or nonsensory, or both, must be responsible for immature behavioral thresholds after 6 months of age.

The relationship between auditory brainstem response and behavioral thresholds in normal hearing infants and adults.

The nature of age-related improvements in auditory sensitivity was explored by comparing behavioral and auditory brainstem response (ABR) thresholds in 3- and 6-month-old infants and in adults. Thresholds were estimated for tone pips at 1, 4, and 8 kHz, presented at a rate of 13.3/s. The time course of development of the two response measures was compared, and the correlation between thresholds for individual subjects was examined. Infant ABR threshold was adultlike at all frequencies, even among 3-month-olds. Infant behavioral thresholds were elevated relative to adult thresholds. Between 3 and 6 months, significant improvement occurred in the 8-kHz behavioral threshold, but no improvement occurred at other frequencies. This difference between ABR and behavioral measures in developmental time course suggests that peripheral sensitivity is not a major determinant of behavioral threshold elevation during infancy. The correlation between behavioral and ABR thresholds was significant at 4 kHz for 3-month-olds and at 8 kHz for adults. This suggests that variability in sensory function at these frequencies contributes to both behavioral and ABR thresholds, although other factors are likely to be involved as well.

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

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

Origins of childhood dental fear.

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

Exploration of prediction models for caries risk assessment of the geriatric population.

The purpose of this study was to demonstrate a method for establishing a model designed to predict the caries risk of elderly individuals. Twenty-three patients over the age of 65 and living in a semi-independent retirement center were examined; several variables were collected and analyzed for their ability to predict the development of new carious lesions. The analysis was performed using logistic regression where the proportion of new decay was used as the dependent variable. The model for prediction of combined coronal and root caries included the variables flow rate, gender, and root caries index. The proposed method has the advantages of easily collected data, individualized criteria, and the ability to order patients as to the relative risk of developing decay.

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

OBJECTIVES: Studies examining satisfaction with dental health care among the poor are quite rare. This study was done to confirm the internal structure and reliability of the Dental Satisfaction Questionnaire (DSQ), a measure of dental care satisfaction, among a low-income population, and provide normative data regarding dental satisfaction among low-income people. METHODS: Subjects were 895 mothers of school-aged children who were administered the DSQ as part of a larger study of dental utilization and dental fears in Seattle. RESULTS: Factor analysis largely confirmed the factor structure of the DSQ. Results also suggested subjects in this sample were less satisfied with pain management than nonpoor people. Self-reported dental health and dental appearance were associated with satisfaction with pain management, quality of care, access to care, and overall satisfaction. Race/ethnicity, education level, marital status, nation of origin, and type of insurance predicted differences in satisfaction with pain management and access. CONCLUSIONS: Barriers to dental care and quality of care among low-income populations are discussed. Uses and research with the DSQ are suggested.

Human auditory brainstem response to temporal gaps in noise.

Gap detection is a commonly used measure of temporal resolution, although the mechanisms underlying gap detection are not well understood. To the extent that gap detection depends on processes within, or peripheral to, the auditory brainstem, one would predict that a measure of gap threshold based on the auditory brainstem response (ABR) would be similar to the psychophysical gap detection threshold. Three experiments were performed to examine the relationship between ABR gap threshold and gap detection. Thresholds for gaps in a broadband noise were measured in young adults with normal hearing, using both psychophysical techniques and electrophysiological techniques that use the ABR. The mean gap thresholds obtained with the two methods were very similar, although ABR gap thresholds tended to be lower than psychophysical gap thresholds. There was a modest correlation between psychophysical and ABR gap thresholds across participants. ABR and psychophysical thresholds for noise masked by temporally continuous, high-pass, or spectrally notched noise were measured in adults with normal hearing. Restricting the frequency range with masking led to poorer gap thresholds on both measures. High-pass maskers affected the ABR and psychophysical gap thresholds similarly. Notched-noise-masked ABR and psychophysical gap thresholds were very similar except that low-frequency, notched-noise-masked ABR gap threshold was much poorer at low levels. The ABR gap threshold was more sensitive to changes in signal-to-masker ratio than was the psychophysical gap detection threshold. ABR and psychophysical thresholds for gaps in broadband noise were measured in listeners with sensorineural hearing loss and in infants. On average, both ABR gap thresholds and psychophysical gap detection thresholds of listeners with hearing loss were worse than those of listeners with normal hearing, although individual differences were observed. Psychophysical gap detection thresholds of 3- and 6-month-old infants were an order of magnitude worse than those of adults with normal hearing, as previously reported; however, ABR gap thresholds of 3-month-old infants were no different from those of adults with normal hearing. These results suggest that ABR gap thresholds and psychophysical gap detection depend on at least some of the same mechanisms within the auditory system.

Effectiveness of local anesthesia in pediatric dental practice.

BACKGROUND: Pain control in dental treatment for children is very important. The purpose of this study is to describe the characteristics of local anesthetic use by pediatric dentists and to examine factors related to its effectiveness in children. METHODS: The authors observed 361 patients in 17 pediatric dental practices in Washington state while each child received restorative or surgical dental treatment. The authors recorded data concerning local anesthetic use and effectiveness. The children's mean age was 87 months, and 181 (50.1 percent) of the patients were girls. A pediatric dentist observer rated each child's anxiety before the initial injection of local anesthetic and the effectiveness of pain control during restorative treatment. The observing dentist asked the treating dentist about the effectiveness of pain control after completion of treatment. RESULTS: Forty-two of 361 children (11.6 percent) were observed to experience ineffective pain control. Fourteen of 17 dentists (82.4 percent) were observed to have at least one patient in whom pain control was ineffective. Lidocaine (2 percent with 1:100,000 epinephrine) was used by 15 of 17 dentists (88.2 percent) and in 312 of 361 cases (86.4 percent). The average amount of agent was one cartridge (36 milligrams of lidocaine). Children who were anxious, who had symptoms before treatment, and who underwent more invasive operative and endodontic procedures were more likely to experience ineffective pain control. CONCLUSIONS: The data suggest that painful treatment is relatively frequent even in specialized pediatric practice. Variability in general practice is likely to be greater. CLINICAL IMPLICATIONS: The incidence of ineffective pain control may be less if clinicians use methods to reduce anxiety and perioperative infection and symptoms.

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

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