Experience, prevalence, need for treatment and cost of care for caries: A multicenter study in a developing country.

OBJECTIVE: To assess the experience, prevalence, need for treatment and economic impact of caries among students 6-12 years old in four cities in Mexico. BASIC RESEARCH DESIGN: Cross-sectional clinical study. SETTING: Elementary public schools. PARTICIPANTS: 500 schoolchildren aged 6 to 12 years. METHOD: Oral clinical examinations using WHO criteria for caries in the primary (dmft) and permanent (DMFT) dentitions. MAIN OUTCOME MEASURES: Indicators of caries in the primary and permanent dentitions: experience, prevalence, severity and the Significant Caries Index. In addition, we calculated the treatment needs, dental care rate and cost of care. RESULTS: dmft in the primary dentition was 2.59±2.83, and DMFT was 0.82±1.44 in the permanent dentition. Caries prevalence reached 67.7% in the primary and 34.1% in permanent dentition. The treatment needs index was 85.9% and 91.3% in the primary and permanent dentitions, respectively; the dental care index was 13.9% and 8.5%, respectively. The cost of care for caries in the primary dentition was estimated at $22.087 millions of international dollars (PPP US$) when amalgam was the restorative material used, and PPP US$19.107 millions for glass ionomer. For the permanent dentition, the cost was PPP US$7.431 millions when amalgam was used and PPP US$7.985 millions when resin/composite was used as restorative material. CONCLUSIONS: The prevalence and experience of caries in the primary dentition were 50% greater than those of other studies carried out in Mexico. In the permanent dentition they were less. There is considerable need for the treatment of caries and minimal experience with restorative care. The cost of care for caries may be assumed to be high for a health system such as Mexico's.

Psychological and behavioral acculturation in a social network of Mexican Americans in the United States and use of dental services.

OBJECTIVES: We used data from the TalaSurvey study to examine associations between dental health experiences, social network characteristics, and levels of behavioral and psychological acculturation in one location in the American Midwest. METHODS: Starting in parishes and community organizations, we identified adults of Mexican origin living in Indianapolis, who were 1st- or 2nd-generation immigrants from Tala, Mexico. Using a social networks methodology and following extensive formative research, we created an egocentric social network survey and administered it via face-to-face interviews. We identified the peers (alters) in interviewees' (egos) personal networks. We asked egos about multiple oral health and dental care variables for self and for alters. Acculturation (psychological and behavioral) was measured with a validated tool. Through logistic and negative binomial regression, we examined the effects of acculturation and network composition on ego's dental insurance status, dental office visits, and the reason for most recent dental office visit. RESULTS: A total of 332 egos (mean age 36; 63% female) were interviewed: 90% were born in Mexico; 45% had completed elementary school or lower; and most had low income. Each ego named 3.9 (SD±1.9) alters in his/her personal network, for a total of 1299 alters (mean age 39; 61% female). Both behavioral acculturation and psychological acculturation were moderately associated with dental insurance coverage, and greater behavioral acculturation predicted more frequent dental care. More psychologically acculturated egos were more likely to seek preventive care. Further, egos with more highly educated networks sought care more frequently and for preventive purposes, net of ego's own education and acculturation. CONCLUSIONS: This study contextualizes acculturation of Mexican Americans within the personal networks in which oral health discussion takes place. The findings underscore the critical importance of acculturation and social network factors in shaping a subgroup of Latinos' orientation toward dental care.

Identification of barriers and beliefs influencing engagement by adult and teen Mexican-Americans in oral health behaviors.

OBJECTIVE: To identify barriers and beliefs influencing oral health and dental care-seeking among Mexican-Americans. RESEARCH DESIGN: Interviews and Likert-scale survey questions were utilized to explore urgent and preventive dental care-seeking, oral hygiene habits and lifestyle practices. Thirty-three interviews were conducted with 16 adults (ages 33-52), and 17 adolescents (ages 14-19). RESULTS: Teens identified the same main barriers to accessing dental care as adults: high cost, financial limitations and lack of insurance. Most Mexican-Americans agreed with the belief that everyone will need urgent dental treatment and the majority believed that going to a dentist in private practice instead of the Emergency Room was important. Although adults recognized the importance of preventive dental care, half reported being unlikely to seek such care while half of teens reported that they were likely to do so. Adults reported relying equally on themselves and on peers to make dental care decisions, while teens mostly depended on others to make decisions about urgent and preventive care. Virtually all respondents believed regular brushing to be important and many flossing too. A major barrier to flossing was being unsure of the proper technique. Another barrier to better oral health was not having seen messages encouraging changes in lifestyle. CONCLUSIONS: This study found that Mexican-American teens and adults may experience oral health similarly. Teens do not have more positive oral health beliefs and encounter mostly the same barriers to care as adults.

Dental problems and Familismo: social network discussion of oral health issues among adults of Mexican origin living in the Midwest United States.

OBJECTIVE: To examine the influence of collectivist orientation (often called familismo when applied to the Latino sub-group in the United States) in oral health discussion networks. BASIC RESEARCH DESIGN: Through respondent-driven sampling and face-to-face interviews, we identified respondents' (egos) personal social network members (alters). Egos stated whom they talked with about oral health, and how often they discussed dental problems in the preceding 12 months. PARTICIPANTS: An urban community of adult Mexican-American immigrants in the Midwest United States. We interviewed 332 egos (90% born in Mexico); egos named an average of 3.9 alters in their networks, 1,299 in total. METHOD: We applied egocentric network methods to examine the ego, alter, and network variables that characterize health discussion networks. RESULTS: Kin were most often leveraged when dental problems arose; egos relied on individuals whom they perceive to have better knowledge about dental matters. However, reliance on knowledgeable alters decreased among egos with greater behavioral acculturation. CONCLUSIONS: This paper developed a network-based conceptualization of familismo. We describe the structure of oral health networks, including kin, fictive kin, peers, and health professionals, and examine how networks and acculturation help shape oral health among these Mexican-Americans.

Maternal characteristics and treatment needs as predictors of dental health services utilisation among Mexican school children.

AIM: To determine whether maternal characteristics and treatment needs are associated with dental health services utilization (DHSU) in school children. MATERIALS AND METHODS: A cross-sectional study in 1373 school children aged 6- 12 years in elementary schools in Campeche, Mexico collected family and sociodemographic characteristics; an oral examination was conducted. The dependent variable was DHSU in the year preceding the study. RESULTS: DHSU prevalence was 65.5%. The variables associated (p<0.05) with DHSU in the final multivariate model were age (OR=1.27), maternal schooling (OR=1.07), mother's attitude toward oral health (OR=1.39), frequency of tooth brushing (OR=1.83), enamel defects (OR=1.55), and unmet oral health needs (moderate: OR=1.42 and high: OR=2.30). CONCLUSION: Specific sociodemographic and maternal variables were associated with DHSU. Strategies are needed to increase appropriate and timely use of services to improve health status.

Letter from America: UK and US state-funded dental provision.

OBJECTIVES: Current UK and US economic conditions have re-focussed attention on the need to deliver dental care with limited finance and resources. This raises hard questions determining which services will be offered and what they should achieve to satisfy public demands and needs. We consider impending dental health reforms in the US and UK within the context of contemporary experiences to identify issues and delivery goals for the two nations. BACKGROUND: The paper provides a brief history and background of the development of social dental care models in the UK and US, highlighting some differences in state-funded delivery of dental care. SHIFTING DEMAND: From the 1950s, demand for dental treatment has increased and acquired a more complex composition growing from predominantly surgical and restorative treatment to encompass preventive care and cosmetic services. PRIORITISING CARE ACCORDING TO NEED: Despite improvements in general health and technology, inequalities in access and utilisation of dental care are still experienced, primarily by groups with low socio-economic status. DELIVERY: BALANCING RESOURCES, DEMAND AND NEED: In developing and delivering reform agendas, much can be learned from previous policy interventions. Pressures of cost, coverage, and capacity, besides demand versus need must be carefully considered and balanced to deliver quality service and value for users and taxpayers. CONCLUSIONS: Ethical and moral consideration should be given to making services needs-driven to address high treatment requirements rather than the high care demands of the worried well. This challenge brings the additional political pressure of convincing many of the voters (and subsequent complainers) that their demands may be less important than the needs of others.

Edentulism risk indicators among Mexican elders 60-year-old and older.

The objective of this study was to determine the prevalence of edentulism in Mexican elders aged 60 years and older, and the associated risk indicators. A cross-sectional study was undertaken in 139 elders living in either of two long-term care (LTC) facilities, or attending an adult day center (ADC) in Pachuca, Mexico. A subject was edentulous when natural teeth were completely absent, determined through a clinical examination. Risk indicators were collected using questionnaires. Analyses were performed using binary logistic regression in STATA 9.0. Mean age was 79.0±9.8 years. Many subjects were women (69.1%). The prevalence of edentulism was 36.7%. In multivariate analysis, after adjusting for age and sex, the variables that were inversely associated (p<0.05) with edentulism were living with a spouse (odds ratio=OR=0.31), and lacking health insurance (OR=0.70). Variables associated with higher risk of being edentate were lower educational attainment (OR=1.61), having received radiation therapy (OR=4.49), being a smoker (OR=4.82), and having diabetes (OR=2.94) or other chronic illnesses (OR=1.82) (with hypertension approaching significance, p=0.067). In this sample of Mexican elders, diverse variables were associated with edentulism, in particular smoking and past radiotherapy. Oral health programs within and outside LTC/ADC should take into account risk factors specific to the older population.

Is there a sound basis for deciding how many dentists should be trained to meet the dental needs of the Canadian population? Systematic review of literature (1968-1999).

A systematic review was conducted of the literature on human resources planning (HRP) in dentistry in Canada, critically assessing the scientific strength of 1968-1999 publications. Inclusion and exclusion criteria were applied to 176 peer-reviewed publications and "grey literature" reports. Thirty papers were subsequently assessed for strength of design and relevance of evidence to objectively address HRP. Twelve papers were position statements or experts' reports not amenable for inclusion in the system. Of the remaining 18 papers, 4 were classified as projections from manpower-to-population ratios, 4 as dental practitioner opinion surveys, 8 as estimates of requisite demand to absorb current capacity and 2 as need-based, demand-weighted studies. Within the 30.5 years reviewed, 53.4% of papers were published between 1982 and 1987. Overall, many papers called for a reduction in human resources, a message that dominated HRP during the 1980s, or noted an increase in the demand for services. HRP publications often had questionable strength or analytic frameworks. The paradigm of busyness-scarcity evolved from a belief around an economic model for the profession into a fundamental tenet of HRP. A formal analysis to establish its existence beyond arbitrary dentist:population ratios has usually been lacking.

Cumulative assessment of factors leading to restorative decisions in an educational environment. A graphical demonstration using an in vitro case.

Even though accuracy and inter-examiner variation assessments of borderline restorative items have been previously reported, no attempt has been made to replicate the effect of cumulative, sequential diagnostic and treatment planning decisions. This study assesses the cumulative effect of factors indicating restorative needs by evaluating how readily tooth restoration was proposed on the basis of restoration quality and presence of caries (compared to gold standards). Ninety-one senior dental students in Mexico City (79% female; mean age 22.8 years) assembled in 19 teams of five students each. They sequentially evaluated 56 restored and unrestored posterior teeth in an in vitro model. Each student examined the set, removed those teeth needing restorative intervention and returned the remaining set for examination by a second student. When the second assessment was completed, the remaining teeth were turned over to the third teammate and so on. Teeth were subsequently assessed for restoration quality and enamel and dentinal caries. When a tooth showed a carious lesion, a dentinal lesion or a defective restoration, the likelihood of it being selected for restorative treatment increased. When more than one feature was present, the chances of the tooth being selected more frequently and earlier increased, accordingly. The specificity of restorative treatment needs was not excellent. A strong graphical association between the presence of caries and/or defects in restorations with proposed restorative treatment was demonstrated using a non-quantitative research model. The more abundant these features were, the higher the probability appeared for a tooth to fit the clinical picture suitable for restorative intervention.

In vitro quantitative microhardness assessment of enamel with early salivary pellicles after exposure to an eroding cola drink.

To assess the erosive effect of a cola drink on enamel incorporating early salivary pellicles, 72 groups of human enamel slabs were immersed in fresh cola, with groups differing in that slabs were (1) incubated in whole or in clarified saliva, (2) under three regimes of frequency intake (1, 5 and 10 times/day); (3) immersed with or without agitation, and (4) the pellicle was incubated for 20 min, 6 or 24 h. Quantitative assessments were done over an 8-day interval using surface microhardness testing. Results for primary enamel showed a sharp decrease from baseline (344.2+/-32.4 Vickers Units; mean +/-SD) to day 1 (268.9+/-36.8), and reached 155.2+/-68.6 on day 8. Results for permanent enamel were 350.8+/-42.2, 315.9+/-39.2, and 149.8+/-85.2. Microhardness was affected by agitation, level of intake and type of saliva, but not by the pellicle incubation interval nor the type of enamel. The joint effect of static baths and higher immersion frequency was the most important factor in decreasing hardness.

Caries experience and treatment needs in a 6- to 12-year-old urban population in relation to socio-economic status.

OBJECTIVE: To report caries experience in the permanent dentition among Mexico City elementary school children and undertakes a comparative analysis of dental caries experience and treatment needs of children of different socio-economic status (SES). RESEARCH DESIGN: SES was established according to an official measure of economic well-being, that of the family income being high enough to allow the child to attend school in a private institution as opposed to a public school. PARTICIPANTS: A probabilistic sample of 4,048 6- to 12-year-old children (47.2% females) was examined using the 1987 WHO caries criteria (546 attended private schools and 3,502 were public school children). RESULTS: The proportion of caries-free 12-year-old children was 28.6% and 9.5% in the private and public schools, respectively (P < 0.01). In 12-year-old children, DMFT was 2.78 (SD 2.9) and 4.64 (SD 3.2) in the private and public school groups, respectively (P < 0.001). Higher treatment needs were found among public schoolchildren (TN = 83.0%) compared with private schoolchildren (TN = 27.6%) (P < 0.001). CONCLUSIONS: Dental caries and treatment needs were considerably higher in children of lower SES. Differences in dietary patterns and toothpaste use could be the more likely explanations for these findings, indicating markedly unequal burdens of disease according to socio-economic status. Special efforts should be developed to improve the oral health status in Mexico City children by implementing preventive health promotion and treatment programmes.

Prosthodontic profiles relating to economic status, social network, and social support in an elderly population living independently in Canada.

STATEMENT OF PROBLEM: Previous evaluations of life satisfaction and health have not completely explained the impact of social network, social support, and economics on the oral health-related behavior of elderly patients, particularly in relation to missing teeth. PURPOSE: This study measured the strength of associations between social network/support/class and the use of complete and removable partial dentures in elderly patients living independently. MATERIAL AND METHODS: A multiple stepwise logistic regression was used to contrast data from previous studies relating to the subject and to explore the influence of these social variables. RESULTS: The results substantiated the links observed in a previous study between some social features and oral fitness. More frequent use of complete dentures was identified among participants who reported higher incomes and among those who thought their incomes were sufficient for their needs. Unreplaced missing anterior teeth were associated more commonly with subjects less willing or able to leave their homes. CONCLUSIONS: Some salient features of prosthodontic care and oral health status were common to 2, comparable social environments. A minority within the elderly population may not see a need to make use of clinical dental services, regardless of how accessible these services are to them. Social network and social support issues may be important determinants in this perceived need to use clinical services.

Knowledge and opinions about dental human health resources planning in Mexico.

Dental human health resource planning (DHHRP), or manpower planning in Mexico has been plagued by fundamental contradictions. In spite of having trained a great many dentists in the past two decades, the dental health status of the population has not significantly improved. Concurrently, the relative scarcity of patients in relation to the number of practising dentists seems to be more marked, a critical issue since most dental care is delivered under private schemes. In the present investigation, 196 practising dentists in Mexico City were interviewed to establish their knowledge and opinions about DHHRP, and their views about the introduction of innovative alternatives in transforming, evaluating and planning human health resources. Concerns were: a need to examine and re-define the aims, skill content and marketability of professional training in professional practice; a lack of consensus as to how this is to be achieved; and a degree of awareness that professional practice has a limited scope in meeting the challenge of providing adequate care because of maldistribution of dentists and of limited financial resources of patients.

An introspective qualitative report on dietary patterns and elevated levels of dental decay in a deprived urban population in northern Mexico.

Disorganized urbanization in Latin America has led to masses of impoverished people to become squatters in the larger urban areas. Using a community development network in the outskirts of Tijuana, in Northern Mexico, this investigation assessed the dental health situation, aiming to establish the underlying behavioral causes of poor oral health in these slums. Using quantitative and qualitative tools, fifty-six mothers (mean age 30.1 +/- 7.2) with their accompanying children (n = 56; mean age 6.1 +/- 3.3; 46.4 percent female) were interviewed and examined. Dental health was poor and characterized by vast unmet treatment needs in adults and children. 22.2 percent of children under three years of age suffered from Early Childhood Caries, strongly linked to inappropriate patterns of bottle use. Dietary patterns for the overall child population included many cariogenic snacks and beverages. A straightforward model to explain behavioral structures incorporates these findings against the background of living in a highly-deprived environment, whereby the allure of more affordable gratifications for self and family is often translated in the form of tokens such as junk food.

A comparison of senior dental students and normative standards with regard to caries assessment and treatment decisions to restore occlusal surfaces of permanent teeth.

STATEMENT OF PROBLEM: Even though assessments of borderline restorative items in terms of accuracy and interexaminer variation have been reported, no attempt has been made to simultaneously evaluate diagnostic and treatment planning decision using objective normative standards. PURPOSE: This study established the accuracy of caries presence assessment as compared with gold standards, interexaminer agreement in assessment of caries presence and restorative needs, and influences of perceived caries status and restoration quality on treatment planning in borderline restorative situations. MATERIALS AND METHODS: Fifteen senior dental students in Mexico City (66% women; mean age 23.2 years) evaluated predetermined areas in 109 restored and unrestored posterior teeth in an in vitro model. Teeth were subsequently assessed for restoration quality and the presence of enamel and dentinal caries by use of histologic and specific dye techniques. Student's t test, Cohen's kappa, and Pearson's correlation analyses were used to analyze the data. RESULTS: There were significant caries misdiagnoses and substantial overtreatment proposed. In a few instances, teeth were left untreated, but usually they were programmed for restoration. Interexaminer agreement varied markedly and was not high. However, performance while correctly detecting lesions was better than in treatment planning. CONCLUSION: There was a high correlation between a diagnosis of caries and restorative treatment in unrestored teeth; the correlation was lower for restored teeth, although they were allocated to restorative treatment more often. This difference hinged on perceived quality of the restoration, an important factor in the frequency of proposed re-restoration.

In vitro quantitative assessment of enamel microhardness after exposure to eroding immersion in a cola drink.

Studies assessing the erosive potential of soft drinks have employed long time intervals of immersion that may not accurately depict the impact of frequent soft drink consumption on enamel. This in vitro study assessed the effect of a cola drink on enamel, replicating an actual drinking pattern. Six groups of 4 human enamel slabs were immersed (5 min each bath) in fresh cola drink, with immersions taking place with or without agitation, and under 3 regimes of frequency intake (low intake, 1 immersion/day; medium, 5/day; high, 10/day). Quantitative assessments of surface erosion were done over an 8-day interval using surface microhardness testing (Vickers). Results showed a sharp decrease from baseline (mean value 352.1 Vickers Hardness Number, SD 32.5) to day 1 (269.3, SD 41.0) and then continued decreasing throughout the assay, although less markedly, to reach 204.5, SD 45.4 on day 8. Microhardness decreased regardless of frequency regime, except on day 8, on which slabs from the low intake group were harder (233.2, SD 25.0) than slabs from the high intake group (169.8, SD 49.5; p < 0.05). Results from the ANOVA on the factorial experiment indicated that the role of agitation was statistically significant (d.f. = 1, F = 7.2, p = 0.020) while the level of intake was of borderline significance (d.f. = 2, F = 3.2, p = 0.075). The main effect resulting from the joint roles of agitation and intake indicated that there was an important interaction between the two variables (d.f. = 3, F = 4.5, p = 0.023).

In vivo diagnostic assessment of dentinal caries utilizing acid red and povidone-iodine dyes.

In order to compare the clinical utilization of diagnostic dyes to identify carious dentin, the present in vivo study compared two caries-detector dyes, acid red (1% acid red in propylene glycol wt/wt) and povidone-iodine (8% povidone-iodine in water wt/vol). A total of 221 cavities prepared by 19 senior dental students under the supervision of two teachers at the Universidad Nacional Autónoma de México Dental School were used. Dyes were applied double-blind under standardized conditions to at least two teeth of the same patient. Data were analyzed using the Mantel-Haenszel chi-square test and a test of proportions. Results showed that molars or premolars did not appear to be positively stained more frequently by one dye or another. Also, 36.7% of teeth tested positive to either one of the two dyes. Prudent utilization of either acid red or povidone-iodine appeared to be equally useful in assisting clinical decisions concerning cavity size while restoring dentinal lesions. However, povidone-iodine may be preferred in clinical settings where acid red is expensive and/or difficult to obtain. Further research is necessary to establish accurately the mechanism of staining by povidone-iodine.