Addressing Oral Health Disparities Via Educational Foci on Cultural Competence.

An ever-present challenge for the oral health profession is to reduce the extent of oral disease among racial and ethnic minority populations. Adding to this complex dilemma is the linkage between oral health and systemic health. We describe enhanced cultural competency, in the context of individual cultural beliefs, values, language, practice, and health behaviors, among dental professionals, as one approach to meeting the dental care needs of the underserved. An overview and examples of teaching methods used by University of Florida dental educators to enhance student cultural competency is provided. Evidence-based evaluation results provide evidence of methodology efficacy. We conclude by describing actions that can be implemented by academic dental institutions to facilitate development of culturally competent practitioners.

Effect of training pediatricians and family physicians in early childhood caries prevention.

OBJECTIVES: To analyze the effect of postresidency early childhood caries prevention training on physicians' oral health knowledge, confidence, and practice patterns and to identify variations by type of training. STUDY DESIGN: We conducted pre- and post-training surveys of pediatricians and family physicians in Florida. Paired t test and repeated-measures ANOVA analyses were used to compare physicians with no oral health training, those with applied in-office training, and those with another type of training on 5 composite measures: fluoride knowledge, nonfluoride oral health knowledge, confidence in advising parents, confidence in conducting oral health screening and caries risk assessment, and frequency in performing recommended oral health practices. RESULTS: The final sample included 229 physicians (162 pediatricians and 67 family physicians). The interaction in the repeated-measures ANOVA between group (training category) and time (pre- and post-training) was significant for the nonfluoride knowledge [F(2, 225) = 4.1, P = .02] and confidence in screening [F(2, 224) = 4.1, P = .02] composite measures, lending support for a positive treatment effect of training on these domains. Greater gains were observed among physicians with in-office training compared with those who received another type of training. A statistically significant treatment effect on oral health practices was not detected. CONCLUSIONS: Efforts to engage physicians in oral health training and to incorporate applied components in training curricula may improve physicians' oral health knowledge and increase their confidence in conducting oral health screenings and caries risk assessments. Additional research is needed to evaluate the relative costs and benefits of different training modalities on specific oral health practices.

An assessment of faculty and dental student decision-making in ethics.

This study reports and compares dental student and dental faculty scores to national norms for the Defining Issues Test 2, a measure of ethical decision-making competency. The findings showed that dental students and faculty tend to make decisions that promote self-interest, paralleling the ethical orientation of business professionals. Differences associated with gender, language, and norms from previous studies were observed. The findings underscore the importance of raising dental faculty and student awareness of their own ethical decision-making approaches. More importantly, the findings highlight the need to ensure that dental faculty have both the knowledge and skills to train dental students about the central role that ethical decision-making must play in patient care.

Preventive oral health care in early childhood: knowledge, confidence, and practices of pediatricians and family physicians in Florida.

OBJECTIVE: To examine the relationships among pediatricians' and family physicians' oral health training, knowledge, confidence, and practice patterns. STUDY DESIGN: A survey of physicians identified through the membership databases of the Florida Academy of Family Physicians and the Florida Pediatric Society was conducted in 2008. Responses of pediatricians and family physicians were compared through bivariate and multivariate analyses. RESULTS: Although training was not directly associated with performing recommended practices, there were positive associations between training and confidence and between confidence and performing recommended practices (P <.05). Pediatricians were more likely than family physicians to answer fluoride-related knowledge questions correctly and reported greater confidence (P <.05). Less than 20% of the respondents reported counseling parents about bringing their child to the dentist before age 1 year or inquiring about the parents' dental health. CONCLUSIONS: Oral health training appears to promote confidence in performing recommended oral health practices. Differences in fluoride knowledge by provider type suggest that fluoride guidance has been disseminated more effectively among pediatricians than among family physicians. Educational content of oral health training programs should place increased emphasis on current fluoride guidance, early dental visits, and assessing parents' oral health. Instructional methods should address physicians' confidence, particularly among family physicians.

Outcomes from the Health Resources and Services Administration's Dental Faculty Development Program.

PURPOSE/OBJECTIVES: While the Commission on Dental Accreditation (CODA) requires programs to conduct faculty development, implementation of faculty development activities vary widely. Faculty development programs can enhance teaching, research, and leadership skills needed to transition from clinical practice to teaching. In 2012, the Health Resources and Services Administration (HRSA) funded 6 institutions to plan, develop, and operate programs for training oral healthcare providers who plan to teach in general, pediatric, public health dentistry, or dental hygiene. This performance study examines the results of the dental faculty development programs. METHODS: After the 5-year grant program (2012-2017), we used descriptive analysis to examine annual performance data including trainee demographics, faculty development activities, post-completion intentions, and course development activities. RESULTS: Nearly 300 trainees participated across 6 funded grantees; the majority were female, aged 30-49 years, and non-Hispanic White. For those who completed, 80% intended to teach. Common faculty development activities included community-based training, curriculum enhancements, Web-based training, and interprofessional education methods. Faculty development modalities included faculty seminars, Master's degrees, and mentoring. Pipeline activities, online resources, and continuing education supported dental students and providers moving into academics. CONCLUSIONS: Faculty development better prepares individuals to compete in academic environments and develop faculty. Community-based programs may utilize faculty development to recruit community preceptors and achieve calibration. HRSA investment in faculty development programs builds resources and infrastructure to promote continuing engagement in clinical education, research, and administrative skills. Future research is needed to establish the impact of faculty development initiatives on practice change and patient outcomes.

Assessing dentists' human papillomavirus-related health literacy for oropharyngeal cancer prevention.

BACKGROUND: Oropharyngeal cancers related to human papillomavirus (HPV) are on the rise. Dentists may be the next group of providers participating in the prevention of HPV. The aim of this study was to assess dentists' health literacy regarding the connection of HPV and oropharyngeal cancer. METHODS: The authors conducted 4 focus groups with dentists (N = 33) during a regional dental conference in 2016. Guided by the health literacy competencies (that is, access, understand, appraise, and apply), the authors used constant comparison methods for data analysis. RESULTS: Dentists mentioned a variety of informational sources (for example, dental journals and colleagues). Knowledge about the link between HPV and oropharyngeal cancer varied among participants. Participants appraised multiple patient and practice factors when deciding to have the discussion with patients. Some dentists discussed the HPV and oropharyngeal cancer connection with patients, and most conducted secondary screenings. CONCLUSIONS: Findings indicate areas for intervention, including creating awareness of trusted informational sources, as well as increasing HPV knowledge and understanding the multiple patient (for example, age) and practice (for example, open operatories) appraisal factors. Moreover, enhancing the communication skills of dentists with patients is needed to improve HPV-related cancer prevention education. PRACTICAL IMPLICATIONS: Addressing dentists' HPV-related health literacy has the potential to improve dentists' HPV-related prevention practices, including expanding patient education about this topic and increasing HPV vaccination knowledge, ultimately contributing to the reduction of oropharyngeal cancers.

Expected Changes in Regulation and Licensure: Influence on Future Education of Dentists.

This article is based on the following assumptions about dental care in the United States: there is an access to oral health care problem; the number of individuals with dental insurance is increasing; the demographics of the dental profession does not mirror the overall demographics of the U.S. population; and emerging oral health workforce models may help improve access to care. Based on these assumptions, this article explores related licensure and regulatory factors that will influence the education and practice of dentists in the future. The issues discussed are licensure of emerging oral health practitioners, mobility of the dental health care workforce, corporate ownership of dental practices, ethical issues related to use of human subjects in dental licensure examinations, interprofessional education and practice, and health care reform. The licensure and regulatory bodies discussed are the Commission on Dental Accreditation (CODA), state legislatures and boards of dentistry, federal legislative activities, judicial activities, and the Federal Trade Commission. Recommendations based on this discussion are presented. This article was written as part of the project "Advancing Dental Education in the 21st Century."

Measuring quality: caries-related emergency department visits and follow-up among children.

OBJECTIVE: This study validated two Dental Quality Alliance system-level measures of oral healthcare quality for children - caries-related emergency department (ED) visits and timely follow-up of those visits with a dentist - including formal validation of diagnosis codes used to identify caries-related ED visits and measurement of follow-up care. METHODS: The measures were specified for implementation with administrative claims data and validated using data from the Florida and Texas Medicaid and Children's Health Insurance Programs. Measure specification testing and measure score validation used administrative data for 7,007,765 children. We validated the diagnosis codes in claims data by comparisons with manual reviews of 300 records from a Florida hospital ED and calculation of the kappa statistic, sensitivity, and specificity. RESULTS: Overall agreement in caries-related ED visit classifications between the claims data and record reviews was 87.7 percent with kappa = 0.71, sensitivity = 82 percent, and specificity = 90 percent. The calculated measure scores using administrative data found more than four-fold variation between programs with the lowest and highest caries-related ED visit rates (6.90/100,000 member months and 30.68/100,000 member months). The percentage of follow-up visits within 7 days and 30 days ranged from 22-39 percent and 34-49 percent, respectively. CONCLUSIONS: These National Quality Forum endorsed measures provide valid methodologies for assessing the rate of caries-related ED visits, an important system-level outcome indicator of outpatient prevention and disease management, and the timeliness of follow-up with a dentist. There is significant variation in caries-related ED visits among state Medicaid programs, and most ED visits do not have follow-up with a dentist within 30 days.

Health Literacy Approaches to Improving Communication between Dental Hygienists and Patients for HPV-Related Oral Cancer Prevention.

Purpose: Human Papillomavirus (HPV) has been identified as a causal agent for oropharyngeal cancers, suggesting a new role for dental hygienists in HPV-related cancer prevention strategies. Health literacy assessment is an approach that can be used to understand providers' informational assets and needs for educating and discussing HPV prevention with patients. This study aimed to understand dental hygienists' level of health literacy regarding HPV-related oropharyngeal cancers.Methods: Four focus group sessions with dental hygienists (n=48) were conducted at a national conference. The constant comparison method, with a priori codes for health literacy competencies (i.e., access/understand/appraise/apply), was utilized for this qualitative study.Results: Participants mentioned a variety of modes (e.g., magazines, journals) for accessing HPV-information; however, descriptions of understanding HPV and its relationship to oropharyngeal cancer varied. Participants considered patients' personal characteristics, the dental practice environment, and professional factors to appraise HPV-related information. Additionally, participants self-described themselves as being "prevention specialists." These factors influenced how dental hygienists applied primary and secondary prevention of HPV-related care issues with their patients (e.g., education and oral-cancer screenings).Conclusions: Dental hygienists recognized the importance of HPV and oropharyngeal cancer prevention efforts, including oral-cancer screenings and promotion of the HPV vaccine. The study findings identified opportunities for intervention focusing on primary prevention.

A welcome to the workshop on "professional promises: Hopes and gaps in access to oral health care".

Starting with the belief held by some of the workshop participants that access to basic oral health care is a natural human right and that the oral health care system in the United States must serve the common good, we conducted a meeting of ethicists, practicing dentists, dental hygienists, dental educators, and others to discuss ethical issues related to access to care. As one of the meeting organizers, the author discusses in these introductory remarks his background and personal perspectives on why the dental profession has a moral obligation to better address the access issue.

Trends in dental-related use of hospital emergency departments in Florida.

OBJECTIVES: The inability to access regular dental care may lead to care seeking at hospital emergency departments (EDs). However, EDs generally are not equipped or staffed to provide definitive dental services. This study examined trends and patterns of hospital ED use for dental-related reasons in Florida, a large, diverse state with serious barriers to accessing dental care. METHODS: Data for this study were drawn from ambulatory ED discharge records compiled by Florida's Agency for Health Care Administration for 2005-2014. Visits for dental-related reasons in Florida were defined by the patient's reported reason for seeking care or the ED physician's primary diagnosis using ICD-9-CM codes. We calculated frequencies, age-specific and age-adjusted rates per 100,000 population, and secular trends in dental-related ED visits and their associated charges. RESULTS: The number of dental-related visits to Florida EDs increased each year, from 104,642 in 2005 to 163,900 in 2014; the age-adjusted rate increased by 43.6 percent. Total charges for dental-related ED visits in Florida increased more than threefold during this time period, from $47.7 million in 2005 to $193.4 million in 2014 (adjusted for inflation). The primary payers for dental-related ED visits in 2014 were Medicaid (38 percent), self-pay (38 percent), commercial insurance (11 percent), Medicare (8 percent), and other (5 percent). CONCLUSIONS: Dental-related visits to hospital EDs in Florida have increased substantially during the past decade, as have their associated charges. Most patients did not receive definitive oral health care in EDs, and this trend represents an increasingly inefficient use of health care system resources.

Assessing Cultural Competence among Florida's Allied Dental Faculty.

PURPOSE: The Commission on Dental Accreditation requires that dental, dental hygiene and dental assisting schools offer educational experiences to ensure that prospective dental health care providers become culturally competent, socially responsible practitioners. To assert that these mandates are met requires that the faculty are knowledgeable and capable of providing this type of training. Currently, little is known about the cultural competence of the state of Florida allied dental faculty. The purpose of this study was to assess the cultural competence among the dental hygiene and dental assistant faculty in the state of Florida. METHODS: One hundred ninety-three faculty were invited to take the Knowledge, Efficacy and Practices Instrument (KEPI), a validated measure of cultural competence. Respondents included 77 (74%) full-time and 27 (26%) part-time faculty. Data were analyzed descriptively and reliabilities (Cronbach's alpha) were computed. RESULTS: Mean scores and internal estimates of reliability on the KEPI subscales were: knowledge of diversity 3.3 (ɑ=0.88), culture-centered practice 3.6 (ɑ=0.88) and efficacy of assessment 2.9 (ɑ=0.74). The participant's score of 3.6 on the culture-centered practice exceeds scores among dental students and faculty who participated in previous studies suggesting the allied dental faculty have a greater awareness of sociocultural and linguistically diverse dental patients' oral health needs. Participants' score on knowledge of diversity subscales suggests a need for moderate training, while their score on the efficacy of assessment subscale indicates a need for more intense training. CONCLUSION: Assessing faculty beliefs, knowledge and skills about cultural competency is critically important in ensuring that accreditation standards are being met and represents one step in the process of ensuring that faculty demonstrate the type of sensitivity and responsiveness, which characterizes behaviors associated with cultural competence.

Assessing Faculty Development Needs among Florida's Allied Dental Faculty.

PURPOSE: Professional schools rarely prepare prospective academic faculty for the responsibilities of college and university teaching. Without this training, faculty are often left to discover on their own and to varying degrees of success what is expected of them once they enter the academy. At the same time, universities and colleges recognize that retention of faculty depends on the successful transition of academics into the related roles and responsibilities of the professoriate. The purpose of this study was to assess the faculty development needs among allied dental faculty, specifically the state of Florida's dental hygiene and dental assisting faculty, by measuring the following: the relationship between their knowledge and priorities for further training, their level of satisfaction with current faculty development opportunities and mentoring, and their perceptions of what additional training and resources might advance their careers. METHODS: Two hundred and four full-time and part-time faculty were invited to participate in this survey research study. McNemar's test for paired binary data was used to analyze the level of agreement between knowledge and indicated priority. Responses to open ended questions were coded and categorized thematically. RESULTS: There were 115 responses (n=204, 74%). There were statistically significant differences between participants' ratings of knowledge and priorities for further training on many items related to teaching, scholarship and leadership skills. Participants also identified 5 categories of unmet needs. CONCLUSION: The findings suggest that universities and colleges need to offer learning experiences aimed at strengthening the teaching, scholarship and leadership skill needs of their allied dental faculty. Additionally, professional schools might consider offering a program track that provides prospective allied dental faculty with the types of opportunities that develops teaching, scholarship and mentoring skills prior to graduation.

The Impact of an Infant Oral Health Program on Dental Students' Knowledge and Attitudes.

The high prevalence of early childhood caries and many general dentists' reluctance to treat young children and pregnant women demand new educational programs to foster delivery of oral health services. The aim of this study was to evaluate the impact of an Infant Oral Health Program (IOHP) at the University of Florida College of Dentistry on dental students' knowledge about and willingness to provide dental care for infants, children up to three years of age, and pregnant women. A total of 233 dental students in the first through fourth years and recent graduates completed a survey that assessed the educational outcomes of the IOHP; only the fourth-year students had received IOHP training. The results showed that females were more likely than males to provide counseling to caregivers about dental and physical development (p=0.024) and to offer restorative treatment to young children (p=0.021). Older students were more likely than younger students to provide restorative treatment (p=0.013). A greater percentage of IOHP-trained students (96%) reported knowing how to use the lap examination technique compared with untrained students (71%; p<0.001). IOHP-trained students were the most uncomfortable dealing with a crying child in the dental chair (p=0.0175). The graduates and fourth-year students were significantly more likely than the other cohorts to provide preventive (p=0.001) and restorative (p<0.001) care for pregnant women. The graduates were least likely to use some form of caries risk assessment (p<0.001). These findings highlight the need for earlier and greater exposure to the IOHP and the importance of promoting awareness about risk assessment and oral disease management.

Anticipated and Actual Implementation of Case-Based Learning by Dental Faculty Members During and After Training.

The aims of this study were to describe the processes used to train dental faculty members in case-based learning (CBL) and to determine their beliefs about the anticipated implementation of CBL and perceptions of actual implementation following use of the CBL approach. Participants were dental faculty members at the University of Florida who received a four-day intensive training course in the use of CBL. Two focus groups were conducted. The first occurred during training to assess how the participants anticipated using CBL. The second was conducted during the faculty members' implementation of CBL. All 19 trainees participated in focus group 1 (100%). During the course of the study, two faculty members left the school; of the remaining 17, 12 participated in focus group 2 (participation rate of 71%). The findings showed that initially the faculty members were hesitant and uncertain about using CBL. Following implementation, those issues dissipated, as the participants began to consider how to optimize the effectiveness of CBL as a legitimate method for fostering student ownership of learning and active participation. Understanding what CBL means for individual educators at varying stages of change will likely allow the dental education community to better anticipate and address tensions and challenges that faculty members are likely to experience.

The effect of Medicaid primary care provider reimbursement on access to early childhood caries preventive services.

OBJECTIVE: To examine receipt of early childhood caries preventive services (ECCPS) in two states' Medicaid programs before and after the implementation of reimbursement to medical primary care providers (M-PCPs). DATA SOURCES: Enrollment and claims data from the Florida and Texas Medicaid programs for children ≤54 months of age during the period 2006-2010. STUDY DESIGN: We conducted time trend-adjusted, difference-in-differences analyses by using modified Poisson regressions combined with generalized estimating equations (GEEs) to analyze the effect of M-PCP reimbursement on the likelihood that an enrollee had an ECCPS visit after controlling for age, sex, health status, race/ethnicity, geographic location, and enrollment duration. DATA EXTRACTION METHODS: Enrollment data were linked to claims data to create a panel dataset with child-month observations. PRINCIPAL FINDINGS: Reimbursement to M-PCPs was associated with an increased likelihood of ECCPS receipt in general and topical fluoride application specifically in both states. CONCLUSIONS: Reimbursement to M-PCPs can increase access to ECCPS. However, ECCPS receipt continues to fall short of recommended care, presenting opportunities for performance improvement.

Developing Dental Students' Awareness of Health Care Disparities and Desire to Serve Vulnerable Populations Through Service-Learning.

Service-learning in dental education helps students integrate knowledge with practice in an underserved community setting. The aim of this study was to explore how a service-learning experience affected a small group of dental students' beliefs about cultural competence, professionalism, career development, desire to practice in a community service setting, and perceptions about access and disparities issues. Prior to beginning their first year of dental school, five first-year dental students at one U.S. dental school participated in a six-week service-learning program in which they interned at one of three at-risk settings in order to experience health care delivery there. After the program, 60 reflective writing assignments completed by the participants were analyzed using grounded theory methods; interviews with the students were used to corroborate the findings from that analysis. Seven themes identified in the journal reflections and interview findings showed enhanced awareness of social health care issues and patient differences, as well as a social justice orientation and desire to address disparities. Building on this study, future research should explore the curricular components of service-learning programs to ensure students receive ample opportunity to reflect upon their experiences in order to integrate previously held assumptions with their newfound knowledge.

Developing and testing pediatric oral healthcare quality measures.

OBJECTIVE: This study describes processes used to develop and test pediatric oral healthcare quality measures and provides recommendations for implementation. METHODS: At the request of the Centers for Medicare and Medicaid Services, the Dental Quality Alliance (DQA) was formed in 2008 as a multi-stakeholder group to develop oral healthcare quality measures. For its initial focus on pediatric care, measure development processes included a literature review and environmental scan to identify relevant measure concepts, which were rated on importance, feasibility, and validity using the RAND/UCLA modified Delphi approach. These measure concepts and a gap assessment led to the development of a proposed set of measures that were tested for feasibility, reliability, and validity. RESULTS: Of 112 measure concepts identified, 59 met inclusion criteria to undergo formal rating. Twenty-one of 59 measure concepts were rated as "high scoring." Subsequently, 11 quality and related care delivery measures comprising a proposed pediatric starter set were developed and tested; 10 measures met feasibility, reliability, and validity criteria and were approved by the DQA stakeholder membership. These measures are currently being incorporated into Medicaid, Children's Health Insurance Program, and commercial quality improvement programs. CONCLUSIONS: Broad stakeholder engagement, rigorous measure development and testing processes, and regular opportunities for public input contributed to the development and validation of the first set of fully specified and tested pediatric oral healthcare quality measures, which have high feasibility for implementation in both public and private sectors. This achievement marks an important essential step toward improving oral healthcare and oral health outcomes for children.

Measuring quality of dental care: Caries prevention services for children.

BACKGROUND: The authors conducted a study to validate the following 3 evidence-based, process-of-care quality measures focused on dental caries prevention for children with an elevated risk of experiencing caries: sealants for 6- to 9-year-olds, sealants for 10- to 14-year-olds, and topical fluoride. METHODS: Using evidence-based guidelines, the Dental Quality Alliance developed measures for implementation with administrative data at the plan and program levels. To validate the measures, the authors used data from the Florida and Texas Medicaid programs and Children's Health Insurance Programs and from national commercial dental benefit plans. Data were extracted from 414 randomly selected dental office records to validate the use of administrative data to accurately calculate the measures. The authors also assessed statistically significant variations in overall measure performance. RESULTS: Agreement between administrative data and dental records was 95% for sealants (κ = 0.82) and 90% for topical fluoride (κ = 0.78). Sensitivity and specificity were 90.7% and 88.5% for topical fluoride and 77.8% and 98.8% for sealants, respectively. Variation in overall measure performance was greatest for topical fluoride (χ(2) = 5,887.1; P < .01); 18% to 37% of children with an elevated risk of experiencing caries received at least 2 topical fluoride applications during the reporting year. Although there was greater variation in performance for sealants for 6- to 9-year-olds (range, 21.0-31.3%; χ(2) = 548.6; P < .01) compared with sealants for 10- to 14-year-olds (range, 8.4-11.1%; χ(2) = 22.7; P < .01), overall sealant placement rates were lower for 10- to 14-year-olds. CONCLUSIONS: These evidence-based, caries prevention process-of-care quality measures can be implemented feasibly and validly using administrative claims data. PRACTICAL IMPLICATIONS: The measures can be used to assess, monitor, and improve the proportion of children with an elevated risk of experiencing dental caries who receive evidence-based caries prevention services.

Improving the oral health status of all Americans: roles and responsibilities of academic dental institutions: the report of the ADEA President's Commission.

Academic dental institutions are the fundamental underpinning of the nation's oral health. Education, research, and patient care are the cornerstones of academic dentistry that form the foundation upon which the dental profession rises to provide care to the public. The oral health status of Americans has improved dramatically over the past twenty-five to thirty years. In his 2000 report on oral health, the Surgeon General acknowledges the success of the dental profession in improving the oral health status of Americans over the past twenty-five years, but he also juxtaposes this success to profound and consequential disparities in the oral health of Americans. In 2002, the American Dental Education Association brought together an ADEA President's Commission of national experts to explore the roles and responsibilities of academic dental institutions in improving the oral health status of all Americans. They have issued this report and made a variety of policy recommendations, including a Statement of Position, to the 2003 ADEA House of Delegates. The commission's work will help guide ADEA in such areas as: identifying barriers to oral health care, providing guiding principles for academic dental institutions, anticipating workforce needs, and improving access through a diverse workforce and the types of oral health providers, including full utilization of allied dental professionals and collaborations with colleagues from medicine.