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.

Sexual behaviors and other risk factors for oral human papillomavirus infections in young women.

BACKGROUND: Oral human papillomavirus (HPV) is associated with a rising incidence of certain head and neck cancers, and oral sex has been associated with oral HPV. This study sought to identify more specific patterns of oral sexual activity, including self-inoculation, that are associated with oral HPV infections in young women. METHODS: A total of 1010 women attending a large university completed a computer-based questionnaire and provided oral specimens that were tested for any oral HPV using a Linear Array assay that detects any HPV as well as 37 HPV genotypes. Twenty-seven women provided additional samples up to 12 months after enrollment. Bivariable and multivariable analyses were conducted to identify oral sexual patterns and other risk factors associated with prevalent oral HPV. RESULTS: Nineteen women had prevalent oral HPV (1.9%), with 10 women (1%) having a type-specific infection. Oral HPV was significantly associated with lifetime coital sex partnership numbers (P = 0.03), lifetime and yearly oral sex partnership numbers (P < 0.01), and hand and/or sex toy transfer from genitals to mouth (P < 0.001). Oral HPV was also associated with greater use of alcohol, cigarettes, marijuana, and sharing of smoking devices, lipstick, or toothbrushes (P < 0.05 for each), with an apparent dose-response for alcohol use and smoking behavior, stratified by number of sexual partners. Of 7 women with prevalent HPV who provided follow-up samples, none had evidence of a persistent type-specific infection. CONCLUSIONS: These data provide additional evidence of transmission of oral HPV from oral sexual activity and also suggest possible transmission from self-inoculation or sharing of oral products.

Health literacy: a pathway to better oral health.

OBJECTIVES: We examined whether health literacy was associated with self-rated oral health status and whether the relationship was mediated by patient-dentist communication and dental care patterns. METHODS: We tested a path model with data collected from 2 waves of telephone surveys (baseline, 2009-2010; follow-up, 2011) of individuals residing in 36 rural census tracts in northern Florida (final sample size n = 1799). RESULTS: Higher levels of health literacy were associated with better self-rated oral health status (B = 0.091; P < .001). In addition, higher levels of health literacy were associated with better patient-dentist communication, which in turn corresponded with patterns of regular dental care and better self-rated oral health (B = 0.003; P = .01). CONCLUSIONS: Our study showed that, beyond the often-reported effects of gender, race, education, financial status, and access to dental care, it is also important to consider the influence of health literacy and quality of patient-dentist communication on oral health status. Improved patient-dentist communication is needed as an initial step in improving the population's oral health.

Psychosocial factors associated with mouth and throat cancer examinations in rural Florida.

OBJECTIVES: We examined the knowledge and prevalence of mouth and throat cancer examinations in a sample drawn from rural populations in north Florida. METHODS: Telephone interviews were conducted across rural census tracts throughout north Florida in 2009 and 2010, in a survey that had been adapted for cultural appropriateness using cognitive interviews. The sample consisted of 2526 respondents (1132 men and 1394 women; 1797 Whites and 729 African Americans). RESULTS: Awareness of mouth and throat cancer examination (46%) and lifetime receipt (46%) were higher than reported in statewide studies performed over the past 15 years. Only 19% of the respondents were aware of their examination, whereas an additional 27% reported having the examination when a description was provided, suggesting a lack of communication between many caregivers and rural patients. Surprisingly, anticipated racial/ethnic differences were diminished when adjustments were made for health literacy and several measures of socioeconomic status. CONCLUSIONS: These findings support the notion that health disparities are multifactorial and include characteristics such as low health literacy, lack of access to care, and poor communication between patient and provider.

Impact of the promotora model on the improvement of oral health knowledge of caregivers.

OBJECTIVE: The objective of this quasi-experimental study was to determine the impact of the Promotora Model (PM) as an educational strategy to increase oral health knowledge in parents/caregivers of children aged 2-5 years at high risk for dental caries. MATERIALS AND METHODS: Sixty-three caregivers who provided informed consent were included in the study. A structured 37-item survey was administered prior to conducting the Promotora educational intervention (PEI) that covered oral health topics and behaviors. Three (3) months after the PEI session, during their child's next dental visit, the same instrument was administered to 46 of the parents/caregivers that had completed the first instrument. RESULTS: Most caregivers were Hispanic (73.9%) and 50% reported completing high school. Before PEI, 56.5% of participants scored as having "good" general knowledge. Three months after PEI, 82.6% achieved that score (paired sample T-test, p< 0.00001). CONCLUSION: Based on the results, it was concluded that the PM significantly increased caregivers' oral health knowledge.

Classification Tree Analysis of Factors Associated with Oral Cancer Exam.

Objective: In this study, we performed a classification tree analysis (CTA) to identify population subgroups that are less likely to have an oral cancer examination (OCE). Methods: We conducted telephone surveys (N = 2401) of adults residing in north Florida to collect data on OCE status and potential OCE predictors including demographics, medical and dental experience, and psychosocial factors. The CTA algorithm exhaustive chi-square automatic interaction detector (E- CHAID) was employed to determine the relationships between OCE status and the predictors. Results: The overall OCE rate was 46.8% in our sample. Participants' rating of the dentist was the first level splitting variable, leading to 15 unique participant subgroups: (1) high dentist rating (N = 1269) led to 5 splits and 11 subgroups; (2) low dentist rating (N = 308) led to zero splits; and (3) no regular dentist (N = 824) led to 2 splits and 3 subgroups. Conclusions: The CTA has identified unique population subgroups that could be targeted in future tailored public health interventions. Among underserved populations, it is important to develop and implement community-based interventions that encourage regular dental visits and provide oral cancer self- examination education..

Oral cancer in African Americans: addressing health disparities.

OBJECTIVES: To explore factors underlying African Americans' perceptions of oral cancer and the oral cancer exam. Study findings were used to guide development of oral cancer messages designed to increase oral cancer exams among African Americans. METHODS: Focus groups were conducted to understand African Americans' attitudes and expectations regarding oral cancer and oral cancer exams. RESULTS: Respondents lacked knowledge of personal susceptibility to and the severity of a late-stage oral cancer diagnosis. Participants had limited knowledge of risk factors. DISCUSSION: Findings point to the need for improved patient education and communication between the public and dental providers.

Dental Visits Mediate the Impact of Smoking on Oral Health.

OBJECTIVES: We explored the mediational relationships among smoking, dental visits, and oral health in a longitudinal study. METHODS: We selected a sample of adult residents of rural communities of North Central Florida and followed them for 3 years (final N = 1170). We examined the impact of smoking on oral health across time and conducted mediation analysis to quantify the effect of dental visits on the relationship between smoking and poor oral health. RESULTS: Our results showed that oral health declined across time for smokers but not for nonsmokers. The mediation analysis found that 18.3% of the difference in followup oral health between smokers and non-smokers was explained by smokers not having any dental visits in the last year. CONCLUSIONS: Our findings suggest that, given the low success rate of quitting smoking, promoting dental visits can help limit the negative effects of smoking on oral health. Future community prevention studies could encourage dental visits among smokers and provide educational materials that aim to increase knowledge of oral self-care.

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.

Demographic and practice characteristics of Medicaid-participating dentists.

OBJECTIVES: The challenges entailed in dental Medicaid programs are well documented. To increase our understanding of Medicaid participation, we surveyed Florida dentists to determine the demographic and practice characteristics of Medicaid-participating dentists. METHODS: Our target population was practicing Florida dentists who treat children, including those who do not currently accept Medicaid as well as those who do. The final sample (n = 882) included (1) pediatric dentists and (2) general dentists who self-reported that they treat children. Participants completed a survey concerning their Medicaid participation. Analyses included survey-sample weighted chi-square tests and multivariable logistic regression. RESULTS: More than two-thirds of the sample dentists are not participating in Medicaid and will not consider doing so. Key findings are that Black dentists across the state and Hispanics in South Florida are more likely to participate in Medicaid than other groups of Florida dentists. Pediatric dentists are more likely to be Medicaid participants than general dentists, but nearly one-fifth of the pediatric dentists might quit participation. Non-Medicaid providers are more likely to report not being busy enough in their practice than Medicaid providers. CONCLUSIONS: If we are to address the shortage of Medicaid dental providers, increasing our understanding of how to capture the excess capacity among general dentists (the reported lack of busyness) in a way acceptable to dentists and to the State of Florida is an important first step. In addition, dental schools should consider implementing a track dedicated to training students for practice success within communities of highest dental need and to seek to increase the number of Black dental students.

Perceptions of oral health, preventive care, and care-seeking behaviors among rural adolescents.

BACKGROUND: An asymmetrical oral disease burden is endured by certain population subgroups, particularly children and adolescents. Reducing oral health disparities requires understanding multiple oral health perspectives, including those of adolescents. This qualitative study explores oral health perceptions and dental care behaviors among rural adolescents. METHODS: Semistructured individual interviews with 100 rural, minority, low socioeconomic status adolescents revealed their current perceptions of oral health and dental care access. Respondents age ranged from 12 to 18 years. The sample was 80% black and 52% male. RESULTS: Perceived threat from dental disease was low. Adolescents perceived regular brushing and flossing as superseding the need for preventive care. Esthetic reasons were most often cited as reasons to seek dental care. Difficulties accessing dental care include finances, transportation, fear, issues with Medicaid coverage and parental responsibility. In general, adolescents and their parents are in need of information regarding the importance of preventive dental care. CONCLUSIONS: Findings illuminate barriers to dental care faced by low-income rural adolescents and counter public perceptions of government-sponsored dental care programs as being "free" or without cost. The importance of improved oral health knowledge, better access to care, and school-based dental care is discussed.

Impact of the promotora model on the improvement of oral health knowledge of caregivers / Impacto del modelo promotora en el mejoramiento del conocimiento sobre salud oral de los cuidadores

ABSTRACT Objective The objective of this quasi-experimental study was to determine the impact of the Promotora Model (PM) as an educational strategy to increase oral health knowledge in parents/caregivers of children aged 2-5 years at high risk for dental caries. Materials and Methods Sixty-three caregivers who provided informed consent were included in the study. A structured 37-item survey was administered prior to conducting the Promotora educational intervention (PEI) that covered oral health topics and behaviors. Three (3) months after the PEI session, during their child's next dental visit, the same instrument was administered to 46 of the parents/caregivers that had completed the first instrument. Results Most caregivers were Hispanic (73.9%) and 50% reported completing high school. Before PEI, 56.5% of participants scored as having "good" general knowledge. Three months after PEI, 82.6% achieved that score (paired sample T-test, p< 0.00001). Conclusion Based on the results, it was concluded that the PM significantly increased caregivers' oral health knowledge.(AU)

RESUMEN Objetivo El propósito de este estudio cuasi-experimental fue determinar el impacto del Modelo Promotora (MP) como estrategia educacional para mejorar el conocimiento sobre salud oral de los padres y/o cuidadores de niños con edades comprendidas entre 2-5 años con alto riesgo de sufrir caries dental. Métodos Sesenta y tres padres y/o cuidadores quienes dieron el consentimiento fueron incluidos en el estudio. Se administró un cuestionario estructurado de 37 preguntas antes de la intervención educativa (IE) con el Modelo Promotora (IEP) el cual cubría tópicos sobre salud oral y conductas. Tres (3) meses después de la sesión de IEP, en la próxima visita dental del niño, el mismo cuestionario fue administrado a 46 padres y/o cuidadores que habían completado el primer cuestionario. Resultados La mayoría de los padres y/o cuidadores eran Hispanos (73,9%) y 50% reporto tener bachillerato completo. Antes del IEP, 56,5% de los participantes presentó un nivel general de conocimiento "Bueno." Tres meses después de la aplicación del IEP, 82,6% obtuvieron el mismo nivel de conocimiento (T-test, p<0.00001). Conclusión Se concluye que el MP mejora considerablemente el conocimiento sobre salud bucal de los padres y/o cuidadores.(AU)

The decision to counsel adolescents about HPV.

OBJECTIVES: To examine factors influencing dentists' intentions to counsel adolescents. METHODS: Florida dentists (N = 929) responded to 3 descriptions of an office visit by an adolescent patient. In the standard-of-care condition the patient consumed excessive sugar. In the other 2 conditions, a reliable source or patient's mother revealed the patient was sexually active and exposed to HPV. RESULTS: Dentists expressed lower intentions to counsel about HPV than sugar consumption. In the 2 HPV conditions, dentists reported higher intentions to counsel when the mother, rather than another reliable source, disclosed the sexual activity. Perceived social pressure against counseling explained differences between conditions in intention to counsel. CONCLUSIONS: Parent /public approval were primary barriers to HPV-counseling.

Disparities in knowledge of mouth or throat cancer among rural Floridians.

OBJECTIVE: The aim of this study was to examine risk factors for reduced mouth or throat cancer (MTC) knowledge using a sample of rural North Floridian adults. METHODS: Telephone interviews were conducted across rural census tracts throughout North Florida in 2009-2010, using a survey adapted for cultural appropriateness. The sample consisted of 2,393 individuals (1,059 males and 1,334 females; 1,681 whites and 712 blacks). FINDINGS: Only 9% of the study respondents indicated they had not heard of MTC; however, only 12% endorsed knowing "a lot." Higher education levels and health literacy indicated they had more MTC knowledge. Among female participants, whites had more knowledge than blacks (OR = 1.9). Among black participants, males had more knowledge than females (OR = 1.7). Conversely, greater concern with MTC was associated with lower education levels, health literacy, and financial status, but higher depression scores. Awareness that excessive sun exposure is a risk factor for MTC was lower than for earlier studies using more urban samples. CONCLUSIONS: This study adds to the literature on MTC knowledge and concern because this sample was drawn exclusively from rural populations in North Florida, a group with the highest MTC morbidity and mortality. An unanticipated finding was that blacks were more concerned than their white rural counterparts. This study was also the first to report that depression was associated with increased concern about MTC. The goal is to persuade at-risk groups to obtain MTC screenings with the goal of reducing disparities in MTC whenever they occur.

Developing an oropharyngeal cancer (OPC) knowledge and behaviors survey.

OBJECTIVES: To use the community participation research model to (1) develop a survey assessing knowledge about mouth and throat cancer and (2) field test and establish test-retest reliability with newly developed instrument. METHODS: Cognitive interviews with primarily rural African American adults to assess their perception and interpretation of survey items. Test-retest reliability was established with a racially diverse rural population. RESULTS: Test-retest reliabilities ranged from .79 to .40 for screening awareness and .74 to .19 for knowledge. Coefficients increased for composite scores. CONCLUSION: Community participation methodology provided a culturally appropriate survey instrument that demonstrated acceptable levels of reliability.