Access to Dental Services for Children with Special Health Care Needs: A Pilot Study at the Dental Department of BC Children's Hospital.

OBJECTIVES: This pilot study at the dentistry department of BC Children's Hospital (DD-BCCH) in Vancouver, British Columbia, Canada, aimed to explore issues of access to dental services for children with special health care needs (CSHCN). METHODS: Caregivers of CSHCN, who were patients of record at DD-BCCH, were recruited to participate in this study. We collected sociodemographic characteristics, insurance coverage and medical diagnosis, and information on caregivers' perceptions of enabling factors and barriers to dental services using a pretested survey instrument with 33 closed and open-ended questions. We also obtained referral source, insurance coverage and medical diagnosis from the child's dental record. We analyzed quantitative data descriptively and qualitative comments from caregivers thematically. RESULTS: Common medical diagnoses among this sample of CSHCN (n = 50) were: genetic disorder/syndrome, developmental delay, sensory impairments and autism. Half of the children were referred by a medical professional; most (90%) had had a dental appointment within the last year that included preventive treatment. Although most caregivers reported some available dental benefits, affordability of dental services was a concern. Lack of dentist's training or comfort treating CSHCN, because of the complexity of the child's medical condition or behavioural challenges was also a reported barrier. CONCLUSIONS: The complexity of the child's medical status, the limited ability of dentists to provide care and financial obstacles were commonly reported barriers to care. Current efforts may best be focused on encouraging the province's health professionals, including dentists, to facilitate early referral to tertiary-level care for CSHCN whom they consider medically or behaviourally complex beyond their skill or comfort level.

WHAT ARE CANADIAN DENTAL PROFESSIONAL STUDENTS TAUGHT ABOUT INFANT, TODDLER AND PRENATAL ORAL HEALTH.

INTRODUCTION: Establishing dental homes for children at an early age is an important step toward instilling good oral health practices and changing trajectories of oral health. The purpose of this study was to determine how accredited dental and dental hygiene programs in Canada prepare students in the areas of infant, toddler and prenatal oral health. METHODS: An electronic questionnaire was sent to associate deans (academic), program directors or curriculum directors of accredited dental (n = 10) and dental hygiene (n = 39) programs. Participants were asked about infant, toddler and prenatal oral health curricula taught at their institution. Descriptive statistics and bivariate analyses were used to assess the results. A p value = 0.05 was considered significant. RESULTS: Representatives of 10 dental (100%) and 25 dental hygiene (64.1%) programs responded. All dental and 56% of dental hygiene programs recommend a first visit by 12 months. Infant and toddler oral health was noted as a component of most schools' curriculum. Barriers to teaching about or providing clinical experiences in infant and toddler oral health include lack of time, patients, program resources and finances. Most dental (70%) and dental hygiene (82.6%) programs include prenatal oral health as a component of their curriculum, yet only 40% of responding dental and 70% of dental hygiene programs reported having designated time in their curriculum for it. Barriers preventing programs from teaching or providing clinical experiences regarding prenatal oral health include lack of time and patients. CONCLUSIONS: Many, but not all dental professional programs are teaching their students about the recommended age for a first dental visit. Better adherence to national guidelines will require programs to address current barriers impeding learning about this important topic and to provide creative opportunities for students regarding prenatal and infant and toddler oral health.

Can a prenatal dental public health program make a difference?

OBJECTIVE: Some pregnant women may be at increased risk of poor oral health. A publicly funded prenatal dental program in Vancouver, British Columbia, called Healthiest Babies Possible (HBP), has been providing oral health education and limited clinical services for over 20 years to low-income women assessed to be at high risk of preterm or low-weight births. This report is an assessment of the initial outcomes. METHODS: A prospective before-after evaluation of a non-probability convenience sample of women was undertaken over 1 year (2005-2006). Participants were seen at the customary 2 clinic visits, and were asked to return for a postnatal visit. Data collected by an inside evaluator, the program's dental hygienist, included questionnaires, semi-structured interviews, observations, clinical indices, appointment statistics and self-reports. Univariate and bivariate analyses (Student's t test and ANOVA) were performed. RESULTS: Of the 67 women in the sample, 61 agreed to participate; 36 (59%) attended all 3 appointments at the clinic, and 40 (66%) completed all 3 interviews and questionnaires either at the clinic or by telephone. Clinical indices of gingival health improved significantly over the time of the evaluation. Improvements in tooth cleaning were demonstrated by a significant decrease in plaque (p < 0.001). The proportion of the women's other children receiving professional dental care increased significantly (p < 0.001). Oral health knowledge improved and, overall, women expressed satisfaction with the program. CONCLUSION: Participants in this evaluation demonstrated improved gingival health, enhanced knowledge of oral health and positive tooth-cleaning behaviour. These women pursued infant oral care and sought professional dental visits for their children.

Factors related to postoperative discomfort in young children following dental rehabilitation under general anesthesia.

PURPOSE: This study, conducted in ambulatory surgical centers, was a response to queries from pediatric dentists who wondered if postoperative discomfort in their patients treated for early childhood caries under general anesthesia was related to specific dental procedures. The purpose of this study was to identify factors related to the occurrence and severity of postoperative discomfort. METHODS: Subjects were children younger than 7 years old. The faces, legs, activity, cry, consolability pain assessment tool measured discomfort immediately postoperatively; the dental discomfort questionnaire (DDQ-8) measured discomfort preoperatively and after treatment. Data was analyzed with bivariate tests and hierarchical linear multiple regression. RESULTS: Of the 160 participants (52.9±15.0 months old), approximately 51% had preoperative dental discomfort (DDQ-8 score=>3). The proportion with discomfort had significantly decreased to 27% by days 2 to 5. Immediate discomfort in recovery was influenced by number of crowns and space maintainers and inversely by the length of postoperative sleep. Dental discomfort in the first week postoperatively was predicted by amount of preoperative discomfort, length of sleep in recovery, and not resuming a regular diet on Day 1. CONCLUSION: In these children, discomfort after treatment was mild, decreased over time, and, other than immediately postoperatively, was not related to specific dental procedures.

Understanding parents' oral health behaviors for their young children.

Young children with extensive dental decay often require a general anesthetic (GA) to enable dental treatment. The purpose of this study was to develop a grounded theory to help our understanding of the processes that influence parental adoption of dentally healthy behaviors following the experience of their child's "dental general anesthetic." Twenty six interviews were conducted. Data were analyzed and a conceptual model was generated. Overall, the dental GA experience had an immediate, but short-lived, impact on parental behavior change. Parents had difficulty over time maintaining these behaviors. Social influences, family context, and parenting strategies were the key categories that influenced parental behavior change; however, parenting strategies occupied the central position in the model. Cultural beliefs, actions of dental professionals, and media/advertising were some of the identified barriers to behavior change. Those parents who were more confident in their ability to successfully carry out dentally healthy practices were more likely to maintain them over time.

Effect of motivational interviewing on rates of early childhood caries: a randomized trial.

PURPOSE: The purposes of this randomized controlled trial were to: (1) test motivational interviewing (MI) to prevent early childhood caries; and (2) use Poisson regression for data analysis. METHODS: A total of 240 South Asian children 6 to 18 months old were enrolled and randomly assigned to either the MI or control condition. Children had a dental exam, and their mothers completed pretested instruments at baseline and 1 and 2 years postintervention. Other covariates that might explain outcomes over and above treatment differences were modeled using Poisson regression. Hazard ratios were produced. RESULTS: Analyses included all participants whenever possible. Poisson regression supported a protective effect of MI (hazard ratio [HR]=0.54 (95%CI=035-0.84)-that is, the M/ group had about a 46% lower rate of dmfs at 2 years than did control children. Similar treatment effect estimates were obtained from models that included, as alternative outcomes, ds, dms, and dmfs, including "white spot lesions." Exploratory analyses revealed that rates of dmfs were higher in children whose mothers had: (1) prechewed their food; (2) been raised in a rural environment; and (3) a higher family income (P<.05). CONCLUSIONS: A motivational interviewing-style intervention shows promise to promote preventive behaviors in mothers of young children at high risk for caries.

Waiting room time: An opportunity for parental oral health education.

OBJECTIVES: The UBC Children's Dental Program (CDP) has provided free dental treatments to underserved low-income children, but its preventive component needs to be enhanced. The study aims were: 1) to develop a "waiting-room based" dental education program engaging caregivers of these children, and 2) to assess the program's feasibility, acceptability and effectiveness. METHODS: In preparation, a situational analysis (SA) included structured interviews with caregivers, and with various stakeholders (e.g., dental students, instructors, health authority) involved in the CDP program. Based on the SA, caregiver-centered education was designed using an interactive power point presentation; after the presentation, each caregiver set personalized goals for modifying his/her child's dental behaviours. Evaluation of the program was done with follow-up telephone calls; the program's effectiveness was assessed by comparing before/after proportions of caregivers brushing their child's teeth, children brushing teeth in the morning and evening, children eating sugar-containing snacks, and children drinking sugar-containing drinks. RESULTS: The program proved to be easy to implement (feasible) and the recruitment rate was 99% (acceptable). The follow-up rate was 81%. The SA identified that the caregivers' knowledge about caries etiology and prevention was limited. All recruited caregivers completed the educational session and set goals for their family. The evaluation demonstrated an increase in caregiver-reported short-term diet and oral self-care behaviours of their children. CONCLUSION: A dental education program engaging caregivers in the waiting room was a feasible, acceptable and promising strategy for improving short-term dental behaviours of children.

The perceptions of first nation participants in a community oral health initiative.

The Children's Oral Health Initiative (COHI) is a federally funded community-based preventive dental program for children and their caregivers living in geographically isolated Canadian Aboriginal communities. The goal of the program is to improve access to preventive dental services for children of 0-7 years of age. It utilises community health workers in collaboration with dental therapists to promote and deliver the program. Almost half of the province of Manitoba's (n=27) First Nations communities have implemented COHI since 2005. The objective of this investigation was to explore the opinions of COHI from the perspective of community members whose children had participated in the program. Purposeful selection identified caregivers of enrolled children for a semi-structured interview. The targeted caregivers had children who met at least one of the following criteria: (1) 0-2 years old; (2) 5-7 years old; (3) had two or more children either currently or formerly enrolled in COHI. Six open-ended questions guided the interview process. Content analysis was used to code transcripts and identify themes. One hundred and forty-one interviews were completed in 13 communities. Participants defined good oral health as the absence of dental cavities, which reflects a Western biomedical model of disease. The local, community-based nature of COHI was viewed as essential to its success in increasing access to preventive dental services and improving children and caregivers' oral health knowledge and behaviours. In conclusion, a local, community-based oral health prevention programme is perceived as having a beneficial effect on children and caregivers' oral health knowledge and behaviours. However, oral health preventive messages need to be further integrated into traditional Aboriginal holistic models of wellness.

Brighter Smiles: Service learning, inter-professional collaboration and health promotion in a First Nations community.

OBJECTIVE: The goal of Brighter Smiles was to improve children's dental health in a remote First Nations community in British Columbia in the context of a service-learning experience for pediatrics residents. SETTING AND PARTICIPANTS: The provincial Ministry of Health had competitive funds available for collaborations between remote communities and medical educators. Hartley Bay (Gitga'at), a tribe of the Tsimshian Nation, responded by declaring children's dental health to be a primary health concern. This northern community has an on-reserve population fluctuating around 200 people and is accessible only by air or water. INTERVENTION: A convenience sample of children had a baseline dental exam; parents also completed a questionnaire about dental health behaviours. Only 31% (4/13) of pre-kindergarten and 8% (2/26) of kindergarten to Grade 12 children had no dental caries. Planning of the Brighter Smiles intervention involved community leaders, teachers, parents, Elders, health care staff, pediatrics residents, and dental and medical faculty from the University of British Columbia (UBC). Brighter Smiles includes school-based brush-ins, fluoride programs, classroom presentations, and regular visits by UBC pediatrics residents to Hartley Bay to provide well-child care that includes age-appropriate dental counselling to parents at the clinic visits. OUTCOMES: An early success indicator was a significantly increased proportion of dental service provider's time scheduled for preventive maintenance services rather than dental rehabilitation (restorations and extractions). CONCLUSIONS: The goal of providing a service-learning experience for trainee pediatricians in a remote community has been achieved. In addition, early indicators demonstrate improvements in child oral health.

Motivating mothers to prevent caries: confirming the beneficial effect of counseling.

BACKGROUND: The purpose of this study was to compare the effect of a motivational interviewing (MI) counseling visit with traditional health education for mothers of young children at high risk of developing dental caries. METHODS: The authors enrolled 240 infants aged 6 to 18 months and their mothers in the study and randomly assigned them to MI or traditional health education (control) groups. Mothers in the control group received a pamphlet and watched a videotape. Those in the MI group received the pamphlet and watched the videotape, as well as received an MI counseling session and six follow-up telephone calls during the first year. There were no interventions in year 2. RESULTS: After two years, children in the MI group exhibited significantly less new caries (decayed or filled surfaces) than those in the control group (that is, a protective effect of MI) (odds ratio = 0.35, 95 percent confidence interval = 0.15 to 0.83). CONCLUSIONS: MI is a promising approach that warrants further attention in a variety of dental contexts. CLINICAL IMPLICATIONS: The results of this study show that MI has a protective effect with regard to the development of early childhood caries. One reason for this clinical effect is greater compliance with recommended fluoride varnish treatment regimens in families who received MI counseling compared with families who received traditional education.

The Children's Oral Health Initiative: An intervention to address the challenges of dental caries in early childhood in Canada's First Nation and Inuit communities.

OBJECTIVE: The objective of the Children's Oral Health Initiative (COHI) is to increase access to preventive oral health services provided to First Nations and Inuit (FN/I) children living on federal reserves and in remote communities. PARTICIPANTS: COHI targets preschool children; 5-7-year-olds; pregnant women; and parents/caregivers in FN/I communities. SETTING: The program was piloted in 2004 by Health Canada and is potentially available to all FN/I communities. However, the community must consent to the program's implementation and agree to support a community member to be trained as a COHI aide. INTERVENTION: Dental therapists and hygienists screen eligible children, apply fluoride varnish and sealants to children's teeth, and stabilize active dental caries with glass ionomer. An innovation was the development of a community oral health worker, the COHI Aide. The COHI Aide is a community member who serves as an advocate for preventive oral health in the community and provides instruction to children, parent/caregivers and expectant mothers in preventing dental caries. RESULTS: COHI was piloted in 41 communities in 2004. By 2014, the program had expanded to 320 FN/I communities, which represents 55% of all eligible FN/I communities. In 2012, 23,085 children had received COHI preventive oral health services. CONCLUSION: The results demonstrate COHI's success as a preventive oral health care delivery model in remote communities. Implementation and delivery of preventive oral health services has been enhanced by the sustained presence of a community-based COHI Aide.

They stole her teeth! An exploration of adults with developmental disability experiences with dental care.

PURPOSE: The aim of this paper was to explore the experiences of adults with developmental disabilities (AWDD) in accessing and utilizing dental services in Vancouver, BC. METHODS: Participants were either self-advocates or parents/caregivers who discussed their experiences in five focus group discussions with 20 participants in total (age range 17-60 years, 2 males). Each focus group lasted on average 40 minutes. Transcripts were coded for thematic analysis; the codes were organized into themes and finally into domains. RESULTS: Seven domains relating to the participants' experiences with dental care were identified, and included communication, trust, and respect as provided-based domains to the quality of the dental experience for AWDD and their parents, while financial issues, transitional services, and waiting times were system-based barriers to access to dental care for theses AWDD. Finally, what makes for a positive dental experience was shared in terms of acknowledging parent's role as advocates and making simple accommodations to see AWDD by the dental office. CONCLUSIONS: Access to a care provider did not necessarily equate to satisfaction with quality of experience. Efforts have to focus on establishing communication and trust with AWDD patients as key to a positive dental experience. We encourage a global discussion on the need to better incorporate dental care for special needs individuals within dental school curricula.

An oral health promotion program for an urban minority population of preschool children.

The objective of this project was to design, implement and evaluate an oral health promotion program for inner-city Vietnamese preschool children in Vancouver, British Columbia, Canada. The project comprised of four general phases: information-gathering, project planning, project implementation, and project evaluation. The information-gathering phase of the project demonstrated extensive tooth decay in young children, bottle use during the day and during sleep-time long past recommended weaning age, and a belief of many parents that primary teeth were not important. Based on this information, the project planning committee designed a program that featured one-to-one counseling supported by community-wide activities. A Vietnamese lay health counselor provided counseling to mothers with telephone follow-up that coincided with scheduled infant immunization visits to a twice-monthly Child Health Clinic for Vietnamese families. At all the follow-up assessment clinics scheduled over the 7-year duration of this continuing project, mothers who had had more than one counseling visit reported significantly less use of sleep-time and daytime bottles for their children, and their children demonstrated significantly reduced prevalence of caries compared to similarly aged children at baseline. One-to-one counseling with regular follow-up provided by a lay person of similar background and culture to the participants is an effective way to facilitate adoption of healthy behaviors and to improve oral health of children.

The Community Dental Facilitator Project: reducing barriers to dental care.

OBJECTIVES: This report describes an initiative developed and implemented by a low-income, urban, Canadian community to respond to their children's dental problems. METHODS: The first strategy pursued by the community was the development of the Community Dental Facilitator Project. This project facilitated children's access to existing government funding for dental treatment, and subsequently facilitated access to treatment at local dental offices. Children in need of treatment were identified by a school dental screening. The facilitation work was done by three lay workers hired from within the community who represented the community's predominant ethnic groups. RESULTS: Parents revealed that barriers to dental care in local dental offices were lack of information about funding programs, language, inflexible work situation, and mistrust of bureaucracy. By the project's end, with the assistance of the facilitators, a significantly increased number of children had been enrolled for government dental benefits (P<.001). In addition to the 123 children identified at the screening as needing treatment, another 30 children "self-referred" to the program. At the end of the project's original funding period, dental appointments had been made for 68 children: 60 (48.8%) of the "screened" group, 8 (26.7%) of the "self-referred" group. One-year telephone follow-up to parents of the screened children revealed that 42 of 59 (71.1%) had completed treatment. CONCLUSIONS: Barriers to dental care for low-income children go beyond economics. A community facilitation model can improve low-income children's access to existing dental services and may reduce the barriers to care for some children requiring treatment.

Motivating parents to prevent caries in their young children: one-year findings.

BACKGROUND: The authors conducted a study to compare the effect of a motivational interviewing counseling treatment with that of traditional health education on parents of young children at high risk of developing dental caries. OVERVIEW: The authors enrolled in the study parents of 240 infants aged 6 to 18 months and randomly assigned them to either a motivational interviewing, or MI, group or a traditional health education (control) group. Parents in the control group received a pamphlet and watched a video. Parents in the MI group also received the pamphlet and watched the video; in addition, they received a personalized MI counseling session and six follow-up telephone calls. RESULTS: After one year, children in the MI group had .71 new carious lesions (standard deviation, or SD, = 2.8), while those in the control group had 1.91 (SD = 4.8) new carious lesions (t[238] = 2.37, one-tailed, P < .01). CONCLUSIONS: MI is a promising approach that should receive further attention. CLINICAL IMPLICATIONS: MI may lead parents and others to better accept dental recommendations about preventing caries in their children.

Oral health promotion for high-risk children: case studies from British Columbia.

Socio-economics, family stress and parenting style each plays as important a role in the development of early childhood caries as dietary and microbiological factors. Therefore, to be successful, oral health promotion initiatives should be designed and implemented with due consideration of issues such as collaboration with community partners, the role of dental health in overall child health and the involvement of the community in program planning. This article briefly describes 3 programs that have been undertaken in British Columbia either as public health initiatives or as demonstration research projects to improve oral health in young children from diverse communities with a high prevalence of early childhood caries.

Effect of povidone-iodine on Streptococcus mutans in children with extensive dental caries.

PURPOSE: The purpose of this pilot project was to determine the effect of a 10% povidone-iodine solution on plaque Streptococcus mutans and on incidence of new caries in young children following dental rehabilitation under general anesthesia. METHODS: Twenty-five children ages 2 to 7 years, scheduled for dental treatment under general anesthesia, were enrolled. Children in the experimental group (N = 13) had povidone-iodine applied 3 times at 2-month intervals. Control children (N = 12) had no treatment. Plaque samples were taken from all children at baseline, 6 months and cultured for total bacteria and S mutans. Dental examinations were conducted at baseline, 6 months, and 1 year. RESULTS: Experimental and control children had similar dietary habits, caries experience, and S mutans levels at baseline. All children's S mutans counts decreased significantly at 6 months (P = .003). The difference between the 2 groups was not significant (P = .58). At 1 year, 5 of 8 children in the control group had new caries compared to 2 of 11 children in the experimental group (P = .06). Povidone-iodine was well accepted by participating families. CONCLUSIONS: Extensive one-time restorative dental treatment resulted in a significant suppression S mutans levels at 6 months. Further exploration of the role of povidone-iodine in caries management is indicated.

Community dental clinics: providers' perspectives.

OBJECTIVES: Not-for-profit community dental clinics attempt to address the inequities of oral health care for disadvantaged communities, but there is little information about how they operate. The objective of this article is to explain from the perspective of senior staff how five community dental clinics in British Columbia, Canada, provide services. METHODS: The mixed-methods case study included the five not-for-profit dental clinics with full-time staff who provided a wide range of dental services. We conducted open-ended interviews to saturation with eight senior administrative staff selected purposefully because of their comprehensive knowledge of the development and operation of the clinics and supplemented their information with a year's aggregated data on patients, treatments, and operating costs. RESULTS: The interview participants described the benefits of integrating dentistry with other health and social services usually within community health centres, although they doubted the sustainability of the clinics without reliable financial support from public funds. Aggregated data showed that 75% of the patients had either publically funded or no coverage for dental services, while the others had employer-sponsored dental insurance. Financial subsidies from regional health authorities allowed two of the clinics to treat only patients who are economically vulnerable and provide all services at reduced costs. Clinics without government subsidies used the fees paid by some patients to subsidize treatment for others who could not afford treatment. CONCLUSIONS: Not-for-profit dental clinics provide dental services beyond pain relief for underserved communities. Dental services are integrated with other health and community services and located in accessible locations. However, all of the participants expressed concerns about the sustainability of the clinics without reliable public revenues.