Increased number of teeth predict acquisition of mutans streptococci in infants.

This longitudinal study of 194 very-low birthweight (VLBW) and 184 normal birthweight (NBW) infants hypothesized that the causal pathway between birth group (VLBW or NBW) and mutans streptococci (MS) acquisition (presence) at 18-20 months is mediated by biological, behavioral, and caregiver MS levels. Biological (number of teeth at 8 and 18-20 months and enamel hypoplasia) and behavioral (brushing/cleaning, sweet snacks, breastfeeding, and dental access) factors were assessed using dental examinations and caregiver questionnaire responses at 8 and 18-20 months. Infant MS acquisition and caregiver MS levels were assessed from saliva and plaque samples collected at 8 and 18-20 months. Structural equation modeling evaluated the causal pathway with latent variables for biology and behavior. Mutans streptococci presence was similar between birth groups at 18-20 months (40% in VLBW infants and 49% in NBW infants), but was significantly higher for NBW infants at 8 months. Increased number of teeth at 8 and 18-20 months was associated with biological risk. Infants whose caregivers had a 1-point higher score on MS had a significantly (1.5) higher odds of MS presence. Caregiver behavior was not associated with MS presence. Early-intervention efforts should focus on delaying initial acquisition and improving caregiver awareness of taking care of erupting primary teeth.

Adoption of New Oral Health Interventions in Primary Care: Qualitative Findings.

Introduction: This is the first study to use the Common-Sense Model of Self-Regulation theory for oral health interventions in pediatric practices. The objective of this qualitative study was to assess adoption and implementation of theory-based multilevel oral health interventions, by clinicians (pediatricians and nurse practitioners) participating in a cluster randomized clinical trial, to create an oral health toolkit for widespread dissemination into pediatric practices. Methods: Semistructured interviews were conducted at the conclusion of the cluster randomized clinical trial with 21 clinicians from 9 practices participating in the intervention arm. Clinicians in this arm received Common-Sense Model of Self-Regulation theory-based education and resources to deliver oral health interventions to parents/caregivers and document in electronic medical record. Semistructured interview questions were based on the Diffusion of Innovations Theory, assessing adoption and implementation. The interviews were coded using NVivo (QRS International) software. Main themes were identified using a thematic analysis approach. Results: Five themes identified from the interviews included strengths of theory-based oral health training for clinicians, oral health resources to improve quality of care, considerations for efficient future implementation, financial considerations, and parent benefits and challenges. Clinicians found that the theory-based training and resources increased knowledge and confidence when addressing oral health with parents and required only ≤2 minutes in their workflow with no financial consequences. Clinicians reported an increase in oral health awareness among parents but suggested an overall need for more pediatric dentists. Conclusions: The Common-Sense Model of Self-Regulation theory-based education and resources were well received by clinicians and perceived to be beneficial without adverse impact on workflow or practice finances. An online toolkit is planned because these oral health interventions can be successfully implemented and delivered in medical settings.

Caries disparities among Medicaid-enrolled young children from pediatric primary care settings.

OBJECTIVES: The objectives of this study are to determine the overall and racial differences in the extent of caries experience and to examine the association between child and parent/caregiver characteristics and caries among 3-6-year-old Medicaid-enrolled children. METHODS: This study reports baseline cross-sectional data from a larger pragmatic clinical trial in pediatric primary care practices. Child-level clinical dental exams included decayed and filled teeth (dft) using ICDAS criteria and parent/caregiver questionnaire collected information on socio-demographics, child oral health behaviors, oral health related quality of life (OHQoL), and food environment. RESULTS: A total of 1,024 parent/caregiver-child dyads participated in the study. The overall caries experience (dft) was 49 percent and untreated decay was 42 percent. Children who were Black had 1.3 and 1.2 times significantly higher frequency of untreated primary decay and caries experience compared to non-Black children. An overall logistic regression model predicted that race, increased age, receiving dental care in the past 12 months for a cavity/toothache, and lower caregiver OHQoL was significantly associated with increased odds of the child having caries. Non-Black caregivers with less education, whose child was older, and lower child OHQoL had increased odds of having a child with caries, but these same variables were not predictive for the Black children. CONCLUSIONS: Racial disparities exist with respect to caries experience and untreated decay within a Medicaid-enrolled population of young children attending well-child visits. Pediatric primary care offices are well-positioned to provide dental surveillance and preventive care and could play an important role in decreasing oral health inequities.

Recruitment strategies for a pragmatic cluster randomized oral health trial in pediatric primary care settings.

OBJECTIVES: To describe multilevel recruitment strategies for an ongoing clinical trial in pediatric primary care settings, and assess adoption and reach of these strategies via the RE-AIM framework. METHODS: This study is part of a larger pragmatic cluster randomized clinical trial focused on the effectiveness of interventions on the practice, provider, and caregiver levels on dental utilization for Medicaid-enrolled 3-6 year old children. Pediatric practices were recruited according to the proportion of Medicaid-eligible children, geographic region, and County. In accordance with the RE-AIM framework, providers reached were those approached directly and consented, and those who participated in the intervention training adopted to deliver the intervention. Caregivers reached were those approached and consented at their child's well-child visit to participate in the trial. RESULTS: Recruitment goals were met over a 21 month period, with an overall enrollment of 18 practices, 62 providers, and 1024 caregivers-child dyads. The majority of practices enrolled were small, suburban, and located in an urban county. The participation rates among approached providers and caregivers was 93% and 84% respectively. Enablers for recruitment was the one-on-one interaction with the provider and caregivers. Barriers to recruitment for caregivers included no-shows and cancellations at well-child visits. Adoption of intervention among providers was high, and caregiver reached were representative of the eligible target population. CONCLUSIONS: Active approaches to recruitment, such as utilizing opinion leaders, in-person recruitment, and building relationships with practice staff, can result in successful enrollment and imp lementation of a multi-level intervention in pediatric primary care settings.

COVID-19 Impact on Community-Based Participatory Randomized Controlled Trials-Lessons From the Oral Health Disparities in Children Consortium.

The COVID-19 pandemic has had a major impact on nearly every sector of science and industry worldwide, including a significant disruption to clinical trials and dentistry. From the beginning of the pandemic, dental care was considered high risk for viral transmission due to frequent aerosol-generating procedures. This resulted in special challenges for dental providers, oral health care workers, patients, and oral health researchers. By describing the effect that the COVID-19 pandemic had on four community-based randomized clinical trials in the Oral Health Disparities in Children (OHDC) Consortium, we highlight major challenges so researchers can anticipate impacts from any future disruptions.

Formative and Pilot Study for an Effectiveness-Implementation Hybrid Cluster Randomized Trial to Incorporate Oral Health Activities into Pediatric Well-Child Visits.

Background: Dental caries in pediatric patients are noted to have broad impacts on systemic health and well-being. Thus, utilizing an effectiveness-implementation hybrid I design, the Pediatric Providers Against Cavities in Children's Teeth (PACT) trial is investigating multi-level interventions at the practice (incorporation of oral health in electronic medical record [EMR]) and provider levels (theory-based didactic and skills training to communicate oral health facts to parent/caregiver, give a prescription to see a dentist and a list of area dentists) to increase dental utilization among 3 to 6 year old Medicaid-enrolled children attending well-child visits (WCV). The formative and pilot work for the larger main trial are presented. Methods: Formative work-Focus groups with 26 participants (Community leaders, providers, parent/caregivers); and key informant interviews with practice leadership (n = 4). Topics discussed were: core oral health (OH) information to communicate at WCVs and study logistics. Transcripts were coded and analyzed using Atlas.ti; Pilot study was refined using the formative findings and was conducted at two pediatric practices to test the implementation of: the provider didactic and skills training curriculum; EMR incorporation of four OH questions; logistics of incorporating OH activities at a WCV; and parent/caregiver recruitment. Results: Formative work showed that providers and parent/caregivers required knowledge of dental caries, and a list of area Medicaid-accepting dentists. Providers and practice leadership advised on the logistics of incorporating oral health into WCVs. All groups suggested asking parent/caregivers their preferred method of contact and emphasizing importance of OH to motivate participation. Utilizing these findings, the curriculum and protocol was revised. The pilot study in two practices successfully implemented the protocol as follows: all seven providers were trained in two 45 min didactic education and skills session; incorporation of OH questions into practices EMR; recruited 86 child-parent dyads (95% participation) at the WCV; providers delivered the OH intervention to parent/caregivers in <2 min and 90% completed EMR documentation of OH questions. These findings were instrumental in finalizing the main PACT trial in 18 practices. The RE-AIM framework is used in the main trial to collect effectiveness and implementation measures at baseline and follow-up visits. Conclusions: The formative and pilot findings were instrumental in refining the OH intervention and protocol which has resulted in successful implementation of the main trial. Trial Registration: Clinical trials.gov, Registered 9 November 2017, NCT03385629.

The psychometric properties of a new oral health illness perception measure for adults aged 62 years and older.

BACKGROUND: Based on the Common-Sense Model of Self-Regulation (CSM), a new integrated Illness Perception Questionnaire Revised for Dental Use in Older/Elder Adults (IPQ-RDE) was developed for single and multiple dental conditions. This study describes psychometric properties of the IPQ-RDE for adults 62 years and older. METHODS: Participants (n = 198) living in 16 subsidized housing facilities completed the IPQ-RDE and a questionnaire assessing their socio-demographics, frequency of dental visits, perceived condition of teeth/gums, depression, social support, and oral health quality of life (OHQOL). Participants received dental screening for presence/absence of teeth, coronal and root caries, and periodontitis. The 43-item IPQ-RDE was tested for internal (construct, discriminant) and external validity (concurrent, construct, discriminant, predictive) and reliability (internal consistency). RESULTS: Confirmatory factor analysis demonstrated that a ten-factor model in accordance with the CSM framework (identity, consequences, control, timeline, illness coherence, treatment burden, prioritization, causal relationship, activity restriction, emotional representations) had good construct validity based on significant factor loadings and acceptable model fit (RMSEA = 0.065, CFI = 0.902). Edentulous participants had significantly higher mean factor scores (inaccurate perception) for overall IPQ-RDE and four constructs indicating concurrent validity. Discriminant validity was suggested by non-relationship with external measures (education, dental visit frequency). Predictive validity was indicated by the negative correlation of most constructs with OHQOL suggesting that inaccurate perception was related to lower quality of life. Internal consistency of eight IPQ-RDE constructs was excellent (Cronbach's alpha > 0.73). CONCLUSIONS: The IPQ-RDE is a valid and reliable new measure for assessing older adult's perception of dental conditions. It can be an important tool for oral health behavioral research to restructure older adult's perception of dental conditions, and subsequently prevent tooth loss and improve oral health quality of life.

Family Access to a Dentist Study (FADS): A multi-center randomized controlled trial.

INTRODUCTION: Many low-income parent/caregivers do not understand the importance of cavity-free primary (baby) teeth and the chronic nature of dental caries (tooth decay). As a consequence, dental preventive and treatment utilization is low even when children are screened in schools and referred for care. This study aims to test a referral letter and Dental Information Guide (DIG) designed using the Common-Sense Model of Self-Regulation (CSM) framework to improve caregivers' illness perception of dental caries and increase utilization of care by children with restorative dental needs. METHODS: A multi-site randomized controlled trial with caregivers of Kindergarten to 4th grade children in urban Ohio and rural Washington State will compare five arms: (1) CSM referral letter alone; (2) CSM referral letter+DIG; (3) reduced CSM referral letter alone; (4) reduced CSM referral letter+DIG; and (5) standard (control) referral. At baseline, children will be screened at school to determine restorative dental needs. If in need of treatment, caregivers will be randomized to study arms and an intervention packet will be sent home. The primary outcome will be dental care based on a change in oral health status by clinical examination 7 months post-screening (ICDAS sealant codes 1 and 2; restoration codes 3-8; extraction). Enrollment commenced summer 2015 with results in summer 2016. CONCLUSION: This study uses the CSM framework to develop and test behavioral interventions to increase dental utilization among low-income caregivers. If effective this simple intervention has broad applicability in clinical and community-based settings.