The basic research factors questionnaire for studying early childhood caries.

BACKGROUND: We describe development of the Early Childhood Caries (ECC) Basic Research Factors Questionnaire (BRFQ), a battery of measures assessing common potential predictors, mediators, and moderators of ECC. Individual-, family-, and community-level factors that are linked to oral health outcomes across at-risk populations are included. Developing standard measures of factors implicated in ECC has the potential to enhance our ability to understand mechanisms underlying successful prevention and to develop more effective interventions. METHODS: The Early Childhood Caries Collaborating Centers (EC4), funded by National Institute of Dental and Craniofacial Research, developed the BRFQ, which was used across four randomized trials to develop and test interventions for reducing ECC in at-risk populations. Forty-five investigators from across the centers and NIDCR were involved in the development process. Eight "measures working groups" identified relevant constructs and effective measurement approaches, which were then categorized as "essential" or "optional" common data elements (CDEs) for the EC4 projects. RESULTS: Essential CDEs include 88 items, with an additional 177 measures categorized as optional CDEs. Essential CDEs fell under the following domains: oral health knowledge, oral health behavior, utilization/insurance and cost, parent/caregiver dental self-efficacy, quality of life, caregiver and family characteristics, and child characteristics. CONCLUSIONS: The BRFQ makes available a battery of measures that support efforts to understand population risk factors for ECC and to compare oral health outcomes across populations at risk. The BRFQ development process may be useful to other clinical research networks and consortia developing CDEs in other health research fields. TRIAL REGISTRATION: All the trial that used the BRFQ were registered at Clinicaltrial.gov NCT01116726 , April 29, 2010; NCT01116739 , May 3, 2010; NCT01129440 , May 21, 2010; and NCT01205971 , September 19, 2010.

Dental Care in an Equal Access System Valuing Equity: Are There Racial Disparities?

BACKGROUND: Racial disparities in dental care have previously been shown in the Veterans Health Administration (VA)-a controlled access setting valuing equitable, high-quality care. OBJECTIVES: The aim of this study is to examine current disparities in dental care by focusing on the receipt of root canal therapy (RCT) versus tooth extraction. RESEARCH DESIGN: This is a retrospective analysis of data contained in the VA's electronic health records. We performed logistic regressions on the independent measures along with a facility-specific random effect, using dependent binary variables that distinguished RCT from tooth extraction procedures. SUBJECTS: VA outpatients who had at least 1 tooth extraction or RCT visit in the VA in fiscal year 2011. MEASURES: A dependent binary measure of tooth extraction or RCT. Other measures are medical record data on medical comorbidities, dental morbidity, prior dental utilization, and demographic characteristics. RESULTS: The overall rate of preferred tooth-preserving RCT was 18.1% during the study period. Black and Asian patients were most dissimilar with respect to dental morbidity, medical and psychological disorders, and black patients had the least amount of eligibility for comprehensive dental care. After adjustment for known confounding factors of RCT, black patients had the lowest RCT rates, whereas Asians had the highest. CONCLUSIONS: Current quality improvement efforts and a value to improve the equity of care are not sufficient to address racial/ethnic disparities in VA dental care; rather more targeted efforts will be needed to achieve equity for all.

Pediatric clinicians can help reduce rates of early childhood caries: effects of a practice based intervention.

OBJECTIVE: Early childhood caries (ECC) is a serious and preventable disease which pediatric clinicians can help address by counseling to reduce risk. RESEARCH DESIGN: We implemented a multifaceted practice-based intervention in a pediatric outpatient clinic treating children vulnerable to ECC (N = 635), comparing results to those from a similar nearby clinic providing usual care (N = 452). INTERVENTION: We provided communication skills training using the approach of patient centered counseling, edited the electronic medical record to prompt counseling, and provided parents/caregivers with an educational brochure. OUTCOME MEASURES: We assessed changes in provider knowledge about ECC after the intervention, and examined providers' counseling practices and incidence of ECC over time by site, controlling for baseline ECC, patient sociodemographics and parents'/caregivers' practice of risk factors (diet, oral hygiene, tooth-monitoring), among 1045 children with complete data. RESULTS: Provider knowledge about ECC increased after the intervention training (percentage correct answers improved from 66% to 79%). Providers at the intervention site used more counseling strategies, which persisted after adjustment for sociodemographic characteristics. Children at the intervention site had a 77% reduction in risk for developing ECC at follow up, after controlling for age and race/ethnicity, sociodemographics and ECC risk factors; P

Use of patient self-report oral health outcome measures in assessment of dental treatment outcomes.

OBJECTIVE: To assess the sensitivity of a newly developed brief measure of oral health-related quality of life (OQOL). METHODS: Self-assessed oral health and OQOL were measured in three groups of patients who had presented for either prophylaxis (n = 32), endodontic care (n = 15), or for a denture (n = 16) in a dental school setting before and after treatment. Main outcome measures included the single-item self-report of oral health (OH-1) and the 6- and 12-item versions of a new OQOL instrument. General linear modeling was used to compute means of self-reported oral health by treatment group. RESULTS: Of the 63 patients who completed the baseline questionnaire, 44 (70 percent) returned questionnaires after treatment. The sample averaged 43 +/- 15 years, 48 percent male and 55 percent with some college education. Ethnic representation included 35 percent White, 33 percent Black, and 32 percent other - mostly Latino. The mean self-reported number of teeth was 20.6. In terms of sensitivity, significant differences were observed between the treatment groups on the items assessing being upset (P < 0.05), feeling depressed (P < 0.05), and uncomfortable about the appearance of teeth or dentures (P < 0.05). However, magnitude of change, as measured by an effect size, was characterized as minimal to small in the recall and endodontic groups and borderline moderate in the denture group. CONCLUSION: The measure was sensitive to differences within groups, with a small to borderline magnitude of change.

Prevalence of early childhood caries among very young urban Boston children compared with US children.

OBJECTIVES: The aims of this study were to compare prevalence of early childhood caries (ECC) in 1- to 3-year-old children seeing primary-care pediatricians at two urban medical centers in Boston to the prevalence of ECC in similarly aged US children surveyed as part of the Third National Health and Nutrition Examination Survey (NHANES III) and to assess risk factors for ECC among this cohort of children compared with risk factors among similarly aged US children. METHODS: Characteristics of 787 1- to 3-year-old children from two urban Boston medical centers were compared with those of 3,644 similarly aged US children surveyed as part of NHANES III. Demographic and social characteristics and ECC prevalence by putative risk factors were compared. A multiple logistic regression model was fit to assess putative risk factors and difference between groups simultaneously. RESULTS: Race, age, previous dental visit, parents' education, and household income were significantly associated with ECC prevalence. Parents' place of birth was a significant effect modifier with lower ECC among Boston children of immigrants than among US children of immigrants. CONCLUSIONS: Lower ECC prevalence among urban Boston children of immigrant parents compared with US children of immigrant parents may reflect changing immigrant composition in the United States since NHANES III or a different immigrant composition in the Boston area compared with the United States. This finding reinforces the need for further research of immigrants in order to understand cultural practices that may affect oral health. Finally, low ECC prevalence among very young children reinforces the importance of early intervention in reducing ECC.

A new brief measure of oral quality of life.

INTRODUCTION: We developed a brief measure of the impact of oral conditions on individual functioning and well-being, known as oral quality of life. METHODS: Among older male veterans (N = 827) and community dental patients (N = 113), we administered surveys consisting of extant oral quality of life items, using clinical dental data from the veteran samples. We assigned each oral quality of life item to a theoretical dimension, conducted an iterative series of multitrait scaling analyses to examine the item-fit with the dimensions, reduced the number of items, and examined the psychometric characteristics of new scales and their association with clinical indices. RESULTS: We developed two brief oral quality of life scales, one consisting of 12 items and the other of 6, the latter a subset of the former. Each demonstrated sound psychometric properties and was sensitive to clinical indices. CONCLUSION: The two brief oral quality of life scales can be used to assess the population-based impact of oral conditions as well as outcomes of dental care.

Dental treatment improves self-rated oral health in homeless veterans--a brief communication.

OBJECTIVE: The aim of this study was to assess homeless veterans' perception of their oral health and the impact that oral disease and treatment have on self-assessed quality of life. METHODS: Outcomes included measures of general and oral-specific quality of life and functional status. Single-item self-report of oral health and the General Oral Health Assessment Index were assessed at baseline and after treatment. RESULTS: One hundred and twelve veterans completed the baseline questionnaire, and 48 completed the follow-up. Veterans who were eligible for ongoing dental care had improved General Oral Health Assessment scores, while patients who received only emergency dental care saw a decreased score (2.46 versus -2.12). General Oral Health Assessment improvement was significantly related to fewer teeth at baseline (18 versus 23), a lower baseline General Oral Health Assessment (23.6 versus 28.1), having a denture visit (22 versus 35 percent), and improvement in self-reported oral health (25 versus 42 percent). CONCLUSION: There was significant improvement in homeless veterans'perceived oral health after receiving dental care.

Racial/Ethnic disparities in health care: lessons from medicine for dentistry.

To describe what is known about racial disparities in provided health care and to better understand the dynamics of this issue within dentistry, this article draws on data from the medical literature, focusing especially on reviewing what is known about disparities in care received by those who have accessed the health care system. An overview of the possible causal factors is presented, along with suggestions for future research.

Need for dental care in older veterans: assessment of patient-based measures.

OBJECTIVES: There is a need for brief and accurate identification of older patients in need of dental care. This study examines the sensitivity and specificity of two screening instruments. DESIGN: Cross-sectional study conducted in older community-dwelling male veterans. SETTING: Four Department of Veterans Affairs (VA) clinics in greater Boston and the VA Dental Longitudinal Study (DLS). PARTICIPANTS: Two hundred thirty-two participants from the Veterans Health Study (VHS) who were outpatients in one of four Department of Veterans Affairs clinics in greater Boston and 206 participants from the VA DLS, community-dwelling veterans who do not use VA for their health care. MEASUREMENTS: Self-report measures included a single-item global self-report of oral health (OH-1) and a six-item dental screening measure called the D-E-N-T-A-L. The D-E-N-T-A-L queries whether participants have Dry mouth, Eating or swallowing problems, Not had a dental examination in the last 2 years, Tooth or mouth problems, Altered eating habits because of teeth or mouth, or Lesions or sores in the mouth. The criterion standard for need for treatment was determined by a clinical examination. Sensitivities and specificities were calculated and receiver operating characteristic curves plotted to identify the best cutpoints for each measure. RESULTS: Need for care was nearly universal (97%) in the VHS and present in 64% of the DLS participants. The single-item self-report of oral health performed as well as the D-E-N-T-A-L in identifying persons in need of care. Compared with the clinical criterion, the OH-1 had a sensitivity of 0.75 and a specificity of 0.67 in identifying persons with severe need for denture care, whereas the D-E-N-T-A-L had a sensitivity of 0.80 and a specificity of 0.62 in identifying persons with severe periodontal need. CONCLUSION: Self-reports of fair or poor oral health are useful in identifying veterans in need of dental care, especially in populations with a large number of persons who do not usually use dental care. The D-E-N-T-A-L may also be useful as a self-screening measure and community education device to encourage older persons to seek regular dental care.

Is depressive symptomatology associated with worse oral functioning and well-being among older adults?

OBJECTIVES: Although depression negatively affects individuals' physical functioning and well-being, its association with oral functioning and well-being has not been examined previously. The objective of this study was to examine the association between depressive symptomatology and oral quality of life. METHODS: We utilized data from two samples of older adults: community-dwelling participants who used community primary care physicians in Los Angeles (n=1,653) and individuals who sought ambulatory care through four Department of Veterans Affairs facilities in the Boston metropolitan area (n=212). Depressive symptomatology was measured with the CES-D scale; Oral Quality of Life was measured with the Geriatric Oral Health Assessment Instrument and the Oral Health-related Quality of Life measure. We conducted hierarchical regression analyses to examine the effects of depression on oral quality of life, controlling for self-reported oral health, age, education, income, and marital status. RESULTS: Individuals with more depressive symptoms reported worse oral quality of life, controlling for sociodemographic factors and self-reported oral health. This finding persisted across multiple samples and both sexes, and using two measures of oral quality of life. CONCLUSION: These findings further emphasize the importance of treating depression among older adults, and suggest that both dentists and physicians have a role in recognizing and referring patients for such treatment.

The Tuskegee Legacy Project: history, preliminary scientific findings, and unanticipated societal benefits.

This article is intended to provide a relatively complete picture of how a pilot study--conceived and initiated within an NIDCR-funded RRCMOH--matured into a solid line of investigation within that center and "with legs" into a fully funded study within the next generation of NIDCR centers on this topic of health disparities, the Centers for Research to Reduce Oral Health Disparities. It highlights the natural opportunity that these centers provide for multicenter. cross-disciplinary research and for research career pipelining for college and dental school students; with a focus, in this case, on minority students. Futhermore, this series of events demonstrates the rich potential that these types of research centers have to contribute in ways that far exceed the scientific outcomes that form their core. In this instance, the NMOHRC played a central--and critical, if unanticipated--role in contributing to two events of national significance, namely the presidential apology to the African American community for the research abuses of the USPHS--Tuskegee syphilis study and the establishment of the National Center for Bioethics in Research and Health Care at Tuskegee University. Research Centers supported by the NIH are fully intended to create a vortex of scientific activity that goes well beyond the direct scientific aims of the studies initially funded within those centers. The maxim is that the whole should be greater than the sum of its initial constituent studies or parts. We believe that NMOHRC did indeed achieve that maxim--even extending "the whole" to include broad societal impact. well beyond the scope of important, but mere, scientific outcomes--all within the concept and appropriate functions of a scientific NIH-funded research center.

Tooth loss and dentures: patients' perspectives.

OBJECTIVE: Despite dramatic improvements in tooth retention around the world, a substantial proportion of older adults have lost natural teeth and many wear removable partial and complete dentures. Problems associated with tooth loss and denture wearing remain important in the context of global ageing. The purpose of this paper is to examine the effects of tooth loss and denture wearing on their day-to-day lives from the patient perspective. DESIGN: Cross-sectional study. SETTING: Greater Boston area, USA. PARTICIPANTS: Community-dwelling older men. METHODS: Brief examination and survey. MAIN OUTCOME MEASURES: Self-reported oral health measures including the single-item self-rating of oral health, the Oral Health Impact Profile (OHIP), the Geriatric Oral Health Assessment Index (GOHAI), Oral-Health-related Quality of Life (OHQOL) and a newly-developed short-form instrument (the DELTA). RESULTS: Men with > or = 25 teeth had better self-rated oral health by all measures. The new, brief DELTA differentiates between dentition/denture groupings as well as or better than existing instruments. Over 80% of men with > or = 25 teeth rated their oral health as excellent, very good or good, compared with 70% of men with no teeth (and dentures) and 54% of men with 1-24 teeth. Avoidance of certain foods discriminates well between dentition groups. To a lesser extent, difficulty with relaxation, pain and distress, and avoidance of going out are associated with tooth loss and/or denture wearing.

Oral health of substance-dependent individuals: impact of specific substances.

Little is known about how different types of substances affect oral health. Our objective was to examine the respective effects of alcohol, stimulants, opioids, and marijuana on oral health in substance-dependent persons. Using self-reported data from 563 substance-dependent individuals, we found that most reported unsatisfactory oral health, with their most recent dental visit more than 1 year ago. In multivariable logistic regressions, none of the substance types were significantly associated with oral health status. However, opioid use was significantly related to a worse overall oral health rating compared to 1 year ago. These findings highlight the poor oral health of individuals with substance dependence and the need to address declining oral health among opioid users. General health and specialty addiction care providers should be aware of oral health problems among these patients. In addition, engagement into addiction and medical care may be facilitated by addressing oral health concerns.

Oral conditions and quality of life.

Oral conditions can have serious, disabling effects. The purposes of this study are 2-fold: first to estimate the prevalence and severity of self-reported oral problems in male veterans who use Department of Veterans Affairs (VA) outpatient medical (but not dental) care and, second, we examine to what extent the impact of oral conditions is associated with measures of general health and well-being. Male veteran users of outpatient VA medical care from the Veterans Health Study (N = 2425) were surveyed using questionnaires, which included sociodemographic information, the SF-36, the Geriatric Oral Health Assessment Index (GOHAI), and the Oral Health and Quality of Life (OHQOL) measure. Only 28% of these users of VA outpatient care rated their oral health as excellent or very good, 32% as good, and nearly 40% as fair or poor. Furthermore, only one half of respondents could always eat without discomfort, were pleased with the looks of their teeth, and had no worries about their teeth. Factor analysis of the SF-36, GOHAI, and OHQOL items confirmed that both the GOHAI and the OHQOL are separate and independent of the 8 scales of the SF-36. Regression analyses showed that the GOHAI but not the OHQOL is significantly associated with the mental and physical component summary scales of the SF-36 when both sociodemographics and disease burden are controlled for in the models. Oral problems, as measured by the GOHAI and the OHQOL, are significant burdens on the health and function of veterans who use VA outpatient care. Oral health, as measured by the GOHAI, contributes in an important way to the functional well-being of users of VA healthcare.

Racial variations in dental procedures: the case of root canal therapy versus tooth extraction.

BACKGROUND: Racial disparities have been widely documented in medical care, but variations in dental care have not been well examined. OBJECTIVES: To determine if there is racial variation in use of root canal therapy versus tooth extraction across different levels of dental insurance coverage and adjusting for other factors known to influence treatment decisions. METHODS: Within 3 different categories of insurance coverage, we examined whether there were racial differences in the provision of the tooth-sparing treatment of root canal therapy (vs. tooth extraction) among 54,423 users of outpatient Veterans Affairs dental care in 1998. Regression analyses adjusted for the severity of tooth- and gum-related disease, age, sex, medical and psychiatric comorbidities, prior use of preventive dental services, tooth extraction and root canal therapy, and clustering by geographic region. RESULTS: In the adjusted regression models, black patients and those with unknown race were less likely overall to receive root canal therapy than whites, whereas Asians were more likely. Among patients with eligibility for continuing and comprehensive dental care, blacks were less likely and Asians more likely to receive root canals than whites. For patients covered only for emergency dental care, Hispanics had a higher likelihood of receiving root canal therapy. Among all other types of coverage, there were no significant racial differences in the care received. CONCLUSION: We observed substantial racial variations in the provision of root canal therapy among patients treated in Department of Veterans Affairs dental clinics. Future research should identify the causes of such variations.

Tooth retention as an indicator of quality dental care: development of a risk adjustment model.

BACKGROUND: Retaining teeth improves oral health and quality of life. Thus, receipt of a root canal (vs. a tooth extraction) is a useful indicator of the quality of dental care. However, use of this quality measure without adjusting for the severity of oral disease could lead to spurious conclusions. OBJECTIVES: This paper describes the development of a dental severity adjustment methodology. RESEARCH DESIGN: Retrospective study. SUBJECTS: 54,423 users of Department of Veterans Affairs (VA) dental care who had either root canal therapy or a tooth extraction at a VA facility in Fiscal year 1998. MEASURES: International Classification of Disease Clinical Modification codes for dental diagnoses and comorbid medical conditions. We modeled the effects of dental disease severity in logistic regression models of the probability of receiving a root canal, using both conceptual and Modified Delphi-Panel derived models, adjusting for age, and medical comorbidities. RESULTS: Conceptual and Modified Delphi models performed similarly. The dental disease severity adjustments increased the fit in models of the probability of receiving a root canal (C-statistic = 0.822 for the conceptual model and 0.804 for the Modified Delphi Panel model) compared with the model including comorbid medical conditions alone (C-statistic = 0.561). CONCLUSIONS: Risk adjustment for dental disease severity improves the fit of models of the probability of receiving a root canal. Studies of the quality of dental care should consider employing risk-adjusted models.

Comparison of patient-based oral health outcome measures.

OBJECTIVES: This project examined psychometric characteristics of four measures of oral-specific health-related quality of life. METHODS: We selected participants from two samples of community-dwelling male veterans from Boston (USA): (1) 538 users of VA outpatient medical care from the Veterans Health Study (VHS: mean age = 62); and (2) 211 relatively healthy men from the VA Dental Longitudinal Study (DLS: mean age = 70). Patient-based measures included the Geriatric Oral Health Assessment Instrument, the Oral Health Impact Profile (OHIP), the Oral Health-related Quality of Life instrument and the single-item self-report of oral health. Clinical variables included number of teeth, coronal decayed surfaces (CDS), a modification of the Root Caries Index (RCI_D), and the Community Periodontal Index of Treatment Need (CPITN). RESULTS: Cronbach's alpha ranged from 0.73 to 0.97. Percent of participants with floor and ceiling scores varied widely by instrument and by item. Patient-based measures were associated with all clinical measures in the combined sample. Number of teeth was associated with patient-based measures (p < 0.001). However, CDS, RCI_D and CPITN scores were associated with patient-based scores in the VHS but not in the DLS. The Geriatric Oral Health Assessment Instrument, the OHIP, the Oral Health-related Quality of Life instrument were strongly linearly related to the single-item global self-report of oral health (p < 0.0001). CONCLUSION: All multi-item measures have high internal consistency and all are valid for measuring oral-specific health-related quality of life.