Real-world comparative effectiveness of mRNA-1273 and BNT162b2 vaccines among immunocompromised adults identified in administrative claims data in the United States.

INTRODUCTION: Head-to-head studies comparing COVID-19 mRNA vaccine effectiveness in immunocompromised individuals, who are vulnerable to severe disease are lacking, as large sample sizes are required to make meaningful inferences. METHODS: This observational comparative effectiveness study was conducted in closed administrative claims data from the US HealthVerity database (December 11, 2020-January 10, 2022, before omicron). A 2-dose mRNA-1273 versus BNT162b2 regimen was assessed for preventing medically-attended breakthrough COVID-19 diagnosis and hospitalizations among immunocompromised adults. Inverse probability of treatment weighting was applied to balance baseline characteristics between vaccine groups. Incidence rates from patient-level data and hazard ratios (HRs) using weighted Cox proportional hazards models were calculated. RESULTS: Overall, 57,898 and 66,981 individuals received a 2-dose regimen of mRNA-1273 or BNT161b2, respectively. Among the weighted population, mean age was 51 years, 53 % were female, and baseline immunodeficiencies included prior blood transplant (8%-9%), prior organ transplant (7%), active cancer (12%-13%), primary immunodeficiency (5-6%), HIV (20%-21%), and immunosuppressive therapy use (60%-61%). Rates per 1,000 person-years (PYs; 95% confidence intervals [CI]s) of breakthrough medically-attended COVID-19 were 25.82 (23.83-27.97) with mRNA-1273 and 30.98 (28.93, 33.18) with BNT162b2 (HR, 0.83; 95% CI, 0.75-0.93). When requiring evidence of an antigen or polymerase chain reaction test before COVID-19 diagnosis, the HR for medically-attended COVID-19 was 0.78 (0.67-0.92). Breakthrough COVID-19 hospitalization rates per 1,000 PYs (95% CI) were 3.66 (2.96-4.51) for mRNA-1273 and 4.68 (3.91-5.59) for BNT162b2 (HR, 0.78; 0.59-1.03). Utilizing open and closed claims for outcome capture only, or both cohort entry/outcome capture, produced HRs (95% CIs) for COVID-19 hospitalization of 0.72 (0.57-0.92) and 0.66 (0.58-0.76), respectively. CONCLUSIONS: Among immunocompromised adults, a 2-dose mRNA-1273 regimen was more effective in preventing medically-attended COVID-19 in any setting (inpatient and outpatient) than 2-dose BNT162b2. Results were similar for COVID-19 hospitalization, although statistical power was limited when using closed claims only. STUDY REGISTRATION: NCT05366322.

Racial differences in predictors of dental care use.

OBJECTIVE: To test five hypotheses that non-Hispanic African Americans (AAs) and non-Hispanic whites (NHWs) differ in responsiveness to new dental symptoms by seeking dental care, and differ in certain predictors of dental care utilization. DATA SOURCES/STUDY SETTING: Florida Dental Care Study, comprising AAs and NHWs 45 years old or older, who had at least one tooth, and who lived in north Florida. STUDY DESIGN: We used a prospective cohort design. The key outcome of interest was whether dental care was received in a given six-month period, after adjusting for the presence of certain time-varying and fixed characteristics. DATA COLLECTION/EXTRACTION METHODS: In-person interviews were conducted at baseline and 24 months after baseline, with six-monthly telephone interviews in between. PRINCIPAL FINDINGS: African Americans were less likely to seek dental care during follow-up, with or without adjusting for key predisposing, enabling, and oral health need characteristics. African Americans were more likely to be problem-oriented dental attenders, to be unable to pay an unexpected $500 dental bill, and to report postbaseline dental problems. However, the effect of certain postbaseline dental signs and symptoms on postbaseline dental care use differed between AAs and NHWs. Although financial circumstance was predictive for both groups, it was more salient for NHWs in separate NHW and AA regressions. Frustration with past dental care, propensity to use a homemade remedy, and dental insurance were significant predictors among AAs, but not among NHWs. The NHWs were much more likely to have sought care for preventive reasons. CONCLUSIONS: Racial differences in responsiveness to new dental symptoms by seeking dental care were evident, as were differences in other predictors of dental care utilization. These differences may contribute to racial disparities in oral health.

Predicting tooth loss during a population-based study: role of attachment level in the presence of other dental conditions.

BACKGROUND: Our objectives were to quantify: 1) the association between incident tooth loss and prior periodontal attachment level; and 2) the contribution to tooth loss made by non-periodontal conditions in increasingly periodontally involved teeth. METHODS: The Florida Dental Care Study was a prospective cohort study of persons who at baseline had at least 1 tooth and were 45 years or older. In-person interviews and clinical examinations were conducted at baseline, and at 24 and 48 months, with telephone interviews at 6-month intervals in between. A regression model was used to simultaneously quantify tooth-specific predictors of tooth loss, with person-level factors taken into account. RESULTS: Of the 687 persons who participated for a 48-month clinical examination, 36% lost 1 or more teeth during follow-up, and 5.0% of all teeth were lost. Attachment level up to 2 years before tooth loss was strongly predictive of incident tooth loss, with increases in risk for each millimeter in attachment loss. Certain other tooth-specific conditions (tooth mobility, bulk restoration fracture, decayed surfaces, filled surfaces, tooth type and arch location, root fragment) were strongly and independently associated with increased risk for tooth loss, while others were not (prosthetic crown coverage, cusp fracture, root surface defect). Propensity to choose extraction over other treatment alternatives, as reported by participants at baseline, was also strongly predictive of tooth loss. CONCLUSIONS: Increasingly severe attachment level was consistently associated with an increased risk for tooth loss in this sociodemographically diverse sample, with or without other tooth-specific conditions taken into account.

Comparison of endodontist versus generalist regarding preference for postendodontic use of cotton pellets in pulp chamber.

A degree of uncertainty exists about the use of cotton pellets in the pulp chamber after canal obturation. The purpose of this study was to poll practicing endodontists and generalists regarding their preference. Forty-six endodontists and an equal number of general dentists were polled in a mail survey regarding their preferences for the use of a cotton pellet in the pulp chamber after canal obturation. Eighty-seven percent of the endodontists and 54% of the generalists responded. Of the endodontists, 62.5% said they thought that the general dentist wanted a cotton pellet, contrasted to 80% of the generalists. The difference in proportions was not statistically significant.

Two-year incidence of oral disadvantage, a measure of oral health-related quality of life.

UNLABELLED: Dental research has progressed from describing the burden of oral disease using traditional epidemiologic measures of incidence and prevalence, to measuring how oral disease, oral signs, and oral symptoms affect the daily activities and the overall quality of life of the individual. However, longitudinal evaluation of these associations remains rare. OBJECTIVES: To (i). describe the 2-year incidence and patterns of oral disadvantage; (ii). identify dimensions of oral health measures that are significant antecedents of oral disadvantage; and (iii). determine which oral health dimensions are the most strongly predictive of oral disadvantage. METHODS: The Florida Dental Care Study was a longitudinal study of oral health in diverse groups of persons who at baseline had at least one tooth and were 45 years or older. Incidence rates, odds ratios, and 95% confidence intervals were used to describe oral disadvantage and its relation to other measures of oral health. RESULTS: Nearly one-half of the participants experienced oral disadvantage at least once during 24 months of follow-up. The strongest antecedents associated with oral disadvantage were toothache pain and chewing difficulty. CONCLUSIONS: The incidence of oral disadvantage is substantial and consistent with the notion that oral health has a substantial impact on quality of life. Measures of oral pain and oral functional limitation were more strongly predictive of oral disadvantage than disease and tissue damage antecedents.

Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence.

OBJECTIVES: This paper estimates the incidence of oral disadvantage based on the subject's approach to dental care, sex, race, and financial status; identifies demographic and socioeconomic characteristics that were associated with oral disadvantage; and determines if these characteristics were differentially associated with the three domains of oral disadvantage. METHODS: The Florida Dental Care Study was a longitudinal study of oral health in diverse groups of persons who at baseline had at least one tooth, were 45 years or older, and were either African American or non-Hispanic white. Incidence rates, odds ratios, and 95 percent confidence intervals were used to describe oral disadvantage and its relation to race, income, and other key sociodemographic characteristics. RESULTS: The strongest independent predictors of oral disadvantage were approach to dental care (problem-oriented attenders or regular), and situation if faced with an unexpected $500 dental bill. Demographic and socioeconomic characteristics were differentially associated with each disadvantage domain. CONCLUSIONS: African Americans, females, rural residents, individuals who did not graduate from high school, individuals with limited financial resources, and problem-oriented dental attenders had significantly higher occurrences of oral disadvantage. Racial and sex disparities in oral disadvantage were largely explained by differences in approach to dental care and financial resources between these groups.

Comparison of two methods of estimating 48-month tooth loss incidence.

OBJECTIVES: This paper quantifies validity of self-reported tooth loss, compares incidence using two methods (semiannual self-report, biannual clinical examination), and compares conclusions about risk factors for tooth loss using these two methods. METHODS: The Florida Dental Care Study included persons who at baseline had at least one tooth. In-person interviews and clinical examinations were conducted at baseline, 24 months, and 48 months, with semiannual telephone interviews in between. RESULTS: Agreement between self-reported and clinically derived tooth loss was high, although some statistically significant differences by certain baseline characteristics were evident. On a nominal scale (some tooth loss, none), kappa was 0.88 and percent concordance was 94 percent. On a ratio scale, Spearman's correlation was 0.90. Using self-report, the incidence estimate would have been 34 percent, as compared to 36 percent based on clinical examination. In a single bivariate (loss by self-report, loss by clinical examination) multiple logistic regression, conclusions about statistical significance and magnitude of seven risk factors for tooth loss did not differ. CONCLUSIONS: Validity of self-reported incidence was excellent. The self-reported method allowed for semiannual estimates and was less resource intensive. Substantive conclusions about tooth loss using either method were similar, although validity did differ between persons with certain baseline characteristics.

Access to dental care in Alabama for children with special needs: parents' perspectives.

BACKGROUND: Access to dental care and delivery of quality dental health services are important for children with special needs. The authors surveyed parents of children with special needs in Alabama to determine their perceptions of access and barriers to dental care for their children. METHODS: The authors sent a questionnaire to 2,057 parents of children aged 3 to 13 years with special needs--cleft lip and/or palate; cerebral palsy, or CP; spina bifida; or epilepsy/seizure disorders--who were listed in a database provided by Children Rehabilitation Services of Alabama. The authors conducted univariate and multivariate analyses to calculate odds ratios and 95 percent confidence intervals. RESULTS: The overall response rate was 38 percent (N = 714). Eighty-five percent of respondents reported that their children had received some form of routine dental care. However, 35 percent of respondents reported they had had problems finding dentists willing to treat their children. Among those with problems, significant barriers to dental care included their children's having Medicaid insurance, poor oral health or CP, as well as a shortage of dentists with training in the care of children with special needs. CONCLUSIONS AND PRACTICE IMPLICATIONS: While the majority of respondents said their children had access to dental care, one-third said their children had problems receiving this care. Many of these problems can be ameliorated. Increasing providers' participation in the Medicaid program and improving their knowledge about, empathy for and training in the care of children with special needs is essential in improving access to dental care for this population.

Chronic oral disadvantage, a measure of long-term decrements in oral health-related quality of life.

UNLABELLED: Few studies have investigated the relation between oral health-related quality of life (HRQL) and key demographic, socioeconomic, and oral health decrements. METHODS: Data were taken from 873 participants from the Florida Dental Care Study. Chronic oral disadvantage was defined from incident oral disadvantage, a measure of oral HRQL, reported for a minimum of two consecutive 6-month intervals. Patterns of chronic oral disadvantage over the 24-month period were described. Associations between the dependent variable, chronic oral disadvantage, and demographic variables, socioeconomic variables, oral health decrements, and dental services were evaluated. RESULTS: During 24 months of follow-up, 30% of subjects reported chronic oral disadvantage. Chronic oral disadvantage was significantly associated with approach to dental care, area of residence, situation if faced with an unexpected dollars 500 dental bill, teeth that are stained or look bad, cavities, sore or infected gums, loose tooth or cap, toothache or abscess, dental sensitivity, and chewing difficulty. A recent dental visit was associated with reduced progression to chronic oral disadvantage. CONCLUSION: A large proportion of subjects avoided certain daily activities due to oral health decrements for longer than 6 months. Recent dental visits were significantly associated with limitation of long-term progression of oral disadvantage.

The paradox of dental need in a population-based study of dentate adults.

BACKGROUND: Studies typically find that predisposing and enabling factors strongly predict dental utilization, but that need factors do not. However, few longitudinal studies have been conducted, and few have comprehensively measured dental need. OBJECTIVES: To describe the paradox of dental need, and to test three hypotheses regarding need and dental care use. MATERIALS AND METHODS: An observational study that included 873 persons who participated for interview and clinical examination at baseline and 24 months, with 6-month telephone interviews in between. RESULTS: Persons who entered the dental care system during follow-up were actually in better dental health than those who did not. The ability of need factors to predict dental care use, and in which direction, varied with how dental need and the dental care use outcome were measured (eg, care of any type, problem-related care, to receive a dental cleaning, to get a dental checkup). CONCLUSIONS: A substantial number of dental problems remained or developed among the population that did not enter the dental care system. The paradox of dental need has three components: (1) need predicts dental care use but is dependent upon how need is measured; (2) however, persons with a higher probability of new dental problems are actually less likely to seek dental care; and (3) self-reported disease and oral pain are associated with a higher likelihood of seeking care, whereas clinically-determined need, such as chewing difficulty, lower self-rating, and satisfaction with oral health, are actually associated with a lower likelihood, the former direction being the predominant and expected direction.

Comparing longitudinal binary outcomes in an observational oral health study.

Observational studies continue to be recognized as viable alternatives to randomized trials when making treatment group comparisons, in spite of drawbacks due mainly to selection bias. Sample selection models have been proposed in the economics literature, and more recently in the medical literature, as a method to adjust for selection bias due to observed and unobserved confounders in observational studies. Application of these models has been limited to cross-sectional observational data and to outcomes that are continuous in nature. In this paper we extend application of these models to include longitudinal studies and binary outcomes. We apply a two-stage probit model using GEE to account for correlated longitudinal binary chewing difficulty outcomes. Chewing difficulty was measured every six months during a 24-month period between two groups of subjects: those either receiving or not receiving dental care. Dental care use was measured at six-month intervals as well. Results from our proposed model are compared to results using a standard GEE model that ignores the potential selection bias introduced by unobserved confounders. In this application, accounting for selection bias made a major difference in the substantive conclusions about the outcomes of interest. This is due in part to an adverse selection phenomenon in which those most in need of treatment (and consequently most likely to benefit from it) are actually the ones least likely to seek treatment. Our application of sample selection models to binary longitudinal observational outcome data should serve as impetus for increased utilization of this promising set of models to other health outcomes studies.