Advancing Oral Health Equity through Medical-Dental Integration: Dental hygienists as catalysts for change in an evolving health care system.

This report explores the changing landscape of oral health care delivery in the United States, highlighting the evolving role of dental hygienists. The 2021 National Institutes of Health report "Oral Health in America: Advances and Challenges" has become a key milestone in addressing oral health inequities, acknowledging the important role that dental hygienists could play in expanding innovative care models, and promoting medical-dental integration (MDI). The Rainbow Model of Integrated Care offers a framework to examine facilitators of MDI care models, revealing supportive policies, interprofessional collaborative practice, incremental change, and local leadership as some of the crucial components needed for success. Dental hygienists emerge as catalysts for change, as such, the overarching aim of this report is to contribute to the broader conversation about optimizing oral health care accessibility through integrated care models led by dental hygienists.

Oral Health Screening by MassHealth Accountable Care Organizations: An opportunity for equity-focused interventions.

Establishing reliable access to dental services for publicly insured patients is an important part of achieving equitable oral health care. In 2023, an oral health screening requirement was added to the MassHealth Accountable Care Organization contract, which has the capacity to affect over 1.3 million members enrolled in MassHealth Accountable Care Organizations throughout the state. The goal of the oral health screening requirement is to identify MassHealth-insured patients who do not have reliable access to dental services and to provide them with resources to establish a dental home with a MassHealth-participating dentist. Primary care providers were surveyed, and results indicate a need for a care coordination mechanism to assist MassHealth-insured patients with establishing a dental home, in addition to an option to request telehealth-enabled and/or urgent dental appointments. This report describes the oral health screening program at one MassHealth Accountable Care Organization and presents some of the data collected during the first year of its implementation, in addition to discussing how this data is being used to guide equity-focused interventions with the potential for policy implications.

Developing Parametric and Nonparametric Models for Model-Informed Precision Dosing: A Quality Improvement Effort in Vancomycin for Patients With Obesity.

BACKGROUND: Both parametric and nonparametric methods have been proposed to support model-informed precision dosing (MIPD). However, which approach leads to better models remains uncertain. Using open-source software, these 2 statistical approaches for model development were compared using the pharmacokinetics of vancomycin in a challenging subpopulation of class 3 obesity. METHODS: Patients on vancomycin at the University of Vermont Medical Center from November 1, 2021, to February 14, 2023, were entered into the MIPD software. The inclusion criteria were body mass index (BMI) of at least 40 kg/m2 and 1 or more vancomycin levels. A parametric model was created using nlmixr2/NONMEM, and a nonparametric model was created using metrics. Then, a priori and a posteriori predictions were evaluated using the normalized root mean squared error (nRMSE) for precision and the mean percentage error (MPE) for bias. The parametric model was evaluated in a simulated MIPD context using an external validation dataset. RESULTS: In total, 83 patients were included in the model development, with a median age of 56.6 years (range: 24-89 years), and a median BMI of 46.3 kg/m2 (range: 40-70.3 kg/m2). Both parametric and nonparametric models were 2-compartmental, with creatinine clearance and fat-free mass as covariates to c clearance and volume parameters, respectively. The a priori MPE and nRMSE for the parametric versus nonparametric models were -6.3% versus 2.69% and 27.2% versus 30.7%, respectively. The a posteriori MPE and RMSE were 0.16% and 0.84%, and 13.8% and 13.1%. The parametric model matched or outperformed previously published models on an external validation dataset (n = 576 patients). CONCLUSIONS: Minimal differences were found in the model structure and predictive error between the parametric and nonparametric approaches for modeling vancomycin class 3 obesity. However, the parametric model outperformed several other models, suggesting that institution-specific models may improve pharmacokinetics management.

Critical shear stress of sunken, No. 6 heavy fuel oil in fresh water.

A series of flume- and laboratory-based experiments defined and quantified the thresholds of sunken oil transport using No.6 heavy fuel oil mixed with kaolinite clay. When the sunken oil became mobile, the current-induced bed shear stress exceeded a threshold value specific to the oil, known as critical shear stress (CSS). The oil's CSS was evaluated as a function of water velocity, water temperature, oil condition, and sediment size. Based on experimental results, the stages of oil transport were defined and empirical relationships using the oil's kinematic viscosity (vo) and sediment size were developed to predict oil CSS at each transport stage. For vo<2 × 104 cSt, multiple thresholds of movement were observed: (1) gravity dispersion, (2) rope formation, (3) ripple formation, and (4) break-apart/resuspension. When vo> 6 × 104 cSt, transport was more likely to occur as a single event with the oil remaining intact, saltating over the bed in the direction of flow.

An Evaluation of STFM's National Addiction Curriculum.

BACKGROUND AND OBJECTIVES: Family physicians are well positioned to treat patients with substance use disorders (SUDs), expand access to care, destigmatize addiction, and provide a biopsychosocial treatment approach. There is a great need to train residents and faculty to competency in SUD treatment. Through the Society of Teachers of Family Medicine (STFM) Addiction Collaborative, we created and evaluated the first national family medicine (FM) addiction curriculum using evidence-based content and teaching principles. METHODS: After launching the curriculum with 25 FM residency programs, we collected formative feedback through monthly faculty development sessions and summative feedback through 8 focus groups with 33 faculty members and 21 residents. We used qualitative thematic analysis to assess the value of the curriculum. RESULTS: The curriculum enriched resident and faculty knowledge across all SUD topics. It changed their attitudes in viewing addiction as a chronic disease within the scope of FM practice, increased confidence, and decreased stigma. It nurtured behavior change, enhancing communication and assessment skills and encouraging collaboration across disciplines. Participants valued the flipped-classroom approach, videos, cases, role plays, ready-made teacher's guides, and one-page summaries. Having protected time to complete the modules and temporally coupling the modules with the live, faculty-led sessions enhanced learning. CONCLUSION: The curriculum provides a comprehensive, ready-made, evidenced-based platform for training residents and faculty in SUDs. It can be implemented by faculty with all levels of prior expertise, cotaught by physicians and behavioral health providers, tailored to each program's didactic schedule, and modified based on the local culture and resource availability.

Establishing Antibiotic Stewardship Programs in Rural Hospitals to Decrease Fluoroquinolone Prescribing: The Vermont Experience.

Critical access and rural community hospitals struggle to develop effective antimicrobial stewardship programs (ASPs). We assisted six Vermont hospitals in developing their antimicrobial stewardship programs to meet the Centers for Disease Control and Prevention's core elements of antibiotic stewardship. We show that rural hospitals in Vermont can (1) extract antimicrobial use data from their electronic medical record; (2) develop interventions to decrease high use antimicrobial agents, such as fluoroquinolones; and (3) successfully develop sustained ASPs meeting the CDC core elements in less than 2 years.

Association between maternal periodontal disease and adverse pregnancy outcomes: an analysis of claims data.

BACKGROUND: While a number of studies have explored the link between periodontal disease and adverse pregnancy outcomes, both epidemiological studies and intervention trials have reached contradictory results with relatively small sample sizes. Utilizing large-scale claims data, we aim to investigate the association between maternal periodontal disease and adverse pregnancy outcomes. OBJECTIVE: Utilizing large-scale claims data, we aim to investigate the association between maternal periodontal disease and adverse pregnancy outcomes. METHODS: Using de-identified claims data from a national commercial insurer in the USA, records of all observed pregnancies from 2015 to 2019 were included in this retrospective cohort study. Adverse pregnancy outcomes, including low birthweight (LBW) of the newborn, preterm birth (PTB) and spontaneous abortion, were primary outcomes. To evaluate the association between periodontal disease and pregnancy outcomes, logistic mixed-effect model was estimated with periodontal disease status, age, existing clinical conditions of mothers and geographic location as covariates. RESULTS: Out of 748 792 observed pregnancy records, 18.66% resulted in adverse pregnancy outcomes; 5.92% in LBW, 14.46% in PTB and 2.22 % in spontaneous abortion. Adjusting for individual-level risk factors, periodontal disease was significantly associated with maternal complications with odds ratios of 1.19 (95% CI:1.15, 1.24) for any adverse pregnancy outcomes, 1.10 (95% CI:1.03, 1.17) for LBW, 1.15 (95% CI:1.10, 1.19) for PTB and 1.34 (95% CI:1.23, 1.46) for spontaneous abortions. CONCLUSIONS: Maternal periodontal disease may be associated with an increased risk of maternal complications and neonatal morbidity. A timely diagnosis and treatment of periodontal disease during pregnancy should be encouraged by considering oral health as part of routine prenatal care.

An AUC Target Simulation for Vancomycin in Patients With Class III Obesity.

OBJECTIVE: The objective of this simulation is to compare 24-hour vancomycin (Vanc24) dosage requirements between a target area under the curve (AUC) versus a target trough approach in patients with class III obesity. METHODS: Adult patients were included if they received vancomycin in accordance with the University of Vermont Medical Center's class III obesity dosage protocol from June 2016 through December 2018. Patient-specific pharmacokinetic parameters were calculated for each patient using the Sawchuck-Zaske method. For this simulation, Vanc24 dosages were calculated to achieve an AUC of 400 mg/L h and a trough concentration of 15 mg/L. RESULTS: Sixty-three patients had Vanc24 dosage requirements calculated. The median age was 59 years (interquartile range [IQR]: 51.5-68), body mass index (BMI): 45.7 kg/m2 (IQR: 42.4-51.5), and 50.7% were male. The mean Vanc24 dosage requirements were 3995 mg (standard deviation [SD] ±1673) in the target trough approach versus 2783 mg (SD ±1149) in the target AUC approach (P < .0001). CONCLUSION: A target AUC approach required less vancomycin over a 24-hour time period relative to a target trough approach. Vancomycin therapeutic drug monitoring that explicitly targets AUC may reduce vancomycin exposure and potentially decrease the risk of nephrotoxicity in patients with class III obesity.

The integration of oral health-related best practice recommendations in the management of patients with diabetes: a cross-sectional survey of primary care physicians.

OBJECTIVE: To determine whether best practice recommendations are being followed by primary care physicians (PCPs) by examining the integration of oral health-related practices in their management of patients with diabetes. METHODS: A cross-sectional study design was used to examine PCPs' knowledge of the bidirectional link between diabetes and periodontal disease (PD), their adherence to international best practice recommendations, and their experience of interprofessional collaboration with dentists via an online survey. RESULTS: In total, 79 of 173 PCPs completed the online survey. Almost 90 percent of PCPs neither inform patients with diabetes about the link with PD nor advise dental care. Approximately, one-third of PCPs (32 percent) felt confident facilitating access to dentists. However, 93 percent of PCPs do not refer patients with diabetes to dentists as part of diabetes management. CONCLUSION: PCPs tend not to inform their patients with diabetes of the bidirectional link with PD, or provide advice or referral to attend dental care as part of diabetes management.

Variation in dental services by rurality among privately insured adults in the United States.

OBJECTIVES: Rurality is associated with reduced dental access and worse oral health outcomes. It is unknown whether there is variation in dental services received by rural adults who visit a dentist. METHODS: This was a retrospective analysis of claims data from a large private insurer. All individuals who had at least one dental visit in 2018 were included. Patient demographics, whether or not a patient's ZIP code was rural as defined by the Federal Office of Rural Health Policy, as well as ZIP code demographics were collected. Differences in the frequency of dental services received were evaluated using χ2 tests. Multilevel logistic regressions were used to evaluate the individual and ZIP code-level correlates of receiving a preventive dental procedure, a tooth extraction, or a denture-related dental procedure. RESULTS: Rates of preventive, oral and maxillofacial surgery, and denture-related procedures were higher among rural adults. Accounting for individual age and gender, and ZIP code average income and dentist density, rural dwellers were more likely to receive a preventive procedure [odds ratio (OR) 1.15, P < 0.0001] or tooth extraction (OR 1.08, P < 0.0001), and less likely to have a denture-related procedure (OR 0.94, P = 0.015) compared to nonrural dwellers. Female gender was the strongest predictor of receiving a preventive procedure (OR 1.30, P < 0.0001). CONCLUSIONS: Even among privately insured individuals with known access to dental care, rurality was associated with significant differences in the frequency of various dental procedures. Rural dental patients may have higher needs for oral surgical procedures, even when they have access to preventive care.

The detection of oral cancer and potentially malignant disorders in Ireland: An observational study of 100 cases.

OBJECTIVE: To describe the diagnostic details of a sample of histologically diagnosed malignant and potentially malignant oral lesions from Ireland; to examine how these lesions were first detected, and by whom; and to determine whether factors influenced how these lesions were detected, who detected them, and the type of lesion diagnosed. METHODS: A retrospective review was carried out of the clinical notes relating to oral lesions histologically diagnosed as squamous cell carcinoma (SCC), carcinoma in-situ, or epithelial dysplasia from biopsies performed in hospital-based specialist units and submitted to a diagnostic pathology service based in Dublin, Ireland, between June and December 2015. In addition to sex, age, and smoking status, details were collected relating to the diagnosis, how the lesion was detected, and by whom. RESULTS: There were 100 cases reviewed: SCC (29), carcinoma in-situ (5), and epithelial dysplasia (66). There were 49 opportunistic findings: dentists detected 47 (94 percent), and 51 presenting complaints: primary care physicians (PCPs) detected 30 (60 percent). There was a lower likelihood of opportunistic findings among males (odds ratio 0.41; 95 percent CI 0.18, 0.91). CONCLUSIONS: Dentists in Ireland detected significant proportions of malignant and potentially malignant oral lesions as opportunistic findings, although opportunistic findings were less likely to occur among male patients.

When are Oral Antibiotics a Safe and Effective Choice for Bacterial Bloodstream Infections? An Evidence-Based Narrative Review.

Bacterial bloodstream infections (BSIs) are a major cause of morbidity and mortality in the United States. Traditionally, BSIs have been managed with intravenous antimicrobials. However, whether intravenous antimicrobials are necessary for the entirety of the treatment course in BSIs, especially for uncomplicated episodes, is a more controversial matter. Patients that are clinically stable, without signs of shock, or have been stabilized after an initial septic presentation, may be appropriate candidates for treatment of BSIs with oral antimicrobials. There are risks and costs associated with extended courses of intravenous agents, such as the necessity for long-term intravenous catheters, which entail risks for procedural complications, secondary infections, and thrombosis. Oral antimicrobial therapy for bacterial BSIs offers several potential benefits. When selected appropriately, oral antibiotics offer lower cost, fewer side effects, promote antimicrobial stewardship, and are easier for patients. The decision to use oral versus intravenous antibiotics must consider the characteristics of the pathogen, the patient, and the drug. In this narrative review, the authors highlight areas where oral therapy is a safe and effective choice to treat bloodstream infection, and offer guidance and cautions to clinicians managing patients experiencing BSI.

Identification of Risk Factors for Elevated Neonatal Gentamicin Trough Concentrations.

OBJECTIVES: The objective of this study was to identify neonatal and maternal characteristics that may be associated with elevated neonatal gentamicin trough concentrations despite application of a previously published gentamicin dosage strategy. METHODS: Retrospective cohort study of all neonates admitted to University of Vermont Medical Center (562-bed academic teaching hospital, Burlington, VT) receiving gentamicin between June 1, 2009, and August 31, 2013. A total of 205 neonates were included, with 41 cases and 164 controls. RESULTS: Postmenstrual age (PMA, gestational age plus chronological age) and small-for-gestational age (SGA) status were independently associated with elevated neonatal gentamicin trough concentrations. No maternal risk factor evaluated remained significantly associated in the multivariate analysis. CONCLUSIONS: The probability of an elevated gentamicin trough concentration increases with lower PMA and is further accentuated in neonates with SGA status. In contrast, the presence of maternal risk factors did not increase the likelihood of elevated gentamicin trough concentrations. Neonates with lower PMA and SGA status may require an individualized dosage and monitoring strategy.