Efficacy of Early Preventive Dental Services in Primary Medical Care Setting: Results From Alabama's 1st Look Program.

Purpose: To evaluate early preventive dental services (PDS) provided by primary care providers (PCPs) in reducing future caries treatments among Alabama Medicaid recipients. Methods: Data from 2009 to 2019 Alabama Medicaid were used to evaluate effectiveness of 1st Look Program on PDS before age three years and incidence of caries treatments after age three years. PDS groups consisted of 1st Look-involved (PDS claims from PCPs), dentist-only (PDS claims from dental providers), and no early fluoride treatment participants (no PDS claims before age three years). Outcomes included frequency and expenditures of fluoride applications, simple restorations, and extensive treatments. Regression models were used to evaluate associations between PDS groups and outcomes while controlling for covariates. Results: Children in 1st Look- involved received more fluoride (3.0 versus 2.1 times; P<0.001) and were applied earlier (12.1 versus 22.9 months old; P<0.001) than dentist-only group. After adjusting for covariates, compared to dentist-only, 1st Look-involved group received earlier fluoride (beta value equals -11.1 months; 95 percent confidence interval [95% CI] equals -11.25 to -10.97) with greater frequency (incident rate ratio equals 1.49; 95% CI equals 1.47 to 1.51). Caries treatment counts were highest in dentist-only followed by 1st Look-involved and no early fluoride treatment groups in both simple restorations (2.7 versus 2.0 versus 0.2 times; P<0.001) and extensive treatments (2.8 versus 2.3 versus 0.2 times; P<0.001), which were consistent after adjusting for covariates. Conclusions: PDS were provided earlier by PCPs in Medicaid-qualified children, with reduced caries treatments on primary teeth, compared to PDS by dental providers only.

Community dental health coordinators' role in community-based pediatric dental education.

PURPOSE: The University of Alabama at Birmingham (UAB) School of Dentistry utilized a Community Dental Health Coordinator (CDHC) to transform a community-based dental education rotation into a positive learning experience for senior dental students. Based in a county health department's Women, Infant, and Children's (WIC) clinic and dental clinic, the initial rotation before implementation of the CDHC was received poorly by students and community partners. This paper reports how CDHC involvement improved student experiences with pediatric patients. METHODS: In 2018, the CDHC embedded in the WIC clinic where student rotations occur and developed relationships with the community partners to identify key issues. The CDHC then implemented qualitative improvements, including a restructured workflow, preparatory educational modules, and assessment systems to address the issues. Student performance reports, focus group discussions, and a postgraduation questionnaire provided data for evaluation of performance. RESULTS: By year 3, dental appointments for patients under age 6 increased, resulting in 95% of UAB students seeing this age patient; 74% completed four or more. Three-quarters of students reported performing restorative procedures on children. Student and community partner acceptance of the rotation also improved. Postgraduation questionnaires (32% response rate) indicate 35% of graduates continue to treat Medicaid patients after graduation. CONCLUSION: The CDHC's unique skills in community relationship-building, community-based dental screenings, and pediatric dental care coordination produced measurable improvements in community participation and student clinical experiences. The CDHC can be a vital part of dental education, especially in community education settings. Community-based dental education generated measurable improvements in students' clinical experiences.

Medicaid participation by private dentists in Alabama.

OBJECTIVE: The objective of this study was to examine the relationship between private dentists' attitudes toward Medicaid and Medicaid patients and their extent of Medicaid participation. METHODS: A survey was mailed to all Medicaid dentists in Alabama in 2003 (N = 518). Descriptive statistics were calculated, and multiple regression models were tested. The "dentists' extent of participation" was a measure of the percentage of Medicaid patients seen in one month. Independent variables included dentists' personal and practice characteristics; market area characteristics; and dentists' attitudes toward Medicaid and Medicaid patients. RESULTS: A total of 277 (54%) surveys was returned. Non-Caucasian dentists in group practice had a higher mean of extent of Medicaid participation than Caucasian dentists in solo practice. Moreover, compared to privately insured families, dentists had significantly higher mean of extent of Medicaid participation if they perceived Medicaid reimbursement as generous; payments being processed faster; and families as not acceptable to non-Medicaid families in the practice. CONCLUSIONS: Dentists' perceptions of Medicaid policies, such as generosity of payment and speed of processing payment, are important to ensure continued provider participation in Medicaid. Strategies to improve dentists' participation in Medicaid must be multifaceted to increase access to dental services for Medicaid children.

Impact of increasing Medicaid dental reimbursement and implementing school sealant programs on sealant prevalence.

UNLABELLED: We examined the impact of two financing strategies--increasing Medicaid dental reimbursements and providing school sealant programs--on dental sealant? prevalence (number of children with at least one sealant) among 7- to 9-year-olds in Alabama and Mississippi counties from 1999 to 2003. METHODS: We used Medicaid claims data in a linear regression model. We regressed number of children sealed per county onto eligible children, median family income, dentist-to-population ratio, and indicator variables for reimbursement increase, presence of community health center (CHC) or school sealant program, and interaction between reimbursement increase and presence of school program or CHC. We also calculated the average incremental cost per sealant from increasing the Medicaid reimbursement rate and then disaggregated it into cost to provide additional sealants and cost to provide the same number of sealants under the higher rate. RESULTS: Increasing the sealant reimbursement rate was associated with a 102 percent increase and a 39 percent increase in sealant prevalence in Mississippi and Alabama, respectively. Introducing school sealant programs more than doubled sealant prevalence in both states. In Mississippi, 85 percent of the average incremental cost from implementing the higher reimbursement rate was due to providing new sealants and 15 percent was due to paying a higher rate for sealants that likely would have been delivered at the old rate. CONCLUSION: Depending on supply and demand conditions in dental markets, both strategies can be effective in increasing sealant prevalence.

Oral health surveillance: past, present, and future challenges.

We reviewed and summarized the efforts in the United States to collect data on oral diseases, conditions, and behaviors implemented at the national and state level. The main characteristics of these efforts were: (1) systematic collection of data from representative samples, mostly at the national level; (2) one-time or sporadic experiences when data are collected at state and local levels; (3) use of visual-tactile protocols implemented at the tooth-surface or tooth-site level for data collection; (4) focus mainly on dental caries and periodontal diseases; and (5) leap-time from data collection to publication of results. Using the definition of surveillance in public health (the ongoing and systematic collection, analysis, and interpretation of outcome-specific data for use in planning, implementing, and evaluating public health practice), we show there is an impending need to develop new techniques to build up surveillance systems for oral diseases, conditions, and behaviors at the national, state, and local levels. In the second part of this review, we presented a number of alternative techniques developed in the last 10 years to collect timely data for oral health. The main characteristics of these efforts include: (1) focusing on data collection at state and local level; (2) integration into existing and ongoing surveillance systems; (3) using visual-only protocols to collect data on oral disease status; (4) focusing on a variety of diseases, conditions, and behaviors; and (5) analyzing the data in a timely matter. Many of these efforts have been integrated into the National Oral Health Surveillance System, which has developed eight indicators in response to national health objectives. Finally, we envision the future of visual-tactile protocols in data collection of representative samples to monitor oral health status at the national level and as a research tool. At the state and local level, however, we envision an integrated system of data collection as a constantly evolving process as new techniques are developed in response to new demands.

Updated comparison of the caries susceptibility of various morphological types of permanent teeth.

UNLABELLED: In 1941, Klein and Palmer published a landmark study that ranked the relative susceptibility to dental caries of various morphological tooth types. Specifically, Klein and Palmer used a four-step approach, which included derivation of: (1) an eruption schedule; (2) posteruptive tooth age; (3) cumulative number of decayed, missing, and filled teeth and cumulative posteruptive tooth age; and (4) relative susceptibility values. Their study was conducted when dental caries prevalence and severity were generally high in the United States, prior to the introduction of preventive measures such as fluoride and dental sealants. This investigation used more recent data to assess whether declines in dental caries prevalence over time have been accompanied by changes in the relative susceptibility of permanent tooth types. METHODS: The data source for this investigation was the oral examination component of the Third National Health and Nutrition Examination Survey. This investigation used analytical methods to derive the relative susceptibility values that were identical with those used during the Klein and Palmer study. Full sample weights were used with SUDAAN so that the descriptive estimates would be representative of the US population. Analysis was limited to children aged 4 through 20 years. RESULTS: The investigation found six categories of susceptibility, with molars being more susceptible than incisors, canines, or premolars. In general, susceptibility values declined since the Klein and Palmer study, providing additional evidence for a caries decline in the United States. First and second molar susceptibility values from the NHANES III data, however, intersected with those of Klein and Palmer, suggesting that factors specific to the molars, such as the selective use of dental sealants on these teeth, might be playing an additional role. CONCLUSIONS: Future research should explore factors that might explain the changes in relative susceptibility values over time.

Esthetically objectionable fluorosis attributable to water fluoridation.

OBJECTIVE: We compared estimates of fluorosis prevalence and risk attributable to fluoridation using an index applied to the entire dentition and to the maxillary anterior teeth. We also estimated the prevalence of perceived esthetic problems attributable to current fluoridation policy (Attributable Burden). METHODS: Fluorosis prevalence estimates were obtained from the National Survey of Oral Health in US School Children (1986-87) for the 1839 survey children aged 12 -14 years who were scored for fluorosis, had never received fluoride drops or tablets, and had lived in only one home. For each child we calculated Dean's fluorosis index, and an anterior fluorosis index (value of the highest scored maxillary anterior tooth). We used each index to calculate risk of fluorosis attributable to fluoridation by subtracting at each level of severity the prevalence of fluorosis among those living in low fluoride areas (F

Prevalence and trends in enamel fluorosis in the United States from the 1930s to the 1980s.

BACKGROUND: The National Survey of Dental Caries in U.S. School Children: 1986-1987 conducted by the National Institute of Dental Research, or NIDR, remains the only source of national data about the prevalence of enamel fluorosis. The authors analyze these data and describe changes in the prevalence of enamel fluorosis since the 1930s, as reported by H. Trendley Dean. METHODS: A sample of children comparable to those described in the 1930s was selected from the NIDR data set among children living in households served by public water systems during the child's first eight years of life. The type of water system (that is, natural, optimal and suboptimal) for each household had been recorded in the NIDR data set using data from the 1985 U.S. Fluoridation Census. The NIDR data set included information about the children's history of fluoride exposure obtained from parents. RESULTS: In the 1986-1987 period, the prevalence of enamel fluorosis (ranging from very mild to severe) was 37.8 percent among children living in residences with natural fluoride (0.7 to 4.0 parts per million fluoride ions, or F-), 25.8 percent in the optimal fluoride group (0.7 to 1.2 ppm F- and 15.5 percent in the suboptimal fluoride group (< 0.7 ppm F-). The largest increase in fluorosis prevalence from the 1930s to the 1980s was in the suboptimal fluoride group (6.5 to 15.5 percent). CONCLUSIONS AND CLINICAL IMPLICATIONS: Exposure to multiple sources of fluoride may explain the increase in enamel fluorosis from the 1930s to the 1980s. The exposure to fluoride from sources such as dietary supplements has decreased since the 1980s because of reductions in the recommended dosage, but these changes occurred too late to have an effect on the study cohort. Evidence of simultaneous use of systemic fluorides indicates the need to reinforce guidelines for the appropriate use of fluorides and promote research on measuring total fluoride exposure.