Identifying sources of variation in added sugar intake for Alaska Native children using a hair biomarker.

Sugars from sugar-sweetened beverages (SSBs) are an important risk factor for tooth decay. The study goal was to determine if there was variation in added sugar intake across communities and between and within households. In this cross-sectional study, intakes of total sugar, added sugar, and sugar-sweetened beverages (SSBs) were estimated for 282 Alaska Native children ages 0-10 years from 131 households in three Yukon-Kuskokwim (YK) Delta communities using biomarker equations based on hair carbon and nitrogen isotope ratios previously developed for the Yup'ik population. ANOVA was used to assess associations between each predictor (community and household) and outcome (estimated total sugars, added sugars, and SSB intake). Between- and within-household variation was estimated using a linear mixed-effects model with a random intercept for households with three or more children. There was no significant difference in mean estimated total sugar (p = 0.29), added sugar (p = 0.24), or SSB intake (p = 0.40) across communities. Significant variations were observed between and within households, with within-household variation amounting to 59% of the between-household variation. Added sugar intake in Alaska Native children from the three study communities is higher than the recommended maximum, and the variation is greater within households than between households.

Nonpharmacological Behavior Guidance for the Pediatric Dental Patient.

Purpose: To present evidence-based recommendations on nonpharmacological behavior guidance for the pediatric dental patient. Methods: The work group assessed eight systematic reviews for effectiveness of nonpharmacological behavior guidance techniques in children undergoing preventive care or a dental treatment visit. The key outcomes assessed included cooperative behavior, anxiety, and procedural pain. To formulate the recommendations, the work group used the GRADE framework to obtain consensus on domains such as priority of the problem, certainty of the evidence, balance between desirable and undesirable consequences, patients' values and preferences, acceptability, and feasibility. Results: Overall, the use of basic nonpharmacological behavior guidance techniques resulted in trivial-to-small effect on improvement in behavior or reduction in anxiety. However, for children and adolescents undergoing preventive care, mobile applications and modeling showed large effects in reduction of anxiety. For those undergoing dental treatment, strategies such as modeling, positive reinforcement, biofeedback relaxation, breathing relaxation, animal-assisted therapy, combined tell-show-do, audiovisual distraction, and cognitive behavior therapy showed large reduction in anxiety. For children and adolescents with special health care needs, audiovisual distraction and sensory-adapted dental environment showed large reduction of anxiety. Conclusions: All the formulated recommendations were conditional and were mostly based on very low certainty of evidence. Conditional recommendations imply that different choices or combinations of behavior guidance techniques may be most appropriate for different patients. Clinicians should use techniques consistent with the parent/patient values and preferences. These recommendations are based on the best available evidence to-date and are intended to aid clinical decision making.

Pediatric Dentists' Use of Nonpharmacological Behavior Guidance Techniques and Experiences with Parent / Caregiver Acceptance: A National Survey.

Purpose: To determine: (1) which nonpharmacological behavior guidance techniques recommended in the American Academy of Pediatric Dentistry's (AAPD) best practice statement are currently routinely used by pediatric dentists; and (2) their perception of parent/ caregiver acceptance of the techniques. Methods: All active AAPD dentist members were invited to participate in this cross-sectional study. Participants (n equals 518) completed an online questionnaire that queried the use of each nonpharmacological behavior guidance technique outlined in the AAPD best practice statement, the frequency with which parent / caregiver hesitancy/refusal is encountered for each, and practice characteristics and demo- graphics. Data were analyzed using descriptive statistics and tests of group differences. Results: Nearly all participants endorsed routine use of the foundational techniques tell-show-do (98.6 percent), counseling skills to build rapport (97.7 percent), and positive reinforcement (95.6 percent). Fewer endorsed using more complex techniques like desensitization (75.3 percent), memory restructuring (22.6 percent), and cognitive behavioral therapy (4.4 percent). There were significant differences in mean years of clinical experience between those who used and did not use some of the more complex techniques. Of the 26 techniques queried, parent / caregiver hesitancy/refusal was encountered most frequently for parental absence, physical restraints, and voice control, and never to rarely for the others. Conclusions: This first-ever study of all nonpharmacological behavior gui- dance techniques outlined in the AAPD's best practice statement suggests that pediatric dentists routinely use foundational techniques but less frequently use more resource-intensive or complex techniques. With few exceptions, these techniques are well accepted by parents / caregivers.

Nonpharmacological Behavior Guidance For Children During Dental Treatment Visits: A Systematic Review and Meta-Analysis-Part 2.

'Purpose: To assess the effectiveness of nonpharmacological behavior guidance interventions used for children undergoing dental treatment visits. METHODS: Databases: Ovid MEDLINE, PsycINFO (EBSCOhost), Embase, and Cochrane Library, were searched from 1946 to February 2022, for randomized clinical trials (RCTs) comparing effectiveness of basic and advanced nonpharmacological techniques rendered during a dental treatment visit including sealants, restorative care, dental local anesthesia, and simple surgical procedures. The primary outcome measures were reduction in anxiety, fear, pain, and improvement in cooperative behavior. Eight authors determined the included RCTs, performed data extraction, and assessed the risk of bias (ROB). Standardized Mean Difference calculation and assignment of quality of evidence by Grading of Recommenda- tions Assessment, Development and Evaluation approach were done. RESULTS: Forty articles qualified for analysis from 219 screened articles. Included studies evaluated the effectiveness of pre-visit preparation and in office strategies rendered pre-/post- or during treatment such as positive imagery, direct observation/modeling, desensitization, tell-show-do and its modifications, voice control, positive reinforcement, memory restructuring, bio- feedback and breathing relaxation, animal assisted therapy, combined therapies, and cognitive behavior therapy. The certainty of evidence ranged from Very low to high and the magnitude of effect varied from trivial to large change in the desired outcomes. CONCLUSIONS: Most of the basic non- pharmacological behavior guidance techniques showed trivial to small reduction in self-reported anxiety and/or improvement in behavior, with modeling, positive reinforcement, biofeedback relaxation, breathing relaxation, animal assisted therapy, combined tell-show-do and audiovisual distraction, and cognitive behavior therapy showing large effects in reduction of anxiety based on some scales.

Nonpharmacological Behavior Guidance for Children with Special Health Care Needs During Preventive and Treatment Dental Visits: A Systematic Review-Part 3.

PURPOSE: To assess the effectiveness of nonpharmacological behavior guidance interventions used for children and youth with special health care needs (CYSHCN) during preventive and dental treatment visits. METHODS: Databases: Ovid MEDLINE, PsycINFO (EBSCOhost), Embase, and Cochrane Library, were searched from 1946 to February 2022, for randomized clinical trials (RCTs) comparing effectiveness of basic and advanced nonpharmacological techniques rendered during a preventive visit (exam, fluoride application, radiographs, and prophylaxis) or a treat- ment visit (simple surgical treatment, sealants, restorative care with or with local anesthesia) with control or other interventions. The primary outcome measures for the studied interventions were reduction in anxiety, fear, pain, and improvement in cooperative behavior. Eight authors determined the included Randomized Controlled Trials (RCTs), performed data extraction, and assessed the risk of bias (ROB). Standardized Mean Difference calculation and assignment of quality of evidence by Grading of Recommendations Assessment, Development and Evaluation approach were done. RESULTS: Eleven articles qualified for analysis from 219 screened articles. Included studies evaluate the effectiveness of in office strategies such as modeling, audio-visual distraction, sensory adapted dental environment, and picture exchange communication system. The certainty of evidence ranged from Very low to Low and the magnitude of effect varied from trivial to large change in the desired outcomes. CONCLUSIONS: Most basic non-pharmacological behavior guidance techniques showed some trivial to small reduction in self-reported anxiety and/ or improvement in behavior, with audiovisual distraction, Sensory Adapted Dental Environment, and Picture Exchange Communication System showing large reduction in anxiety based on some rating scales. Systematic Review Registration Number: PROSPERO: CRD42022314723.

Nonpharmacological Behavior Guidance for Children During Preventive Dental Visits: A Systematic Review-Part 1.

PURPOSE: To assess the effectiveness of nonpharmacological behavior guidance interventions used for a child undergoing preventive dental visits. METHODS: Databases: Ovid MEDLINE, PsycINFO (EBSCOhost), Embase, and Cochrane Library, were searched from 1946 to February 2022, for randomized clinical trials (RCTs) comparing effectiveness of basic and advanced nonpharmacological techniques rendered during a pre- ventive visit including examination, prophylaxis, fluoride application and radiographs. Workgroup (WG) identified moderate-to-high quality system- atic reviews (SRs) published on hypnosis, audiovisual distraction, and parental presence/ absence; and decided to exclude these interventions from current SR to avoid duplication. The primary outcome measures for the studied interventions included reduction in anxiety, fear, pain, and improve- ment in cooperative behavior. Eight authors determined the included RCTs, performed data extraction, and assessed the risk of bias. Standardized Mean Difference calculation and assignment of quality of evidence by Grading of Recommendations Assessment, Development and Evaluation approach were done. RESULTS: Fifteen articles qualified for analysis from 219 screened articles. WG found studies evaluating effectiveness of pre- visit preparation and in-office strategies rendered pre- or during treatment such as positive imagery, communication, modeling, tell-show-do, magic tricks, mobile applications, positive reinforcement, and sensory adapted dental environment. The certainty of evidence ranged from Very low to Moderate and the magnitude of effect varied from trivial to a large change in the desired outcomes. CONCLUSIONS: Most basic nonpharmacological behavior guidance techniques showed trivial to small reduction in self-reported anxiety and/or improvement in behavior, with mobile application and modeling showing large effects in reduction of anxiety based on some rating scales. Systematic Review Registration Number: PROSPERO: CRD42022314723.

Changes in children's dental fear after restorative treatment under different sedation types: Associations with parents' experiences and dental health.

BACKGROUND: Dentists often use sedative medications such as nitrous oxide inhaled sedation and general anesthesia (GA) to help decrease patient fear and manage paediatric patients' behavior during treatment. AIM: The goal of this study was to examine factors associated with dental fear changes after restorative dental treatment under nitrous oxide or GA in children 4-12 years old. DESIGN: A prospective cohort study of 124 children examined changes in dental fear, number of treatment visits, and parental factors among children receiving restorative dental treatment under nitrous oxide (n = 68) or GA (n = 56) sedation. Data were collected at pretreatment (T1), 16 weeks post-treatment (T2), and at 29-month follow-up (T3). RESULTS: Dental fear increased slightly, but not significantly, under both forms of sedation between T1 and T3. Children's dental fear was associated with parents' poor dental experiences and oral health, but not with number of treatment visits. CONCLUSIONS: Progression of children's dental fear seems not dependent solely on the type of sedation used but is likely predicted by factors including pretreatment dental fear and dental needs. Dentists recommending sedation for children's dental care may consider pretreatment dental need, fear levels, and parental factors when determining which type of sedation to use.

Perspectives on the future of dissemination and implementation research in oral and craniofacial sciences.

Dissemination and implementation science is a field of research that promotes the adoption and maintenance of evidence-based interventions in healthcare delivery and community settings and seeks to understand the processes by which such adoption and maintenance occur. While dissemination and implementation science is an established field in health services research, it is relatively new and making inroads in dental, oral and craniofacial research. This article summarizes the proceedings from a scientific panel on 'Dissemination and Implementation Science for Oral and Craniofacial Health' that was held during the international Behavioral and Social Oral Health Sciences Summit. The panelists were four experts on dissemination and implementation science in dental and non-dental academic settings in the United States and Scotland, with affiliations ranging from schools of dentistry and public health to the National Institutes of Health and a healthcare system with integrated dental services. The panel discussion addressed how dissemination and implementation science can be used to further oral health research. The narrative report presented here aims to describe the panelists' reflections and insights on their current initiatives in dissemination and implementation research to inform future research endeavors within the oral and craniofacial sciences. Specifically, this article focuses on six discussion topics: (1) how organizational determinants can serve as facilitators or barriers to the implementation of evidence-based dental practice; (2) how dentistry can 'de-implement' practices that are not effective; (3) how implementation science can support the delivery of evidence-based dental practice using adaptation; (4) how to get started in implementation science; (5) how the broader environment can support large-scale implementation efforts; and (6) how oral and craniofacial science is well suited for advancing dissemination and implementation research.

Dissemination and implementation research for oral and craniofacial health: Background, a review of literature and future directions.

Oral conditions are highly prevalent globally and have profound consequence on individuals and communities. Clinical (e.g. dental treatments, behavioural counselling) and non-clinical (e.g. community-based programming, water fluoridation, oral health policy) evidence-based interventions have been identified, recommended and applied at the clinic, community and policy levels. Still, the burden of oral conditions persists, with inequitable distribution across populations. A major driver of this lack of progress is poor translation of research findings, which results in an evidence-to-practice gap. Dissemination and implementation science (DIS) has emerged to address this gap. A relatively new field, application of DIS represents an important avenue for achieving good dental, oral and craniofacial health for all. The goal of this introductory article is to provide a brief background on DIS relevant to researchers in dentistry and oral health. The problem of knowledge translation, basic concepts and terminology in DIS, and approaches to doing dissemination and implementation research-including implementation strategies, key outcomes, and implementation theories, models and frameworks-are discussed. Additionally, the article reviews literature applying DIS to dentistry and oral health. Results of published studies and their implications for the field are presented. Drawing on the literature review and contemporary thinking in DIS, current gaps, opportunities and future directions are discussed. Resources for understanding and applying DIS are provided throughout. This article serves as a primer on DIS for dental and oral health researchers of all types working across a range of contexts; it also serves as a call to action for increased application of DIS to address the burden of oral conditions globally.

Using Trainee Failures to Enhance Learning: A Qualitative Study of Pediatric Hospitalists on Allowing Failure.

INTRODUCTION: Attendings allow trainee failure when perceived educational benefits outweigh potential patient harm. This strategy has not been explored in pediatrics, where it may be shaped by unique factors. Our objectives were to understand if, when, and how pediatric hospitalists allow trainees to fail during clinical encounters. METHODS: Using constructivist grounded theory, we conducted semistructured interviews with 21 pediatric hospitalists from a children's hospital in the United States. Iterative, constant comparative analysis took place concurrent with data collection. During regular team meetings, we refined and grouped codes into larger themes. RESULTS: Nineteen of the 21 participants shared that they intentionally allowed failure as a teaching strategy, acknowledging this strategy's emotional power and weighing the educational benefits against harms to current and future patients, caregivers, and trainees. Participants described a multistep process for allowing failure: 1) initiate an orientation to signal that they prioritize a psychologically safe learning environment; 2) consider factors which influence their decision to allow failure; and 3) debrief with trainees. However, participants did not explicitly alert trainees to this teaching strategy. They also avoided using the word "failure" during debriefs to protect trainees from psychological harm. CONCLUSIONS: Most pediatric hospitalists in this study allowed failure for educational purposes. However, they did so cautiously, weighing the educational value of the failure against the safety of both current and future patients, the relationship with the caregivers, and the trainees' well-being. Future research should involve trainees to more comprehensively understand the experience and effectiveness of this teaching strategy.

The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States.

PhenomenonMoral distress, which occurs when someone's moral integrity is seriously compromised because they feel unable to act in accordance with their core values and obligations, is an increasingly important concern for physicians. Due in part to limited understanding of the root causes of moral distress, little is known about which approaches are most beneficial for mitigating physicians' distress. Our objective was to describe system-level factors in United States (U.S.) healthcare that contribute to moral distress among pediatric hospitalist attendings and pediatric residents.ApproachIn this qualitative study, we conducted one-on-one semi-structured interviews with pediatric hospitalist attendings and pediatric residents from 4 university-affiliated, freestanding children's hospitals in the U.S. between August 2019 and February 2020. Data were coded with an iteratively developed codebook, categorized into themes, and then synthesized.FindingsWe interviewed 22 hospitalists and 18 residents. Participants described in detail how the culture of medicine created a context that cultivated moral distress. Norms of medical education and the practice of medicine created conflicts between residents' strong sense of professional responsibility to serve the best interests of their patients and the expectations of a hierarchical system of decision-making. The corporatization of the U.S. healthcare system created administrative and financial pressures that conflicted with the moral responsibility felt by both residents and hospitalists to provide the care that their patients and families needed.InsightsThese findings highlight the critical role of systemic sources of moral distress. These findings suggest that system-level interventions must supplement existing interventions that target individual health care providers. Preventing and managing moral distress will require a broad approach that addresses systemic drivers, such as the corporatization of medicine, which are entrenched in the culture of medicine.

Dental trainees' mental health changes, sources of stress, coping strategies, and suggestions for mental health improvement 1 year into the pandemic.

OBJECTIVES: The goal of this study was to assess how the mental health of dental trainees has changed during the pandemic and to identify the most stressful aspects of trainees' programs, stress coping strategies, and suggestions for individual and institution-driven solutions to improve wellness. METHODS: The study focused on dental trainees at the University of Washington who completed a wellness survey in fall 2020 (n = 126; response rate = 35.5%) and spring 2021 (n = 105; response rate = 29.6%). The survey included self-report measures assessing four mental health outcomes: depression, anxiety, isolation from peers, and burnout. Stressful aspects of the training program, coping strategies, and institution-driven solutions were measured with open-ended survey items. The chi-square test was used to compare mental health outcome measures between fall and spring and open-ended survey responses were inductively coded. RESULTS: The prevalence of self-reported depression and anxiety did not change between fall 2020 and spring 2021 (17.2% vs. 21.1%, p = 0.473; 22.4% vs. 23.7%, p = 0.818). Isolation from peers and burnout each significantly increased by almost 20% from fall 2020 to spring 2021 (46.8% vs. 64.3%; p = 0.009 and 26.6% vs. 43.9%; p = 0.017). Trainees identified workload as the most stressful aspect of their program and described using exercise and social support to cope with stress. Trainees suggested institution-supported increases in social events and mental health resources. CONCLUSIONS: One year into the coronavirus disease 2019 pandemic, poor mental health outcomes were common among dental trainees because of high workload and isolation from peers. Dental schools should promote targeted programs and services aimed at improving dental trainees' well-being.

The Impact of the COVID-19 Pandemic on Patients from a Bariatric Program: A Qualitative Analysis of Their Perceptions of Health and Well-Being.

INTRODUCTION: The study was conducted to explore the perceptions of patients from a bariatric program who have undergone or will undergo bariatric surgery during the ongoing COVID-19 pandemic, specifically as related to their struggles with health issues and their psychological well-being. MATERIALS AND METHODS: We conducted semi-structured, in-depth interviews with nineteen pre- or post-bariatric patients to generate data on their perceptions of COVID-19. Consistent with the methods of constructivist grounded theory, we collected and analyzed data iteratively through a constant comparative process for data coding and develop themes in the transcripts. RESULTS: We identified themes to summarize the pandemic-associated experiences of our cohort as follows: their life structure before COVID-19, the turning point with changes and adaptations, and the impact of isolation on psychological well-being. We identified grief due to loss of social contacts as well as physical and psychological health impairment as consequences of pandemic-related lifestyle changes. Most participants were not aware of overweight and obesity being major risk factors for worse outcomes of COVID-19. We developed a theme-based theory on patients' perceptions and fears regarding the pandemic as they live through phases of grief. DISCUSSION: Most participants shared critical perceptions about their own somatic and psychological health. These findings may inform recommendations and strategies for both patients and healthcare professionals to manage the challenges potentially presented by this vulnerable patient group in the context of the COVID-19 pandemic.

Adolescent Dental Fear and Anxiety: Background, Assessment, and Nonpharmacologic Behavior Guidance.

Adolescence, the period from 11 to 21 years of age, bridges the chasm between childhood and adulthood. Adolescence can be challenging as bodies, cognition, and personality go through major transformations, but it is also a time of great joy as confident adults with a clear identity develop. Dentists need to be knowledgeable about the developmental characteristics of this group because some of the cognitive and emotional changes make adolescents vulnerable to new fears. Dentists must tailor behavior guidance to this developing psyche in a way that respects independence and promotes confidence to foster lifelong positive views of dentistry.

Longitudinal Analysis of Children's Oral Health-Related Quality of Life After Restorative Dental Treatment.

Purpose: To document mid- and long-term changes in oral health-related quality of life (OHRQoL) following dental intervention in a sample of restorative treatment-naïve children receiving different levels of care, with and without general anesthesia (GA). Methods: This prospective cohort study followed 132 children. Parents completed the pediatric OHRQoL instrument (POQL) before, 16 weeks after (i.e., posttreatment), and 18 to 45 (mean equals 29.5) months after (i.e., follow-up) child receipt of treatment. Parents provided child demographic and oral health information. The number of restored surfaces and anesthesia type were abstracted from dental records. The mean differences in POQL scores were compared across groups. Results: The sample was 49 percent female (age range equals four to 12 years; mean±standard deviation equals 5.8±1.8). Overall, from pretreatment to posttreatment, mean POQL scores decreased by 4.5 points (P<0.001), representing improved OHRQoL. Only among children with 10 or more surfaces restored or who received GA did follow-up POQL scores remain significantly lower than pretreatment scores (mean difference equals -7.4 and -8.0, respectively, P<0.01). Overall, follow-up scores were significantly higher than posttreatment scores, representing a decline from the initial improvement. Conclusions: Regardless of disease severity, children experience an immediate improvement in OHRQoL following restorative treatment. Improvements in OHRQoL are sustained over the long-term only among children with more extensive pretreatment needs.

How Attendings Can Help Residents Navigate Moral Distress: A Qualitative Study.

OBJECTIVE: To explore how pediatric hospitalist attendings can recognize, prevent, and mitigate moral distress among pediatric residents. METHODS: We conducted a qualitative study, utilizing a deductive approach, from August 2019 to February 2020 at 4 university-affiliated, freestanding children's hospitals in the United States using semistructured, one-on-one interviews with pediatric residents and pediatric hospitalist attendings. All transcripts were coded by pairs of research team members. Using constant comparative analysis, codes were categorized into themes and subsequently grouped into domains. We then conceptualized the relationships between the domains. RESULTS: We interviewed 40 physicians (18 residents, 22 attendings) and identified specific strategies for attendings to help residents navigate moral distress, which were categorized into 4 proactive and 4 responsive themes. The proactive themes included strategies employed before morally distressing events to minimize impact: ensuring attendings' awareness of residency factors influencing residents' moral distress; knowing available support resources; creating a learning environment that lays the foundation for mitigating distress; and recognizing moral distress in residents. The responsive themes included strategies that help mitigate the impact of morally distressing situations after they occur: partnering with the senior resident to develop a team-specific plan; consideration of who will participate in, the timing of, and content of the debrief. CONCLUSIONS: We present multiple strategies that attendings can implement to learn to recognize, prevent, and mitigate moral distress among residents. Our findings highlight the need for both proactive and reactive strategies and offer a possible roadmap for attending physicians to help their residents navigate moral distress.

Dental trainees' mental health and intention to leave their programs during the COVID-19 pandemic.

BACKGROUND: Dental trainees (dental students, graduate students, and postdoctoral residents) are at increased risk of experiencing poor mental health, which can lead to intentions to leave their program, especially during the COVID-19 pandemic. METHODS: The authors invited 355 dental trainees at the University of Washington School of Dentistry to complete an 83-item questionnaire in August and September 2020. The outcome analyzed was intention to leave their programs. There were 4 self-reported predictors: anxiety, burnout, depression, and COVID-19 impact on overall mental health. The authors ran multiple variable logistic regression models to evaluate relationships between each predictor and outcome (α = .05) and reported odds ratios (ORs) and 95% CIs. RESULTS: The survey response rate was 35.5%. Overall, 12.7% of participants reported any intention to leave. In total, 22.2% and 16.7% of participants endorsed clinically significant anxiety or depression symptomatology, respectively; 28.6% reported 1 or more burnout symptoms; and 69.0% reported that COVID-19 affected their overall mental health. Participants reporting anxiety (OR, 8.87; 95% CI, 1.80 to 43.57; P = .007), depression (OR, 11.18; 95% CI, 1.84 to 67.74; P = .009), or burnout (OR, 8.14; 95% CI, 1.73 to 38.23; P = .008) were significantly more likely to report intention to leave than those not reporting mental health problems. All participants reporting that the COVID-19 pandemic impacted their mental health expressed intention to leave. CONCLUSIONS: Poor mental health is common among dental trainees and is associated with intention to leave their program. PRACTICAL IMPLICATIONS: COVID-19 has exacerbated the prevalence and consequences of poor mental health among dental students, highlighting the importance of providing wellness resources.