Oral Health Behaviors for Young Low-Income Urban Children during the COVID-19 Pandemic: A Mixed Methods Analysis.

This research assessed oral health behaviors changes in urban families with young children during the stay-at-home period of the COVID-19 pandemic (Nov 2020-August 2021). Survey data on oral health behaviors were collected in homes at three points before COVID-19, and via phone during COVID-19. A subset of parents and key informants from clinics and social service agencies completed in-depth interviews via video/phone. Of the 387 parents invited, 254 completed surveys in English or Spanish (65.6%) during COVID-19. Fifteen key informant interviews (25 participants) and 21 family interviews were conducted. The mean child age was 4.3 years. Children identified as mainly Hispanic (57%) and Black race (38%). Parents reported increased child tooth brushing frequency during the pandemic. Family interviews highlighted changes in family routines that impacted oral health behaviors and eating patterns, suggesting less optimal brushing and nutrition. This was linked to changed home routines and social presentability. Key informants described major disruptions in oral health services, family fear, and stress. In conclusion, the stay-at-home period of the COVID-19 pandemic was a time of extreme routine change and stress for families. Oral health interventions that target family routines and social presentability are important for families during times of extreme crisis.

Association between neighborhood disadvantage and children's oral health outcomes in urban families in the Chicago area.

Purpose: The prevalence of childhood caries in urban Chicago, compared with national and state data, indicates that neighborhood context influences oral health. Our objective was to delineate the influence of a child's neighborhood on oral health outcomes that are predictive of caries (toothbrushing frequency and plaque levels). Methods: Our study population represents urban, Medicaid-enrolled families in the metropolitan Chicago area. Data were obtained from a cohort of participants (child-parent dyads) who participated in the Coordinated Oral Health Promotion (CO-OP) trial at 12 months of study participation (N = 362). Oral health outcomes included toothbrushing frequency and plaque levels. Participants' neighborhood resource levels were measured by the Area Deprivation Index (ADI). Linear and logistic regression models were used to measure the influence of ADI on plaque scores and toothbrushing frequency, respectively. Results: Data from 362 child-parent dyads were analyzed. The mean child age was 33.6 months (SD 6.8). The majority of children were reported to brush at least twice daily (n = 228, 63%), but the mean plaque score was 1.9 (SD 0.7), classified as "poor." In covariate-adjusted analyses, ADI was not associated with brushing frequency (0.94, 95% CI 0.84-1.06). ADI was associated with plaque scores (0.05, 95% CI 0.01-0.09, p value = 0.007). Conclusions: Findings support the hypothesis that neighborhood-level factors influence children's plaque levels. Because excessive plaque places a child at high risk for cavities, we recommend the inclusion of neighborhood context in interventions and policies to reduce children's oral health disparities. Existing programs and clinics that serve disadvantaged communities are well-positioned to support caregivers of young children in maintaining recommended oral health behaviors.

Oral health behaviors for young low-income urban children during the COVID-19 pandemic: a mixed methods analysis.

This research assessed oral health behaviors changes in urban families with young children during the stay-at-home period of the COVID-19 pandemic. Survey data on oral health behaviors were collected in homes at three points over one year before COVID-19, and then via phone during COVID-19. Multivariate logistic regression was used to model tooth brushing frequency. A subset of parents completed in-depth interviews via video/phone that expanded on oral health and COVID-19. Key informant interviews via video/phone were also conducted with leadership from 20 clinics and social service agencies. Interview data were transcribed and coded, and themes were extracted. COVID-19 data collection went from Nov 2020 - August 2021. Of the 387 parents invited, 254 completed surveys in English or Spanish (65.6%) during COVID-19. Fifteen key informant (25 participants) and 21 parent interviews were conducted. The mean child age was approximately 4.3 years. Children identified as mainly Hispanic (57%) and Black race (38%). Parents reported increased child tooth brushing frequency during the pandemic. Parent interviews highlighted significant changes in family routines that impacted oral health behaviors and eating patterns, suggesting less optimal brushing and nutrition. This was linked to changed home routines and social presentability. Key informants described major disruptions in their oral health services and significant family fear and stress. In conclusion, the stay-at-home period of the COVID-19 pandemic was a time of extreme routine change and stress for families. Oral health interventions that target family routines and social presentability are important for families during times of extreme crisis.

Parental Perception of Oral Health and Oral Health Status of Pediatric Patients Attending an Urban Craniofacial Center.

OBJECTIVE: The objectives of this study were to assess the oral health status and parental perception of oral health needs of pediatric patients in an urban Craniofacial Center. DESIGN: This research utilized a prospective cross-sectional matched study design. The data was collected prospectively via clinical oral examinations measuring dental caries experience and gingival health status. Parental perception of oral health was assessed through a validated questionnaire. SETTING: The study was conducted at a Pediatric Dentistry Department and Craniofacial Center (CFC) in a large urban American city. PATIENTS/PARTICIPANTS: Participants were recruited and enrolled from a CFC and Pediatric Dental Clinic. MAIN OUTCOME MEASURE(S): The outcome measures were the oral health status and parental perception thereof. RESULTS: CFC patients' caries experience in primary teeth was significantly lower than that of a healthy matched cohort, but statistically similar in permanent teeth. CFC patients had significantly higher unmet dental treatment needs. CFC patients had poor oral hygiene and were shown to have significantly higher plaque levels and worse gingival health than that of a healthy matched cohort. Parental perception of oral health did not show a statistically significantly difference between the two groups. CONCLUSIONS: Patients in our study in an urban CFC were found to have a high unmet dental and poor oral hygiene. Despite the poor oral health status, parents of children with craniofacial anomalies did perceive their oral health as different from a matched cohort of patients without these conditions.

Calibration and reliability testing of a novel asynchronous photographic plaque scoring system in young children.

OBJECTIVES: The Simplified Oral Hygiene Index for Maxillary Incisors (OHI-MIS) is a novel plaque scoring system adapted for young children. This study describes calibration training and testing used to establish the inter- and intra-rater reliability for OHI-MIS measured from clinical photographs. METHODS: Two raters from the Coordinated Oral Health Promotion Chicago (CO-OP) and one from the Behavioral EConomics for Oral health iNnovation (BEECON) randomized controlled trials (RCTs) underwent calibration with gold standard raters, followed by annual re-calibration. Raters from CO-OP also completed inter-rater reliability testing; all three raters completed intra-rater reliability testing rounds. Photographs were obtained from children aged 9-39 months. RESULTS: All three raters achieved greater than 0.77 Lin's Concordance Correlation (LCC) versus gold standard consensus during calibration. All three raters had LCC ≥0.83 at recalibration 1 year later. CO-OP trial raters scored 604 photos (151 sets of 4 photographs); mostly both raters were somewhat/very confident in their scoring (≥89%), describing the most photos as "clear" (90% and 81%). The CO-OP inter-rater LCC for total OHI-MIS score was 0.86, changing little when low quality or confidence photos were removed. All three raters demonstrated high intra-rater reliability (≥0.83). CONCLUSIONS: The OHI-MIS plaque scoring system on photos had good reliability within and between trials following protocol training and calibration. OHI-MIS provides a novel asynchronous plaque scoring system for use in young children. Non-clinicians in field or clinical settings can obtain photographs, offering new opportunities for research and clinical care.

Evaluation of the (hu)MANid program for sex and ancestry estimation in a diverse, contemporary CT scan-based sample.

Human remains from forensic and bioarcheological contexts are often fragmentary, requiring methods for estimating a forensic profile that are based upon limited skeletal features. In 2017, Berg and Keryhercz created an online application, (hu)MANid, that provides sex and ancestry estimation from mandibular morphoscopic traits and linear measurements. In this study, we examine the utility of the (hu)MANid application in a diverse, urban US adult sample (aged 20-45; n = 143) derived from computed tomography (CT) scans. We secondarily conduct a preliminary analysis of the program's utility in a sample of adolescents (aged 15-17; n = 40). Six morphoscopic, and eleven morphometric traits were recorded as directed by the literature associated with the (hu)MANid program. Percent correct classification and posterior predictive values were calculated for the sex and ancestry estimations output by the program; chi-squared tests were employed to compare self-reported and predicted ancestry. In the adult sample, sex was accurately predicted for 75.52% of the sample. Ancestry prediction, however, was less favorable ranging from 19.3% to 50% correct. For the adolescent sample, correct sex estimation (45%) did not surpass what could occur by chance alone, though ancestry prediction fared better than in the larger adult sample (percent correct prediction overall average: 47.5%, range 35.71%-71.43%). The (hu)MANid application shows utility for use with CT scan-derived adult samples for sex estimation, but caution is warranted for ancestry estimation and use with samples that may not have reached full adult maturity.

Community health worker intervention to improve tooth brushing in young children: Results from a cluster randomized controlled trial.

OBJECTIVES: Coordinated Oral health Promotion (CO-OP) Chicago is a cluster randomized controlled trial testing the efficacy of a community health worker (CHW) intervention to improve tooth brushing in low-income children. METHODS: Four hundred twenty children under 3 years old (mean 21.5 months) were recruited from 20 sites in or near Chicago, IL. Children were identified mainly as Black race (41.9%) or Hispanic ethnicity (53.8%) and most (85.2%) had Medicaid. Intervention families were offered four CHW home visits over 1 year. Brushing frequency was self-reported. Plaque score was determined from images collected in homes using disclosing solution. Analyses used GEE logistic models with variable selection at p < .05. RESULTS: At enrolment, 45.0% of families reported twice a day or more child brushing frequency, and child plaque scores were poor (mean of 1.9, SD: 0.6). Data were obtained from 87.1% of children at 6 months and 86.2% at 12 months. In the CHW intervention arm (10 sites, N = 211), 23.7% received 4 visits, 12.8% 3 visits, 21.3% 2 visits, 23.2% 1 visit and 19% no visits from CHWs. No intervention effect was seen for brushing frequency or plaque score. Child brushing frequency improvement over time was associated with a range of child and caregiver factors. The only factor associated with a change in plaque score over time was parent involvement in brushing. CONCLUSIONS: Oral-health-specific CHW services were not associated with improved brushing behaviours in these young children. However, caregiver involvement with brushing supported more quality brushing. More robust interventions are needed to support families during this critical developmental period.

A longitudinal assessment of sex differences in the growth of the mandibular retromolar space.

OBJECTIVE: To assess longitudinal variation in patterns of retromolar space growth, with regard to sex and cervical vertebrae maturation. DESIGN: We utilized serial lateral cephalograms from three craniofacial growth studies (Denver, Iowa, Oregon), measuring retromolar space and cervical vertebrae maturation in 99 subjects (56% male) from 8 to 18 years of age for each subject. Repeated measures ANOVA and a linear mixed effects model were used to assess retromolar space growth through time. RESULTS: Our analyses revealed an average increase in retromolar space of 8.73 mm from 8 to 18 years. While t-tests failed to find differences in retromolar space growth between males and females at the measured age points, repeated measures ANOVA and linear mixed effects models revealed modest differences in growth trends between sexes, with females having more growth earlier but a younger age of deceleration of growth (between 12 and 14 years of age). CONCLUSIONS: Our results confirm large increases in retromolar space through growth, reaching an average of 1.38 mm/year around puberty. Importantly, we add to the conversation regarding sex differences, showing differences in timing of growth. This highlights the importance of using longitudinal data and analytical approaches to address questions of this nature.

The Impact of the Covid-19 Pandemic on Applicants to Advanced Education in Pediatric Dentistry Programs and Recommendations for Virtual Interviews.

Purpose:To assess the impact of the Covid-19 pandemic on applicants for advanced education programs in pediatric dentistry in the United States and provide recom- mendations for virtual interviews (VI).
Methods:A cross-sectional survey was emailed to pediatric dentistry applicants in the 2020-2021 cycle.
Results:One hundred seventy-five applicants responded. Virtual interviews were the universal format during this timeframe. Forty-four percent admitted to applying to programs they were not initially strongly considering and 42 percent accepted inter- views they would have declined if they had to travel. Applicants found social events with residents only (80 percent), a program overview presentation (86 percent), a virtual tour (77 percent) and a question-and-answer session with residents (85 percent) to be helpful. One-on-one or paired faculty interviews were the most preferred inter- view method. More than half (55 percent) thought programs were not able to learn about them as effectively through virtual compared to an in-person format.
Conclusions: VI caused different applicant behavior due to the low time and financial investment. Applicants valued their time with residents to learn about programs, but were split in their preferences for virtual, in-person or hybrid interviews. Programs can use findings from this study to plan future recruitment cycles.

Oral community health worker-led interventions in households with average levels of psychosocial factors.

Introduction: Household-level psychosocial stress levels have been linked to child tooth brushing behaviors. Community health worker (CHW) interventions that target psychosocial factors in high-risk communities have been associated with changes in health behaviors. Aim: Observe changes in psychosocial factors over time and an association between psychosocial factors and CHW intervention dose amongst urban Chicago families. Patients and methods: Participants (N = 420 families) were recruited from 10 community clinics and 10 Women, Infants, or Children (WIC) centers in Cook County, Illinois to participate in a clinical trial. Research staff collected participant-reported psychosocial factors (family functioning and caregiver reports of depression, anxiety, support, and social functioning) and characteristics of CHW-led oral health intervention visits (number, content, child engagement) at 0, 6, and 12 months. CHWs recorded field observations after home visits on household environment, social circumstances, stressors, and supports. Results: Participants across the cohort reported levels of psychosocial factors consistent with average levels for the general population for nearly all measures. Psychosocial factors did not vary over time. Social functioning was the only measure reported at low levels [32.0 (6.9); 32.1 (6.7); 32.7 (6.9); mean = 50 (standard deviation)] at 0, 6, and 12 months. We did not observe a meaningful difference in social functioning scores over time by exposure to CHW-led intervention visits (control arm, 0, 1, 2, 3, and 4 visits). Field observations made by CHWs described a range of psychosocial stress related to poverty, language barriers, and immigration status. Conclusion: The unexpectedly average and unchanging psychosocial factors over time, in the context of field observations of stress related to poverty, lack of support, immigration status, and language barriers, suggests that our study did not adequately capture the social determinants of health related to oral health behaviors or that measurement biases precluded accurate assessment. Future studies will assess psychosocial factors using a variety of instruments in an attempt to better measure psychosocial factors including social support, depression, anxiety, functioning, trauma and resilience within our urban population. We will also look at neighborhood-level factors of community distress and resilience to better apply the social ecologic model to child oral health behaviors.

General Anesthesia Versus Moderate Sedation: Factors Affecting Caregivers' Decisions for Children's Dental Treatment Modality.

Purpose: Treatment for early childhood caries may include advanced behavior management modalities, such as moderate sedation (MS) or general anesthesia (GA). The purpose of this study was to determine which factors are important to parents when considering MS or GA for their child.
Methods: Parents completed a cross-sectional survey to determine which factors they considered in their decision between MS or GA for dental treatment. The relative importance of social, financial, and patient-level factors, the importance of dentists' recommendations, and the reported knowledge levels and sources of information regarding treatment modality were also assessed.
Results: The majority of 130 parents surveyed reported at least a moderate amount of knowledge about GA and MS. Although most identified their dentist as the primary source of information (45 percent for GA, 51 percent for MS), many reported having no source of information about either (23 percent for GA, 16 percent for MS). For both groups, the dentist's recommendation for MS or GA was more influential than cost, risk profile, and the number of missed work and school days (P <0.001). Being well-informed about the treatment modality was more influential than the dentist's recommendation only for the parents who chose MS (P <0.001).
Conclusion: Parents' self-reported knowledge regarding their treatment modality was relatively low. The choice of treatment modality for pediatric dental care relied mostly on the dentist's recommendation.

Assessment of automatic cephalometric landmark identification using artificial intelligence.

OBJECTIVE: To compare the accuracy of cephalometric landmark identification between artificial intelligence (AI) deep learning convolutional neural networks (CNN) You Only Look Once, Version 3 (YOLOv3) algorithm and the manually traced (MT) group. SETTING AND SAMPLE POPULATION: The American Association of Orthodontists Federation (AAOF) Legacy Denver collection was used to obtain 110 cephalometric images for this study. MATERIALS AND METHODS: Lateral cephalograms were digitized and traced by a calibrated senior orthodontic resident using Dolphin Imaging. The same images were uploaded to AI software Ceppro DDH Inc The Cartesian system of coordinates with Sella as the reference landmark was used to extract x- and y-coordinates for 16 cephalometric points: Nasion (Na), A point, B point, Menton (Me), Gonion (Go), Upper incisor tip, Lower incisor tip, Upper incisor apex, Lower incisor apex, Anterior Nasal Spine (ANS), Posterior Nasal Spine (PNS), Pogonion (Pg), Pterigomaxillary fissure point (Pt), Basion (Ba), Articulare (Art) and Orbitale (Or). The mean distances were assessed relative to the reference value of 2 mm. Student paired t-tests at significance level of P < .05 were used to compare the mean differences in each of the x- and y-components. SPSS (IBM-vs. 27.0) software was used for the data analysis. RESULTS: There was no statistical difference for 12 out of 16 points when analysing absolute differences between MT and AI groups. CONCLUSION: AI may increase efficiency without compromising accuracy with cephalometric tracings in routine clinical practice and in research settings.

Success of Biodentine and Ferric Sulfate as Pulpotomy Materials in Primary Molars: A Retrospective Study.

OBJECTIVE: To determine the clinical and radiographic success of Biodentine® (BD) and Ferric Sulfate (FS) as primary molar pulpotomy materials and to compare their outcomes. STUDY DESIGN: Retrospective data was obtained from the electronic health records (EHR) of a university-based pediatric dental clinic. Participants were enrolled according to specified inclusion and exclusion criteria. Two trained and calibrated examiners evaluated the EHR using validated criteria for clinical and radiographic outcomes. Study data was numerically coded and analyzed. Cohen's Kappa and Chi-square tests were used (p<0.05). RESULTS: Eighty-three participants (62.7% females, age range two to eight years, average age of 4.5 years) with 102 pulpotomies were enrolled. FS was used in 78% (n=79) and BD in 22% (n=23) of the cases. Follow-up periods ranged from six to 36 months (mean of 17 months). BD showed 100% clinical and radiographic success, while FS demonstrated 84% clinical and 70% radiographic success. The two groups were compared at one year with no statistically significant differences. At 18 months, BD outperformed FS clinically (p=.012) and radiographically (p=.001). Intra-rater and inter-rater agreement were κ>0.88. CONCLUSIONS: Both materials can be recommended for clinical practice, however BD may be the preferred choice for its better outcomes at 18 months.

A qualitative analysis of caregiver perceptions of pediatric dental surgery under general anesthesia.

BACKGROUND: Dental surgery under general anesthesia (GA) is a common treatment for severe childhood caries and thus may serve as an event to motivate behavior change. The frequency of recurrent caries, however, indicates opportunities within current practice to change a child's oral health behaviors. AIM: To assess caregiver experiences related to their child's dental surgery to inform development of a behavioral intervention. DESIGN: Semi-structured interviews with caregivers of children receiving GA for dental surgery. Transcripts (n = 19) were analyzed using qualitative thematic methods. RESULTS: Children were 2-5 years of age, mean 3.8 years. Limited access to GA services was a source of caregiver frustration and a barrier to caries treatment. Surgical events elicited emotional reactions including guilt, anxiety, and a sense of caregiver accountability for development of severe caries. There was variation in caregiver awareness and/or motivation to change oral health behaviors. CONCLUSIONS: A child's dental surgery under GA is an emotionally challenging event yet may inspire hope and expectations for improvement. Surgery offers an opportunity to implement interventions at a time when caregivers may be open to assistance with behavior change, though stress and anxiety may create barriers. Behavioral interventions should be tailored to individual caregiver needs/barriers and stage of developmental readiness.

Oral Health Behaviors in Very Young Children in Low-Income Urban Areas in Chicago, Illinois, 2018-2019.

INTRODUCTION: Because most data on oral health do not include infants and toddlers, we aimed to describe the oral health behaviors of low-income children younger than 3 years and determine factors associated with child tooth brushing. METHODS: We obtained data from the Coordinated Oral Health Promotion Chicago study, which included 420 families with children aged 6 to 36 months and their caregivers in Cook County, Illinois. We assessed child frequency of brushing from caregiver reports and objectively determined child dental plaque scores. Significant factors associated with tooth brushing frequency and dental plaque score were identified using the Least Absolute Shrinkage and Selection Operator variable selection. RESULTS: Mean child age was 21.5 (SD, 6.9) months, and only 45% of caregivers brushed their children's teeth twice per day or more. The mean plaque score was 1.9 (SD, 0.6), indicating high levels of plaque. Child brushing frequency was higher when children were older; used the correct toothpaste amount; brushed for a longer duration; and when caregivers brushed their own teeth more frequently, had more help with the overall care of the child's teeth, and had family to help. Child brushing frequency was lower for caregivers with more interference from activities of daily life. Children whose caregivers had more adult help with child brushing had better plaque scores; worse plaque scores were seen in children with higher sugary beverage and food consumption and lower household incomes. CONCLUSION: The tooth brushing behaviors of young children are strongly associated with those of their parents and with the level of family support for brushing. Interventions to improve brushing in young children should focus on the entire family.

Tooth Brushing Behaviors and Fluoridated Toothpaste Use Among Children Younger Than Three Years Old in Chicago.

Purpose: To describe toothbrushing frequency/duration and toothpaste use among young children in an urban, vulnerable population in Chicago, Ill., USA.
Methods: Caregivers of children younger than three years old were recruited from university and community pediatric dental clinics. Caregivers completed a 37-item questionnaire in English or Spanish about predictors/covariates (demographics, child/caregiver oral health, access to dental care) and primary outcomes (child toothbrushng behaviors, toothpaste use). Models employed generalized logit and ordinal logistic regression.
Results: A total of 148 caregivers completed the survey. The average child age was 18.8 months (±7.4 SD). Approximately 41 percent of children brushed once a day or less, and 19 percent of caregivers did not regularly assist. Almost all children used toothpaste (96 percent), but 36 percent of caregivers did not know if it contained fluoride. Increased child brushing frequency was associated with older child age, higher caregiver brushing frequency, history of a child dental visit, and caregiver assistance (P<0.05). Children with a history of dental visits were seven times more likely to brush for 30 seconds or more, and receiving caregiver assistance was associated with brushing longer than two minutes (P <0.05).
Conclusion: Most children brushed at least once daily and nearly all of them used toothpaste. Access to dental care, parental involvement, and parental oral health were associated with favorable child toothbrushing behaviors. Toothbrushing duration, frequency, and encouraging family assistance are modifiable protective factors and opportunities for intervention.

Design and sample characteristics of COordinated Oral health Promotion (CO-OP) Chicago: A cluster-randomized controlled trial.

COordinated Oral health Promotion (CO-OP) Chicago is a two-arm cluster-randomized trial with a wait-list control. The primary aim is to evaluate the efficacy of an oral health community health worker (CHW) intervention to improve oral health behaviors in low-income, urban children under the age of three years. Exploratory aims will determine cost-effectiveness, and if any CHW intervention impact on child tooth brushing behaviors varies when CHWs are based out of a medical clinic compared to a community setting. This paper describes progress toward achieving these aims. Participating families were recruited from community social service centers and pediatric primary care medical clinics in Cook County, Illinois. Sites were cluster-randomized to CHW intervention or usual services (a wait-list control). The intervention is oral health support from CHWs delivered in four visits to individual families over one year. The trial sample consists of 420 child/caregiver dyads enrolled at the 20 participating sites over 11 months. Participant demographics varied across the sites, but primary outcomes values at baseline did not. Data on brushing frequency, plaque, and other oral health behaviors are collected at three timepoints: baseline, 6-, and 12-months. The primary analysis will assess differences in caregiver-reported child brushing frequency and observed plaque score between the two arms at 12-months. The trial is currently in the active intervention phase. The trial's cluster-randomized controlled design takes a real-world approach by integrating into existing health and social service agencies and collecting data in participant homes. Results will address an important child health disparity. ClinicalTrials.gov identifier: NCT03397589. CLINICAL TRIAL REGISTRATION: University of Illinois at Chicago Protocol Record 2017-1090. National Institutes of Dental & Craniofacial Research of the National Institutes of Health (NIDCR) Protocol Number: 17-074-E. NCT03397589.

Understanding Oral Health Behaviors Among Children Treated for Caries Under General Anesthesia.

Purpose: To identify factors that influence oral health behaviors in the pediatric population treated for caries under general anesthesia (GA).
Methods: Nineteen semi-structured key informant interviews were conducted with caregivers while their children received comprehensive dental care under GA. Interviews were recorded on audio and professionally transcribed. Transcripts were coded using an inductive approach, with codes categorized and themes identified in an iterative process among four investigators.
Results: Data from 14 English and five Spanish interviews were reported. Factors that impacted accessing dental services, toothbrushing, and sugar intake were related to experiences living with severe caries and family dynamics. Many caregivers found the process of accessing care challenging, with barriers ranging from a caregiver's denial of disease severity to insurance status and provider availability. Discordant dynamics between parents and their children hindered efforts to change oral health behaviors. Stress of daily life impacted the ability for some caregivers to prioritize oral health.
Conclusion: Our findings provide a better understanding of how a family's experiences and dynamics prior to dental care under GA can serve as barriers to changing oral health behaviors within an urban, Medicaid-enrolled population. Future work should address the complexity and context of familial interactions in efforts to improve surgical outcomes.

What really happens in the home: a comparison of parent-reported and observed tooth brushing behaviors for young children.

BACKGROUND: Most studies of tooth brushing behaviors rely on self-report or demonstrations of behaviors conducted in clinical settings. This study aimed to determine the feasibility of objective assessment of tooth brushing behaviors in the homes of high-risk children under three years old. We compared parent self-report to observations to determine the accuracy of self-report in this population. METHODS: Forty-five families were recruited from dental and medical clinics and a community social service agency. Research staff asked questions about oral health behaviors and observed tooth brushing in the homes. Brushing was also video-recorded. Video-recordings were coded for brushing behaviors by staff that did not collect the primary data; these abstracted data were compared to those directly observed in homes. RESULTS: Most families were Hispanic (76%) or Black (16%) race/ethnicity. The majority of parents had a high school education (42%) or less (24%). The mean age of children was 21 months. About half of parents reported brushing their child's teeth twice a day (58%). All parents tried to have their children brush, but three children refused. For brushing duration, 70% of parents reported differently than was observed. The average duration of brushing was 62.4 s. Parent report of fluoride in toothpaste frequently did not match observations; 39% said they used toothpaste with fluoride while 71% actually did. Sixty-eight percent of parents reported using a smear of toothpaste, while 61% actually did. Brushing occurred in a variety of locations and routines varied. Abstracted data from videos were high in agreement for some behaviors (rinse with water, floss used, brushing location, and parent involvement: Kappa 0.74-1.0). Behaviors related to type of brushing equipment (brushes and toothpaste), equipment storage, and bathroom organization and clutter had poor to no agreement. CONCLUSIONS: Observation and video-recording of brushing routines and equipment are feasible and acceptable to families. Observed behaviors are more accurate than self-report for most components of brushing and serve to highlight some of the knowledge issues facing parents, such as the role of fluoride.

Formative research implications on design of a randomized controlled trial for oral health promotion in children.

BACKGROUND: The COordinated Oral health Promotion (CO-OP) Chicago trial will test the efficacy of a community health worker (CHW) intervention to improve oral health behaviors for children at high risk for early childhood caries. Before implementing the cluster-randomized controlled trial, we conducted a formative assessment to determine the final design. We used qualitative methods to assess the feasibility and acceptability of the proposed recruitment, data collection, and intervention plan. METHODS: Key informant interviews (N = 37) and site observations were conducted at 10 pediatric primary care clinics and 10 Special Supplemental Nutrition Program for Women Infant and Children (WIC) centers to gain insight from providers and administrators at the locations where recruitment and intervention will occur. Eight focus groups (N = 68) were conducted with caregivers of children to capture the parent perspective. Conceptual coding methods from grounded theory were applied to organize the data into the final themes. RESULTS: Families, clinics, and WIC centers were all very interested in additional supports for oral health and were enthusiastic about CHWs. Challenges included competing family priorities that might interfere in study enrollment and intervention efficacy. Physical space for enrollment and intervention delivery was a major barrier for some sites. Home visits for data collection and intervention delivery would be unacceptable for some families. These challenges and barriers prompted us to make major changes in our trial design. We opened the option for data collection to occur in multiple locations. We eliminated the home-only arm of the trial. Clinics and WIC centers that are randomized to the non-intervention arm will now have CHWs available at the study conclusion. Finally, we aligned the CHW oral health topics to the needs of families. CONCLUSIONS: We conducted this comprehensive formative assessment to determine the feasibility and acceptability of the CO-OP Chicago trial. While overall acceptance of the trial was high, the results highlighted specific issues with the proposed trial implementation plan and led to several critical design changes. This type of formative work requires a significant upfront investment but we expect it will translate into savings through better recruitment, retention, intervention implementation and adherence, and result dissemination.