Dental Use and Spending in Medicare Advantage and Traditional Medicare, 2010-2021.

This cross-sectional study examines Medicare Advantage and traditional Medicare beneficiaries' use of and spending for dental services.

Treatment deferral for elevated blood pressure at a dental school clinic.

OBJECTIVES: Current guidelines by the American Dental Association (ADA) recommend deferral of elective dental care for elevated blood pressure. However, it is unknown how frequently this impacts dental treatment. The purpose of this study was to evaluate rates of asymptomatic hypertension and treatment deferral at a dental school clinic. METHODS: This was a retrospective study with data extracted from a chart review of all patients presenting for care at a dental school teaching practice. Differences in dental procedures, the time between visits, and the number of antihypertensive medications were calculated between patients with and without a blood pressure reading exceeding current guidelines for elective treatment. RESULTS: Among 26,821 individuals, 1265 had a visit with elevated blood pressure. Blood pressure readings at the next visit were significantly lower (systolic blood pressure 137 [95% confidence interval {CI} 135-138] mmHg, diastolic blood pressure 82 [95% CI 81-83 mmHg], p < 0.001), although only 24 patients reported taking a new medication. Only 4.1% of these patients had a procedure deferred; for those that did, the average intervisit time was 88.2 days (95% CI 77.7-98.7 days). CONCLUSIONS: The majority of patients with blood pressure readings exceeding current ADA recommendations for treatment were treated without evidence of harm. Patients were also unlikely to return to the clinic with new medications for blood pressure after a visit with an elevated blood pressure reading. Oral health providers must weigh the risks and benefits of care deferral and can consider an expanded role in hypertension management in dental settings when caring for patients with elevated blood pressure.

Mapping Oral health and Local Area Resources (MOLAR): protocol for a randomised controlled trial connecting emergency department patients with social and dental resources.

INTRODUCTION: There are substantial inequities in oral health access and outcomes in the USA, including by income and racial and ethnic identity. People with adverse social determinants of health (aSDoH), such as housing or food insecurity, are also more likely to have unmet dental needs. Many patients with dental problems present to the emergency department (ED), where minimal dental care or referral is usually available. Nonetheless, the ED represents an important point of contact to facilitate screening and referral for unmet oral health needs and aSDoH, particularly for patients who may not otherwise have access to care. METHODS AND ANALYSIS: Mapping Oral health and Local Area Resources is a randomised controlled trial enrolling 2049 adult and paediatric ED patients with unmet oral health needs into one of three trial arms: (a) a standard handout of nearby dental and aSDoH resources; (b) a geographically matched listing of aSDoH resources and a search link for identification of geographically matched dental resources; or (c) geographically matched resources along with personalised care navigation. Follow-up at 3, 6, 9 and 12 months will evaluate oral health-related quality of life, linkage to resources and dental treatment, ED visits for dental problems and the association between linkage and neighbourhood resource density. ETHICS AND DISSEMINATION: All sites share a single human subjects review board protocol which has been fully approved by the Mass General Brigham Human Subjects Review Board. Informed consent will be obtained from all adults and adult caregivers, and assent will be obtained from age-appropriate child participants. Results will demonstrate the impact of addressing aSDoH on oral health access and the efficacy of various forms of resource navigation compared with enhanced standard care. Our findings will facilitate sustainable, scalable interventions to identify and address aSDoH in the ED to improve oral health and reduce oral health inequities. TRIAL REGISTRATION NUMBER: NCT05688982.

Challenges connecting emergency department patients with oral health care: A qualitative analysis of patients, emergency department clinicians, and dentists.

BACKGROUND: Unmet dental need shares many risk factors with unmet health-related social needs (HRSN) such as housing and food security and are a common cause for seeking treatment at the emergency department (ED). METHODS: The authors recruited a purposive sample of English-speaking and Spanish-speaking patients, ED clinicians at 3 urban EDs, and dentists from nearby communities to participate in qualitative interviews to explore barriers to and facilitators of screening for HRSN and unmet dental needs in the ED. Themes were identified from transcripts using a modified grounded theory approach. RESULTS: Interviews were conducted with 25 ED patients, 19 ED clinicians, and 4 dentists. Four themes were identified: (1) a preference for formalized resources, which more frequently exist for HRSN than for oral health; (2) frequent use of ad hoc resources that are less reliable or structured, particularly for dental referral information; (3) limited knowledge of oral health care resources in the community; and (4) desire for more assistance with identifying and addressing resource needs for both HRSN and oral health. Patients were amenable to screening through a variety of modalities and felt it would be helpful, but clinicians emphasized the need for easier referral processes because of frequent failure to connect patients to oral health care. CONCLUSIONS: More robust infrastructure and clinician support are needed to ensure successful referral and screening without undue provider burden for both medical and dental clinicians. PRACTICAL IMPLICATIONS: Patients are amenable to screening for unmet oral health needs and HRSN in the ED, which may improve access to care.

Stressful life events, oral health, and barriers to dental care during pregnancy.

OBJECTIVES: Poor oral health during pregnancy poses risks to maternal and infant well-being. However, limited research has documented how proximate stressful life events (SLEs) during the prenatal period are associated with oral health and patterns of dental care utilization. METHODS: Data come from 13 states that included questions on SLEs, oral health, and dental care utilization in the Pregnancy Risk Assessment Monitoring System for the years 2016-2020 (n = 48,658). Multiple logistic regression analyses were used to assess the association between levels of SLE (0, 1-2, 3-5, or 6+) and a range of (1) oral health experiences and (2) barriers to dental care during pregnancy while controlling for socio-demographic and pregnancy-related characteristics. RESULTS: Women with more SLEs in the 12 months before birth-especially six or more-reported worse oral health experiences, including not having dental insurance, not having a dental cleaning, not knowing the importance of caring for teeth and gums, needing to see a dentist for a problem, going to see a dentist for a problem, and unmet dental care needs. Higher levels of SLEs were also associated with elevated odds of reporting barriers to dental care. CONCLUSIONS: SLEs are an essential but often understudied risk factor for poor oral health, unmet dental care needs, and barriers to dental care services. Future research is needed to understand better the mechanisms linking SLEs and oral health.

From childhood adversity to latent stress vulnerability in adulthood: the mediating roles of sleep disturbances and HPA axis dysfunction.

Childhood adversity is a prominent predisposing risk factor for latent stress vulnerability, expressed as an elevated likelihood of developing stress-related psychopathology upon subsequent exposure to trauma in adulthood. Sleep disturbances have emerged as one of the most pronounced maladaptive behavioral outcomes of childhood adversity and are also a highly prevalent core feature of stress-related psychopathology, including post-traumatic stress disorder (PTSD). After reviewing the extensive literature supporting these claims, the current review addresses the notion that childhood adversity-induced sleep disturbances may play a causal role in elevating individuals' stress vulnerability in adulthood. Corroborating this, sleep disturbances that predate adult trauma exposure have been associated with an increased likelihood of developing stress-related psychopathology post-exposure. Furthermore, novel empirical evidence suggests that sleep disturbances, including irregularity of the sleep-wake cycle, mediate the link between childhood adversity and stress vulnerability in adulthood. We also discuss cognitive and behavioral mechanisms through which such a cascade may evolve, highlighting the putative role of impaired memory consolidation and fear extinction. Next, we present evidence to support the contribution of the hypothalamic-pituitary-adrenal (HPA) axis to these associations, stemming from its critical role in stress and sleep regulatory pathways. Childhood adversity may yield bi-directional effects within the HPA stress and sleep axes in which sleep disturbances and HPA axis dysfunction reinforce each other, leading to elevated stress vulnerability. To conclude, we postulate a conceptual path model from childhood adversity to latent stress vulnerability in adulthood and discuss the potential clinical implications of these notions, while highlighting directions for future research.

Dental Services Use: Medicare Beneficiaries Experience Immediate And Long-Term Reductions After Enrollment.

Traditional Medicare does not cover routine dental care, but little is known about transitions in dental outcomes upon reaching Medicare eligibility at age sixty-five. Using data from the 2010-19 Medical Expenditure Panel Surveys, we examined dental insurance, utilization, and outcomes among US adults before and after age sixty-five, using a regression discontinuity design and segmented regression analysis. Among 97,108 US adults representing a weighted population of 104,787,300 people, complete edentulism, or the loss of all teeth, increased by 4.8 percentage points at age sixty-five, and the percentage of people receiving restorative dental care decreased by 8.7 percentage points. Enrollment in Medicare Advantage, which may offer a dental benefit, was not associated with greater use of dental services relative to traditional Medicare, and Medicare Advantage enrollees had a significantly larger drop in dental spending from private insurance at age sixty-five than traditional Medicare enrollees. Expanding Medicare to cover dental services may help counteract these effects among all enrollees.

Multi-trajectory analysis uncovers latent associations between psychological and physiological acute stress response patterns.

Encounter with an acute stressor elicits multiple physiological and psychological response trajectories that spread at different times-scales and directions. Associating a single physiological response trajectory with a specific psychological response has remained a challenge, due to putative interactions between the different stress response pathways. Hence, multidimensional analysis of stress response trajectories may be better suited to account for response variability. To test this, 96 healthy female participants underwent a robust acute laboratory stress induction procedure while their psychological [positive and negative affect (PANAS)] and physiological [heart rate (HR), heart rate variability (HRV), saliva cortisol (CORT)] responses were recorded before, during and after stress. Combining these data using unsupervised group-based multi-trajectory modelling uncovered three latent classes that best accounted for variability across psychological and physiological stress response trajectories. These classes were labelled based on their psychological response patterns as: A prototypical response group that depict a moderate increase in negative and decrease in positive affect during stress, with both patterns recovering after stress offset (n = 55); A heightened response group that depict excessive affective responses during stress that recover after stress offset (n = 24); and a lack of recovery group that depict a moderate increase in negative and decrease in positive affect during stress, with both patterns not recovering after stress offset (n = 17). With respect to physiological acute stress trajectories, all three groups exhibited comparable increases in HR and CORT during stress that recovered after stress offset, yet only the prototypical group expressed the expected stress-induced reduction in HRV, while the other two groups exhibited blunted HRV response. Critically, focusing on a single physiological stress response trajectory, including HRV, did not account for psychological response variability and vice versa. Taken together, a multi-trajectory approach may better account for the multidimensionality of acute stress response and uncover latent associations between psychological and physiological response patterns. Compared to the other two groups, the prototypical group also exhibited significantly lower overall stress scores based on the DASS-21 scale. This, alongside the uncovered response patterns, suggest that latent psycho-physiological associations may shed light on stress response adaptivity or lack thereof.

Predicting Chronic Stress among Healthy Females Using Daily-Life Physiological and Lifestyle Features from Wearable Sensors.

Background: Chronic stress is a highly prevalent condition that may stem from different sources and can substantially impact physiology and behavior, potentially leading to impaired mental and physical health. Multiple physiological and behavioral lifestyle features can now be recorded unobtrusively in daily-life using wearable sensors. The aim of the current study was to identify a distinct set of physiological and behavioral lifestyle features that are associated with elevated levels of chronic stress across different stress sources. Methods: For that, 140 healthy female participants completed the Trier inventory for chronic stress (TICS) before wearing the Fitbit Charge3 sensor for seven consecutive days while maintaining their daily routine. Physiological and lifestyle features that were extracted from sensor data, alongside demographic features, were used to predict high versus low chronic stress with support vector machine classifiers, applying out-of-sample model testing. Results: The model achieved 79% classification accuracy for chronic stress from a social tension source. A mixture of physiological (resting heart-rate, heart-rate circadian characteristics), lifestyle (steps count, sleep onset and sleep regularity) and non-sensor demographic features (smoking status) contributed to this classification. Conclusion: As wearable technologies continue to rapidly evolve, integration of daily-life indicators could improve our understanding of chronic stress and its impact of physiology and behavior.

Is Oral Health Essential?

Since 1840, when the first dental school in the United States was founded, educational and policy outcomes have reinforced the separation of dentistry from medicine. Originating in serial historical divides, this separation has produced grave health inequity. The COVID-19 pandemic illuminates differences in medical and dental care delivery streams and also suggests how to design a unified health care system that transcends historical precedent.

The acetyltransferase p300 is recruited in trans to multiple enhancer sites by lncSmad7.

The histone acetyltransferase p300 (also known as KAT3B) is a general transcriptional coactivator that introduces the H3K27ac mark on enhancers triggering their activation and gene transcription. Genome-wide screenings demonstrated that a large fraction of long non-coding RNAs (lncRNAs) plays a role in cellular processes and organ development although the underlying molecular mechanisms remain largely unclear (1,2). We found 122 lncRNAs that interacts directly with p300. In depth analysis of one of these, lncSmad7, is required to maintain ESC self-renewal and it interacts to the C-terminal domain of p300. lncSmad7 also contains predicted RNA-DNA Hoogsteen forming base pairing. Combined Chromatin Isolation by RNA precipitation followed by sequencing (ChIRP-seq) together with CRISPR/Cas9 mutagenesis of the target sites demonstrate that lncSmad7 binds and recruits p300 to enhancers in trans, to trigger enhancer acetylation and transcriptional activation of its target genes. Thus, these results unveil a new mechanism by which p300 is recruited to the genome.

Which factors are associated with the number of dental providers employed in correctional settings?

OBJECTIVES: Individuals experiencing incarceration are at increased risk of poor oral health. The purpose of this study was to identify state-level factors that influence the number of oral healthcare providers employed in US correctional settings. METHODS: This ecological study utilized the National Survey of Prison Health Care (NSPHC) to identify the total number of dentists employed in US correctional facilities. Descriptive statistics were calculated and a linear regression was used to identify predictors of the total number of dentists employed in correctional settings by state. RESULTS: The mean number of dentists and dental hygienists/assistants per 10,000 individuals experiencing incarceration was 9.33 ± 4.54 and 11.53 ± 7.02, respectively. The only significant contributor to dental employment was healthcare spending per individual experiencing incarceration (Coefficient = 0.96; p = 0.004). CONCLUSIONS: These findings illustrate the need to develop novel methods of encouraging oral healthcare providers to join the correctional healthcare workforce.

Dental care utilization in Massachusetts before and after initiation of medication for opioid use disorder: A cross-sectional study of a state all-payer claims database.

BACKGROUND: Individuals with opioid use disorder (OUD) are at higher risk of poor oral health. Medication for opioid use disorder (MOUD) has been shown to improve outcomes for patients with OUD, but it is unknown how initiation of MOUD affects access to oral health services. METHODS: This was a retrospective analysis of all individuals in the Massachusetts All-Payer Claims Database prescribed oral buprenorphine-naloxone or injectable naltrexone from 2013 to 2016. We evaluated dental utilization in the year before and after beginning MOUD. A logistic regression predicting dental utilization was conducted. RESULTS: Among the 54,791 individuals, rates of dental utilization were low both before and after MOUD (10.5% and 10% with a dental visit, respectively). Of those who did not have a dental visit in the year before starting MOUD, 95.1% did not have a dental visit in the year after. Rates of various procedure types were comparable before and after MOUD. In a logistic regression, a prior dental visit was associated with 9.82 times the odds (95% CI 9.14-10.55) of having a dental visit after starting MOUD; increasing age, being prescribed naltrexone, having a mood disorder or HIV, year of initiation or being on Medicaid were also associated with having a dental visit. Male patients and those with Medicare or private insurance were less likely to have a dental visit. CONCLUSIONS: Initiating MOUD did not substantially result in increased dental access or substantial changes in dental procedures received. Patients receiving treatment for OUD may require additional support to access dental care.

Changes in dental care use patterns due to COVID-19 among insured patients in the United States.

BACKGROUND: Demand for dental services has been known to be linked closely to dental insurance and disposable income. Widespread economic uncertainty and health systems changes due to COVID-19 thus may have a significant impact on dental care use. METHODS: Using deidentified dental practice management data from 2019 and 2020, the authors observed variations in dental care use among insured patients since the COVID-19 outbreak (during the period of practice closure and after the reopening) by patient age, procedure type, insurance type, practice size, geographic area, and reopening status. The authors examined whether the rebound in procedure volumes at dental practices can be explained by county-level characteristics using hierarchical regression models. RESULTS: Although dental care use among privately insured patients fully rebounded by August 2020, use still remained lower than the prepandemic level by 7.54% among the publicly insured population. Demand for teledentistry increased 60-fold during practice closure. Geographic characteristics-such as median household income, percentages of rural or Black populations, and dental care professional shortage designations-were associated significantly with the number of procedures performed at dental practices. CONCLUSIONS: As a result of COVID-19, dental practices experienced substantial decreases in procedure volume, particularly among patients covered by public insurance or residing in underserved areas. PRACTICAL IMPLICATIONS: During economic downturns, state health officials should be encouraged to adopt policies to expand access to oral health care for vulnerable populations via oral health promotion strategies and increasing the supply of dentists or midlevel dental care providers in underserved areas.

Dental services use before and after inpatient admission among privately insured adults in the United States.

BACKGROUND: Oral health has been connected to worse outcomes among hospitalized patients, but access to oral health care services in the hospital setting is limited. It is unknown how a hospital admission affects subsequent dental services use. METHODS: The authors conducted a retrospective analysis of insurance claims data from a national private insurer. Patients were included if they were admitted to the hospital and had visited a dentist at least once in the year before or after admission. Total number of dental visits, as well as Code on Dental Procedures and Nomenclature codes associated with these visits in the year before and after a hospital stay, patient demographic characteristics, hospital admission diagnosis, and length of stay were recorded. Differences in dental services use before and after the hospital stay were calculated. RESULTS: In total, 107,116 patients met inclusion criteria. There were fewer dental visits after admission (mean [standard deviation {SD}] 1.6 [1.7] than before admission (mean [SD] 1.9 [1.8]; P < .0001). Fewer procedures were recorded in the year after discharge (mean [SD] 7.0 [11.4] total Code on Dental Procedures and Nomenclature codes versus 8.5 [12.5] in the year before admission; P < .0001). The number of diagnostic and restorative services delivered was higher after admission, and the number of periodontic, endodontic, oral surgery, and prosthodontic services decreased (overall Pearson χ2, P < .0001). CONCLUSIONS: Patients are less likely to visit a dentist after a hospital stay, although impact on oral health is unknown. PRACTICAL IMPLICATIONS: Hospitalization may contribute to already existing oral health disparities. Hospital teams and dentists should work together to enhance access to oral health care after hospital admission.

Now or Later? Stress-Induced Increase and Decrease in Choice Impulsivity Are Both Associated with Elevated Affective and Endocrine Responses.

Exposure to acute stress elicit physiological and psychological responses that can impact decision-making, often expressed as an increased tendency to act in an impulsive manner following stress. Delay discounting (DD) task has emerged as a reliable measure of impulsive behavior in the form of choice impulsivity (CI). Interestingly, studies that examined the effect of acute stress on DD performance reported mixed results. To address this, we conducted a within-subject examination of the impact of acute stress on CI, focusing on individual differences in response patterns. One hundred and fifty healthy female participants completed the DD task twice, before and after undergoing an acute laboratory stress induction procedure. Saliva samples and self-report mood and affect measures were collected at four time points throughout the session. Fifty-nine matched healthy control participants completed only the DD task twice, with no stress in between. Results indicate that the acute stress procedure elicited the expected effects of increased cortisol release and increased negative mood and affect, at the group level. With respect to DD, stress indeed increased CI at the group level, yet participants differed in the magnitude and direction of this effect. Interestingly, regression analysis revealed quadratic relations between stress-induced changes in CI and cortisol release. Indeed, dividing the sample into three sub-groups based on the impact of stress on CI revealed that, compared to participants that exhibited no substantial change in their CI following stress, participants that exhibited either stress-induced increase or decrease in their CI also exhibited more stress-induced cortisol release, as well as more negative affect. Taken together, these findings suggest that elevated physiological and psychological responses to stress are associated with either increased or decreased choice impulsivity, thus depicting quadratic relations between stress and impulsivity.