Oral Health Among Medicare Beneficiaries in Nursing Homes.

This cross-sectional study investigates rates of dental problems among Medicare beneficiaries in nursing homes and characteristics associated with these rates.

Advancing oral health policy through persuasive messaging and effective research measures.

Oral health is often excluded from broad health policy discussions, addressed only in a policy silo. There is a paucity of research to guide policymaking as it relates to oral health. In response, AcademyHealth's Oral Health Interest Group organized a meeting during the 2019 AcademyHealth Annual Research Meeting to promote transdisciplinary dialog on the current state of oral health policy and the steps necessary to improve the oral health of Americans. This article summarizes the two main themes that emerged from the proceedings of the Oral Health Interest Group meeting: a) recommendations for advocating the inclusion of oral health in policy discussions and b) critical research topics and measures needed for effective oral health policies in the future.

Grade C molar-incisor pattern periodontitis subgingival microbial profile before and after treatment.

Aim: This study evaluated the influence of periodontal therapy on the microbiological profile of individuals with Grade C Molar-Incisor Pattern Periodontitis (C/MIP). Methods: Fifty-three African-American participants between the ages of 5-25, diagnosed with C/MIP were included. Patients underwent full mouth mechanical debridement with systemic antibiotics (metronidazole 250 mg + amoxicillin 500 mg, tid, 7 days). Subgingival samples were collected from a diseased and a healthy site from each individual prior to treatment and at 3, 6, 12, 18 and 24 months after therapy from the same sites. Samples were subjected to a 16S rRNA gene based-microarray. Results: Treatment was effective in reducing the main clinical parameters of disease. Aggregatibacter actinomycetemcomitans (A.a.) was the strongest species associated with diseased sites. Other species associated with diseased sites were Treponema lecithinolyticum and Tannerella forsythia. Species associated with healthy sites were Rothia dentocariosa/mucilaginosa, Eubacterium yurii, Parvimonas micra, Veillonella spp., Selenomonas spp., and Streptococcus spp. Overall, treatment was effective in strongly reducing A.a. and other key pathogens, as well as increasing health-associated species. These changes were maintained for at least 6 months. Conclusions:Treatment reduced putative disease-associated species, particularly A.a., and shifted the microbial profile to more closely resemble a healthy-site profile. (Clinicaltrials.gov registration #NCT01330719).

Antibiotic and opioid prescribing for dental-related conditions in emergency departments: United States, 2012 through 2014.

BACKGROUND: Patients visiting the emergency department (ED) for nontraumatic dental conditions usually receive nondefinitive health care and are referred to treatment elsewhere. This may lead to potentially avoidable antibiotic and opioid use. METHODS: A retrospective study was conducted in IBM MarketScan Research Databases in Treatment Pathways from 2012 through 2014. This study included patients with commercial insurance or enrolled in Medicaid. Patients receiving a diagnosis of a dental condition in the ED with no secondary diagnosis warranting an antibiotic prescription were included. Patients were stratified on the basis of the primary payer and available demographics, as well as on the basis of repeat visits to the ED. RESULTS: A higher proportion of Medicaid beneficiaries (280,410, 4.9%) had dental-related visits compared with the commercially insured (159,066, 1.3%). The most common diagnoses were similar for both groups and included caries. In both cohorts, the 18- through 34-year age group had the highest rate of dental-related ED visits. Within 7 days of a dental-related ED visit, 54.9% of Medicaid beneficiaries and 55.0% of commercially insured beneficiaries filled a prescription for an antibiotic and 39.6% of Medicaid patients and 42.0% of commercially insured patients filled an opioid prescription. CONCLUSIONS: Antibiotics and opioids are frequently prescribed during ED visits for dental conditions. Access to preventive and acute oral health care for routine dental symptoms, such as caries, may reduce unnecessary prescriptions in both the commercially insured and Medicaid beneficiary populations. PRACTICAL IMPLICATIONS: Treatment of dental conditions in the ED often indicates a lack of access to preventive or acute oral health care. Data-driven solutions, such as guideline implementation, could improve oral health access, reduce medication-related harms, and avert health care expenditures.

Sex and race or ethnicity disparities in opioid prescriptions for dental diagnoses among patients receiving Medicaid.

BACKGROUND: The objective of this study was to identify specific factors (sex, race or ethnicity, and health care provider type) associated with patient receipt of an opioid prescription after a dental diagnosis. METHODS: The authors used Medicaid claims dated from January 1, 2013, through September 30, 2015, for 13 U.S. states in this study. The authors identified oral health-related conditions by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 520.0 through 529.9. RESULTS: During the 2013 through 2015 study period, among the more than 1,008,400 Medicaid patients with a dental diagnosis, 19.8% filled an opioid prescription within 14 days of diagnosis. Female patients were 50% more likely to receive an opioid prescription for pain management of a dental condition than were men (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.49 to 1.52). Non-Hispanic whites and African Americans were approximately twice as likely to receive opioids than were Hispanics (OR, 2.12; 95% CI, 2.05 to 2.19; OR, 1.90; 95% CI, 1.84 to 1.96, respectively). Patients receiving oral health care in an emergency department were more than 7 times more likely to receive an opioid prescription than were patients treated in a dental office (OR, 7.28; 95% CI, 7.13 to 7.43). Patients with a dental condition diagnosed were more than 4 times as likely to receive an opioid from a nurse practitioner as from a dentist (OR, 4.31; 95% CI, 4.19 to 4.44). Opioid use was substantially higher among African American female patients (OR, 2.02; 95% CI, 1.93 to 2.10) and non-Hispanic white female patients (OR, 2.16; 95% CI, 2.07 to 2.24) than among Hispanic female patients. CONCLUSIONS: Opioid prescribing patterns differ depending on patient race or ethnicity, sex, and health care provider source in patients with a dental diagnosis in the United States. PRACTICAL IMPLICATIONS: Dentists are providing substantially fewer opioid prescriptions compared with their medical colleagues for pain treatment after a dental diagnosis in the Medicaid population. When considering pain management for dental and related conditions, dentists should continue with conservative prescribing practices as recommended.

Opioid Prescriptions for Acute and Chronic Pain Management Among Medicaid Beneficiaries.

INTRODUCTION: Millions of Americans are affected by acute or chronic pain every year. This study investigates opioid prescription patterns for acute and chronic pain management among U.S. Medicaid patients. METHODS: The study used medical and pharmacy claims data obtained from the multistate Truven MarketScan Medicaid Database from 2013 to 2015 for Medicaid patients receiving health care. Medicaid beneficiaries who utilized an outpatient healthcare facility for back pain, neck pain (cervicalgia), joint pain (osteoarthritis and rheumatoid arthritis), orthopedics (simple/closed fractures and muscle strains/sprains), headache (cluster headaches and migraines), dental conditions, or otorhinolaryngologic (otalgia) diagnoses, based on the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes, and received an opioid prescription within 14 days of diagnosis were included in this study. RESULTS: There were 5,051,288 patients with 1 of the 7 diagnostic groupings; 18.8% had an opioid prescription filled within 14 days of diagnosis. Orthopedic pain (34.8%) was the primary reason for an opioid prescription, followed by dental conditions (17.3%), back pain (14.0%), and headache (12.9%). Patients receiving an opioid for conditions associated with acute pain management, such as otorhinolaryngologic (OR=1.93, 95% CI=1.85, 2.0), dental (OR=1.50, 95% CI=1.48, 1.53), or orthopedic conditions (OR=1.31, 95% CI=1.29, 1.32), were more likely to receive the prescription from an emergency department provider versus a general practitioner. However, compared with general practitioners, other providers were more likely to prescribe opioids for conditions associated with chronic pain management. CONCLUSIONS: More than half of Medicaid beneficiaries receiving an opioid for pain management do so for orthopedic- and dental-related reasons, with emergency department providers more likely to prescribe opioids. Modifications to the guidelines addressing temporary acute pain management practices with opioids would be likely to benefit emergency department providers the most.

Person-centered care model in dentistry.

BACKGROUND: To achieve optimal health and oral health, the system of care must place a person and their social well-being at the center of decision making and understand factors spent outside the clinical settings, including individual behavior, context and lifestyle. MAIN TEXT: Person-centered care offers a unique and compelling opportunity for dentistry, and its practitioners, to improve quality of care and overall health outcomes. For decades, the dominant treatment modalities within dentistry primarily focused on a surgical, treatment-oriented approach as opposed to health promotion and improvement. However, new business and care models are disrupting the dental care system, and transforming it into one that is focused on disease management and prevention-oriented primary care that considers overall health and well-being. We proposed a person-centered care model to improve oral health as an integral part of overall health. The model identified three key players who act as change agents with their respective roles and responsibilities: Person, provider, and health care system designer. CONCLUSIONS: While previous person-centered models in dentistry focused on the role of providers within the clinical setting, this work emphasizes the role of the care designer in creating an environment where both person and provider are able to communicate effectively and achieve improved health outcomes.

Sex and race or ethnicity disparities in opioid prescriptions for dental diagnoses among patients receiving Medicaid.

BACKGROUND: The objective of this study was to identify specific factors (sex, race or ethnicity, and health care provider type) associated with patient receipt of an opioid prescription after a dental diagnosis. METHODS: The authors used Medicaid claims dated from January 1, 2013, through September 30, 2015, for 13 US states in this study. The authors identified oral health-related conditions by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 520.0 through 529.9. RESULTS: During the 2013-2015 study period, among the more than 890,000 Medicaid patients with a dental diagnosis, 23% received an opioid within 14 days of diagnosis. Female patients were 50% more likely to receive an opioid for pain management of a dental condition than were men (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.52 to 1.55). Non-Hispanic whites and African Americans were approximately twice as likely to receive opioids than were Hispanics (OR, 2.11; 95% CI, 2.05 to 2.17 and OR, 1.88; 95% CI, 1.83 to 1.93, respectively). Patients receiving oral health care in an emergency department were nearly 5 times more likely to receive an opioid prescription than were patients treated in a dental office (OR, 4.66; 95% CI, 4.59 to 4.74). Patients with a dental condition diagnosed were nearly 3 times as likely to receive an opioid from a nurse practitioner as from a dentist (OR, 2.64; 95% CI, 2.57 to 2.70). Opioid use was substantially higher among African American female patients (OR, 3.29; 95% CI, 3.18 to 3.40) and non-Hispanic white female patients (OR, 3.24; 95% CI, 3.14 to 3.35) than among Hispanic female patients. CONCLUSIONS: Opioid prescribing patterns differ depending on patient race or ethnicity, sex, and health care provider source in patients with a dental diagnosis in the United States. PRACTICAL IMPLICATIONS: Dentists are providing substantially less opioid prescriptions compared to their medical colleagues for pain treatment following a dental diagnosis in the Medicaid population. When considering pain management for dental and related conditions, dentists should continue with conservative prescribing practices as recommended.

Trends in Pediatric Dental Care Use.

This article explores trends in 3 areas of dental services use for children less than 21 years of age. First, it examines the change in access to prevention, diagnostic, and treatment services over time among Medicaid-enrolled children and how access to care is affected by state-level factors. Second, it evaluates trends and health care costs associated with the treatment of oral health conditions in the operating room of pediatric hospitals. Third, it examines the trends in use of emergency departments for dental needs among children in the United States.

Racial Disparities in Emergency Department Utilization for Dental/Oral Health-Related Conditions in Maryland.

OBJECTIVES: Hospital emergency departments (EDs) are a place where many Americans seek treatment of dental conditions. Racial and ethnic minorities consistently have higher rates of ED utilization than whites for dental conditions. The reasons for these disparities and significant public health concerns are investigated less often. In this paper, we measure trends in racial disparities in ED discharges for dental conditions in Maryland from 2010 to 2013. To understand these disparities, we also describe differences between racial groups in age, gender, income, location, payer, comorbidities, and the availability of dental care. METHODS: 2010-2013 State Emergency Department Data for Maryland were used in the analysis. Rates per 100,000 of the population are calculated using information from census population estimates. Cost-to-charge ratios are used to estimate the costs of ED discharges. Dental/oral health-related conditions (DOHRC) are defined as discharge diagnoses of ICD-9-CM codes 520.0 through 529.9. Descriptive statistics and fixed effects logistic regression models with a rare event correction are used to analyze the data. RESULTS: Blacks, especially females aged 25-34, have larger proportions of total ED discharges due to DOHRC, and higher population rates of DOHRC, than any other racial or ethnic group. In 2013, Blacks represented 30% of Maryland's population and accounted for 52% of ED costs for DOHRC. Hispanics and those of other races have much lower rates of DOHRC discharges. The regression results show that the high proportion of DOHRC discharges among Blacks may be explained by the concentration of Blacks in low-income central cities with less access to dental care. CONCLUSION: There are significant racial disparities in the ED utilization for DOHRC in Maryland. These disparities reflect the lack of access to dental care due to both cost and geographic limitations. This results in high healthcare costs and ineffective solutions for patients. Addressing oral health disparities will require policy solutions that are targeted to the populations most at need, and action plans that combine community and state level efforts.

Children's Access to Dental Care Affected by Reimbursement Rates, Dentist Density, and Dentist Participation in Medicaid.

OBJECTIVES: To assess the relation between Medicaid reimbursement rates and access to dental care services in the context of dentist density and dentist participation in Medicaid in each state. METHODS: Data were from Early and Periodic Screening, Diagnostic, and Treatment reports for 2014, Medicaid reimbursement rate in 2013, dentist density in 2014, and dentist participation in Medicaid in 2014. We assessed patterns of mediation or moderation. RESULTS: Reimbursement rates and access to dental care were directly related at the state level, but no evidence indicated that higher reimbursement rates resulted in overuse of dental services for those who had access. The relation between reimbursement rates and access to care was moderated by dentist density and dentist participation in Medicaid. We estimate that more than 1.8 million additional children would have had access to dental care if reimbursement rates were higher in states with low rates. CONCLUSIONS: Children who access the dental care system receive care, but reimbursement may significantly affect access. States with low dentist density and low dentist participation in Medicaid may be able to improve access to dental services significantly by increasing reimbursement rates.

After Medicaid Expansion In Kentucky, Use Of Hospital Emergency Departments For Dental Conditions Increased.

Access to oral health care is a critical need for the adult Medicaid population. Following the 2014 expansion of Medicaid eligibility in Kentucky, millions of adults became eligible to receive dental benefits. We examined the impact of the expansion on adult Medicaid enrollees' use of hospital emergency departments (EDs) for conditions related to dental or oral health in the period 2010-14. Based on our analysis of data for Kentucky from the State Emergency Department Databases, we found that the rate of discharges for these conditions from the ED increased significantly, from 1,833 per 100,000 population in 2013 to 5,635 in 2014. Adults covered by Medicaid who used the ED for treatment of oral health conditions in 2014 had high levels of chronic comorbidities and were more likely to be male and nonwhite than those in earlier years. To avoid costly and inappropriate use of the ED, states considering adding an adult Medicaid dental benefit should consider also making changes to assist beneficiaries in obtaining access to the dental health care delivery system.

Development of an Analysis Pipeline Characterizing Multiple Hypervariable Regions of 16S rRNA Using Mock Samples.

OBJECTIVES: There is much speculation on which hypervariable region provides the highest bacterial specificity in 16S rRNA sequencing. The optimum solution to prevent bias and to obtain a comprehensive view of complex bacterial communities would be to sequence the entire 16S rRNA gene; however, this is not possible with second generation standard library design and short-read next-generation sequencing technology. METHODS: This paper examines a new process using seven hypervariable or V regions of the 16S rRNA (six amplicons: V2, V3, V4, V6-7, V8, and V9) processed simultaneously on the Ion Torrent Personal Genome Machine (Life Technologies, Grand Island, NY). Four mock samples were amplified using the 16S Ion Metagenomics Kit™ (Life Technologies) and their sequencing data is subjected to a novel analytical pipeline. RESULTS: Results are presented at family and genus level. The Kullback-Leibler divergence (DKL), a measure of the departure of the computed from the nominal bacterial distribution in the mock samples, was used to infer which region performed best at the family and genus levels. Three different hypervariable regions, V2, V4, and V6-7, produced the lowest divergence compared to the known mock sample. The V9 region gave the highest (worst) average DKL while the V4 gave the lowest (best) average DKL. In addition to having a high DKL, the V9 region in both the forward and reverse directions performed the worst finding only 17% and 53% of the known family level and 12% and 47% of the genus level bacteria, while results from the forward and reverse V4 region identified all 17 family level bacteria. CONCLUSIONS: The results of our analysis have shown that our sequencing methods using 6 hypervariable regions of the 16S rRNA and subsequent analysis is valid. This method also allowed for the assessment of how well each of the variable regions might perform simultaneously. Our findings will provide the basis for future work intended to assess microbial abundance at different time points throughout a clinical protocol.

Subgingival microbial communities in Leukocyte Adhesion Deficiency and their relationship with local immunopathology.

Leukocyte Adhesion Deficiency I (LAD-I) is a primary immunodeficiency caused by single gene mutations in the CD18 subunit of ß2 integrins which result in defective transmigration of neutrophils into the tissues. Affected patients suffer from recurrent life threatening infections and severe oral disease (periodontitis). Microbial communities in the local environment (subgingival plaque) are thought to be the triggers for inflammatory periodontitis, yet little is known regarding the microbial communities associated with LAD-I periodontitis. Here we present the first comprehensive characterization of the subgingival communities in LAD-I, using a 16S rRNA gene-based microarray, and investigate the relationship of this tooth adherent microbiome to the local immunopathology of periodontitis. We show that the LAD subgingival microbiome is distinct from that of health and Localized Aggressive Periodontitits. Select periodontitis-associated species in the LAD microbiome included Parvimonas micra, Porphyromonas endodontalis, Eubacterium brachy and Treponema species. Pseudomonas aeruginosa, a bacterium not typically found in subgingival plaque is detected in LAD-I. We suggest that microbial products from LAD-associated communities may have a role in stimulating the local inflammatory response. We demonstrate that bacterial LPS translocates into the lesions of LAD-periodontitis potentially triggering immunopathology. We also show in in vitro assays with human macrophages and in vivo in animal models that microbial products from LAD-associated subgingival plaque trigger IL-23-related immune responses, which have been shown to dominate in patient lesions. In conclusion, our current study characterizes the subgingival microbial communities in LAD-periodontitis and supports their role as triggers of disease pathogenesis.

Pulp and plaque microbiotas of children with severe early childhood caries.

BACKGROUND AND OBJECTIVE: Bacterial invasion into pulps of primary teeth can lead to infection and premature tooth loss in children. This pilot study aimed to explore whether the microbiota of carious exposures of dental pulps resembles that of carious dentin or that of infected root canals. DESIGN: Children with severe early childhood caries were studied. Children were consented and extent of caries, plaque, and gingivitis measured. Bacteria were sampled from carious lesion biofilms and vital carious exposures of pulps, and processed by anaerobic culture. Isolates were characterized from partial sequences of the 16S rRNA gene and identified by comparison with taxa in the Human Oral Microbiome Database (http://www.HOMD.org). The microbiotas of carious lesions and dental pulps were compared using univariate and multivariate approaches. RESULTS: The microbiota of cariously exposed pulps was similar in composition to that of carious lesion biofilms except that fewer species/taxa were identified from pulps. The major taxa identified belonged to the phyla Firmicutes (mainly streptococci) and Actinobacteria (mainly Actinomyces species). Actinomyces and Selenomonas species were associated with carious lesions whereas Veillonella species, particularly Veillonella dispar was associated with pulps. Other bacteria detected in pulps included Streptococcus mutans, Parascardovia denticolens, Bifidobacterium longum, and several Lactobacillus and Actinomyces species. By principal, component analysis pulp microbiotas grouped together, whereas those in caries biofilms were widely dispersed. CONCLUSIONS: We conclude that the microbiota of cariously exposed vital primary pulps is composed of a subset of species associated with carious lesions. Vital primary pulps had a dominant Firmicutes and Actinobacteria microbiota which contrasts with reports of endodontic infections which can harbor a gram-negative microbiota. The microbiota of exposed primary pulps may provide insight into bacterial species at the forefront of caries invasion in dentinal lesions that can invade into the pulp and the nature of species that need suppressing for successful pulp therapy.

Effects of glass ionomer temporary restorations on pulpal diagnosis and treatment outcomes in primary molars.

PURPOSE: To evaluate 1) if glass ionomer interim temporary restorations (ITR) placed for 1-3 months prior to vital pulp therapy (VPT) improved accuracy of diagnosing the pulp's clinical status and subsequent VPT success, and 2) the effect of the location of the carious lesion on VPT. METHODS: Primary molars (N=117) receiving pulp therapy with or without ITR were evaluated retrospectively. All teeth had caries extending >50 percent into dentin; caries lesion location was identified (proximal or non-proximal). Two examiners rated pulp status assessment, caries location, and pulp treatment, and correlated treatment outcomes after a mean of 34.7 months to these factors. RESULTS: VPT failed more often in first primary molars (P<.001) than in second primary molars. Using ITR improved diagnosis of the pulp status, clinical success of VPT, (P=.013) and first molar VPT success (P=.02). First primary molars had more proximal lesions than second molars (P<.001). Failure of VPT was greater for teeth with proximal lesions (P=.03). Use of ITR significantly improved VPT in teeth with proximal lesions (P=.007) but not non-proximal lesions (P=.38). CONCLUSIONS: ITR placed prior to VPT improved pulpal diagnosis and VPT outcomes. Vital pulp therapy was less successful in primary molars with proximal lesions, and ITR significantly improved the success.

Biology and genome sequence of Streptococcus mutans phage M102AD.

M102AD is the new designation for a Streptococcus mutans phage described in 1993 as phage M102. This change was necessitated by the genome analysis of another S. mutans phage named M102, which revealed differences from the genome sequence reported here. Additional host range analyses confirmed that S. mutans phage M102AD infects only a few serotype c strains. Phage M102AD adsorbed very slowly to its host, and it cannot adsorb to serotype e and f strains of S. mutans. M102AD adsorption was blocked by c-specific antiserum. Phage M102AD also adsorbed equally well to heat-treated and trypsin-treated cells, suggesting carbohydrate receptors. Saliva and polysaccharide production did not inhibit plaque formation. The genome of this siphophage consisted of a linear, double-stranded, 30,664-bp DNA molecule, with a GC content of 39.6%. Analysis of the genome extremities indicated the presence of a 3'-overhang cos site that was 11 nucleotides long. Bioinformatic analyses identified 40 open reading frames, all in the same orientation. No lysogeny-related genes were found, indicating that phage M102AD is strictly virulent. No obvious virulence factor gene candidates were found. Twelve proteins were identified in the virion structure by mass spectrometry. Comparative genomic analysis revealed a close relationship between S. mutans phages M102AD and M102 as well as with Streptococcus thermophilus phages. This study also highlights the importance of conducting research with biological materials obtained from recognized microbial collections.