Using the Expanded Andersen Model to Determine Factors Associated with Mexican Adolescents' Utilization of Dental Services.

Many factors contribute as facilitators of or barriers to adolescents' use of dental services. Guided by the expanded Andersen model for dental service utilization, the aim of this study was to identify factors associated with the use of dental services among adolescents ages 12-16 in south Mexico City (n = 247). Adolescents answered a questionnaire on predisposing factors (age and gender), enabling factors (socioeconomic status, oral health support, parental years of education, and previous dental treatments), and psychosocial and behavioral factors (attitudes towards oral health; knowledge of gingivitis; alcohol, drug, and tobacco use; and depressive symptoms), and they underwent a visual clinical exam to determine their need factors (caries and gingivitis). The adolescents reported whether or not they had attended a dental visit in the last year for any reason. Multiple logistic regression was used to evaluate these factors. Having oral health support increased the odds of a dental visit by 2.69 (95% CI = 1.24-5.84). Previous dental treatment increased the odds of a dental visit by 2.25 (95% CI = 1.12-4.52). The presence of depressive symptoms reduced the odds of a dental visit by 4% (OR = 0.96, 95% CI = 0.94-0.99). Enabling and psychosocial factors of oral health support and previous dental treatment were positively associated with the utilization of dental services, while depressive symptoms were negatively associated.

Aging Out of Dependent Coverage and Health Insurance Trends, 2014-2019.

OBJECTIVE: To examine changes in health insurance coverage when adults age out of dependent coverage at age 26 after the implementation of most Affordable Care Act (ACA) provisions. Our analysis also documented differences by sex, race and ethnicity, and state Medicaid expansion status. METHODS: We used a regression discontinuity design and the 2014-2019 American Community Survey to estimate coverage changes (uninsured, any private, employer-sponsored coverage, direct purchase, and Medicaid) at age 26. Our main sample consisted of adult citizens aged 22-29 years. RESULTS: Uninsurance increased by 2.7% points [95% CI; 1.8-3.4] at age 26, which was driven by a significant decline in any private insurance (3.7% point decrease). Young adults experienced a smaller increase in the uninsured rate on turning age 26 in states that expanded in 2014 compared to nonexpansion states (2.2% and 3.2% point increases, respectively), but the difference was not significant (P = .07). Changes in the uninsured rate at age 26 did not differ significantly by sex or race and ethnicity. CONCLUSIONS: The 2010 dependent coverage provision led to more coverage options among young adults and in turn the uninsured rate declined among a population historically among the most likely to lack coverage. The 2014 Medicaid and Marketplace expansions reduced the uninsured rate even further among young adults. Despite important progress, our findings for 2014-2019 were similar to previous studies using pre-ACA data suggesting that coverage loss remains a risk when adults age out of dependent coverage at age 26.

Association between maternal decision-making and mental health and the nutritional status of children under 6 years of age in sub-urban Nigeria.

BACKGROUND: We assessed the association between decision-making power and mental health status of mothers and the nutritional status of their children less than 6 years old in Ile-Ife, Nigeria. METHODS: This was a secondary data analysis of 1549 mother-child dyads collected through a household survey conducted between December 2019 and January 2020. The independent variables were maternal decision-making and mental health status (general anxiety, depressive symptoms, parental stress). The dependent variable was the child's nutritional status (thinness, stunting, underweight and overweight). Confounders were maternal income, age, and education status, and the child's age and sex. The associations between the dependent and independent variables were determined using multivariable binary logistic regression analysis after adjusting for confounders. The adjusted odds ratios (AORs) were determined. RESULTS: Children of mothers with mild general anxiety had lower odds of stunting than children of mothers with normal anxiety (AOR: 0.72; p = 0.034). Mothers who did not make decisions on children's access to health care (AOR: 0.65; p < 0.001) had children with lower odds of being thin than those whose mothers made decisions on their access to health care. Children of mothers with clinically significant parenting stress levels (AOR: 0.75; p = 0.033), severe depressive symptoms (AOR: 0.70; p = 0.041) and who were not decision makers on the access of their children to health care (AOR: 0.79; p = 0.035) had lower odds of underweight. CONCLUSIONS: Maternal decision-making status and mental health status were associated with the nutritional status of children less than 6 years in a sub-urban community in Nigeria. Further studies are needed to understand how maternal mental health is associated with the nutritional status of Nigerian preschool children.

Relationship Between Sexual Orientation and Human Papillomavirus-Related Oral Cancer Knowledge and Awareness.

Purpose: Human papillomavirus (HPV)-related oral cancers are increasing, and lesbian, gay, bisexual, and other people with a minority sexual orientation may be disproportionately impacted. This study examined the relationship between sexual orientation and HPV-related oral cancer knowledge. Methods: Data from 10,859 adult participants in the 2017-2019 Health Information National Trends Survey 5, cycles 1-3, were obtained. The three data sets were merged, and weighted multiple imputation (n = 15) was applied to address missingness. Weighted logistic regression analyses examined differences in HPV-related oral cancer knowledge between sexual minority versus heterosexual participants by sex, after adjustment for race, ethnicity, age, education, income, insurance, regular medical provider, and smoking status. Results: In this weighted sample, age ranged from 18 to 101 years (mean = 56.3 years); 42% were males, 5.2% were sexual minority men/women, and 94.8% were heterosexual/straight. Overall, only 19% of respondents were aware that HPV can cause oral cancer. After controlling for sociodemographic factors, there were no significant differences in HPV-related oral cancer knowledge for sexual minority men (adjusted odds ratio [AOR]: 1.10; 95% confidence interval [95% CI]: 0.86-1.42) or women (AOR: 0.98; 95% CI: 0.76-1.26) compared with those who were heterosexual/straight. Conclusion: Overall, knowledge of HPV-related oral cancer was low, regardless of sexual orientation. There were no differences in HPV-related oral cancer knowledge between sexual minority men and women compared with their heterosexual counterparts. Educational programs are needed to increase awareness of the HPV/oral cancer link. Further research on differences in HPV-related oral cancer knowledge and attitudes by sexual orientation and the intersection of other demographic factors is warranted.

Association Between Medicaid Dental Payment Policies and Children's Dental Visits, Oral Health, and School Absences.

Importance: Although all state Medicaid programs cover children's dental services, less than half of publicly insured children receive recommended care. Objective: To evaluate the association between the ratio of Medicaid payment rates to dentist charges for an index of services (fee ratio) and children's preventive dental visits, oral health, and school absences. Design, Setting, and Participants: In this cross-sectional study, a difference-in-differences analysis was conducted between September 2021 and April 2022 of 15 738 Medicaid-enrolled children and a control group of 16 867 privately insured children aged 6 to 17 years who participated in the 2016-2019 National Survey of Children's Health. Exploratory subgroup analyses by sex and race and ethnicity were also performed. A 2-sided P < .05 was considered significant. Main Outcomes and Measures: Past-year preventive dental visits (at least 1 and at least 2), parent-reported excellent oral health, and number of days absent from school (at least 4 days and at least 7 days). Results: The Medicaid-enrolled sample included a weighted estimate of 51.20% boys and 48.80% girls (mean age, 11.24 years; Black, 21.65%; Hispanic, 37.75%; White, 31.45%). By weighted baseline estimates, 87% and 48% of Medicaid-enrolled children had at least 1 and at least 2 past-year dental visits, respectively, and 29% had parent-reported excellent oral health. Increasing the fee ratio by 1 percentage point was associated with percentage point increases of 0.18 in at least 1 dental visit (95% CI, 0.07-0.30), 0.27 in at least 2 visits (95% CI, 0.04-0.51), and 0.19 in excellent oral health (95% CI, 0.01-0.36). Increases in at least 2 visits were larger for Hispanic children than for White children. By weighted baseline estimates, 28% and 15% of Medicaid-enrolled children had at least 4 and at least 7 past-year school absences, respectively. Regression estimates for school absences were not statistically significant for the full sample but were estimated to be significantly reduced among girls. Conclusions and Relevance: This cross-sectional study found that more generous Medicaid payment policies were associated with significant but modest increases in children's preventive dental visits and excellent oral health. Further research is needed to understand the potential association between policies that improve access to dental care and children's academic success.

Periodontal disease and incident prediabetes and diabetes: The Hispanic Community Health Study/Study of Latinos.

AIM: To examine whether baseline periodontal disease is independently associated with incident prediabetes and incident diabetes in Hispanics/Latinos in the United States. MATERIALS AND METHODS: This study examined 7827 individuals, 18-74 years of age without diabetes, from the Hispanic Community Health Study/Study of Latinos. Participants received a full-mouth periodontal examination at baseline (2008-2011), and the disease was classified using the Centers for Disease Control and Prevention/American Academy of Periodontology case definitions. At Visit 2 (2014-2017), incident prediabetes and diabetes were assessed using multiple standard procedures including blood tests. Multivariable survey Poisson regressions estimated the rate ratio (RR) and 95% confidence intervals (CIs) of incident prediabetes and incident diabetes associated with periodontal disease severity. RESULTS: Among the individuals without prediabetes or diabetes at baseline, 38.8% (n = 1553) had developed prediabetes and 2.2% (n = 87) had developed diabetes after 6 years. Nineteen percent (n = 727) of individuals with prediabetes at baseline developed diabetes after 6 years. Adjusting for all potential confounders, no significant association was found between periodontal disease severity and either incident prediabetes (RR: 0.93; 95% CI: 0.82-1.06) or incident diabetes (RR: 0.99; 95% CI: 0.80-1.22). CONCLUSIONS: Our findings suggest that among a diverse cohort of Hispanic/Latino individuals living in the United States, there was no association between periodontal disease severity and the development of either prediabetes or diabetes during a 6-year follow-up period.

Association between Participation in Counseling and Retention in a Buprenorphine-Assisted Treatment Program for People Experiencing Homelessness with Opioid Use Disorder.

The opioid epidemic is a public health crisis that disproportionately affects our unsheltered neighbors. Because medication-assisted treatment (MAT) is effective for preventing deaths from drug overdose and retention is associated with better health outcomes, there is a clear need for more research on factors impacting retention in care. This retrospective cohort analysis examines the relationship between attendance in counseling and retention on buprenorphine for three or more months for individuals experiencing homelessness being treated at a Federally Qualified Health Center (FQHC) and Public Health Service Act §330(h) Health Care for the Homeless Program grantee in San Diego County, California. The cohort included 306 adults experiencing homelessness who had at least one prescription for buprenorphine and participated in a MAT program between 2017 and 2019. The sample included 64.4% men, almost exclusively white, and 35% lived in a place not meant for human habitation. Of the sample, 97 patients were retained at 3 months and 209 were not. Results from a logistic regression model showed that counseling appointments were positively associated with retention at three months (OR = 1.57, p < 0.001). Findings from this study inform future MAT program design components for people experiencing homelessness.

The Association Between Medicaid Adult Dental Coverage And Children's Oral Health.

Although all state Medicaid programs cover children's dental care, Medicaid-eligible children are more likely to experience tooth decay than children in higher-income families. Using data from the 1999-2016 National Health and Nutrition Examination Survey and the 2003, 2007, and 2011-12 waves of the National Survey of Children's Health, we examined the association between Medicaid adult dental coverage (an optional benefit) and children's oral health. Adult dental coverage was associated with a statistically significant 5-percentage-point reduction in the prevalence of untreated caries among children after Medicaid-enrolled adults had access to coverage for at least one year. These policies were also associated with a reduction in parent-reported fair or poor child oral health with a two-year lag between the onset of the policy and the effect. Effects were concentrated among children younger than age twelve. We estimated declines in poor oral health among all racial and ethnic subgroups, although there was some evidence that non-Hispanic Black children experienced larger and more persistent effects than non-Hispanic White children. Future assessments of the costs and benefits of offering adult dental coverage may consider potential effects on the children of adult Medicaid enrollees.

Epidemiological profile of early childhood caries in a sub-urban population in Nigeria.

BACKGROUND: The aim of the study was to determine the prevalence and severity of early childhood caries (ECC) in children 6-71-months; identify the teeth most at risk for ECC; and identify risk indicators associated with significant caries index (SiC) score in different age groups. METHODS: This was a cross-sectional study that collected data (using a household survey) on the ECC risk indicators (frequency of tooth brushing, consumption of refined carbohydrate in-between-meals, daily use of fluoridated toothpaste, and dental service utilization in the 12 months) in Ile-Ife, Nigeria. We computed the prevalence of ECC using the International Caries Detection and Assessment System (ICDASI (d1-6)) index; caries severity using the ICDAS-2(d1-2) and ICDAS-3(d3-6) for non-cavitated and cavitated lesions respectively, decayed missing, filled teeth (dmft), and surfaces (dmfs) and SiC indices; and caries complications using the pulp (p), ulceration (u), fistula (f) and abscesses (a) (pufa) index, for children 6-11-months-old, 12-23-months-old, 23-35-months-old, 35-47-months-old; 48-59-months-old and 60-71-months-old. The differences in the mean dmft, dmfs, pufa scores, and ICDAS 1, 2, and 3 scores, and proportion of children with each ECC risk indicator were computed. Logistic regression analysis was conducted to identify risk indicators for the ECC SiC index score for each age group. RESULTS: The prevalence of ECC was 4.7%: 2.9% had non-cavitated lesions and 2.8% had cavitated lesions. The mean (SD) dmft, dmfs and pufa scores were 0.13 (0.92), 0.24 (1.91) and 0.04 (0.46) respectively. The dmft and dmfs scores were highest among the 24-35-months-olds while the SiC score was highest among the 12-23-months-olds. There were no significant differences in dmft, dmfs, and pufa scores between the different age groups. Toothbrushing more than once a day was the only factor associated with the SiC score: it decreases the odds for the SiC score in children 48-59-months-old. The teeth worst affected by ECC were #85 and #61. CONCLUSION: The prevalence, severity and risk indicator for ECC seems to differ for each age group. The granular details on the risk profile of children with ECC in this population with a low ECC prevalence and burden can allow for the planning of age-targeted interventions.

Early childhood caries: Are maternal psychosocial factors, decision-making ability, and caries status risk indicators for children in a sub-urban Nigerian population?

OBJECTIVE: Early childhood caries (ECC) is caries in children below the age of 72 months. The aim of the study was to determine the association of maternal psychosocial factors (general anxiety, dental anxiety, sense of coherence, parenting stress, fatalism, social support, depressive symptoms, and executive dysfunction), decision-making abilities, education, income and caries status with the prevalence and severity of ECC among children resident in Ile-Ife, Nigeria. METHODS: A dataset of 1549 mother-child (6-71-months-old) dyads collected through examinations and a household survey, using validated psychometric tools to measure the psychosocial factors, were analyzed. The DMFT for the mothers and the dmft for the child were determined. The association between maternal psychosocial factors, education, income, and decision-making ability, the prevalence of maternal caries, and the prevalence of ECC was determined using logistic regression analysis. RESULTS: The prevalence of maternal caries was 3.3%, and the mean (standard deviation-SD) DMFT was 0.10 (0.76). The ECC prevalence was 4.3%, and the mean (SD) dmft was 0.13 (0.92). There was no significant difference between the prevalence and severity of maternal caries and ECC by maternal age, education, income, or decision-making abilities. There was also no significant difference in maternal caries, ECC prevalence and ECC severity by maternal psychosocial factors. The only significant association was between the prevalence of caries in the mother and children: children whose mothers had caries were over six times more likely to have ECC than were children with mothers who had no caries (AOR: 6.67; 95% CI 3.23-13.79; p < 0.001). CONCLUSION: The significant association between ECC and maternal caries prevalence suggests that prenatal oral health care for mothers may reduce the risk for ECC.

Social support and dental caries experience: Findings from the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study.

OBJECTIVE: To examine the association of social support with dental caries experience in Hispanics/Latinos living in the United States (US) and to assess whether the relationship is modified by nativity status. METHODS: This cross-sectional study analysed data for 4459 dentate men and women aged 18-74 years in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study. At baseline (2008-2011), dentists quantified dental caries experience as the number of decayed, missing, and filled permanent tooth surfaces (DMFS) for all teeth excluding third molars. Social support was assessed according to measures of structural support (Social Network Index) and functional support (Interpersonal Support Evaluation List). Covariate-adjusted multiple linear regression estimated the relationship between social support and dental caries experience and tested whether the association was modified by nativity status (born within the 50 US states, foreign-born <10 years in the United States, foreign-born >10 years or more in the United States). RESULTS: In covariate-adjusted models, each additional role in the social network was associated with 1.39 fewer DMF tooth surfaces (95% CI: -2.21, -0.58) among foreign-born Hispanics/Latinos with fewer than 10 years lived in the US. For foreign-born Hispanics/Latinos with 10 years or more in the United States, each additional social network role was associated with 0.57 fewer DMF tooth surfaces (95% CI: -1.19, 0.04). No association was observed between functional social support and dental caries experience regardless of nativity status. CONCLUSIONS: Our findings suggest that structural social support is protective against dental caries experience among recent immigrants of Hispanic/Latino background. This association may reflect the importance of social support to integration into the medical and dental infrastructure and thus receipt of dental care. Future research that examines the behavioural and cultural factors that moderate the relationship between social support and dental caries experience will inform development of culturally sensitive dental caries prevention programs for Hispanics/Latinos in the United States.

Validation of maternal report of early childhood caries status in Ile-Ife, Nigeria.

BACKGROUND: To determine the validity of maternal reports of the presence of early childhood caries (ECC), and to identify maternal variables that increase the accuracy of the reports. METHODS: This secondary data analysis included 1155 mother-child dyads, recruited through a multi-stage sampling household approach in Ile-Ife Nigeria. Survey data included maternal characteristics (age, monthly income, decision-making ability) and maternal perception about whether or not her child (age 6 months to 5 years old) had ECC. Presence of ECC was clinically determined using the dmft index. Maternally reported and clinically determined ECC presence were compared using a chi-squared test. McNemar's test was used to assess the similarity of maternal and clinical reports of ECC. Sensitivity, specificity, positive and negative predictive values, absolute bias, relative bias and inflation factor were calculated. Statistical significance was determined at p < 0.05. RESULTS: The clinically-determined ECC prevalence was 4.6% (95% Confidence interval [CI]: 3.5-5.0) while the maternal-reported ECC prevalence was 3.4% (CI 2.4-4.6). Maternal reports underestimated the prevalence of ECC by 26.1% in comparison to the clinical evaluation. The results indicate low sensitivity (9.43%; CI 3.13-20.70) but high specificity (96.9%; CI 95.7-97.9). The positive predictive value was 12.8% (CI 4.3-27.4) while the negative predictive value was 95.7% (CI 94.3-96.8). The inflation factor for maternally reported ECC was 1.4. Sensitivity (50.0%; CI 6.8-93.2) and positive predictive value were highest (33.3%; CI 4.3-77.7) when the child had a history of visiting the dental clinic. CONCLUSIONS: Mothers under-reported the presence of ECC in their children in this study population. The low sensitivity and positive predictive values of maternal report of ECC indicates that maternal reporting of presence of ECC may not be used as a valid tool to measure ECC in public health surveys. The high specificity and negative predictive values indicate that their report is a good measure of the absence of ECC in the study population. Child's history of dental service utilization may be a proxy measure of presence of ECC.

Family monetary incentives as a value-based care model for oral hygiene: rationale and design of the BEhavioral EConomics for Oral health iNnovation (BEECON) trial.

BACKGROUND: Effective prevention-focused, value-based strategies are needed to improve oral health. Despite evidence that monetary incentives can motivate healthy behavior, well-powered studies have yet to examine incentives for improving children's oral hygiene. AIM: Describe the rationale and design of the BEhavioral EConomics for Oral health iNnovation (BEECON) trial, which tests lottery-based monetary incentives as a consumer-oriented, value-based care model for improving children's oral hygiene. DESIGN: Phase II, stratified, permuted block randomized, controlled, two-arm, parallel groups, prevention trial. SETTING: Study visits occur at three Los Angeles, CA health clinics. PARTICIPANTS: Two hundred and forty-four parent-child dyads with a child aged 6-48 months. INTERVENTIONS: Eligible dyads were randomized in equal allocation to one of two groups: lottery incentive group or waitlist (delayed incentive) control group. Weekly lottery incentives were offered for 6 months based on Bluetooth-recorded toothbrushing frequency. Both groups received weekly text message feedback on toothbrushing performance. OUTCOMES: The primary outcome was toothbrushing performance from baseline to 6 months, measured as the mean number of qualifying half-day Bluetooth-recorded episodes per week when the child's teeth were brushed. Secondary outcomes included toothbrushing performance sustainability through 12 months and dental caries status. CONCLUSIONS: BEECON offers a consumer-oriented approach to promoting value-based oral health care. We hypothesize that lottery-based incentives can improve oral hygiene in young children. Study results will inform programming efforts to enhance oral disease prevention in young children. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT03576326.

Malnutrition, enamel defects, and early childhood caries in preschool children in a sub-urban Nigeria population.

OBJECTIVES: The study tried to determine if malnutrition (underweight, stunting, wasting, overweight) and enamel defects (enamel hypoplasia, hypomineralized second molar, amelogenesis imperfecta, fluorosis) were associated with early childhood caries (ECC). The study also examined whether malnutrition was associated with the presence of enamel defects in 0-5-year-old children. METHODS: The study was a secondary analysis of primary data of a cross-sectional study assessing the association between maternal psychosocial health and ECC in sub-urban Nigerian population collected in December 2018 and January 2019. One hundred and fifty nine children were recruited. Exploratory variables were malnutrition and enamel defects. The outcome variables were the prevalence of ECC in 0-2-year-old, 3-5-year-old, and 0-5-year-old children. Multivariable Poisson regression analysis was used to determine the associations, and socioeconomic status, oral hygiene status, and frequency of in-between-meals sugar consumption were adjusted for. The adjusted prevalence ratios, 95% confidence intervals, and p values were calculated. RESULTS: The prevalence of ECC was 2.1% in 0-2-year-old children and 4.9% in 3-5-year-old children. In adjusted models, underweight, stunting, and wasting/overweight were not significant risk indicators for ECC in either age group. 0-2-year-old children who had amelogenesis imperfecta (p<0.001) and fluorosis (p<0.001) were more likely to have ECC than were children who did not have these lesions. 3-5-year-old children who had hypoplasia (p = 0.004), amelogenesis imperfecta (p<0.001) and fluorosis (p<0.001) were more likely to have ECC than were children who did not have these lesions. 0-5-year-old children with hypoplasia (p<0.001) and fluorosis (p<0.001) were more likely to have ECC than were children who did not have these lesions. There were significant associations between various types of malnutrition and various types of enamel defects. CONCLUSION: Although different types of malnutrition were associated with enamel defects, and enamel defects were associated with ECC, malnutrition was not associated with ECC. Further studies are needed to clarify the association between malnutrition and genetically and toxin-induced enamel defects.

Association between maternal socioeconomic factors, decision-making status, and dental utilization by children with early childhood caries in sub-urban Nigeria.

AIM: To determine the association between maternal education, income, and decision-making status and the presence of early childhood caries (ECC) and dental-service utilization among young children. METHODS: This cross-sectional study was based on data from a household survey of 1,549 mother-preschool-aged-child dyads conducted in Ife Central Local Government Area, Nigeria. The explanatory variables were maternal education, income, and decision-making status (related to healthcare, large household purchases, and visits to family/relatives). Outcome variables were the presence of ECC and the child's history of dental-service utilization. Poisson regression analyses were conducted to identify factors associated with outcomes; the models were adjusted for maternal age, child's socioeconomic status, oral hygiene status, and frequency of sugar consumption. RESULTS: The study recruited 1,549 mother-child dyads, of which 66 (4.3 percent) children had ECC, and 90 (5.9 percent) children had a history of dental-service utilization. Fewer than half (42.3 percent) of the mothers earned between N18,001($49.00) and 60,000 ($168.00) per month. Also, 896 (57.8 percent) reported not making any independent decisions, 152 (9.8 percent) made one of three decisions independently, and 313 (20.2 percent) made two or three decisions independently. In the adjusted model, children of mothers with monthly income higher than N60,000 were more likely to have used dental services than were those whose mother's monthly income was less than or equal to N18,000 (adjusted prevalence ratio = 2.29; 95%CI: 1.30-4.02; P = 0.004). No other maternal factor was associated with ECC. CONCLUSIONS: Although maternal socioeconomic factors and decision-making abilities were not associated with ECC prevalence, more preschool children whose mothers had high income used dental services.

Monetary incentives for improving smartphone-measured oral hygiene behaviors in young children: A randomized pilot trial.

AIMS: To assess feasibility, acceptability, and early efficacy of monetary incentive-based interventions on fostering oral hygiene in young children measured with a Bluetooth-enabled toothbrush and smartphone application. DESIGN: A stratified, parallel-group, three-arm individually randomized controlled pilot trial. SETTING: Two Los Angeles area Early Head Start (EHS) sites. PARTICIPANTS: 36 parent-child dyads enrolled in an EHS home visit program for 0-3 year olds. INTERVENTIONS: Eligible dyads, within strata and permuted blocks, were randomized in equal allocation to one of three groups: waitlist (delayed monetary incentive) control group, fixed monetary incentive package, or lottery monetary incentive package. The intervention lasted 8 weeks. OUTCOMES: Primary outcomes were a) toothbrushing performance: mean number of Bluetooth-recorded half-day episodes per week when the child's teeth were brushed, and b) dental visit by the 2-month follow-up among children with no prior dental visit. The a priori milestone of 20% more frequent toothbrushing identified the intervention for a subsequent trial. Feasibility and acceptability measures were also assessed, including frequency of parents syncing the Bluetooth-enabled toothbrush to the smartphone application and plaque measurement from digital photographs. FINDINGS: Digital monitoring of toothbrushing was feasible. Mean number of weekly toothbrushing episodes over 8 weeks was 3.9 in the control group, 4.1 in the fixed incentive group, and 6.0 in the lottery incentive group. The lottery group had 53% more frequent toothbrushing than the control group and 47% more frequent toothbrushing than the fixed group. Exploratory analyses showed effects concentrated among children ≤24 months. Follow-up dental visit attendance was similar across groups. iPhone 7 more reliably captured evaluable images than Photomed Cannon G16. CONCLUSIONS: Trial protocol and outcome measures were deemed feasible and acceptable. Results informed the study protocol for a fully powered trial of lottery incentives versus a delayed control using the smart toothbrush and remote digital incentive program administration. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT03862443.

A comprehensive assessment for community-based, person-centered care for older adults.

BACKGROUND: Many health and social needs can be assessed and met in community settings, where lower-cost, person-centered, preventative and proactive services predominate. This study reports on the development and implementation of a person-centered care model integrating dental, social, and health services for low-income older adults at a community dental clinic co-located within a senior wellness center. METHODS: A digital comprehensive geriatric assessment (CGA) and referral system linking medical, dental, and psychosocial needs by real-time CGA-derived metrics for 996 older adults (age ≥ 60) was implemented in 2016-2018 as part of a continuous quality improvement project. This study aims to describe: 1) the development and content of a new CGA; 2) CGA implementation, workflows, triage, referrals; 3) correlations between CGA domains, and adjusted regression models, assessing associations with self-reported recent hospitalizations, emergency department (ED) visits, and clinically-assessed dental urgency. RESULTS: The multidisciplinary team from the senior wellness and dental centers planned and implemented a CGA that included standard medical history along with validated instruments for functional status, mental health and social determinants, and added oral health. Care navigators employed the CGA with 996 older adults, and made 1139 referrals (dental = 797, care coordination = 163, social work = 90, mental health = 32). CGA dimensions correlated between oral health, medical status, depressive symptoms, isolation, and reduced quality of life (QoL). Pain, medical symptoms, isolation and depressive symptoms were associated with poorer self-reported health, while general health was most strongly correlated with lower depressive symptoms, and higher functional status and QoL. Isolation was the strongest correlate of lower QoL. Adjusted odds ratios identified social and medical factors associated with recent hospitalization and ED visits. General and oral health were associated with dental urgency. Dental urgency was most strongly associated with general health (AOR = 1.78,95%CI [1.31, 2.43]), dental symptoms (AOR = 2.39,95%CI [1.78, 3.20]), dental pain (AOR = 2.06,95%CI [1.55-2.74]), and difficulty chewing (AOR = 2.80, 95%CI [2.09-3.76]). Dental symptoms were associated with recent ED visits (AOR = 1.61, 95%CI [1.12-2.30]) or hospitalizations (AOR = 1.47, 95%CI [1.04-2.10]). CONCLUSION: Community-based inter-professional care is feasible with CGAs that include medical, dental, and social factors. A person-centered care model requires coordination supported by new workflows. Real-time metrics-based triage process provided efficient means for client review and a robust process to surface needs in complex cases.

Longitudinal analysis of cost and dental utilization patterns for older adults in outpatient and long-term care settings in Minnesota.

BACKGROUND: Dental utilization patterns and costs of providing comprehensive oral healthcare for older adults in different settings have not been examined. METHODS: Retrospective longitudinal cohort data from Apple Tree Dental (ATD) were analyzed (N = 1,159 total; 503 outpatients, 656 long-term care residents) to describe oral health status at presentation, service utilization patterns, and care costs. Generalized estimating equation (GEE) repeated measures analysis identified significant contributors to service cost over the three-year study period. RESULTS: Cohort mean age was 74 years (range = 55-104); the outpatient (OP) group was younger compared to the long-term care (LTC) group. Half (56%) had Medicaid, 22% had other insurance, and 22% self-paid. Most (72%) had functional dentitions (20+ teeth), 15% had impaired dentitions (9-19 teeth), 6% had severe tooth loss (1-8 teeth), and 7% were edentulous (OP = 2%, LTC = 11%). More in the OP group had functional dentition (83% vs. 63% LTC). The number of appointments declined from 5.0 in Year 1 (OP = 5.7, LTC = 4.4) to 3.3 in Year 3 (OP = 3.6, LTC = 3.0). The average cost to provide dental services was $1,375/year for three years (OP = $1,427, LTC = $1,336), and costs declined each year, from an average of $1,959 (OP = $2,068, LTC = $1,876) in Year 1 to $1,016 (OP = $989, LTC = $1,037) by Year 3. Those with functional dentition at presentation were significantly less costly than those with 1-19 teeth, while edentulous patients demonstrated the lowest cost and utilization. Year in treatment, insurance type, dentition type, and problem-focused first exam were significantly associated with year-over-year cost change in both OP and LTC patients. CONCLUSION: Costs for providing comprehensive dental care in OP and LTC settings were similar, modest, and declined over time. Dentate patients with functional dentition and edentulous patients were less costly to treat. LTC patients had lower utilization than OP patients. Care patterns shifted over time to increased preventive care and decreased restorative care visits.

Psychosocial, education, economic factors, decision-making ability, and caries status of mothers of children younger than 6 years in suburban Nigeria.

BACKGROUND: Little information is available on the relationship between mothers' psychosocial profile and caries status, and less information is available on the oral health status and psychosocial status of mothers of young children in Africa. This study examined the association between the psychosocial profile of mothers in Nigeria and their prevalence of caries. METHODS: The prevalence of caries and severe caries (DMFT > 3) in mothers with children 71 months old and younger recruited through a household survey in Ile-Ife, Nigeria, was estimated through clinical examination. The explanatory variables were maternal education, income, decision-making status, and psychosocial status (dental anxiety, general anxiety, depressive symptoms, parenting stress, executive dysfunction, sense of coherence, fatalism and social support). The risk indicators for maternal caries were analyzed with logistic regression. RESULTS: The prevalence of caries was 3.3%. Twenty (39.2%) of the 51 women with caries had DMFT > 3. Most study participants were 25-34 years old (59.3%), had secondary level education (63.1%), earned N18,000 ($49)-N30000 ($84) per month (42.9%), and can make autonomous decisions about their health care, household purchases, or visits to family/relatives (68.8%). Most women had normal general anxiety (79.9%), low dental anxiety (90.4%), and normal stress (76.4%) levels. Most also had high fatalism (56.6%), perceived moderate social support (81.6%), had normal depressive symptoms (75.9%), low executive dysfunction (55.9%), and high sense of coherence (53.8%). Mothers who had clinically significant levels of stress were twice more likely to have caries than were those whose level of stress was normal (AOR: 2.26; 95%CI: 1.04-4.89; P = 0.039). Also, mothers who had high fatalism were less likely to have caries than were those with low fatalism (AOR: 0.40; 95%CI: 0.21-0.75; P = 0.004). CONCLUSION: High levels of parenting stress was a risk indicator for caries while high fatalism was protective from caries in mothers of children younger than 6-years. Maternal education, income and decision-making ability were not associated with maternal caries. Though the caries prevalence for women with young children was low, the prevalence of severe caries was high and this because of the possible negative effect on their health and wellbeing.

Association between nutritional status and early childhood caries risk profile in a suburban Nigeria community.

BACKGROUND: Malnutrition is associated with oral health problems. AIM: To determine the association between malnutrition (undernourished and over-nourished) and early childhood caries (ECC) in a suburban population in Nigeria. DESIGN: Data were extracted from a database of a household survey of 1549 under 6-year-old children. Explanatory variables were nutritional status (normal, undernourished [wasted, stunted and underweight], or over-nourished). The outcome measure was the prevalence of ECC. Children's sociodemographic characteristics (socio-economic status, sex, age) and caries-risk variables (frequency of sugar consumption in-between-meals, oral hygiene status) were the confounders. Association between ECC and malnutrition was determined using the Poisson regression analysis. Statistical significance was set at P ≤ .05. RESULTS: About one-third (31.4%) of children had expected height/weight for age; 848 (54.7%) were undernourished; and 215 (13.9%) were over-nourished. Nutritional status was not significantly associated with the prevalence of ECC. Children who consumed sugar in-between-meals three or more times a day were twice as likely to have ECC as were those who consumed sugar less often in-between-meals (APR: 2.23; 95% CI: 1.30-3.81; P = .003). Children 3-5 years old were more likely to have ECC than were those 0-2 years old (APR: 2.40; 95% CI: 1.10-5.22; P = .03). CONCLUSIONS: ECC was not associated with undernourished and over-nourished in a suburban population in Nigeria.