Testing dental quality measures: Emergency department visits for nontraumatic dental conditions and subsequent follow-up dental visits.

BACKGROUND: The goal of this study was to test the feasibility, reliability, and validity of the Dental Quality Alliance's adult dental quality measures for system-level implementation for ambulatory care sensitive (ACS) emergency department (ED) visits for nontraumatic dental conditions (NTDCs) in adults and follow-up after ED visits for NTDCs in adults. METHODS: Medicaid enrollment and claims data from Oregon and Iowa were used for measure testing. Testing included validation of diagnosis codes in claims data through patient record reviews of ED visits and calculations of κ statistic, sensitivity, and specificity. RESULTS: Adult Medicaid enrollees' ACS NTDC ED visits ranged from 209 through 310 per 100,000 member-months. In both states, patients in the age category 25 through 34 years and non-Hispanic Black patients had the highest rates of ACS ED visits for NTDCs. Only one-third of all ED visits were associated with a follow-up dental visit within 30 days, decreasing to approximately one-fifth with a 7-day follow-up. The agreement between the claims data and patient records for identification of ACS ED visits for NTDCs was 93%, κ statistic was 0.85, sensitivity was 92%, and specificity was 94%. CONCLUSIONS: Testing revealed the feasibility, reliability, and validity of 2 DQA quality measures. Most beneficiaries did not have a follow-up with a dentist within 30 days of an ED visit. PRACTICAL IMPLICATIONS: Adoption of quality measures by state Medicaid programs and other integrated care systems will enable active tracking of beneficiaries with ED visits for NTDCs and develop strategies to connect them to dental homes.

Launching an innovative educational model addressing substance use disorders and dental pain management (Project ECHO® in dentistry).

BACKGROUND: Uninformed opioid prescribing by dentists has contributed to the current opioid crisis. This report describes the development and implementation of an innovative, interactive, multidisciplinary, and participant-centric telementoring program "Pain Management and Substance Use Disorders Dental ECHO (Extension for Community Health Care Outcomes)". We disseminated information to dentists about appropriate opioid prescribing practices and engaged them with a focus on pain management and substance use disorders. The objective of this study was to assess the effectiveness of this program for self-reported: (1) change in knowledge and confidence related to clinical skills for dental pain management of patients with substance use disorders; (2) change in clinical behavior of dentists for safe opioids prescribing; and (3) change in clinic policies regarding safe opioids prescribing. METHODS: An interdisciplinary panel of experts in medicine, pharmacy, social work, and dentistry designed and led the "Pain Management and Substance Use Disorders Dental ECHO" for invited dental care providers and dental students. Six cohorts each consisting of six, 1-h-long sessions were conducted via the Zoom videoconference platform in years 2020 and 2021. Each session included a didactic expert presentation, a participant-presented patient case and discussion. Each participant completed pre- and post-program surveys to assess the program's influence on participant knowledge, clinical confidence and behavior change. RESULTS: The participants (N = 151) were dentists (n = 109), dental faculty (n = 15), dental residents (n = 6), dental hygienists/assistants (n = 13) and nurses and clinic administrators (n = 8). Self-reported perceived medication knowledge, confidence in identification, treatment and willingness to engage with substance use disorders patients, and reported compliance with Prescription Drug Monitoring Program (PDMP) checks increased significantly from before to after the sessions (p < 0.001). Overall, participants expressed high levels of satisfaction with the content and reported that the sessions provided high benefit. CONCLUSION: The Project ECHO model is effective in rapidly disseminating evidence-based information. Dentists viewed this model as having a high degree of benefit for the optimal management of dental pain and the recognition and treatment of substance use disorders.

Racial and oral health equity in dental school curricula.

OBJECTIVES: The objective of this study was to assess the current efforts to move dental school curriculum beyond diversity and inclusion toward an anti-racism approach to racial equity. METHODS: In this cross-sectional study, an electronic Qualtrics survey was sent to 67 Dental School Associate Deans/Deans of Academic Affairs and 15 Dental Public Health (DPH) Residency Program Directors. Survey topics included oral health equity, Critical Race Theory (CRT), racism and the physiologic impacts of racism on oral health. Descriptive statistics were used to demonstrate frequencies. RESULTS: Overall response rate was 31.7% (DPH = 6, predoctoral Dental = 20). The majority of respondents that answered the question stated that the educational program offered instruction in oral health equity (96.2%), racism (75%), and the physiologic impacts of racism on oral health (83.3%). Only 17.4% of the respondents stated that the educational program offered instruction in CRT. The main barriers to providing the instruction was limited faculty trained in the topics to offer the instruction or there was limited time to offer additional content in the curriculum. CONCLUSIONS: Findings demonstrate that oral health equity, racism and the physiologic impacts of racism are being discussed in dental education to some extent, but there is limited instruction in CRT. More robust efforts are needed to ensure dental students and DPH residents are competent in providing anti-racist and unbiased health care; there should be an incorporation of anti-racism standards in the Commission on Dental Accreditation (CODA)'s predoctoral and Advanced Education Program standards.

Addressing Black men's oral health through community engaged research and workforce recruitment.

BACKGROUND: Racism negatively affects the life experiences and subsequent health of Black men, including oral disease prevalence and outcomes. Few examples in the literature discuss how racism may affect successful, unsuccessful, and non-attempts to address Black men's oral health. AIMS: This commentary describes anti-racism approaches to address Black men's oral health through community-based participatory research, oral health promotion, and workforce recruitment. MATERIALS AND METHODS: Stakeholders from two organizations and one dental school share their experiences and key insights on how to strengthen efforts while minimizing the influence of racism on Black men's participation. RESULTS: Common insights identified were a need to engage a diverse range of Black men within varying social and economic contexts, race and gender concordance among program leaders and participants, and the value of partnership to reach Black men in places where they feel comfortable and supported. DISCUSSION AND CONCLUSION: These examples stress the imperative of addressing racism among Black men in the development and improvement of targeted oral health interventions. They also emphasize the value of commitment from institutional leadership, relationship building with Black men, and the empowerment of Black men to lead program development and implementation efforts.

Training dental hygienists to place interim therapeutic restorations in a school-based teledentistry program: Oregon's virtual dental home.

OBJECTIVES: The objectives of this study on Oregon's virtual dental home were to: 1) demonstrate the feasibility of pilot project training of existing Expanded Practice Dental Hygienists (EPDHs) to perform interim therapeutic restorations (ITRs) in the community settings after diagnosis by the supervising dentist via teledentistry and 2) evaluate satisfaction of parents/guardians of children participating in a pilot program that provides school-based/on-site preventive dental care services utilizing expanded scope EPDHs to conduct dental screenings and place ITRs. METHODS: This demonstration project was a 4-years longitudinal cohort study (2016-2019) in the school/community-based settings focusing on children in kindergarten to 3rd grade. EPDHs and dentists from a Dental Care Organization were trained to utilize teledentistry and EPDHs were trained to place ITRs, the latter provided onsite dental care. Data was collected regarding child's demographics and oral health status; and parents reported level of satisfaction from services received by their children. Data analysis included descriptive statistics and logistic regression analysis to assess the relative importance of demographic and clinical factors on caries status. RESULTS: Onsite dental care was provided to 759 children. Of repeat patients (n = 377), 201 (53.3%) children had untreated decay at their first visit. Of these, 13% saw improvements in oral health status at their most recent visit (MRV). There were 162 ITRs planned out of which 50 patients received 99 ITRs. No adverse events were experienced. Of the repeat children receiving ITRs (n = 43), 28% saw improvement in their caries status at their MRV. Parents reported very high levels of satisfaction with the dental care program. CONCLUSION: Oregon's virtual dental home project was successful in training EPDHs to perform ITRs safely in school settings after caries diagnosis by the supervising dentist via teledentistry and in integrating this component into a regular school-based preventive dental program.

Faculty and dental student knowledge, attitudes, and practices concerning the prescribing of opioids: Informing curricular change.

OBJECTIVES: This study aimed to assess the knowledge, attitudes, and practices surrounding the prescribing of opioids and addiction in a dental school population. METHODS: Predoctoral dental students, residents, and dental faculty were surveyed about their beliefs, awareness, opinions about, and prior training in the prescribing of opioids, current prescribing practices, and confidence with risk mitigation strategies. Demographic information collected included gender, race/ethnicity, faculty/student role, year of birth, and year of graduation. RESULTS: Responses were received from 220 faculty and students (n = 47 and n = 173, respectively). Both faculty and students agreed that opioids were overprescribed for the treatment of dental pain. A majority of faculty and dental students (DS)3 + DS4 and DS1 + DS2 students expressed no or limited prior training in (1) the approved state opioid guidelines (75%, 79%, and 95%, respectively), (2) the identification/assessment of substance use disorders (68%, 81%, and 92%, respectively), and (3) patient education to accompany the prescribing of opioids (71%, 80%, and 92%, respectively). A majority of faculty reported moderate or extreme confidence in their clinical skills related to the prescribing of opioids (75%), their ability to identify patients with substance use disorders (55%), and their ability to discuss addiction risk and secure storage of opioids (65%). In contrast, DS3 + DS4 and DS1 + DS2 students expressed significantly less confidence and training. Faculty and students agreed that the role of a dentist included risk mitigation, but reported actions did not match their beliefs, reportedly due to lack of time, less confidence, and the assumption that a pharmacist would assume risk mitigation conversations. CONCLUSIONS: A cohesive curriculum across the four predoctoral years is needed focusing on factual knowledge about the prescribing of opioids, safe prescribing, and confidence with patient communication and risk mitigation strategies. In addition, a need for parallel faculty development synchronized with and reinforced by curricular content was identified.

Oral health clinical training and dental referral program for nurses: An interprofessional collaborative project.

INTRODUCTION: The overall objective of this study was to establish an interprofessional oral health training program for nursing personnel at Oregon Health & Science University. METHODS: Fifteen registered nurses participated in didactic and clinical training and screened the oral health of patients. Nurses completed confidence assessments and patients completed satisfaction surveys. Data analysis included descriptive statistics and non-parametric tests for comparisons of mean scores. RESULTS: Pre- and post-training surveys demonstrated significant increases in nurses' knowledge, confidence in discussing dental problems, performing dental screenings, and referring patients to dentists (p < 0.05). Patient satisfaction surveys (n = 89) denoted satisfaction with oral screenings and willingness for nurses to perform them. CONCLUSIONS: Nurses participating in oral health and clinical screening training programs supervised by dentists significantly increased their confidence in providing dental referrals. Longitudinal studies are needed to determine the impact of such training programs on patient health.

Barriers and Facilitators of Dental Care in African-American Seniors: A Qualitative Study of Consumers' Perspective.

OBJECTIVE: To identify African-American seniors' perceptions of the barriers and facilitators to their dental care. MATERIALS AND METHODS: In this cross-sectional qualitative study, we conducted in-depth interviews with 16 community-based, self-identified African-American seniors from March 2017 to August 2017 in Oregon. We coded data in ATLAS. ti and used thematic analysis to identify emergent themes within the social ecological framework and a cross-case comparative analysis to explore variation by participant characteristics. RESULTS: Regardless of dental insurance status, cost and perceived urgency of treatment were the primary drivers of participant's ability and interest in seeking dental care. Participants identified four solutions to improve oral health care in African-American seniors: affordable/free care and vouchers for dental work, better oral health education at a younger age, onsite community dental services, and navigators who can educate patients about insurance and dental providers who see low-income patients. CONCLUSIONS: Oral health decisions by African-American seniors were primarily driven by cost and perceived urgency irrespective of insurance coverage. Affordable dental care, early intervention, on-site services, and navigation may help to address key barriers and reduce oral health disparities faced by African-Americans.

Dental Student to Patient Communication Analysis: A Pilot Study.

It is very crucial that dental students who comprise our future dental workforce are adequately trained in communication skills. This training is especially important because of the increasing population of English as Second Language (ESL) patients in our community health centers, dental offices, and dental schools. The objective of this exploratory pilot study was to analyze dental student conversations about patient treatment plans to native English and ESL patients. The study recruited four dental students who spoke English as their first language and four patients, two with English as their native language and two with English as their second language from Oregon Health & Science University School of Dentistry. A Panasonic Palmcorder video camera was used to record the dental student to patient procedural conversations, which were then transcribed. Data analysis included rhetorical analysis to explore the argument structures and conversation analysis to explore the linguistic moves used in treatment plan conversations. The results showed three common errors that dental students made while dealing with ESL patients that did not exist with the native speaking patients: The consistent assumption of patient comprehension, the use of over technical jargon, and a lack of use of multi-mediated forms of communication to bridge communicative barriers. There are obvious skills to be learned by the dental students for communicating treatment plans and dealing with ESL patients. Further research and effective teaching resources are needed to better serve our patient population.

Opioid-prescribing Practices in a Graduate Endodontic Clinic before and after Implementation of the Federal Schedule II Prescribing Mandate.

INTRODUCTION: Opioid prescriptions have the potential for misuse. In October 2014, the federal schedule II prescribing mandate reclassified hydrocodone combination products from schedule III to schedule II drugs that required a written prescription. The aim of this study was to evaluate the opioid-prescribing practices in a graduate endodontic clinic (GEC) before and after the mandate. METHODS: Electronic health records from all patients treated in the GEC from 2010 to 2018 were reviewed retrospectively for opioid prescribing, the date of prescription, and the Current Dental Terminology code. Where opioid prescribing was documented in the electronic health record, additional data were extracted about pulpal and periapical diagnosis, pain level, opioid type, and prescription details. Prescribing rates were calculated and analyzed by using chi-square, analysis of variance, logistic regression, and multivariable analysis. Significance was set at P < .05. RESULTS: Overall, 4851 patients underwent 7841 procedures; 92.2% of patients were never prescribed opioids. The remaining 380 patients underwent 420 procedures, and 509 prescriptions were provided. Prescribing rates were 7.5% (228/3021) before versus 4.0% (192/4820) after the mandate (P < .001). Hydrocodone combinations were the most prescribed opioid (77%, 392/509). Tramadol prescribing increased after the mandate (P = .023). Multivariable analysis showed significantly higher prescribing for apicoectomy procedures (P < .001). Preoperative pulpal and periapical diagnosis and pain level were not significantly associated with opioid prescribing. CONCLUSIONS: An overall reduction in opioid-prescribing rates occurred coincidentally with the 2014 federal mandate. The lack of correlation between prescribing and pain level highlighted the need for evidence-based rather than habitual prescribing protocols in the GEC.

Tooth wear in patients treated with HIV anti-retroviral therapy.

BACKGROUND: The objective of this study was to elucidate the relationship between HIV anti-retroviral therapy and tooth wear. METHODS: Assessment of tooth wear was conducted both with a survey questionnaire and clinical assessment at Russell Street Dental Clinic in Portland, Oregon. The survey questionnaire comprised of questions on study participant's gender, age, HIV status, current medications, awareness of tooth grinding or clenching, jaw soreness, tooth or gum soreness, and frequency of headaches. For the clinical evaluation, a dental provider recorded the degree of wear on each tooth using a scale of 0-3. An individual tooth-wear index was used to rank patients with regard to incisal and occlusal wear. Data analysis included descriptive analysis, tests of association and regression analysis using SPSS V.24. RESULTS: The study sample involved 93 patients (HIV + ve = 60, HIV-ve = 33) with age range of 20-90 yrs. (mean = 49 yrs., s.d = 13.3). 92 and 67% participants of the HIV + ve and HIV-ve groups, respectively, presented with tooth wear. The mean tooth wear index was higher in HIV + ve patients than HIV-ve patients (8.2 vs. 7.8), however, this difference was not statistically significant (p > 0.05). A significant, positive correlation was found between HIV presence and tooth wear index, after accounting for age (B = 0.71, p < 0.05). The number of years on anti-retroviral therapy alone was positively correlated with tooth wear index (R2 = 0.116, p < 0.05). After controlling for age, years of anti-retroviral therapy use was positively correlated with tooth wear index (B = 0.047, p > 0.05). CONCLUSIONS: The findings from this study suggest that HIV + ve patients, who are on anti-retroviral therapy have significant tooth wear, although more studies with larger sample size are needed to confirm this. There is a critical need to initiate a dialogue with medical providers about tooth wear as a possible side effect of antiretroviral therapy and to introduce appropriate preventive measures.

Oral health needs, dental care utilization, and quality of life perceptions among Oregonian seniors.

BACKGROUND: For a relevant planning process and advocate for improvement in oral health conditions of the senior population up-to-date data are necessary. The objective of this study was to assess the oral health status, dental care utilization and quality of life perceptions of seniors in Clackamas County in Oregon. METHODS: Data were collected in a cross-sectional study on institutionalized and community dwelling older adults where participants completed a self-reported oral health survey, the short-form Oral Health Impact Profile (OHIP-14 questionnaire) and had clinical screenings. RESULTS: Overall, the participants (n = 177) reported mean OHIP-14 score of 0.6 ± 1.1, with "physical pain" as the highest scored domain. Seniors who were white, had teeth, dental insurance, were having a regular dentist and living in the community were 4.2 to 33.1 times more likely to visit the dentist in the previous 12 months compared to those respondents who were nonwhite, edentulous, uninsured, not having a regular dentist and living in long-term care facility (r2 = 0.67, p < 0.05). CONCLUSION: Clackamas county senior population has considerable oral health needs, dental utilization, and quality of life issues. Better dental insurance plans, health literacy opportunities and culturally competent dental providers may help to improve the oral health situation and reduce barriers.

Dental care practices and oral health training for professional caregivers in long-term care facilities: An interdisciplinary approach to address oral health disparities.

The objectives of this study were to: 1) Assess and analyze the knowledge and attitudes of caregivers towards dental care for older adults in long-term care facilities; and 2) Train administrators, medical staff, and caregivers in the oral health competencies necessary to provide daily oral health care for residents of Assisted Living Communities in Oregon. Our results indicate that although the majority of caregivers felt comfortable with regard to their oral health background and daily activities, they expressed a need for additional training in several areas. Caregivers who participated in the training recognized the poor oral health of their residents and felt the training curriculum provided them with competencies needed to improve their daily oral health services. This innovative training demonstrates that oral health can be integrated into daily routines which could improve oral and systemic health and reduce inequities in oral health care for older adults.

Oral microbiota species in acute apical endodontic abscesses.

BACKGROUND AND OBJECTIVES: Acute apical abscesses are serious endodontic diseases resulting from pulpal infection with opportunistic oral microorganisms. The objective of this study was to identify and compare the oral microbiota in patients (N=18) exhibiting acute apical abscesses, originating from the demographic region in Portland, Oregon. The study hypothesis is that abscesses obtained from this demographic region may contain unique microorganisms not identified in specimens from other regions. DESIGN: Endodontic abscesses were sampled from patients at the Oregon Health & Science University (OHSU) School of Dentistry. DNA from abscess specimens was subjected to polymerase chain reaction amplification using 16S rRNA gene-specific primers and Cy3-dCTP labeling. Labeled DNA was then applied to microbial microarrays (280 species) generated by the Human Oral Microbial Identification Microarray Laboratory (Forsyth Institute, Cambridge, MA). RESULTS: The most prevalent microorganisms, found across multiple abscess specimens, include Fusobacterium nucleatum, Parvimonas micra, Megasphaera species clone CS025, Prevotella multisaccharivorax, Atopobium rimae, and Porphyromonas endodontalis. The most abundant microorganisms, found in highest numbers within individual abscesses, include F. nucleatum, P. micra, Streptococcus Cluster III, Solobacterium moorei, Streptococcus constellatus, and Porphyromonas endodontalis. Strong bacterial associations were identified between Prevotella multisaccharivorax, Acidaminococcaceae species clone DM071, Megasphaera species clone CS025, Actinomyces species clone EP053, and Streptococcus cristatus (all with Spearman coefficients >0.9). CONCLUSIONS: Cultivable and uncultivable bacterial species have been identified in endodontic abscesses obtained from the Portland, Oregon demographic region, and taxa identifications correlated well with other published studies, with the exception of Treponema and Streptococcus cristae, which were not commonly identified in endodontic abscesses between the demographic region in Portland, Oregon and other regions.

Differential Diagnoses for Persistent Pain Following Root Canal Treatment: A Study in the National Dental PBRN.

INTRODUCTION: Pain present six months following root canal treatment (RCT) may be either of odontogenic or non-odontogenic origin. This is important because treatments and prognoses are different; therefore, the aim of this study was to provide specific diagnoses of patients reporting pain six months after receiving initial orthograde RCT. METHODS: We enrolled patients from the Midwest region of an existing prospective observational study of pain after RCT. Pain at six months was defined as ≥ 1 day of pain and average pain intensity of at least 1/10 over the preceding month. An endodontist and an orofacial pain practitioner independently performed clinical evaluations, which included periapical and cone-beam computed tomograph (CT) radiographs, to determine diagnoses. RESULTS: Thirty-eight out of the 354 eligible patients in the geographic area (11%) met the pain criteria, with 19 (50%) consenting to be clinically evaluated. As the sole reason for pain, 7 patients (37%) were given odontogenic diagnoses (4 involving the RCT tooth, 3 involving an adjacent tooth). Eight patients (42%) were given non-odontogenic pain diagnoses (7 from referred temporomandibular disorder [TMD] pain, 1 from persistent dentoalveolar pain disorder [PDAP]). Two patients (11%) had both odontogenic and non-odontogenic diagnoses, while 2 (11%) no longer fit the pain criteria at the time of the clinical evaluation. CONCLUSION: Patients reporting "tooth" pain 6 months following RCT had a non-odontogenic pain diagnosis accounting for some of this pain, with TMD being the most frequent non-odontogenic diagnosis. Dentists should have the necessary knowledge to differentiate between these diagnoses to adequately manage their patients.

Differential diagnoses for persistent pain after root canal treatment: a study in the National Dental Practice-based Research Network.

INTRODUCTION: Pain present 6 months after root canal treatment (RCT) may be of odontogenic or nonodontogenic origin. This is important because treatments and prognoses are different; therefore, the aim of this study was to provide specific diagnoses of patients reporting pain 6 months after receiving initial orthograde RCT. METHODS: We enrolled patients from the Midwest region of an existing prospective observational study of pain after RCT. Pain at 6 months was defined as ≥1 day of pain and average pain intensity of at least 1 of 10 over the preceding month. An endodontist and an orofacial pain practitioner independently performed clinical evaluations, which included periapical and cone-beam computed tomographic radiographs, to determine diagnoses. RESULTS: Thirty-eight of the 354 eligible patients in the geographic area (11%) met the pain criteria, with 19 (50%) consenting to be clinically evaluated. As the sole reason for pain, 7 patients (37%) were given odontogenic diagnoses (4 involving the RCT tooth and 3 involving an adjacent tooth). Eight patients (42%) were given nonodontogenic pain diagnoses (7 from referred temporomandibular disorder pain and 1 from persistent dentoalveolar pain disorder). Two patients (11%) had both odontogenic and nonodontogenic diagnoses, whereas 2 (11%) no longer fit the pain criteria at the time of the clinical evaluation. CONCLUSIONS: Patients reporting "tooth" pain 6 months after RCT had a nonodontogenic pain diagnosis accounting for some of this pain, with temporomandibular disorder being the most frequent nonodontogenic diagnosis. Dentists should have the necessary knowledge to differentiate between these diagnoses to adequately manage their patients.

Comparison of perceptions of oral health-related quality of life in adolescents affected with ectodermal dysplasias relative to caregivers.

The objective of this study was to assess the perceived oral health-related quality of life (OHQoL) of adolescents affected with one of the ectodermal dysplasias (EDs). Data were collected from 2003 to 2007 in a cross-sectional study of a convenience sample of individuals affected by ED (n = 35) using the Child Perceptions Questionnaire (CPQ11-14) for children and the Parent-Caregiver Perceptions Questionnaire for their caregivers. The main findings of this study were that individuals who were affected with ED in the older age group (15- to 19-year-olds) perceived more functional problems than younger individuals (11- to 14-year-olds) (p= .04). Females with ED (n = 13) perceived more emotional problems than males (n = 22; p= .01). Although caregivers tended to report slightly higher OHQoL scores (indicating worse OHQoL), no significant differences were observed between children's and parents' total OHQoL and individual domains' median scores (p > .05). Thus, the perceptions of oral health and well-being may vary by age and gender for children who have ED. Caution is warranted concerning using parents as proxies for their children when assessing the child's OHQoL.