Effects of depression and stress on oral self-care among perinatal women in Appalachia: A longitudinal study.

OBJECTIVES: Oral health during the perinatal period and beyond affects the health and well-being of women and their offspring. Oral self-care behaviours can maintain or improve oral health; depression or stress during the perinatal period may compromise these behaviours. The aim of the study was to investigate the independent and combined effects of depression and stress on oral self-care behaviours of perinatal women in Appalachia, given the high burden of oral disease in this region. METHODS: A total of 1172 women in the first or second trimester of pregnancy were enrolled in the Center for Oral Health Research in Appalachia, cohort 2 (COHRA2) in West Virginia or Pittsburgh, Pennsylvania. Participants completed the Center for Epidemiological Studies Depression Scale, Perceived Stress Scale-10, and self-report items about oral self-care behaviours (i.e. toothbrushing and flossing) during pregnancy and five times in the 2+ years following birth. A Generalized Estimating Equation approach was used to analyse the longitudinal data. RESULTS: Maternal depression and stress were independently negatively related to toothbrushing and flossing frequency. These findings for toothbrushing were more pronounced in those with high levels of depression and high levels of stress, so there were both independent and combined effects. Frequency of toothbrushing and flossing stayed constant over time, so time was not associated with outcomes. About three-fourths of the sample reported toothbrushing levels that are consistent with established guidelines (i.e. two times daily), but almost half of the participants had very low levels of flossing (i.e. once or less a week). CONCLUSION: Interventions targeting stress and depression throughout the perinatal period might be helpful in improving oral self-care behaviours and oral health among women in Appalachia, in addition to the benefit of decreasing emotional distress.

Pain, Fear, Anxiety, and Stress: Relations to the Endogenous Opioid System.

Pain, fear, stress, and anxiety are separate yet interrelated phenomena. Each of these concepts has an extensive individual body of research, with some more recent work focusing on points of conceptual overlap. The role of the endogenous opioid system in each of these phenomena is only beginning to be examined and understood. Research examining the ways in which endogenous opioids (e.g., beta-endorphin; ßE) may mediate the relations among pain, fear, stress, and anxiety is even more nascent. This chapter explores the extant evidence for endogenous opioid activity as an underpinning mechanism of these related constructs, with an emphasis on research examining ßE.

Maternal perceptions of assisting preschool-aged children with toothbrushing.

BACKGROUND: Parent-led toothbrushing with fluoride toothpaste is part of an evidence-based strategy to prevent caries in children. There is a gap in the literature regarding perceptions of how and when to assist a child with toothbrushing from the maternal perspective. METHODS: A qualitative cross-sectional study was conducted with participants in North and North Central Appalachia to examine maternal perceptions of when and how to assist with toothbrushing. From 2018 through 2022, 301 mothers of children aged 3 through 5 years volunteered to participate in semistructured interviews from a more extensive parent study (Center for Oral Health Research in Appalachia cohort). The qualitative data were transcribed, coded, and analyzed using Nvivo software, Version 12 (QSR International). The data were analyzed using grounded theory, constant comparative method, and template analysis. RESULTS: A total of 301 mothers were interviewed for this study; 156 (52%) lived in West Virginia and 145 (48%) lived in Pittsburgh, Pennsylvania. Four main themes emerged: (1) assisting with child toothbrushing, (2) ceasing to provide assistance with child toothbrushing, (3) lacking recommendations from dental care professionals on child toothbrushing, and (4) adhering to recommendations from dental care professionals on child toothbrushing assistance. CONCLUSIONS: Understanding the factors that influence how parents brush their children's teeth and the information they receive to guide daily dental hygiene behavior for children is essential in developing effective interventions for preventing caries in children. PRACTICAL IMPLICATIONS: These insights can improve child toothbrushing quality through improved oral hygiene education, recommendations, terminology, and policies from the dental community.

Risk of Postpartum Dental Caries: Survival Analysis of Black/African American and White Women in Appalachia.

Background: Pregnancy is associated with increased risk of caries, but the extent this increase extends into the postpartum period is poorly understood. Study Objective: Describe the epidemiology of dental decay in the postpartum period among Black/African American and White American women and explore associations with potentially modifiable risk factors. Materials and Methods: We analyzed data from 1,131 Black/African American and White women participating in Center for Oral Health Research in Appalachia cohorts. Women were enrolled during the first two trimesters of pregnancy. Calibrated dental professionals completed dental examinations at the prenatal enrollment visit, and 2-month, 1-year, 2-year, and 3-year postpartum visits. Results: Between the prenatal visit and 2-month visit, the incidence of decayed, missing, and filled teeth (DMFT) increase was 6.92/100 person-months, compared to 3.6/100 person-months between the 2-month and 1-year visit. In a multivariate Cox proportional hazard regression predicting incidence of caries up to 3-years postpartum, being younger, having less than college education, a household income <$50,000, smoking cigarettes, a DMFT >0, a very poor or poor Oral hygiene Rating Index, lower salivary pH at enrollment, or frequently drinking 100% juice increased the hazard of new dental caries. Adjusting for race/ethnic group did not affect the direction or magnitude of observed associations. Conclusions: The strong associations of prior DMFT and Oral Rating Index with occurrence of new dental caries postpartum suggests that targeting young women for interventions to improve oral health may be more valuable for reducing caries incidence during pregnancy and in the postpartum period than targeting women only during pregnancy.

Potential risk factors and genetic variants associated with dental caries incidence in Appalachia using genome-wide survival analysis.

OBJECTIVE: The aim of this study was to identify the potential risk factors and genetic variants associated with dental caries incidence using survival analysis. METHODS: The Center for Oral Health Research in Appalachia recruited and prospectively followed pregnant women and their children. A total of 909 children followed from birth for up to 7 years were included in this study. Annual intra-oral examinations were performed to assess dental caries experience including the approximate time to first caries incidence in the primary dentition. Cox proportional hazards models were used to assess the associations of time to first caries incidence with self-reported risk factors and 4.9 million genetic variants ascertained using a genome-wide genotyping array. RESULTS: A total of 196 of 909 children (21.56%) had their first primary tooth caries event during follow-up. Household income, home water source, and mother's educational attainment were significantly associated with time to first caries incidence in the stepwise Cox model. The heritability (i.e., proportion of variance explained by genetics) of time to first caries was 0.54. Though no specific genetic variants were associated at the genome-wide significance level (P < 5E-8), we identified 14 loci at the suggestive significance level (5E-8 < P < 1E-5), some of which were located within or near genes with plausible biological functions in dental caries. CONCLUSION: Our findings indicate that household income, home water source, and mother's educational attainment are independent risk factors for dental caries incidence. We nominate several suggestive loci for further investigation.

Gastrointestinal distress as a potential mediator between stress and periodontal inflammation.

OBJECTIVES: Periodontal disease is multifactorial in its aetiology, which encompasses biopsychosocial contributors, including psychological stress. Gastrointestinal distress and dysbiosis have been associated with several chronic inflammatory diseases yet have rarely been investigated with respect to oral inflammation. Given the implications of gastrointestinal distress on extraintestinal inflammation, this study aimed to evaluate the potential role of such distress as a mediator between psychological stress and periodontal disease. METHODS: Utilizing a cross-sectional, nationwide sample of 828 adults in the USA generated via Amazon Mechanical Turk, we evaluated data collected from a series of validated self-report psychosocial questionnaires on stress, gut-specific anxiety around current gastrointestinal distress and periodontal disease, including periodontal disease subscales targeted at physiological and functional factors. Structural equation modelling was used to determine total, direct and indirect effects, while controlling for covariates. RESULTS: Psychological stress was associated with gastrointestinal distress (ß = .34) and self-reported periodontal disease (ß = .43). Gastrointestinal distress also was associated with self-reported periodontal disease (ß = .10). Gastrointestinal distress likewise mediated the relation between psychological stress and periodontal disease (ß = .03, p = .015). Given the multifactorial nature of periodontal disease(s), similar results were demonstrated using the subscales of the periodontal self-report measure. CONCLUSIONS: Associations exist between psychological stress and overall reports of periodontal disease as well as more specific physiological and functional components. Additionally, this study provided preliminary data supporting the potential mechanistic role that gastrointestinal distress plays in connecting the gut-brain and the gut-gum pathways.

Position statement: management of rotator cuff tears in adults.

We sought to compare success and re-tear rates of surgically treated full-thickness tears of the rotator cuff in men and women older than 18 years of age to develop a guideline intended for orthopedic surgeons and other health care providers who assess, counsel and care for these patients. We searched Medline, Embase and Cochrane databases through to Apr. 20, 2021, and included all English-language randomized trials comparing single-row versus double-row fixation via arthroscopic approaches; latissimus dorsi transfer (LDT) versus partial rotator cuff repair, lower trapezius transfer (LTT), and superior capsular reconstruction (SCR); and early versus late arthroscopic rotator cuff repair for traumatic tears. We also considered observational studies comparing LDT with LTT and partial repair and studies comparing early versus late treatment of traumatic rotator cuff tears. Outcomes of interest were functional outcomes, pain outcomes, and re-tear rates associated with these interventions. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline will benefit patients seeking surgical intervention of full thickness rotator cuff tears by improving counselling on surgical treatment options and outcomes. It will also benefit surgical providers by expanding their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.

Genome-Wide Analysis of Dental Caries Variability Reveals Genotype-by-Environment Interactions.

Genotype-by-environment interactions (GEI) may influence dental caries, although their effects are difficult to detect. Variance quantitative trait loci (vQTL) may serve as an indicator of underlying GEI effects. The aim of this study was to investigate GEI effects on dental caries by prioritizing variants from genome-wide vQTL analysis. First, we identified vQTLs from ~4.3 M genome-wide variants in three cohorts of white children aged 3-5 (n = 396, n = 328, n = 773) using Levene's test. A total of 39 independent vQTLs with p < 1 × 10-6 were identified, some of which were located in or near genes with plausible biological roles in dental caries (IGFBP7, SLC5A8, and SHH involved in tooth development and enamel mineralization). Next, we used linear regression to test GEI effects on dental caries with the 39 prioritized variants and self-reported environmental factors (demographic, socioeconomic, behavioral, and dietary factors) in the three cohorts separately. We identified eight significant GEIs indicating that children with vQTL risk genotypes had higher caries experience if they had less educated parents, lower household/parental income, brushed their teeth less frequently, consumed sugar-sweetened beverages more frequently, were not breastfed, and were female. We reported the first genome-wide vQTL analysis of dental caries in children nominating several novel genes and GEI for further investigations.

Behavioural and cognitive-behavioural theories in oral health research: Current state and future directions.

OBJECTIVES: Behavioural and cognitive-behavioural theories, models and frameworks have been incorporated for decades in behavioural and social oral health sciences, oral health care, and education of dentists, hygienists, and other oral healthcare professionals. METHODS: While a myriad of these conceptualizations have been incorporated in this work, there are six of them that have had the greatest impact in the oral health arena: (a) Health Belief Model; (b) Theory of Reasoned Action, Theory of Planned Behavior and Integrated Behavioral Model, which are considered in unison; (c) Social Learning Theory and Social Cognitive Theory which are considered together; (d) Transtheoretical Model/Stages of Change Model; (e) Salutogenesis Model/Theory and Sense of Coherence Framework; and the (f) Behavior Change Wheel, Capability-Opportunity-Motivation-Behavior Model and Theoretical Domains Framework, which are categorized together. RESULTS: An analysis of nomenclature (i.e. theories, models, frameworks and conceptualizations) is provided in the context of a description of each of these theories and models, with discussion about their aspects that particularly relate to oral health. Additionally, a quantitative, longitudinal view is provided of the frequency of use of these theories and models in the oral health arena. Given the benefits of theory-based intervention development, dissemination and implementation, it is important to consider these theories and models in a collective context. CONCLUSIONS: At a basic level, these theories and models help in identifying and acting on mechanisms, both of behaviour itself and behaviour change. Future directions are discussed in terms of need for theory evolution and development.

Vaccination intention and uptake within the Black community in Appalachia.

OBJECTIVE: Black communities have disproportionately experienced adverse health effects from the COVID-19 pandemic while simultaneously having less vaccination access and decreased vaccine utilization. As such, predictors of vaccination uptake within Black communities are a public health imperative. Black Americans from socio-geographic regions associated with health inequities (e.g., Appalachia), including vaccination disparities, represent an intersection of racial, economic, and ethnic social identities. To better understand the preventive health needs of Black communities in Appalachia and elsewhere, this study examined psychosocial predictors of vaccination intention or behavior. METHOD: Adults (n = 336) identifying as Black or African American from West Virginia indicated demographics, reported COVID-19 vaccination intention, flu vaccination uptake, and human papillomavirus (HPV) vaccination uptake, and completed assessments of vaccine hesitancy, medical mistrust, and racial discrimination. Hierarchical logistic regression modeling examined potential associations between psychosocial predictors and each vaccine type. RESULTS: Results showed variation in significant predictors across the vaccines of focus. Racial discrimination (OR = 0.64) and medical mistrust (OR = 0.93) were negatively associated with COVID-19 vaccination intention. Vaccine confidence was positively associated with COVID-19 vaccination intention (OR = 2.17) and HPV vaccination uptake (OR = 1.77). Total household income was the only predictor associated with flu vaccination uptake (OR = 1.12). CONCLUSIONS: These findings suggest that social interventions targeting racial discrimination in healthcare may significantly help address vaccination disparities in rural Black communities. Moreover, results emphasize unique aspects of vaccination behavior in the Black community within Appalachia that may generalize to other Black communities living in rural regions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Food insecurity and consumption of cariogenic foods in mothers and their two-year-old children in Appalachia.

OBJECTIVES: To describe the association between household food insecurity and intake of cariogenic foods that increase risk of dental caries. METHODS: Cross-sectional analysis of 842 mothers in Appalachia and their children participating in the Center for Oral Health Research Cohort 2 between 2011 and 2017 when their children were ~ 24 months of age. Mothers completed a telephone interview regarding cariogenic food consumption and food insecurity. Associations between food insecurity and daily food intake were adjusted for education, income, state residence, and daily snacking. RESULTS: After adjustment for household income, state residence, daily snacking, and maternal education, mothers from moderately/severely food insecure households drank on average ½ more sugar-sweetened beverage servings per day (p = 0.005) and children drank almost 1/3 servings more (p = 0.006). Further, mothers and children from moderately/severely food insecure households had lower, but not statistically significant, daily average consumption of vegetables (mothers: 1/5 less of a vegetable serving per day, children: ~1/10 less) and fruits (mothers: 1/5 less of a fruit serving per day, children: ~ 1/10 les) and elevated consumption of sweets (mothers: ~ 1/25 more sweet servings per day, children: ~ 2/25 more); differences based on state residence were noted. CONCLUSIONS: Food insecurity is associated with higher consumption of foods that increase risk of dental caries, but this association is modified by maternal education, income, and state residence. Food insecurity, and its socioeconomic determinants, should be considered when designing and implementing interventions to prevent dental caries.

Maternal factors and risk of early childhood caries: A prospective cohort study.

OBJECTIVE: To evaluate the associations between time-varying factors (mother's oral health, oral hygiene, smoking habits, diet, food insecurity and stress) socioeconomic factors (mother's employment, marital status, household income, insurance status, household size) and medical history on children's risk of developing a carious lesion in the first 3 years of life. METHODS: Longitudinal data from the Center for Oral Health Research in Appalachia Cohort Two (COHRA2) were analysed. Pregnant women ≥18 years in the USA were recruited during pregnancy; all consenting women delivering at term and their babies had regular dental assessments and complete in-person surveys and telephone interviews regarding sociodemographic factors, medical and dental history, and oral health behaviours. RESULTS: In a logistic regression model adjusting for covariates, children whose mother had two or more prior pregnancies, smoked cigarettes post-partum, or had a recent unfilled carious lesion were at least twice as likely to experience a dental lesion by the three-year visit. The magnitude of these associations varied by maternal education and state of residence. CONCLUSIONS: Untreated maternal decay but not maternal oral hygiene or diet were associated with cumulative risk of childhood caries by age three but were modified by maternal education and state of residence. Addressing structural and behavioural issues that reduce use of restorative dental care are needed to prevent the adverse impacts associated with early childhood caries.

Factors affecting maternal decision making about grandparents' cariogenic dietary choices for children: A qualitative study.

BACKGROUND: Added sugar in children's diets puts them at higher risk of developing caries. Researchers have reported that grandparents frequently give their grandchildren cariogenic foods and beverages (for example, those with added sugars) and disagreements between grandparents and parents can ensue over this issue. This study's objective was to examine factors that influence whether mothers address grandparents about giving their grandchildren cariogenic foods and beverages. METHODS: In-person, semistructured qualitative interviews were conducted with 126 mothers of children aged 3 through 5 years from Pittsburgh, Pennsylvania, and West Virginia from 2018 through 2020. Qualitative data for this study were audio recorded, transcribed verbatim, imported into NVivo for coding, and analyzed using iterative theme development via a constant comparative process. RESULTS: In this study, 72% of mothers (91 of 126) indicated that grandparents gave their grandchildren cariogenic foods and beverages, and 51% of those mothers (46 of 91) addressed the issue with grandparents. Mothers described that the following factors influenced whether they addressed grandparents on this issue: frequency of interaction between grandparents and children, mothers' dependency on grandparents for childcare, quantity of cariogenic foods and beverages that grandparents provided, and strength of mothers' relationships with grandparents. CONCLUSIONS: There is evidence that some mothers consider the frequency and quantity of cariogenic foods and beverages, as well as social factors, when deciding whether to engage with grandparents about the cariogenic foods and beverages they give to their grandchildren. PRACTICAL IMPLICATIONS: Initiatives aimed to decrease childhood caries should consider how interpersonal family relationships may need to be addressed as part of successful sugar-reduction interventions.

Mother's Experience of Conflict Within Their Family Social Network when Advocating for Children's oral Health.

OBJECTIVES: Examine whether mothers perceived that child oral health was a source of conflict in family relationships. METHODS: This cross-sectional qualitative study consisted of 126 semi-structured interviews with mothers of 3-5 year-old children from West Virginia and Pittsburgh, Pennsylvania. Interviews consisted of open-ended questions on the mother's social relationships that affected child dental visits, oral hygiene, and diet. The data were analyzed using template analysis. RESULTS: Over 85% (n = 111/126) of mothers reported interpersonal conflict in their familial relationships related to child oral health. Most (78%) mothers reported conflict with their partners and 58% of mothers reported conflict with the child's grandparents. Conflicts primarily centered around keeping a consistent oral hygiene routine for the child and the promotion of a low-cariogenic diet. CONCLUSIONS FOR PRACTICE: Mothers perceived child oral health promotion as a source of conflict in the family. This study suggests that identifying effective strategies to reduce conflict with caretakers are indicated. Oral health professionals can take an active role not only in communicating with the mother, but also with other caretaking adults in the family to promote oral health practices that benefit all children.

Evaluating the ecological hypothesis: early life salivary microbiome assembly predicts dental caries in a longitudinal case-control study.

BACKGROUND: Early childhood caries (ECC)-dental caries (cavities) occurring in primary teeth up to age 6 years-is a prevalent childhood oral disease with a microbial etiology. Streptococcus mutans was previously considered a primary cause, but recent research promotes the ecologic hypothesis, in which a dysbiosis in the oral microbial community leads to caries. In this incident, density sampled case-control study of 189 children followed from 2 months to 5 years, we use the salivary bacteriome to (1) prospectively test the ecological hypothesis of ECC in salivary bacteriome communities and (2) identify co-occurring salivary bacterial communities predicting future ECC. RESULTS: Supervised classification of future ECC case status using salivary samples from age 12 months using bacteriome-wide data (AUC-ROC 0.78 95% CI (0.71-0.85)) predicts future ECC status before S. mutans can be detected. Dirichlet multinomial community state typing and co-occurrence network analysis identified similar robust and replicable groups of co-occurring taxa. Mean relative abundance of a Haemophilus parainfluenzae/Neisseria/Fusobacterium periodonticum group was lower in future ECC cases (0.14) than controls (0.23, P value < 0.001) in pre-incident visits, positively correlated with saliva pH (Pearson rho = 0.33, P value < 0.001) and reduced in individuals who had acquired S. mutans by the next study visit (0.13) versus those who did not (0.20, P value < 0.01). In a subset of whole genome shotgun sequenced samples (n = 30), case plaque had higher abundances of antibiotic production and resistance gene orthologs, including a major facilitator superfamily multidrug resistance transporter (MFS DHA2 family PBH value = 1.9 × 10-28), lantibiotic transport system permease protein (PBH value = 6.0 × 10-6) and bacitracin synthase I (PBH value = 5.6 × 10-6). The oxidative phosphorylation KEGG pathway was enriched in case plaque (PBH value = 1.2 × 10-8), while the ABC transporter pathway was depleted (PBH value = 3.6 × 10-3). CONCLUSIONS: Early-life bacterial interactions predisposed children to ECC, supporting a time-dependent interpretation of the ecological hypothesis. Bacterial communities which assemble before 12 months of age can promote or inhibit an ecological succession to S. mutans dominance and cariogenesis. Intragenera competitions and intergenera cooperation between oral taxa may shape the emergence of these communities, providing points for preventive interventions. Video Abstract.

Early Childhood Diet in Relation to Toddler Nighttime Sleep Duration Trajectories.

The objective of this study was to evaluate whether dietary habits at age 2 associate with sleep duration trajectories through age 5 in children from north and central Appalachia. A total of 559 children from the Center for Oral Health Research in Appalachia (COHRA) cohort 2 were followed via caregiver phone interviews up to six times between ages 2 and 5. Exposures included data from the year 2 interview: sleep habits, household and demographic characteristics, meal patterns and consumption frequencies of fruits, vegetables, water, juice, milk, and soda. Sleep duration trajectories were identified using group-based trajectory models from ages 2 to 5. Three distinct nightly sleep duration trajectories were identified: short, increasing duration (4.5% of the study population); steady, 9 h of sleep (37.3%); and longer, slightly decreasing sleep duration (58.2%). Using multinomial logistic models that accounted for confounders, children with consistent meal patterns (i.e., meals and snacks at same time every day) and with higher fruit and vegetable consumption were more likely to follow the longer duration sleep trajectory compared to the steady sleep trajectory. In contrast, children who drank milk more frequently at age 2 were less likely to be in the longer duration sleep trajectory than the steady sleep trajectory.

Racism in oral healthcare settings: Implications for dental care-related fear/anxiety and utilization among Black/African American women in Appalachia.

OBJECTIVE: To explore the association of racism in oral healthcare settings and dental care-related fear/anxiety with dental utilization among Black/African American women in Appalachia. METHODS: We analyzed self-report measures of racism in oral healthcare settings, dental care-related anxiety and fear, recency of a dental visit, and demographic information from 268 pregnant women participating in the Center for Oral Health Research in Appalachia (COHRA) SMILE cohort. All participants self-identified as African American or Black and resided in Appalachia (i.e., either West Virginia or Pittsburgh, PA). RESULTS: Over one-third of the participants reported at least one instance of racism in oral healthcare settings, with "not being listened to" due to their race or color as the most frequent issue (24.4%). Clinically significant levels of dental care-related anxiety and fear were reported by 14.3% of the sample. A mediational model demonstrated that the experience of racism in oral healthcare settings was a significant predictor of dental fear/anxiety, and that dental fear/anxiety was a significant predictor of dental utilization. There was a significant relationship between racism in oral healthcare settings and dental utilization only when mediated by the presence of dental care-related fear and anxiety. CONCLUSIONS: Together, experiences of racism in oral healthcare settings and dental care-related fear/anxiety are predictive of decreased dental utilization for Black/African American women living in Appalachia. This study provides insight into racism in oral healthcare settings as a social determinant of dental anxiety/fear and inequities in dental utilization.