A Predictive Model for Primary Care Providers to Identify Children at Greatest Risk for Early Childhood Caries.

Purpose: The purpose of this study was to create an early childhood caries (ECC) risk-screening tool that fits into the primary care provider (PCP) well-child workflow. Methods: Integrated health records were employed to develop a predictive model for infants/toddlers at ECC risk; 2,009 patients with 12-, 15-, or 18-month well-child visits and at least one dental visit were used to develop a predictive model for ECC risk at the first dental visit. Independent model validation used 880 18- to 48-month-olds at their first dental appointment after at least one well-child visit. Results: Age at the first dental visit strongly predicted caries risk (odds ratio for one-year increase in age equals 2.11; 95 percent confidence interval equals 1.80 to 2.47). Three factors predicted high-caries risk: breast feeding status, preferred language not English, and no-show rates for pediatric clinic visits greater than 20 percent. All three non-age risk factors in well-child exams prior to 18 months predicted 42 percent probability of having caries if present for the first dental visit at 18 months. If that child was not seen until four years of age for the first dental visit, the probability of high caries risk increased to 83 percent. Model performance for independent validation was very close to expected performance. Conclusions: Existing clinical documentation plus a validated predictive model enables an effective caries risk assessment within well-child visits.

The Effect of a Unique Pacifier on Anterior Open Bite and Overjet in the Primary Dentition: A Pilot Study.

PURPOSES: Pacifiers are the most common device used by children to satisfy their sucking needs. Because of their design, reports of anterior open bite and increased overjet are common. The purposes of this pilot study were to measure the effects of a unique pacifier in toddlers who have existing open bites and increased overjets; and secondly to determine the feasibility of recruiting and retaining toddlers for a six-month study. METHODS: Toddlers with existing open bite and increased overjet currently using a conventional pacifier were recruited from a university pediatric dental clinic. Baseline information was obtained. Visual examination and intraoral measurements were obtained. The study pacifier was introduced to replace the existing pacifier. Follow-up data was collected at three and six months post-intervention. RESULTS: Eight of the 11 toddlers (73 percent) completed the study. Recruitment was challenging because of the inclusion criteria and transportation; retaining participants required numerous reminders to parents. There was a significant difference between initial and final open bite and overjet measurements. CONCLUSION: It is feasible to recruit and retain toddlers but it required significant staff interventions. There was a significant improvement in reducing existing open bite and overjet with the pacifier after six months.

Do Early Dental Visits Reduce Treatment and Treatment Costs for Children?

PURPOSE: The purpose of this paper was to determine if number and cost of dental treatments in high caries-risk children differs in children with early dental intervention compared to children with later intervention. METHODS: Billing data from children age zero to seven years old, whose first dental visit was between January 1, 2004 and December 31, 2004, were collected from 20 corporate treatment centers serving children from lower socioeconomic status backgrounds. Data included age at first visit, dental treatment codes, and associated costs for eight years after the first dental visit. Treatment included restorations, crowns, pulpotomies, and extractions. First visit age was categorized into early starters (younger than four years old) and late starters (four years of age or older). Linear regression with cluster adjustment for clinic determined a difference in costs and dental treatments by early and late starters. RESULTS: Of 42,532 subjects, 17,040 (40 percent) were early starters and 25,492 (60 percent) were late starters. There were 3.58 more dental procedures per- formed on late starters, over eight years of follow-up, than on early starters (P < .001). Late starters spent $360 more over eight years of follow-up than early starters (P < .001). CONCLUSION: In this study, number of procedures per- formed were fewer and cost of treatment less for children seen earlier versus later.

Do early dental visits reduce treatment and treatment costs for children?

PURPOSE: The purpose of this paper was to determine if number and cost of dental treatments in high caries-risk children differs in children with early dental intervention compared to children with later intervention. METHODS: Billing data from children age zero to seven years old, whose first dental visit was between January 1, 2004 and December 31, 2004, were collected from 20 corporate treatment centers serving children from lower socioeconomic status backgrounds. Data included age at first visit, dental treatment codes, and associated costs for eight years after the first dental visit. Treatment included restorations, crowns, pulpotomies, and extractions. First visit age was categorized into early starters (younger than four years old) and late starters (four years of age or older). Linear regression with cluster adjustment for clinic determined a difference in costs and dental treatments by early and late starters. RESULTS: Of 42,532 subjects, 17,040 (40 percent) were early starters and 25,492 (60 percent) were late starters. There were 3.58 more dental procedures performed on late starters, over eight years of follow-up, than on early starters (P<.001). Late starters spent $360 more over eight years of follow-up than early starters (P<.001). CONCLUSION: In this study, number of procedures performed were fewer and cost of treatment less for children seen earlier versus later.

Visioneros o soñadores? la historia de la salud oral del infante / Visionaries or Dreamers? The Story of Infant Oral Health

Objetivo: revisar la historia inicial de la promoción de la salud oral para los bebés y niños peque-ños, el impacto de la directiva de la AAPD sobre los cuidados al niño, la salud oral y las formas de maximizar los resultados de salud. Métodos: revisión de literatura. Resultados: conceptos sobre la prevención primaria y la intervención temprana fueron reportados ya en el siglo XIX. Los avances para impactar positivamente en la salud oral de los niños se han realizado. Sin embargo, el consejo de los primeros entendidos y médicos que la atención bucodental y la prevención debe comenzar tempranamente con los cuidadores y la aparición del primer diente del bebé no han sido plenamente aceptado por la profesión. Conclusiones: Se presenta una perspectiva histórica sobre el cuidado de la salud oral para los bebés y niños pequeños. Existe la necesidad de alejarse de la vía de abordaje de las enfermedades bucodentales e incorporar los conceptos de atención primaria a partir del período perinatal, y de manera más amplia sobre los factores determinantes sociales de la salud.

Purpose: To review the early history of the promotion of oral health for infants and toddlers, the impact of the AAPD guideline on infant oral health care and ways to maximize health outcomes. Methods: Review of the literature. Results: Concepts on primary prevention and early intervention were reported as early as the 19th century. Progress to positively impact the oral health of children has been made. Nevertheless, the advice of early scholars and clinicians that oral care and prevention must begin early with the caregivers and the emergence of the infantÆs first tooth have not been fully embraced by the profession. Conclusions: A historical perspective on oral health care for infants and toddlers has been presented. There is a need to move away from the surgical approach of managing oral disease and embrace the concepts of primary care beginning perinatally while more broadly addressing social determinants of health.

Paradigm shift: Infant oral health care--primary prevention.

OBJECTIVES: To demonstrate that the profession and society has been historically focused on repair of disease and not health promotion. METHODS: A search of the historical and contemporary literature and the author's academic and clinical experiences. RESULTS: Progress has been made in developing programmes to prevent dental disease, but the prevalence of the disease remains high and the co-morbidities are increasing. Decay in primary teeth has increased in all populations but greater in minority, less educated and poor populations. Many preventive interventions have been shown to be effective in cohort studies, but only fluoride use has received a high recommendation grade with the highest level of evidence. CONCLUSIONS: A cure for dental disease has been elusive. Until a cure is discovered, we must select those interventions that have the highest level of success and target them to at risk populations. Educational programmes must be relevant and applicable to the community and lifestyles of the targeted populations.

Visionaries or dreamers? The story of infant oral health.

PURPOSE: To review the early history of the promotion of oral health for infants and toddlers, the impact of the AAPD guideline on infant oral health care and ways to maximize health outcomes. METHODS: Review of the literature. RESULTS: Concepts on primary prevention and early intervention were reported as early as the 19th century. Progress to positively impact the oral health of children has been made. Nevertheless, the advice of early scholars and clinicians that oral care and prevention must begin early with the caregivers and the emergence of the infant's first tooth have not been fully embraced by the profession. CONCLUSIONS: A historical perspective on oral health care for infants and toddlers has been presented. There is a need to move away from the surgical approach of managing oral disease and embrace the concepts of primary care beginning perinatally while more broadly addressing social determinants of health.

Facilitating the transition of patients with special health care needs from pediatric to adult oral health care.

BACKGROUND: Without guidelines or policies in dentistry for transitioning adolescents with special heath care needs from pediatric to adult oral health care, little is known about traditional support services. The authors surveyed pediatric dentists about their transition of adolescent patients with and without special health care needs (SHCNs) to adult care. METHODS: In 2009, the authors e-mailed a pilot-tested survey modified from a survey used for U.S. pediatricians to 4,000 pediatric dentists. The survey included demographic questions and questions regarding services and barriers associated with the transition of patients to adult care. RESULTS: Responses were obtained from 1,686 (42.2 percent response) pediatric dentists who were mostly in group or solo private practices and were younger, in that most had completed their education in the preceding 15 years. More than one-half practiced in suburban settings, and most worked with both dental hygienists and dental assistants. Most assisted patients with SHCNs with their transitions to adult care, and the predominant barrier to transitioning to adult care was availability of general dentists and specialists who were willing to accept these new patients. Pediatric dentists' answers paralleled those of pediatricians for the most part in terms of services provided and barriers to transition. CONCLUSIONS: Most responding dentists helped adolescents with and without SHCNs make the transition into adult care, but the major barrier was the availability of general dentists and specialists. CLINICAL IMPLICATIONS: With an office protocol in place that includes trained staff members, transitioning patients (especially those with SHCNs) to adult care can be facilitated to provide the appropriate oral health and support services.

Oral health policies and clinical guidelines.

The American Academy of Pediatric Dentistry (AAPD) has developed oral health policies, clinical guidelines, and definitions to serve as a reference for healthcare providers, the public, and others. These documents are developed by the AAPD Council on Clinical Affairs with input from the Council on Scientific Affairs. In addition, the AAPD has endorsed policies and guidelines published by other associations that have some relevance to the oral health care of children. The purpose of this presentation was to review the extent to which the AAPD policies and guidelines includes mention of persons with special health care needs (PSHCN). Recommendations are made for the inclusion of references to PSHCN in additional AAPD polices and guidelines.

Overview of the evidence for clinical interventions in pediatric dentistry.

PURPOSE: The purpose of this report was to describe the quantity of published literature and types of studies supporting the use of 4 pediatric dentistry procedures: (1) ferric sulfate pulpotomy; (2) stainless steel crowns; (3) space maintainers; and (4) atraumatic restorative technique (ART). METHODS: When available, titles and abstracts of reports written in English and published over a 36-year period (1966-2002) concerning these procedures were retrieved from MEDLINE. They were classified using a modified classification scheme that, in addition to the study designs, also considered the 4 dimensions of measuring dental outcomes. RESULTS: The quantity of available literature concerning each dental procedure varied considerably. Even though many reports were published on treatments, only a small proportion of the published literature for each procedure was found to evaluate outcomes, regardless of outcome dimension. Besides outcomes evaluations, studies on techniques, material properties, and review articles comprised a large proportion of the literature. Clinical dimension of outcomes was most commonly studied. Case series and case reports were the most frequently used study designs to report outcomes. CONCLUSIONS: The outcomes-related literature to support some of the commonly performed treatments is limited both in quantity and study types. More reports are needed to develop the evidence base to support the commonly performed procedures in pediatric dental practice. Additional analyses reporting of the literature are also needed to assess internal and external validity of the studies.

Patients with special health care needs in pediatric dental practices.

PURPOSE: The objective of this study was to determine the involvement of pediatric dentists in practice in managing patients with special health care needs (SCHN) upon completion of training. METHODS: A questionnaire was developed, pilot tested, modified and sent to a randomly selected sample of 950 pediatric dentists in practice who were active and fellow members of the American Academy of Pediatric Dentistry. RESULTS: Fifty-one percent of the dentists responded. The majority were males between the ages of 41 and 50 years. Most practiced in communities with over 500,000 citizens. Most were trained in hospital-based programs, and 84% reported comprehensive didactic courses on SHCN patients during training. SCHN patients were routinely appointed in an integrated schedule in their practices. Seventy-one percent of responders continue to follow the patients after 21 years of age. Most had buildings and offices that were handicapped accessible. Patient profiles remained similar since initiating private practice with notable increases reported in the new and recall patients and patients with complicated medical histories categories. CONCLUSIONS: The results of this survey demonstrate the continuing involvement of pediatric dentists in private practice in scheduling and treating patients with special health care needs after the completion of training.

Associations of pacifier use, digit sucking, and child care attendance with cessation of breastfeeding.

OBJECTIVE: Breast milk is the recommended method of nutrition for newborns and infants. Several studies have investigated factors associated with the cessation of breast-feeding. This study assessed the associations between pacifier use, digit sucking, childcare attendance, and breastfeeding cessation among 1387 infants in the Iowa Fluoride Study. STUDY DESIGN: This was a longitudinal questionnaire survey. Mothers completed mailed questionnaires sent at infant ages 6 weeks, 3 months, and 6 months. POPULATION: Parents were recruited postpartum at 8 Iowa hospitals. OUTCOMES MEASURED: Survival analysis (using Cox proportional hazards model) assessed the time covariate effects of pacifier use, digit sucking, and child care attendance on cessation of breastfeeding, while adjusting for other possible confounding variables (not planning to breastfeed, maternal smoking, infants' sex and antibiotic use, maternal and paternal age and education, and income group). RESULTS: Percentages of women who did any breastfeeding were 46%, 36%, and 27%, at 6 weeks, 3 months, and 6 months, respectively. Percentages using pacifiers were 81%, 71%, and 59%. Combinations of pacifier use and digit sucking for various levels of child care had statistically significant associations with cessation of breastfeeding, with the effect being strongest for pacifier users and digit suckers with no child care days (hazard ratio = 1.88; 95% CI, 1.36-2.62). CONCLUSIONS: Pacifier use and digit sucking were associated with cessation of breastfeeding, with results dependent on the level of childcare attendance. The strongest associations were found for those not attending childcare and for combined use of pacifier with digit sucking.

Stretching the safety net too far waiting times for dental treatment.

PURPOSE: The objective of this study was to survey pediatric dentistry program directors on perceived resource needs and changes over the last 5 years in the characteristics of their patient population and on waiting times for dental treatment with sedation or general anesthesia (GA) for children with complex dental and medical histories in hospital- and dental school-based training programs. METHODS: A 47-question survey was sent electronically to all pediatric dentistry program directors in the United States using the University of Washington's Catalyst Tools program. Two reminder messages were sent. After 3 months, the data was downloaded and descriptive statistics were performed using the SPSS for Windows version 8.0. RESULTS: Twenty-eight of 54 program directors responded with 26 usable survey responses (48%). Thirty-one percent reported outpatient clinics located in a dental school, 31% reported that their clinics were in a hospital, and 38% had clinics in both settings. Program directors perceive that the number of new, recall and emergency patients and the number of pre-school aged children and children with special health care needs had increased in their programs in the last 5 years. Payment by Medicaid was the most common insurance for children cared for in these settings. The mean waiting time for scheduling treatment with GA for a child in pain is 28 days; without pain 71 days. The mean waiting time for scheduling treatment with sedation is 36 days. The majority of program directors reported they had an adequate number of faculty and residents (61% and 66%, respectively) even though 52% of the directors were presently actively recruiting faculty. CONCLUSIONS: 1. Dental school and hospital-based training programs are an important source for an increasing number of children with complex dental needs; 2. The majority of patients treated in the programs are Medicaid beneficiaries; 3. Average waiting times for complex dental care for children in pain is 28 days with GA; without pain and need for GA 71 days; 4. There was an average 36-day wait for treatment with sedation.