Are U.S. Dentists Adequately Trained to Care for Children?

For decades, dental educators have noted changes in predoctoral dental education in pediatric dentistry, beginning with shifts in patients' characteristics and their availability for dental schools. During the same period, national data exposed a lingering dental caries epidemic in U.S. children yet reported more treatment of young poor children. The professional literature suggests a reluctance of the general dental community to care for children, particularly the very young who would most benefit from a dental home. The purpose of this commentary was to weigh evidence of several decades of studies on this seeming contradiction and provide the perspectives of dental students in training, those seeking advanced pediatric dentistry education or providing it, and end-users of our educational system who employ U.S. dental graduates to care for children. The usefulness of dental education establishment indicators is also reviewed, and recommendations for improvement are proposed.

Appraisal of Pediatric Dental Resident Research Presented at the American Academy of Pediatric Dentistry Annual Meeting.

Purpose: Majority of research in pediatric dentistry is carried out in advanced education programs in the country. The purpose of this study was to evaluate the abstracts of resident research posters presented at AAPD annual session for research design and topic and to assess if the resident research was published in the peer-reviewed journals. Methods: All the U.S programs based resident posters presented at AAPD between years 2013 to 2016 were evaluated. We also conducted a search on Google Scholar and PubMed to ascertain how many of these resident projects were published as manuscripts in peer reviewed journals between the years 2013-2017. All data was synthesized and analyzed using Excel Sheet and Wizard Pro Statistical software. Results: An average of 321 resident research posters were presented at AAPD annual session each year. Though a variety of research design is being presented, majority studies were cross-sectional design and case reports. Conclusions: Survey design makes for one-third of the total research. Importantly, only 3.7 percent of the research is being published in peer-reviewed journals.

Strengthening the American Academy of Pediatric Dentistry's Public Policy Advocate Network: Identifying Advocacy Efforts and Recommendations.

PURPOSE: The purposes of this study were to collect information on involvement, training, and barriers to participation in advocacy efforts for Public Policy Advocates (PPAs) of the American Academy of Pediatric Dentistry (AAPD) and make recommendations to the AAPD. METHODS: Preliminary data were collected from the PPAs during structured AAPD program meetings, conference calls, and individual interviews. Based on these data, a survey was created, piloted, and sent electronically to all PPAs. Data were analyzed and collated by frequencies. RESULTS: Responses from 38 PPAs (100 percent) revealed they were involved with state legislatures and state chapters of the AAPD and American Dental Association. Eighty-two percent of the PPAs requested additional public policy training and clearer communication channels within the network. PPAs are funding their own advocacy efforts, and the time and resources spent away from patient care is a financial barrier. CONCLUSIONS: The Public Policy Advocate network holds a broad policy skill set and voluntarily commits time and resource to advocate for the support of the pediatric dental patient at state and federal government levels. The American Academy of Pediatric Dentistry can strengthen the PPA's self-directed leadership role at state and federal levels through formalized training, restructuring of the network, and increased resources.

Primary Tooth Vital Pulp Therapy: A Systematic Review and Meta-analysis.

PURPOSE: This systematic review and meta-analysis assessed outcomes in primary teeth for the vital pulp therapy (VPT) options of indirect pulp therapy (IPT), direct pulp capping (DPC), and pulpotomy after a minimum of 12 months to determine whether one VPT was superior. METHODS: The following databases were searched from 1960 to September 2016: MEDLINE, EMBASE, CENTRAL, EBSCO, ICTRP, Dissertation abstracts, and grey literature for parallel and split-mouth randomized controlled trials of at least 12 months duration comparing the success of IPT, DPC, and pulpotomy in children with deep caries in primary teeth. Our primary outcome measure was overall success (combined clinical and radiographic). Three authors determined the included RCTs, performed data extraction, and assessed the risk of bias (ROB). Meta-analysis and assignment of quality of evidence by Grading of Recommendations Assessment, Development and Evaluation approach were done. RESULTS: Forty-one articles qualified for meta-analysis (six IPT, four DPC, and 31 pulpotomy) from 322 screened articles. The 24-month success rates were: IPT=94.4 percent, and the liner material (calcium hydroxide [CH]/bonding agents) had no effect on success (P=0.88), based on a moderate quality of evidence; DP =88.8 percent, and the capping agent (CH/alternate agent) did not affect success (P=0.56), based on a low quality of evidence. The combined success rate for all pulpotomies was 82.6 percent based on 1,022 teeth. Mineral trioxide aggregate (MTA) (89.6 percent) and formocresol (FC) (85.0 percent) success rates were the highest of all pulpotomy types and were not significantly different (P=0.15), with a high quality of evidence. MTA's success rate (92.2 percent) was higher than ferric sulfate (FS) (79.3 percent) and approached significance (P=0.06), while FS's success rate (84.8 percent) was not significantly different from FC (87.1 percent), both with a moderate quality of evidence. MTA and FC success rates were significantly better than CH (P=0.0001), with a moderate quality of evidence. At 18 months, sodium hypochlorite (NaOCl) success rate was significantly less than FC (P=0.01) with a low quality of evidence. CONCLUSIONS: The highest level of success and quality of evidence supported IPT and the pulpotomy techniques of MTA and FC for the treatment of deep caries in primary teeth after 24-months. DPC showed similar success rates to IPT and MTA or FC pulpotomy, but the quality of the evidence was lower. Systematic Review Registration Number: PROSPERO 2015: CRD42015006942.

Preparedness of Entering Pediatric Dentistry Residents: Advanced Pediatric Program Directors' and First-Year Residents' Perspectives.

For children to receive needed oral health care, adequate training at both the predoctoral and postdoctoral levels of dental education is required, but previous studies have found inadequacies in predoctoral education that lead to general dentists' unwillingness to treat certain young populations. As another way of assessing predoctoral preparation, the aim of this study was to determine the perspectives of first-year residents and pediatric program directors about residents' preparedness to enter advanced education programs in pediatric dentistry. Surveys were sent to all 74 U.S. program directors and 360 first-year residents. The survey focused on procedures related to prevention, behavior management, restorative procedures, pulp therapy, sedation, and surgery, as well as treating patients funded by Medicaid and with special health care needs. Among the first-year residents, 173 surveys were returned for a 48% response rate; 61 directors returned surveys for an 82% response rate. Only half of the residents (55%) reported feeling adequately prepared for their first year in residency; less than half cited adequate preparation to place stainless steel crowns (SSCs) (42%) and perform pulpotomies (45%). Far fewer felt adequately prepared to provide treatment for children six months to three years of age, including examinations (29%), infant oral exams (27%), and children with severe caries (37%). The program directors were even less positive about the adequacy of residents' preparation. Only 17% deemed them adequately prepared to place SSCs and 13% to perform pulpotomies. Approximately half reported their first-year residents were inadequately prepared to treat very young children and children with severe caries (55% each). This study found that the perceived inadequacy of predoctoral education in pediatric dentistry was consistent at both the learner and educator levels, supporting previous studies identifying inadequacies in this area.

Protocol for a Systematic Review and Meta-analysis of Vital Pulp Therapy for Children with Deep Caries in the Primary Dentition.

PURPOSE: The purpose of this protocol for a systematic review of randomized controlled trials of primary tooth vital pulp therapy is to describe the reasoning and need for the review, the objectives of the review, and the methodology that will be used to analyse data from the included studies. Publication of a systematic review protocol also helps establish and maintain transparency of the process and accountability for the stated methods and outcomes sought. METHODS: This protocol adheres to PRISMA-P standards for protocol reporting. A variety of relevant databases and resources will be searched. Trials selection, data extraction, and risk of bias assessment will be performed by two independent investigators. Primary outcome measures include clinical and radiographic success. Evidence tables will be generated for included study characteristics. The Cochrane risk of bias assessment tool will be applied to the selected studies. For meta-analysis, results will be pooled to provide estimates of appropriate effect size and heterogeneity of trials. The quality of evidence for outcomes will be determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: The proposed systematic review will provide findings useful for pediatric and general dentists, researchers, guideline developers, policymakers, and public and private insurers and can be the basis for an evidence-based guideline on pulp treatment of vital primary teeth with deep caries approximating the pulp.

Adequacy of patient pools to support predoctoral students' achievement of competence in pediatric dentistry in U.S. dental schools.

The aim of this study was to characterize the current status of predoctoral pediatric dentistry patient pools in U.S. dental schools and compare their status to that in 2001. A 2014 survey of school clinic-based and community-based dental patient pools was developed, piloted, and sent to pediatric predoctoral program directors in 57 U.S. dental schools via SurveyMonkey. Two follow-up contacts were made to increase the response rate. A total of 49 surveys were returned for a response rate of 86%. The responding program directors reported that their programs' patient pools had declined in number and had changed in character with more diversity and fewer procedures. They attributed the changes to competition, cost, and location of the dental school. The respondents reported that community-based dental education clinical sites continued to provide additional service experiences for dental students, with contributions varying by the nature of the site. A large number of the respondents felt that their graduates lacked some basic pediatric dentistry clinical skills and were not ready for independent practice with children. The results of this study suggest that the predoctoral pediatric dentistry patient pool has changed and general dentists may be graduating with inadequate experiences to practice dentistry for children.

The use of stainless steel crowns: a systematic literature review.

PURPOSE: The purpose was to review the published literature on stainless steel crowns (SSCs) from 2002 to the present as an update to an earlier review published in 2002. METHODS: Included were published papers on clinical studies, case series, and laboratory testing on SSCs (including esthetic SSCs and the Hall technique) in peer-reviewed journals. Study quality and strength of evidence presented were assessed for papers reporting clinical results for SSCs as a primary study outcome using a list of weighting criteria. RESULTS: Sixty-one papers fulfilled the inclusion criteria (24 papers on 22 clinical studies, three case reports, 21 reviews and surveys, and 13 laboratory testing reports on SSCs and esthetic preformed metal crowns for primary and permanent molar teeth). Ten clinical studies achieved weighting scores ranging from 68 percent to 26 percent, with the two highest scoring studies (68 percent and 63 percent) considered good quality. CONCLUSIONS: Within the confines of the studies reviewed, primary molar esthetic crowns and SSCs had superior clinical performance as restoratives for posterior primary teeth, and the Hall technique was shown to have validity. No clinical studies were available on zirconia crowns. Further well-designed prospective studies on primary molar esthetic crowns and the Hall technique are needed.

The Affordable Care Act and Health Insurance Exchanges: Advocacy Efforts for Children's Oral Health.

PURPOSE: To evaluate legislative differences in defining the Affordable Care Act's (ACA) pediatric dental benefit and the role of pediatric advocates across states with different health insurance Exchanges. METHODS: Data were collected through public record investigation and confidential health policy expert interviews conducted at the state and federal level. RESULTS: Oral health policy change by the pediatric dental profession requires advocating for the mandatory purchase of coverage through the Exchange, tax subsidy contribution toward pediatric dental benefits, and consistent regulatory insurance standards for financial solvency, network adequacy and provider reimbursement. CONCLUSIONS: The pediatric dental profession is uniquely positioned to lead change in oral health policy amidst health care reform through strengthening state-level formalized networks with organized dentistry and commercial insurance carriers.

The Affordable Care Act and health insurance exchanges: effects on the pediatric dental benefit.

PURPOSE: To examine the relationship between state health insurance Exchange selection and pediatric dental benefit design, regulation and cost. METHODS: Medical and dental plans were analyzed across three types of state health insurance Exchanges: State-based (SB), State-partnered (SP), and Federally-facilitated (FF). Cost-analysis was completed for 10,427 insurance plans, and health policy expert interviews were conducted. One-way ANOVA compared the cost-sharing structure of stand-alone dental plans (SADP). T-test statistics compared differences in average total monthly pediatric premium costs. RESULTS: No causal relationships were identified between Exchange selection and the pediatric dental benefit's design, regulation or cost. Pediatric medical and dental coverage offered through the embedded plan design exhibited comparable average total monthly premium costs to aggregate cost estimates for the separately purchased SADP and traditional medical plan (P=0.11). Plan designs and regulatory policies demonstrated greater correlation between the SP and FF Exchanges, as compared to the SB Exchange. CONCLUSIONS: Parameters defining the pediatric dental benefit are complex and vary across states. Each state Exchange was subject to barriers in improving the quality of the pediatric dental benefit due to a lack of defined, standardized policy parameters and further legislative maturation is required.

Relative value of oral health in well-child care: a survey of pediatricians in Texas and Ohio.

PURPOSE: The purpose of this study was to assess knowledge, penetration, and support of the American Academy of Pediatrics' (AAP) 2003 oral health policy statement among pediatricians and compare the perceived relative value of oral health among health topics. METHODS: A 33-question survey was sent to 1,320 randomly selected pediatricians in Texas and Ohio. The survey queried practice patterns, perceived importance of oral health, and familiarity/implementation of the AAP policy. RESULTS: The return rate was 30 percent, with a 23 percent useable response rate; 51 percent of the pediatricians had read the policy, and 74 percent were implementing some component. Overall, 40 percent referred one-year-old infants to a dentist and 29 percent believed it was important. Parental acceptance was identified to be the most common barrier for dental referral by one year of age. Oral health anticipatory guidance ranked fifth at the six- and 12-month office visits but ranked second at the 24-month visit. CONCLUSION: While three out of four pediatricians were implementing some portion of the AAP's 2003 oral health policy, referral rates and perceived importance of oral health remained low among pediatricians.

Multi-surface composite vs stainless steel crown restorations after mineral trioxide aggregate pulpotomy: a randomized controlled trial.

PURPOSE: Parents increasingly request esthetic restorations for their children's teeth. This split mouth, randomized controlled trial compared primary molars treated with white MTA pulpotomies and restored with either multi-surface composites (MSC) or stainless steel crowns (SSC). METHODS: Forty matched, contra-lateral pairs of molars received MTA pulpotomies and were randomly assigned to MSC or SSC restorations and evaluated clinically and radiographically at 6 and 12 months. Two calibrated, blinded examiners evaluated and scored radiographs. RESULTS: Thirty-seven matched pairs were evaluated at 6 months, and 31 were available at 12 months. All teeth in both groups were radiographically and clinically successful at 6 and 12 months. Dentin bridge formation was noted in 20% of the primary molars by 12 months. Although not significant, the composite group exhibited fewer intact clinical margins than the SSC group. The vast majority (94%) of teeth restored with composite displayed gray discoloration at follow-up exams, which did not appear to affect the quality of the restoration and is believed to be associated with the white MTA. CONCLUSIONS: The white MTA pulpotomies succeeded over 12 months regardless of the restoration; however, the teeth restored with composite were not as durable nor considered an esthetic alternative to the SSC.

Pulpotomy versus pulpectomy for carious vital primary incisors: randomized controlled trial.

PURPOSE: The purpose of this prospective, randomized, split-mouth investigation was to compare the success rates of formocresol pulpotomies (FC) and Vitapex(®) pulpectomies (RCT) in asymptomatic carious vital primary incisors. METHODS: Matched contralateral pairs of asymptomatic, carious, vital primary incisors were randomized to receive FC or RCT by 2 standardized operators and restored with stainless steel crowns. Seventy-four incisors were followed clinically and radiographically for up to 23 months. Two standardized examiners evaluated radiographic findings using separate pulpotomy and pulpectomy scales (modified Zurn/Seale). RESULTS: Incisors present at each interval (5-9, 10-14, and 15-23 months) showed no clinical failures. One FC incisor was lost early and counted as a failure. Though not significantly different, there were higher numbers of successful radiographic outcomes for FC than RCT at each observation interval. Cumulative final radiographic success was 89% (n=33) for FC and 73% (n=27) for RCT. (P=.11). CONCLUSIONS: Anecdotal claims that pulpotomies are unsuccessful in primary incisors are unfounded. There was no significant difference in success rates of pulpotomies and pulpectomies in the pulp treatment of asymptomatic vital primary incisors. Intracanal resorption of Vitapex(®) was seen in all pulpectomy teeth and did not affect pulpectomy outcome.