Children's oral health-related behaviours and early childhood caries: A latent class analysis.

OBJECTIVE: In this cross-sectional study in a large community-based sample of preschool-age children, we sought to identify distinct clusters of modifiable early childhood oral health-related behaviours (OHBs) and quantify their association with clinical and parent-reported measures of early childhood oral health. METHODS: We relied upon a questionnaire (n = 8033; 11% in Spanish) and clinical oral health data (n = 6404; early childhood caries [ECC] prevalence = 54%] collected in the context of an epidemiologic study of early childhood oral health among 3- to 5-year-old children in North Carolina. Latent class analysis was used to identify clusters of modifiable OHBs based on parents' responses to 6 questionnaire items pertaining to their children's oral hygiene, diet and dental home. The optimal number of clusters was determined based on measures of model fit and interpretability. We examined associations of OHB clusters with clinical and parent-reported child oral health status (ie, ECC prevalence, severity and proportion with untreated disease) using bivariate association tests and multivariable regression modelling with marginal effects estimation accounting for clustered data. We used Mplus v.8.6 (Muthén & Muthén, Los Angeles, CA, USA) and Stata v.16.1 (StataCorp, College Station, TX, USA) for data analyses. RESULTS: We identified 2 OHB clusters, a favourable (74%) and an unfavourable (26%) one. Children in the favourable OHB cluster had better oral hygiene practices (ie, tooth brushing frequency and fluoridated toothpaste use), lower consumption frequency of sugar-containing snacks and beverages, less frequent reports of night-time bottle-feeding history and a higher likelihood of a dental home. Children in the unfavourable cluster had significantly higher ECC prevalence (57% vs 53%), caries burden (mean dmfs = 9.3 vs 7.6), untreated disease (43% vs 33%) and worse parent-reported oral health status than the favourable cluster. CONCLUSIONS: Our findings demonstrate the importance and utility of clustering common, modifiable ECC risk factors in population studies - health promotion efforts may centre on groups of people rather than individual behavioural risk factors.

An Algorithm for Managing Emergent Dental Conditions for Children.

The amount of emergency department dental utilization and related trend analysis data in peer-reviewed literature has increased; yet, little has been written on the actual management of dental emergencies. Often pre-existing medical conditions complicate what might otherwise be a straightforward dental emergency, challenging office-based dentists to manage dental emergencies in a safe manner. With the profession taking a stance on child safety, algorithms and checklists are becoming more important and common in healthcare during complicated scenarios. Additionally, more children are living longer with chronic medical conditions. This manuscript offers an algorithm that can guide clinicians through challenges presented during a dental emergency in children.

Identification of Preferred Healthy Weight Counseling Approaches for Children in the Dental Setting.

OBJECTIVE: There is a gap in the literature regarding optimal methods for the dental team to help address the childhood obesity epidemic; accordingly, this investigation sought to identify preferred communication approaches the dental team can rely upon to initiate dialogue with caregivers regarding the weight of their children. STUDY DESIGN: A structured interview guide containing seven potential Healthy Weight Counseling (HWC) approaches and eight follow up questions was developed, pilot-tested, revised and utilized as a structured interview guide. Interviews were conducted at the Children's Clinic at the School of Dentistry at the University of North Carolina at Chapel Hill (UNC-CH) with 50 participants who are English-speaking caregivers of children ages 4-12. RESULTS: Ninety-four percent of the participants were receptive to HWC in the dental setting. Caregivers indicated varying levels of acceptance for the seven HWC-approaches based on specific word choices in each approach. Sixty percent preferred HWC to be delivered with the child not present while 34% preferred the child's presence and 6% had no preference. CONCLUSIONS: Caregivers were open to weight-related conversations in the dental setting but to be well received, the dental team must choose their approach carefully and establish the proper doctor/patient relationship prior to HWC delivery. An individualized HWC-approach tailored to the specific needs of each family is indicated.

An Algorithm-Based Approach for Behavior and Disease Management in Children.

Pharmacologic behavior management for dental treatment is an approach to provide invasive yet compassionate care for young children; it can facilitate the treatment of children who otherwise may not cooperate for traditional in-office care. Some recent highly publicized procedural sedation-related tragedies have drawn attention to risks associated with pharmacologic management. However, it remains widely accepted that, by adhering to proper guidelines, procedural sedation can assist in the provision of high-quality dental care while minimizing morbidity and mortality from the procedure. The purpose of this paper was to propose an algorithm for clinicians to consider when selecting a behavior and disease management strategy for early childhood caries. This algorithm will not ensure a positive outcome but can assist clinicians when counseling caregivers about risks, benefits, and alternatives. It also emphasizes and underscores best-safety practices.

A Cost Analysis of Three Pharmacologic Behavior Guidance Modalities in Pediatric Dentistry.

Purpose: The aims of this study was to compare dental treatment costs for three pharmacologic behavior guidance modalities: (1) dental office-based moderate sedation (SED); (2) hospital-based general anesthesia (GA-H); and (3) dental office-based general anesthesia (GA-OFF). Methods: Data were collected for healthy two- to six-year-olds who had full-mouth rehabilitation using GA-H at the University of North Carolina Children's Hospital, Chapel Hill, N.C., USA. Patients served as their own controls to compare costs across the three modalities. Rendered treatments were quantified using relative value units (RVUs). Costs included opportunity costs and administrative data. We relied upon ordinary least squares analyses to examine the relationship between total costs and RVUs. Results: Of 200 consecutive hospital records, 65 met the inclusion criteria. The mean age was 4.4 years old (range equals two to six years old; 41 ASA I, 24 ASA II). Dental treatment using GA-H averaged 118 minutes (range equals 62 to 256 minutes), with a mean of 12 teeth (range equals six to 20) treated. GA-H costs were 4.1 times greater than GA-OFF costs (range equals 1.1 to 4.9), and 4.5 times greater than SED costs (range equals 0.9 to 7.1); GA-OFF costs were 1.1 times greater than SED costs (range equals 0.7 to 1.6). Conclusions: Treatment completed (measured in relative value units) was correlated highest with costs for dental office-based moderate sedation and least for hospital-based general anesthesia. If more than four SED appointments are needed, GA-OFF may provide cost-savings; however, at no point does GA-H offer cost-savings.

The Impact of Non-nutritive Sucking on the Risk for Sleep-disordered Breathing in Children.

PURPOSE: Sleep-disordered breathing (SDB) is not uncommon in children. The purposes of this study were to investigate the relationship between non-nutritive sucking (NNS) and the risk of SDB in children as well as assess the effect of infant feeding practices on SDB. METHODS: Eighty-four healthy four- to 12-year-old children were categorized either as high or low risk for SDB based on the Pediatric Sleep Questionnaire (PSQ). NNS and feeding practices were determined using a customized caregiver questionnaire. RESULTS: There was no statistically significant difference (P=0.21) between low- and high-risk children for a history of NNS. A statistically significant difference (P<0.001) was found for breastfed versus bottlefed children, with breastfeeding having a protective effect for SDB. CONCLUSION: NNS had no effect on SDB, while breastfeeding reduced the risk substantially.

Caregivers' health literacy and gaps in children's Medicaid enrollment: findings from the Carolina Oral Health Literacy Study.

BACKGROUND AND OBJECTIVES: Recent evidence supports a link between caregivers' health literacy and their children's health and use of health services. Disruptions in children's health insurance coverage have been linked to poor health care and outcomes. We examined young children's Medicaid enrollment patterns in a well-characterized cohort of child/caregivers dyads and investigated the association of caregivers' low health literacy with the incidence of enrollment gaps. METHODS: We relied upon Medicaid enrollment data for 1208 children (mean age = 19 months) enrolled in the Carolina Oral Health Literacy project during 2008-09. The median follow-up was 25 months. Health literacy was measured using the Newest Vital Sign (NVS). Analyses relied on descriptive, bivariate, and multivariate methods based on Poisson modeling. FINDINGS: One-third of children experienced one or more enrollment gaps; most were short in duration (median = 5 months). The risk of gaps was inversely associated with caregivers' age, with a 2% relative risk decrease for each added year. Low health literacy was associated with a modestly elevated risk increase [Incidence Rate Ratio (IRR) = 1.17 (95% confidence interval (CI) 0.88-1.57)] for enrollment disruptions; however, this estimate was substantially elevated among caregivers with less than a high school education [IRR = 1.52 (95% CI 0.99-2.35); homogeneity p<0.2]. CONCLUSIONS: Our findings provide initial support for a possible role of caregivers' health literacy as a determinant of children's Medicaid enrollment gaps. Although the association between health literacy and enrollment gaps was not confirmed statistically, we found that it was markedly stronger among caregivers with low educational attainment. This population, as well as young caregivers, may be the most vulnerable to the negative effects of low health literacy.

Dietary recommendations for infants and toddlers among pediatric dentists in North Carolina.

PURPOSE: The purposes of this study were to: describe practice patterns, knowledge, and attitudes of pediatric dentists in North Carolina (N.C.) in delivering dietary recommendations to the parents/caregivers of infants and toddlers; and identify barriers that limit the implementation of related recommendations. METHODS: Our survey instrument included 30 questions covering eight domains of barriers to guideline adherence. Surveys were mailed to 150 practicing pediatric dentists in N.C. Descriptive and bivariate analyses were performed. Exploratory factor analysis was used to identify subscales and inform the multivariable model. RESULTS: The response rate was 57 percent (86/150), 80 percent of whom reported providing infant and toddler feeding recommendations routinely. Knowledge of and agreement with the recommendation regarding breast-feeding duration was lower than that for bottle-feeding recommendations. Stepwise logistic regression analysis indicated that survey respondents were less likely to provide dietary recommendations regularly to the parents/caregivers of infants and toddlers when they have practice constraints and the respondents disagree with American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD) recommendations on bottle and juice consumption. CONCLUSIONS: Most respondents routinely provide dietary recommendations to the parents/caregivers of infants and toddlers. Disagreement with AAP and AAPD recommendations on bottle, and juice consumption as well as practice constraints impedes practitioners from providing dietary recommendations regularly to the parents/caregivers of infants and toddlers.

Influence of caregivers and children's entry into the dental care system.

OBJECTIVES: Early preventive dental visits are essential in improving children's oral health, especially young children at high risk for dental caries. However, there is scant information on how these children enter the dental care system. Our objectives were as follows: (1) to describe how a population-based cohort of young Medicaid-enrolled children entered dental care; and (2) to investigate the influence of caregiver characteristics on their children's dental care-seeking patterns. METHODS: We relied on Medicaid claims and interview data of caregiver-child dyads who were enrolled in the Carolina Oral Health Literacy study during 2007-2008. The analytical cohort comprised 1000 children who had no dental visits before enrollment. Additional information was collected on sociodemographic characteristics, oral health status, health literacy, dental neglect, and access to care barriers. Our analyses relied on descriptive, bivariate, and multivariate methods. RESULTS: During the 25-month median follow-up period, 39% of the children (mean baseline age: 16 months) entered the dental care system, and 13% of their first encounters were for emergency care. Caregivers' dental neglect emerged as a significant predictor of nonentrance. Children with reported oral health problems at baseline were more likely to enter the dental care system compared with children with better oral health, but they were also more likely to require emergency care. CONCLUSIONS: Caregivers have a pivotal role in children's oral health and care. Interventions aimed at improving children's oral health should involve community outreach to engage caregivers in a culturally appropriate manner when their children are infants or toddlers.

A cross sectional study examining social desirability bias in caregiver reporting of children's oral health behaviors.

BACKGROUND: Our previous research (Pediatrics 2010:126) found a strong association between caregiver oral health literacy (OHL) and children's oral health status; however, we found a weak association with oral health behaviors (OHBs). We hypothesize that this may be due to social desirability bias (SDB). Our objectives were to compare caregivers' responses to traditional OHB items and newer SDB-modulating items, and to examine the association of caregiver literacy with OHBs. METHODS: We performed a cross-sectional study of 102 caregiver-child dyads, collecting data for OHBs using both traditional and new SDB-modulating items. We measured OHL using REALD-30, a validated word recognition test. We relied upon percent agreement and Cohen's kappa (k) to quantify the concordance in caregivers' responses and multivariate log-binomial regression to estimate the impact of OHL on OHBs. RESULTS: Caregivers' mean REALD-30 score was 20.7 (SD = 6.0), range 1-30. We found an association between OHL and 4 of 8 OHBs examined. A subset of behavior questions compared traditional versus SDB-modulating items: history of bottle-feeding: agreement = 95%, k = 0.83 (95% CL:0.68,0.99); daily tooth brushing: agreement = 78%, k = 0.25 (95% CL:0.04,0.46); fluoridated toothpaste use: agreement = 88%, k = 0.67 (95% CL:0.49,0.85). After controlling for caregivers' race, marital status and study site, higher literacy scores remained associated with a decreased prevalence of parental report of "decided not brush the child's teeth because it would be frustrating". CONCLUSIONS: Agreement between responses was high for 2 of 3 behavior items. Item 3 (tooth brushing frequency) revealed discordance, likely due to SDB. Use of the SDB-modulating items appears to yield a better estimate of OHB.

Breastfeeding: an overview of oral and general health benefits.

BACKGROUND: Breastfeeding is the reference against which alternative infant feeding models must be measured with regard to growth, development and other health outcomes. Although not a systematic review, this report provides an update for dental professionals, including an overview of general and oral health-related benefits associated with breastfeeding. TYPES OF STUDIES REVIEWED: The authors examined the literature regarding general health protections that breastfeeding confers to infants and mothers and explored associations between breastfeeding, occlusion in the primary dentition and early childhood caries. To accomplish these goals, they reviewed systematic reviews when available and supplemented them with comparative studies and with statements and reports from major nongovernmental and governmental organizations. RESULTS: When compared with health outcomes among formula-fed children, the health advantages associated with breastfeeding include a lower risk of acute otitis media, gastroenteritis and diarrhea, severe lower respiratory infections, asthma, sudden infant death syndrome, obesity and other childhood diseases and conditions. Evidence also suggests that breastfed children may develop a more favorable occlusion in the primary dentition. The results of a systematic review in which researchers examined the relationship between breastfeeding and early childhood caries were inconclusive. CONCLUSIONS AND CLINICAL IMPLICATIONS: The American Academy of Pediatric Dentistry, Chicago, suggests that parents gently clean infants' gums and teeth after breastfeeding. The American Academy of Pediatrics, Elk Grove Village, Ill., recommends that breastfeeding should be exclusive for about the first six months of life and should continue, with the introduction of appropriate complementary foods, to at least age 12 months or beyond, as desired by mother and child. Dentists and staff members can take steps to ensure they are familiar with the evidence and guidelines pertaining to breastfeeding and to oral health. They are encouraged to follow the surgeon general's recommendations to promote and support optimal breastfeeding and oral health practices among their patients.

The safety of sedation for overweight/obese children in the dental setting.

PURPOSE: The goal of this study was to examine childhood overweight/obesity as a risk factor for adverse events during sedation for dental procedures. METHODS: This was a cross-sectional, retrospective, IRB-approved study that included 17 years of data (1992-2009). The outcome variables were desaturation, nausea/vomiting, prolonged sedation, and true apnea. The major explanatory variables were weight percentiles and BMI percentiles. RESULTS: A total of 510 patients met the inclusion criteria. Of these, 431 (86%) experienced no adverse events, 73 (14%) experienced one or more adverse events, and 6 had missing data. BMI data were available for a nested cohort of 103 children. Patients who experienced one or more adverse events had higher mean weights and BMI percentiles, though differences were not statistically significant. Another way to conceptualize the BMI data is to consider that 12% of the normal weight children experienced one or more adverse events versus 18% of the overweight/obese. CONCLUSIONS: Overall, weight percentiles were higher in children who had one or more adverse events. Similarly, patients with higher BMI percentiles were more likely to experience adverse events. Although preliminary in nature, these findings suggest that childhood overweight/obesity may be associated with adverse events during sedation for dental procedures.

Examining the accuracy of caregivers' assessments of young children's oral health status.

BACKGROUND: Caregivers' perceptions of their young children's oral health status (OHS) are a strong determinant of whether the children visit a dentist. Our aims were to quantify the correlation between caregivers' assessments and their children's clinically determined restorative treatment needs, while investigating factors related to this association. METHODS: One hundred eight caregivers assessed their children's OHS by answering a question on the self-reported National Health and Nutrition Examination Survey III instrument. Children underwent clinical oral examinations at one of two study sites of the Carolina Oral Health Literacy Project: a dental school-based clinic and a community-based health clinic. Examiners recorded the children's clinical treatment needs by using a modification of the caries severity index. The authors quantified concordance between the two measures with use of the Spearman rank correlation (ρ) and Kendall τ rank correlation, whereas they assessed differences in sociodemographic factors and oral health literacy (OHL) levels by using a homogeneity χ(2) test (P < .2 criterion). RESULTS: The concordance between caregivers' assessments and clinically determined OHS was lower for younger children (< 2 years, ρ = 0.29 versus = 2 years, ρ = 0.63 [homogeneity P = .03]), a pattern that was evident in the community clinic but not in the university clinic. Caregivers' age, education and OHL did not influence the accuracy of self-reports. CONCLUSIONS: For children younger than 2 years, caregivers' assessments correlated poorly with clinical needs, which routinely were underestimated. Practice Implications. These findings underscore the importance of preventive dental visits at a young age and the early establishment of a dental home.

Oral health literacy and knowledge among patients who are pregnant for the first time.

BACKGROUND: The authors conducted an observational cohort study to determine the levels of and examine the associations of oral health literacy (OHL) and oral health knowledge in low-income patients who were pregnant for the first time. METHODS: An analytic sample of 119 low-income patients who were pregnant for the first time completed a structured 30-minute, in-person interview conducted by two trained interviewers in seven counties in North Carolina. The authors measured OHL by means of a dental word recognition test and assessed oral health knowledge by administering a six-item knowledge survey. RESULTS: The authors found that OHL scores were distributed normally (mean [standard deviation], 16.4 [5.0]). The percentage of correct responses for each oral health knowledge item ranged from 45 to 98 percent. The results of bivariate analyses showed that there was a positive correlation between OHL and oral health knowledge (P < .01). Higher OHL levels were associated with correct responses to two of the knowledge items (P < .01). CONCLUSIONS: OHL was low in the study sample. There was a significant association between OHL and oral health knowledge. CLINICAL IMPLICATIONS: Low OHL levels and, thereby, low levels of oral health knowledge, might affect health outcomes for both the mother and child. Tailoring messages to appropriate OHL levels might improve knowledge.

Pediatricians' assessments of caries risk and need for a dental evaluation in preschool aged children.

BACKGROUND: Risk-based prioritization of dental referrals during well-child visits might improve dental access for infants and toddlers. This study identifies pediatrician-assessed risk factors for early childhood caries (ECC) and their association with the need for a dentist's evaluation. METHODS: A priority oral health risk assessment and referral tool (PORRT) for children < 36 months was developed collaboratively by physicians and dentists and used by 10 pediatricians during well-child visits. PORRT documented behavioral, clinical, and child health risks for ECC. Pediatricians also assessed overall ECC risk on an 11-point scale and determined the need for a dental evaluation. Logistic regression models calculated the odds for evaluation need for each risk factor and according to a 3-level risk classification. RESULTS: In total 1,288 PORRT forms were completed; 6.8% of children were identified as needing a dentist evaluation. Behavioral risk factors were prevalent but not strong predictors of the need for an evaluation. The child's overall caries risk was the strongest predictor of the need for an evaluation. Cavitated (OR = 17.5; 95% CI = 8.08, 37.97) and non-cavitated (OR = 6.9; 95% CI = 4.47, 10.82) lesions were the strongest predictors when the caries risk scale was excluded from the analysis. Few patients (6.3%) were classified as high risk, but their probability of needing an evaluation was only 0.36. CONCLUSIONS: Low referral rates for children with disease and prior to disease onset but at elevated risk, indicate interventions are needed to help improve the dental referral rates of physicians.

Emerging therapies for the management of traumatized immature permanent incisors.

Early loss of immature permanent teeth due to pulpal necrosis secondary to trauma can have dire consequences for a child's growth and development. The treatment alternatives include surgical endodontics, traditional calcium hydroxide apexification, and mineral trioxide aggregate (MTA) apexification. These options pose potential complications, including: arrest of root development; weakened dentinal walls; and increased potential for fracture. Revascularization of the dentin-pulp complex is a new approach that involves disinfecting the root canal system followed by tissue repair and regeneration while allowing for continued root development and thickening of the lateral dentinal walls through deposition of new hard tissue. The purpose of this report was to present the revascularization of an immature permanent maxillary central incisor that had evidence of external root resorption. Six months later, internal bleaching was performed to remove cervical discoloration from the triple antibiotic paste. At 18 months, the tooth remained vital and had evidence of continued root development.

The relationship of oral health literacy and self-efficacy with oral health status and dental neglect.

OBJECTIVES: We examined the associations of oral health literacy (OHL) with oral health status (OHS) and dental neglect (DN), and we explored whether self-efficacy mediated or modified these associations. METHODS: We used interview data collected from 1280 female clients of the Special Supplemental Nutrition Program for Women, Infants and Children from 2007 to 2009 as part of the Carolina Oral Health Literacy Project. We measured OHL with a validated word recognition test (REALD-30), and we measured OHS with the self-reported National Health and Nutrition Examination Survey item. Analyses used descriptive, bivariate, and multivariate methods. RESULTS: Less than one third of participants rated their OHS as very good or excellent. Higher OHL was associated with better OHS (for a 10-unit REALD increase: multivariate prevalence ratio = 1.29; 95% confidence interval = 1.08, 1.54). OHL was not correlated with DN, but self-efficacy showed a strong negative correlation with DN. Self-efficacy remained significantly associated with DN in a fully adjusted model that included OHL. CONCLUSIONS: Increased OHL was associated with better OHS but not with DN. Self-efficacy was a strong correlate of DN and may mediate the effects of literacy on OHS.

Antibiotic use for treating dental infections in children: a survey of dentists' prescribing practices.

BACKGROUND: The authors conducted a study to examine the antibiotic prescribing practices of general and pediatric dentists in the management of odontogenic infections in children. METHODS: The authors relied on a cross-sectional study design to assess the antibiotic prescribing practices of general and pediatric dentists in North Carolina. The survey instrument consisted of five clinical case scenarios that included antibiotic-prescribing decisions in a self-administered questionnaire format. The participants were volunteers attending one of four continuing education courses. The authors invited all pediatric dentists in private practice to participate in the study, as well as general practitioners who treated children in general practice. The authors compared the practitioners' responses for each clinical case scenario with the prescribing guidelines of the American Academy of Pediatric Dentistry and the American Dental Association. RESULTS: A total of 154 surveys were completed and returned (55 percent response rate). The mean age of respondents was 47 years, and the mean number of years in practice was 19. Of the 154 overall, 106 (69 percent) were general practitioners and 48 (31 percent) were pediatric dentists. Across the three in-office clinical case scenarios, adherence to professional prescribing guidelines ranged from 10 to 42 percent. For the two weekend scenarios, overall adherence to the professional prescribing guidelines dropped to 14 and 17 percent. Dentists who had completed postgraduate education (n = 73 [51 percent]) were more likely (P < .05) to have adhered to published guidelines in prescribing antibiotics. CONCLUSIONS: The results of this survey show that dentists' adherence to professional guidelines for prescribing antibiotics for odontogenic infections in children was low. There appears to be a lack of concordance between recommended professional guidelines and the antibiotic prescribing practices of dentists. Clearer, more specific guidelines may lead to improved adherence among dentists.