Factors Associated with Development of Tuberculosis Disease Among Refugees, Massachusetts, 2008-2018.

Refugees and immigrants undergo tuberculosis screening prior to arrival in the United States. CDC Technical Instructions for screening changed in 2007. Our goal was to quantify TB disease in refugees after 2007 and identify risks for disease. Massachusetts refugee and tuberculosis databases were matched to identify refugees who arrived 2008-2017 and were diagnosed with tuberculosis infection or disease 2008-2018. Factors associated with disease were analyzed in SAS. Of 19,583 refugees, 4706 were diagnosed with infection at arrival and 60 with disease during the observation period. Lack of treatment for infection was strongly associated (OR = 26.5, p = 0.0001) with diagnosis of disease; in a multivariate logistic regression model, positive screening test (AOR = 12.5, p = 0.0001), class B1 status (AOR = 4.0, p = 0.0004), and < 2 years since arrival (AOR = 60.0, p = 0.0001) were associated with disease. Providers should continue screening new arrivals, providing accessible services, and treating infection to further reduce tuberculosis morbidity and mortality.

Potential Impact of COVID-19 on Recently Resettled Refugee Populations in the United States and Canada: Perspectives of Refugee Healthcare Providers.

Recently resettled refugee populations may be at greater risk for exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a virus that causes coronavirus 2019 (COVID-19), and face unique challenges in following recommendations to protect their health. Several factors place resettled refugees at elevated risk for exposure to persons with COVID-19 or increased severity of COVID-19: being more likely to experience poverty and live in crowded housing, being employed in less protected, service-sector jobs, experiencing language and health care access barriers, and having higher rates of co-morbidities. In preparing for and managing COVID-19, resettled refugees encounter similar barriers to those of other racial or ethnic minority populations, which may then be exacerbated by unique barriers experienced from being a refugee. Key recommendations for resettlement and healthcare providers include analyzing sociodemographic data about refugee patients, documenting and resolving barriers faced by refugees, developing refugee-specific outreach plans, using culturally and linguistically appropriate resources, ensuring medical interpretation availability, and leveraging virtual platforms along with nontraditional community partners to disseminate COVID-19 messaging.

Recovery From Malnutrition Among Refugee Children Following Participation in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) Program in Massachusetts, 1998-2010.

OBJECTIVES: (1) To examine patterns of catch-up growth and anemia correction in refugee children younger than 5 years after participation in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) program, and (2) to identify factors associated with recovery from growth abnormalities. DESIGN: Records on 1731 refugee children younger than 5 years who arrived in Massachusetts between 1998-2010 were matched to WIC program records and then restricted to 779 children who had at least 2 WIC visits. Kaplan-Meier curves and Cox proportional hazards models were used to examine how sex affected time to recovery from malnutrition and anemia. Factors associated with recovery were analyzed in SAS using multivariate logistic regression. SETTING: Massachusetts. PARTICIPANTS: Refugee children younger than 5 years on arrival, who visited a WIC program at least twice between 1998 and 2010. MAIN OUTCOME MEASURES: (1) Proportion of children who recovered from low height-for-age (stunting), low weight-for-age, low weight-for-height (wasting), and anemia; (2) odds ratios for factors associated with recovery; and (3) Kaplan-Meier curves showing recovery over time from low height-for-age, low weight-for-age, and low weight-for-height. RESULTS: The number of WIC visits was associated with recovery from stunting, wasting, low weight-for-age, and anemia; results reached statistical significance for stunting (odds ratio [OR] = 8.64; 95% confidence interval [CI], 2.25-33.19), low weight-for-age (OR = 5.28; 95% CI, 1.35-20.73), and anemia (OR = 6.50; 95% CI, 2.69-15.69). Female sex was associated with recovery from stunting, wasting, and low weight-for-age, whereas male sex was associated with recovery from anemia; the associations were statistically significant between female sex and stunting (OR = 9.14; 95% CI, 1.93-43.29), wasting (OR = 14.78; 95% CI, 1.57-138.85), and low weight-for-age (OR = 4.29; 95% CI, 1.09-16.79). CONCLUSIONS: Children who remained engaged in WIC may recover better from malnutrition than children with fewer WIC visits, although there are limitations to the available data.These findings suggest that those working with refugee families should prioritize outreach toward initiating and maintaining WIC program enrollment for eligible refugee children.

Trends in Elevated Blood Lead Levels Using 5 and 10 µg/dL Levels of Concern Among Refugee Children Resettled in Massachusetts, 1998-2015.

OBJECTIVES: Refugee children are known to have a high prevalence of elevated blood lead levels (EBLLs). We sought to determine trends in EBLLs among refugee children during an 18-year period and examine relationships between descriptive characteristics and EBLLs by using 10 µg/dL and 5 µg/dL levels of concern. METHODS: We retrospectively evaluated refugee health screening data from Massachusetts for 1998 through 2015 for refugee children aged <7 years. We performed bivariate and multivariate analyses of variables including sex, age, region of origin, anemia, intestinal parasites, tuberculosis test results, and anthropometric measurements and used both 5 µg/dL and 10 µg/dL levels of concern for EBLLs. RESULTS: Of 3421 eligible refugee children, 3054 (88.2%) were tested. Using 5 µg/dL and 10 µg/dL levels of concern, 1279 (41.9%) and 241 (7.9%) children, respectively, had EBLLs. Mean BLLs declined steadily from 7.58 µg/dL in 2004 to 4.03 µg/dL in 2015. African (adjusted odds ratio [aOR] = 2.49; 95% confidence interval [CI], 1.81-3.43), East Asian and Pacific (aOR = 1.98; 95% CI, 1.35-2.91), and South-Central Asian (aOR = 2.47; 95% CI, 1.53-4.01) regions of origin and anemia (aOR = 1.50; 95% CI, 1.14 -1.97) were significantly associated with BLLs ≥5 µg/dL. CONCLUSIONS: The prevalence of EBLLs among refugees compared with US-born children is high. Because EBBLs increase the risk for neurocognitive impairment in children, public health professionals, policy makers, researchers, refugee resettlement staff members, and health care providers must remain vigilant in screening for lead poisoning and educating refugees about the hazards posed to young children by lead.

Refugee Children's Participation in the Women, Infants, and Children Supplemental Nutrition (WIC) Program in Massachusetts, 1998-2010.

OBJECTIVES: To (1) describe prevalence of growth abnormalities and anemia in refugee children; (2) describe the proportion of age-eligible refugee children enrolled in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and (3) identify risk factors for lack of enrollment in WIC. DESIGN: Data were collected from 1731 health screenings for refugee children younger than 5 years in Massachusetts in 1998-2010 and matched to WIC program records. Risk factors for lack of WIC enrollment were analyzed in SAS using multivariate logistic regression. SETTING: Massachusetts. PARTICIPANTS: Refugee children under age 5 years. MAIN OUTCOME MEASURES: (1) prevalence of growth abnormalities and anemia in refugee children, (2) proportion of age-eligible refugee children enrolled in WIC, and (3) association of risk factors with lack of WIC enrollment. RESULTS: Overall, 33% of refugee children under age 5 in Massachusetts had at least 1 growth and nutrition problem, including anemia (31%), stunting (10%), wasting (8%), and low weight for age (10%). WIC enrollment among refugee children under 5 years of age was only 62%, lower than that of all eligible children under 5 in Massachusetts (86%). Risk factors for lack of WIC enrollment among refugee children included age, world region of origin, and arrival cohort. CONCLUSIONS: Although many refugee children under age 5 experience growth or nutrition problems, one-third of refugee children in Massachusetts were not enrolled in WIC for nutrition assistance, representing a failure of the system. Agencies providing services at the local level should be supported to facilitate enrollment and participation for shared clients.

Relationships Between English Language Proficiency, Health Literacy, and Health Outcomes in Somali Refugees.

Little is known about the impacts of health literacy and English proficiency on the health status of Somali refugees. Data came from interviews in 2009-2011 of 411 adult Somali refugees recently resettled in Massachusetts. English proficiency, health literacy, and physical and mental health were measured using the Basic English Skills Test Plus, the Short Test of Health Literacy in Adults, and the Physical and Mental Component Summaries of the Short Form-12. Associations were analyzed using multiple linear regression. In adjusted analyses, higher English proficiency was associated with worse mental health in males. English proficiency was not associated with physical health. Health literacy was associated with neither physical nor mental health. Language proficiency may adversely affect the mental health of male Somali refugees, contrary to findings in other immigrant groups. Research on underlying mechanisms and opportunities to understand this relationship are needed.

Acculturation and a Potential Relationship with Oral Health Outcomes Among Somali Refugees in Massachusetts.

This paper explores the relationship between acculturation and oral health in a study of Somali refugees. This cross-sectional survey included structured surveys and dental examinations of a convenience sample of 439 Somali adults living in Massachusetts. Associations between an acculturation scale and: (1) lifetime history of caries and (2) access to oral health services were calculated. In bivariate analyses, many individual questions in the scale were associated with outcomes. In multivariate analysis, speaking English (OR 0.5, CI 0.28-0.84) was associated with better access to, and utilization of, dental health services while reading American books and newspapers in English was associated with increased lifetime history of dental disease (OR 2.6, CI 1.1-6.0). As specific elements of acculturation have different relationships with oral health among Somali refugees, a summary acculturation scale may have limited utility. Ongoing efforts to remove language barriers may improve oral health.

Giving It Our Best Shot? Human Papillomavirus and Hepatitis B Virus Immunization Among Refugees, Massachusetts, 2011-2013.

INTRODUCTION: The receipt rate of hepatitis B virus vaccine among adolescents in the United States is high, while the receipt rate of human papillomavirus vaccine is low. Rates have not been closely studied among refugees, whose home countries have high rates of disease caused by these viruses. METHODS: We examined human papillomavirus and hepatitis B virus immunization rates among 2,269 refugees aged 9 to 26 years who resettled in Massachusetts from 2011 through 2013. This was a secondary analysis of data from their medical screenings. We used binary logistic regression to assess characteristics associated with immunization and bivariate analyses to compare refugee immunization rates with those of the general US population. RESULTS: Forty-five percent of US adolescents aged 13 to 17 years received 1 dose of human papillomavirus vaccine, compared with 68% of similarly aged refugees. Males (adjusted odds ratio [aOR], 0.62; 95% confidence interval [CI], 0.52-0.74), refugees older than 13 years (aOR, 0.74; 95% CI, 0.60-0.93), and refugees not from Sub-Saharan Africa (aOR, 0.74; 95% CI, 0.59-0.92) were less likely to receive human papillomavirus vaccine, while arrivals in 2012 through 2013 were more likely (aOR, 1.6; 95% CI, 1.3-1.9) than those arriving in 2011. Refugees older than 13 years were less likely to receive 2 doses of hepatitis B virus vaccine (aOR, 0.49; 95% CI, 0.37-0.63) than older refugees. CONCLUSION: Specialized post-arrival health assessment may improve refugees' immunization rates.

The basic research factors questionnaire for studying early childhood caries.

BACKGROUND: We describe development of the Early Childhood Caries (ECC) Basic Research Factors Questionnaire (BRFQ), a battery of measures assessing common potential predictors, mediators, and moderators of ECC. Individual-, family-, and community-level factors that are linked to oral health outcomes across at-risk populations are included. Developing standard measures of factors implicated in ECC has the potential to enhance our ability to understand mechanisms underlying successful prevention and to develop more effective interventions. METHODS: The Early Childhood Caries Collaborating Centers (EC4), funded by National Institute of Dental and Craniofacial Research, developed the BRFQ, which was used across four randomized trials to develop and test interventions for reducing ECC in at-risk populations. Forty-five investigators from across the centers and NIDCR were involved in the development process. Eight "measures working groups" identified relevant constructs and effective measurement approaches, which were then categorized as "essential" or "optional" common data elements (CDEs) for the EC4 projects. RESULTS: Essential CDEs include 88 items, with an additional 177 measures categorized as optional CDEs. Essential CDEs fell under the following domains: oral health knowledge, oral health behavior, utilization/insurance and cost, parent/caregiver dental self-efficacy, quality of life, caregiver and family characteristics, and child characteristics. CONCLUSIONS: The BRFQ makes available a battery of measures that support efforts to understand population risk factors for ECC and to compare oral health outcomes across populations at risk. The BRFQ development process may be useful to other clinical research networks and consortia developing CDEs in other health research fields. TRIAL REGISTRATION: All the trial that used the BRFQ were registered at Clinicaltrial.gov NCT01116726 , April 29, 2010; NCT01116739 , May 3, 2010; NCT01129440 , May 21, 2010; and NCT01205971 , September 19, 2010.

Listening to paediatric primary care nurses: a qualitative study of the potential for interprofessional oral health practice in six federally qualified health centres in Massachusetts and Maryland.

OBJECTIVES: To explore the opportunities for interprofessional collaboration (IPC) to improve paediatric oral health in federally qualified health centres (FQHCs), to identify challenges to IPC-led integration of oral health prevention into the well-child visit and to suggest strategies to overcome barriers. SAMPLE: Nurse managers (NMs), nurse practitioners (NPs), paediatric clinical staff and administrators in six FQHCs in two states were interviewed using a semistructured format. DESIGN: Grounded theory research. Topics included feasibility of integration, perceived barriers and strategies for incorporating oral health into paediatric primary care. MEASUREMENTS: Qualitative data were coded and analysed using NVivo 10 to generate themes iteratively. RESULTS: Nurses in diverse roles recognised the importance of oral health prevention but were unaware of professional guidelines for incorporating oral health into paediatric encounters. They valued collaborative care, specifically internal communication, joint initiatives and training and partnering with dental schools or community dental practices. Barriers to IPC included inadequate training, few opportunities for cross-communication and absence of charting templates in electronic health records. CONCLUSIONS: NMs, NPs and paediatric nursing staff all value IPC to improve patients' oral health, yet are constrained by lack of oral health training and supportive charting and referral systems. With supports, they are willing to take on responsibility for introducing oral health preventive measures into the well-child visit, but will require IPC approaches to training and systems changes. IPC teams in the health centre setting can work together, if policy and administrative supports are in place, to provide oral health assessments, education, fluoride varnish application and dental referrals, decrease the prevalence of early childhood caries and increase access to a dental home for low-income children.

Absence of Fluoride Varnish-Related Adverse Events in Caries Prevention Trials in Young Children, United States.

INTRODUCTION: Fluoride varnish is an effective prevention intervention for caries in young children. Its routine use in clinical care is supported by meta-analyses and recommended by clinical guidelines, including the US Preventive Services Task Force (B rating). This report is the first prospective systematic assessment of adverse events related to fluoride varnish treatment in young children. METHODS: We determined the incidence of adverse events related to fluoride varnish treatment in 3 clinical trials on the prevention of early childhood caries, conducted under the auspices of the Early Childhood Caries Collaborating Centers, an initiative sponsored by the National Institute of Dental and Craniofacial Research. Each trial incorporated use of fluoride varnish in its protocol and systematically queried all children's parents or legal guardians about the occurrence of acute adverse events after each fluoride varnish treatment. RESULTS: A total of 2,424 community-dwelling, dentate children aged 0 to 5 years were enrolled and followed for up to 3 years. These children received a cumulative total of 10,249 fluoride varnish treatments. On average, each child received 4.2 fluoride varnish treatments. We found zero fluoride varnish-related adverse events. CONCLUSION: Fluoride varnish was not associated with treatment-related adverse events in young children. Our findings support its safety as an effective prevention intervention for caries in young children.

Erratum to: Suicidal Ideation and Mental Health of Bhutanese Refugees in the United States.

In the original version of this article, one of the ten author names was listed incorrectly as "Trong Aoe." The name should be listed as "Trong Ao." The affiliation of two of the co-authors (Sharmila Shetty and Eboni Taylor) was incorrect. The correct affiliation is: Immigrant, Refugee and Migrant Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention. The correct full list of author names and their affiliations is presented above.

Integration of Oral Health Into the Well-Child Visit at Federally Qualified Health Centers: Study of 6 Clinics, August 2014-March 2015.

INTRODUCTION: Early childhood caries, the most common chronic childhood disease, affects primary dentition and can impair eating, sleeping, and school performance. The disease is most prevalent among vulnerable populations with limited access to pediatric dental services. These same children generally receive well-child care at federally qualified health centers. The objective of this study was to identify facilitators and barriers to the integration of oral health into pediatric primary care at health centers to improve problem recognition, delivery of preventive measures, and referral to a dentist. METHODS: We collected and analyzed background data and data from structured observations and 39 interviews with administrators and staff at 6 clinics in 2 states, Maryland and Massachusetts. RESULTS: Participants valued oral health across professional roles but cited limited time, lack of training and expertise, low caregiver literacy, and lack of shared medical and dental electronic records as barriers to cooperation. Facilitators included an upper-level administration with the vision to see the value of integration, designated team leaders, and champions. An administration's vision, not structural determinants, patient characteristics, or geographic location, predicted the level of integration. Interviewees generated multilevel recommendations to promote delivery of oral health preventive measures and services during a well-child visit. CONCLUSION: Poor oral health contributes to health care disparities. Barriers to integrating dental care into pediatric medical practice at health centers must be overcome to improve oral health for children living in poverty, with a disability, at a rural address, or any combination of these. Implementation will require adapting delivery systems to support multidisciplinary collaboration. Strategies suggested here may point the way to enhancing children's oral health.

Suicidal Ideation and Mental Health of Bhutanese Refugees in the United States.

Refugee agencies noticed a high number of suicides among Bhutanese refugees resettled in the United States between 2009 and 2012. We aimed to estimate prevalence of mental health conditions and identify factors associated with suicidal ideation among Bhutanese refugees. We conducted a stratified random cross-sectional survey and collected information on demographics, mental health conditions, suicidal ideation, and post-migration difficulties. Bivariate logistic regressions were performed to identify factors associated with suicidal ideation. Prevalence of mental health conditions were: depression (21 %), symptoms of anxiety (19 %), post-traumatic stress disorder (4.5 %), and suicidal ideation (3 %), significant risk factors for suicidal ideation included: not being a provider of the family; perceiving low social support; and having symptoms of anxiety and depression. These findings suggest that Bhutanese refugees in the United States may have a higher burden of mental illness relative to the US population and may benefit from mental health screening and treatment. Refugee communities and service providers may benefit from additional suicide awareness training to identify those at highest risk.

A planned care approach and patient registry to improve adherence to clinical guidelines for the diagnosis and management of attention-deficit/hyperactivity disorder.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) affects almost 2.4 million US children. Because American Academy of Pediatrics guidelines for ADHD recommend use of standardized diagnostic instruments, regular follow-up and the chronic care model, this pilot project sought to implement and assess an electronic registry of patients with ADHD combined with care coordination by a planned care team. METHODS: This quality improvement project was structured with 2 intervention and 2 control clinics to facilitate evaluation of the use of a planned care system for management of ADHD. Care teams included a pediatrician, nurse, medical assistant, and care coordinator and tracked patients using an electronic registry with data drawn from the EMR. Clinical work flows were pilot tested to facilitate use of the Vanderbilt scales and their incorporation into the EMR at intervention sites. Outcome measures included 2 recommended clinical follow-ups based on HEDIS measures as well as use of the Vanderbilt rating scales. Initiation phase measure was for follow-up after initiating medication, while the continuation phase measure was for subsequent follow-up during the first year of treatment. Measures were monitored during the project year and then also in the ensuing period of spread of the intervention to other sites. RESULTS: Although the modified HEDIS initiation phase measure for patients newly on medication remained static at approximately 50% throughout the project period, the continuation phase measure showed improvement from 35% at baseline to 45% at the end of the project assessment year, a 29% increase. Follow-up for patients stable on medications also remained unchanged during the project period, but during subsequent spreading of the intervention to nonproject sites, follow-up of these patients improved to over 90%. In adjusted analyses, patients with ADHD at intervention sites were over 2 times more likely than patients at control sites to have had a Vanderbilt score documented in their records. CONCLUSIONS: The project achieved modest improvements in the diagnostic and treatment process for patients with ADHD. The use of a planned care system and electronic patient registry shows promise for improving the diagnosis and treatment process for patients with ADHD.

Looking Islam in the Teeth: The Social Life of a Somali Toothbrush.

The Arabic miswak (Somali, adayge) is a tooth-cleaning stick from the Salvadora persica plant. In this article, we trace the social life of a "thing," examining meanings inscribed in the stick brush, drawing on interviews with 82 Somali refugees in Massachusetts and an analysis of local and transnational science and marketing. The miswak toothbrush symbolizes relationships to nature, homeland culture, global Islam, globalizing dental medicine, and the divine as it intersects with the lives of producers, marketers, distributors, and users, creating hybrid cultural forms in new contexts.

Understanding Bhutanese refugee suicide through the interpersonal-psychological theory of suicidal behavior.

Attention has been drawn to high rates of suicide among refugees after resettlement and in particular among the Bhutanese refugees. This study sought to understand the apparent high rates of suicide among resettled Bhutanese refugees in the context of the Interpersonal-Psychological Theory of Suicidal Behavior (IPTS). Expanding on a larger investigation of suicide in a randomly selected sample of Bhutanese men and women resettled in Arizona, Georgia, New York, and Texas (Ao et al., 2012), the current study focused on 2 factors, thwarted belongingness and perceived burdensomeness, examined individual and postmigration variables associated with these factors, and explored how they differed by gender. Overall, factors such as poor health were associated with perceived burdensomeness and thwarted belongingness. For men, stressors related to employment and providing for their families were related to feeling burdensome and/or alienated from family and friends, whereas for women, stressors such as illiteracy, family conflict, and being separated from family members were more associated. IPTS holds promise in understanding suicide in the resettled Bhutanese community.

Health literacy, acculturation, and the use of preventive oral health care by Somali refugees living in massachusetts.

This study investigated the impact of English health literacy and spoken proficiency and acculturation on preventive dental care use among Somali refugees in Massachusetts. 439 adult Somalis in the US ≤10 years were interviewed. English functional health literacy, dental word recognition, and spoken proficiency were measured using STOFHLA, REALD, and BEST Plus. Logistic regression tested associations of language measures with preventive dental care use. Without controlling for acculturation, participants with higher health literacy were 2.0 times more likely to have had preventive care (P = 0.02). Subjects with higher word recognition were 1.8 times as likely to have had preventive care (P = 0.04). Controlling for acculturation, these were no longer significant, and spoken proficiency was not associated with increased preventive care use. English health literacy and spoken proficiency were not associated with preventive dental care. Other factors, like acculturation, were more predictive of care use than language skills.

The cultural basis for oral health practices among Somali refugees pre-and post-resettlement in Massachusetts.

BACKGROUND: Oral health disparities related to socioeconomic status have been well described in the U.S., but oral health among refugee groups has not been well characterized. This article examines oral health among Somali refugees in Massachusetts. METHODS: Eighty-three (83) participants were purposively selected for an in-depth, open-ended interview related to oral health. RESULTS: Older individuals associated use of the stick brush with the Islamic practice of cleansing before prayer. When unable to find stick brushes in the U.S., many adopted the Western toothbrush. Parents expressed concern that their children had adopted U.S. practices of brushing with a toothbrush only once or twice a day. CONCLUSIONS/IMPLICATIONS: Somali oral health practices have changed following arrival to the U.S., but the underlying model for oral health care remains rooted in Islam. By acknowledging the value of traditional practices, dentists may communicate the value of Western preventive and restorative dentistry, and recommend approaches to integrating the two.

The impact of functional health literacy and acculturation on the oral health status of Somali refugees living in Massachusetts.

OBJECTIVES: We assessed the impact of health literacy and acculturation on oral health status of Somali refugees in Massachusetts. METHODS: Between December 2009 and June 2011, we surveyed 439 adult Somalis who had lived in the United States 10 years or less. Assessments included oral examinations with decayed, missing, and filled teeth (DMFT) counts and measurement of spoken English and health literacy. We tested associations with generalized linear regression models. RESULTS: Participants had means of 1.4 decayed, 2.8 missing, and 1.3 filled teeth. Among participants who had been in the United States 0 to 4 years, lower health literacy scores correlated with lower DMFT (rate ratio [RR] = 0.78; P = .016). Among participants who had been in the country 5 to 10 years, lower literacy scores correlated with higher DMFT (RR = 1.37; P = .012). Literacy was not significantly associated with decayed teeth. Lower literacy scores correlated marginally with lower risk of periodontal disease (odds ratio = 0.22; P = .047). CONCLUSIONS: Worsening oral health of Somali refugees over time may be linked to less access to preventive care and less utilization of beneficial oral hygiene practices.