Systems mapping of multilevel factors contributing to dental caries in adolescents.

Dental caries is a prevalent chronic disease among adolescents. Caries activity increases significantly during adolescence due to an increase in susceptible tooth surfaces, immature permanent tooth enamel, independence in pursuing self-care, and a tendency toward poor diet and oral hygiene. Dental caries in permanent teeth is more prevalent among adolescents in low-income families and racial/ethnic minority groups, and these disparities in adolescent dental caries experience have persisted for decades. Several conceptual and data-driven models have proposed unidirectional mechanisms that contribute to the extant disparities in adolescent dental caries experience. Our objective, using a literature review, is to provide an overview of risk factors contributing to adolescent dental caries. Specifically, we map the interactive relationships of multilevel factors that influence dental caries among adolescents. Such interactive multilevel relationships more closely reflect the complex nature of dental caries experience among the adolescent population. The methods that we use are two-fold: (1) a literature review using PubMed and Cochrane databases to find contributing factors; and (2) the system dynamics approach for mapping feedback mechanisms underlying adolescent dental caries through causal loop diagramming. The results of this study, based on the review of 138 articles, identified individual, family and community-level factors and their interactions contributing to dental caries experience in adolescents. Our results also provide hypotheses about the mechanisms underlying persistence of dental caries among adolescents. Conclusions: Our findings may contribute to a deeper understanding of the multilevel and interconnected factors that shape the persistence of dental caries experience among adolescents.

Measurement of Early Childhood Oral Health for Research Purposes: Dental Caries Experience and Developmental Defects of the Enamel in the Primary Dentition.

Epidemiological investigations of early childhood oral health rely upon the collection of high-quality clinical measures of health and disease. However, ascertainment of valid and accurate clinical measures presents unique challenges among young, preschool-age children. The paper presents a clinical research protocol for the conduct of oral epidemiological examinations among children, implemented in ZOE 2.0, a large-scale population-based genetic epidemiologic study of early childhood caries (ECC). The protocol has been developed for the collection of information on tooth surface-level dental caries experience and tooth-level developmental defects of the enamel in the primary dentition. Dental caries experience is recorded using visual criteria modified from the International Caries Detection and Assessment System (ICDAS), and measurement of developmental defects is based upon the modified Clarkson and O'Mullane Developmental Defects of the Enamel Index. After a dental prophylaxis (toothbrushing among all children and flossing as needed), children's teeth are examined by trained and calibrated examiners in community locations, using portable dental equipment, compressed air, and uniform artificial light and magnification conditions. Data are entered directly onto a computer using a custom Microsoft Access-based data entry application. The ZOE 2.0 clinical protocol has been implemented successfully for the conduct of over 6000 research examinations to date, contributing phenotype data to downstream genomics and other "omics" studies of ECC and DDE, as well as traditional clinical and epidemiologic dental research.

A Developmental Approach to Pediatric Oral Health.

Orofacial growth and development is a complex process spanning the life course. This article provides an oral health overview in the context of overall growth, physical and social development from infancy through adolescence. It reviews oral health-specific developmental milestones during childhood (0-12 years) and adolescence (≥13 years). It examines issues particular to each age category or spanning multiple ages (eg, pediatric overweight and obesity, tobacco use, and dental trauma) in relation to oral health and development. In addition, the oral microbiome and its potential role in informing personalized oral health care across the life course is discussed.

Oral literacy demand of preventive dental visits in a pediatric medical office: a pilot study.

PURPOSE: The purpose of this study was to examine the oral literacy demands placed on parents of young children during preventive dental visits in a pediatric medical office. METHODS: Transcripts of audio recordings for 15 pediatric medical visits were analyzed to assess the oral literacy demand of the visit, as measured by use of terminology, language complexity, and structural characteristics of the dialogue. Parent-completed surveys were used to determine recall of dental concepts discussed during the visit. Pearson's correlation coefficients were calculated to identify relationships among these measures and parental recall of the visit. RESULTS: Visits were interactive and used limited jargon and uncomplicated language. Oral literacy demand measures were associated with each other. Parental recall of the visit was associated with measures of high oral literacy demand. CONCLUSIONS: Assessing measures of oral literacy demand is a novel method for examining provider communication used during preventive dental visits in a pediatric medical office. Providers displayed low oral literacy demand when communicating with parents. Parental recall of dental concepts, however, was associated unexpectedly with higher oral literacy demand. Further research should examine a larger sample size and the effect of measures of oral literacy demand among low- and high-literacy patients.

Cost-effectiveness of preventive oral health care in medical offices for young Medicaid enrollees.

OBJECTIVE: To estimate the cost-effectiveness of a medical office-based preventive oral health program in North Carolina called Into the Mouths of Babes (IMB). DESIGN: Observational study using Medicaid claims data (2000-2006). SETTING: Medical staff delivered IMB services in medical offices, and dentists provided dental services in offices or hospitals. PARTICIPANTS: A total of 209 285 children enrolled in Medicaid at age 6 months. INTERVENTIONS: Into the Mouths of Babes visits included screening, parental counseling, topical fluoride application, and referral to dentists, if needed. The cost-effectiveness analysis used the Medicaid program perspective and a propensity score-matched sample with regression analysis to compare children with 4 or more vs 0 IMB visits. MAIN OUTCOME MEASURES: Dental treatments and Medicaid payments for children up to age 6 years enabled assessment of the likelihood of whether IMB was cost-saving and, if not, the additional payments per hospital episode avoided. RESULTS: Into the Mouths of Babes is 32% likely to be cost-saving, with discounting of benefits and payments. On average, IMB visits cost $11 more than reduced dental treatment payments per person. The program almost breaks even if future benefits from prevention are not discounted, and it would be cost-saving with certainty if IMB services could be provided at $34 instead of $55 per visit. The program is cost-effective with 95% certainty if Medicaid is willing to pay $2331 per hospital episode avoided. CONCLUSIONS: Into the Mouths of Babes improves dental health for additional payments that can be weighed against unmeasured hospitalization costs.

Effectiveness of preventive dental treatments by physicians for young Medicaid enrollees.

OBJECTIVE: To estimate the effectiveness of a medical office-based preventive dental program (Into the Mouths of Babes [IMB]), which included fluoride varnish application, in reducing treatments related to dental caries. METHODS: We used longitudinal claims and enrollment data for all children aged 72 months or younger enrolled in North Carolina Medicaid from 2000 through 2006. Regression analyses compared subgroups of children who received up to 6 IMB visits at ages 6 to 35 months with children who received no IMB visits. Analyses were adjusted for child and area characteristics. RESULTS: Children enrolled in North Carolina Medicaid with ≥ 4 IMB visits experienced, on average, a 17% reduction in dental-caries-related treatments up to 6 years of age compared with children with no IMB visits. When we simulated data for initial IMB visits at 12 and 15 months of age, there was a cumulative 49% reduction in caries-related treatments at 17 months of age. The cumulative effectiveness declined because of an increase in treatments from 24 to 36 months, an increase in referrals for dental caries occurred with increasing time since fluoride application, and emergence of teeth not initially treated with fluoride. CONCLUSIONS: North Carolina's IMB program was effective in reducing caries-related treatments for children with ≥ 4 IMB visits. Multiple applications of fluoride at the time of primary tooth emergence seem to be most beneficial. Referrals to dentists for treatment of existing disease detected by physicians during IMB implementation limited the cumulative reductions in caries-related treatments, but also contributed to improved oral health.

Impact of poor oral health on children's school attendance and performance.

OBJECTIVES: We examined school days missed for routine dental care versus dental pain or infection to determine the relationship between children's oral health status and school attendance and performance. METHODS: We used 2008 data from the North Carolina Child Health Assessment and Monitoring Program. The study sample, weighted to reflect the state's population, included 2183 schoolchildren. Variables assessed included school absences and performance, oral health status, parental education, health insurance coverage, race, and gender. RESULTS: Children with poor oral health status were nearly 3 times more likely (odds ratio = 3.89; 95% confidence interval = 1.96, 7.75) than were their counterparts to miss school as a result of dental pain. Absences caused by pain were associated with poorer school performance (P < .05), but absences for routine care were not. Mediation analyses revealed that oral health status was associated with performance independent of absence for pain. CONCLUSIONS: Children with poorer oral health status were more likely to experience dental pain, miss school, and perform poorly in school. These findings suggest that improving children's oral health status may be a vehicle to enhancing their educational experience.

Multiple imputation of dental caries data using a zero-inflated Poisson regression model.

UNLABELLED: Excess zeros exhibited by dental caries data require special attention when multiple imputation is applied to such data. OBJECTIVE: The objective of this study was to demonstrate a simple technique using a zero-inflated Poisson (ZIP) regression model, to perform multiple imputation for missing caries data. METHODS: The technique is demonstrated using data (n = 24,403) from a medical office-based preventive dental program in North Carolina, where 27.2 percent of children (n = 6,637) were missing information on physician-identified count of carious teeth. We first estimate a ZIP regression model using the nonmissing caries data (n = 17,766). The coefficients from the ZIP model are then used to predict the missing caries data. RESULTS: This technique results in imputed caries counts that are similar to the non-missing caries data in their distribution, especially with respect to the excess zeros in the nonmissing caries data. CONCLUSION: This technique can be easily applied to impute missing dental caries data.

How a North Carolina program boosted preventive oral health services for low-income children.

Dental caries (tooth decay), the most common chronic disease affecting young children, is exacerbated by limited access to preventive dental services for low-income children. To address this problem, North Carolina implemented a program to reimburse physicians for up to six preventive oral health visits for Medicaid-enrolled children younger than age three. Analysis of physician and dentist Medicaid claims from the period 2000-2006 shows that the program greatly increased preventive oral health services. By 2006 approximately 30 percent of well-child visits for children ages six months up to three years included these services. However, additional strategies are needed to ensure preventive oral health care for more low-income children.

Agreement between structured checklists and Medicaid claims for preventive dental visits in primary care medical offices.

For program evaluation purposes, the feasibility of matching Medicaid claims with physician-completed structured checklists (encounter forms, EFs) was assessed in a pediatric office-based preventive dental program. We examined agreement on visits (weighted kappa) and predictors of a match between EFs and claims (multinomial logit model with practice-level clustering). In total, 34,171 matches occurred between 41,252 EFs and 40,909 claims, representing 82.8 per cent of EFs and 83.5 per cent of claims. Agreement on visits was 56 per cent (weighted kappa = 0.66). Pediatric practices provided the majority of visits (82.4%) and matches. Increasing age of child and residence in same county as the medical practice increased the likelihood of a match. Structured checklists can be combined with claims to better assess provision of preventive dental services in pediatric primary care. However, future research should examine strategies to improve the completion of structured checklists by primary care providers if data beyond claims are to be used for program evaluation.

Patient- and population-reported outcomes in public health dentistry: oral health-related quality of life.

At present no process is in place in the United States to comprehensively monitor the national burden of oral diseases from the perspective of oral health-related quality of life (OHRQoL), yet available evidence shows that a substantial percentage of the adult population rates their oral health poorly. This article reviews applications of OHRQoL in dental public health. The authors specifically review its use, contributions, and needed advances in: (1) monitoring the impacts of oral diseases on OHRQoL at the national level, and in public health surveillance at the state and local levels; (2) treatment outcomes research and program evaluation; and (3) clinical practice.

Follow-up preventive dental visits for Medicaid-enrolled children in the medical office.

OBJECTIVE: To describe the frequency and determinants of follow-up preventive oral health visits at medical offices among children screened for dental disease, receiving fluoride varnish and counseling. METHODS: Parents of Medicaid children enrolled in a clinical trial completed a baseline questionnaire before their child's medical visit. The providers completed patient dental encounter forms at each visit, documenting dental services, caries risk, and dental disease. Questionnaires, encounter forms, and Medicaid claims were linked to create a database with information on visits, child and caregiver characteristics, and oral health practices. Descriptive and multivariate analyses assessed associations of variables with likelihood of follow-up visits. RESULTS: A total of 744 children with mean age of 15 months at enrollment had 1,415 oral health visits. Children averaged 0.9 follow-up oral health visits and 1.3 follow-up well-child visits. Fewer children had follow-up oral health visits (55 percent) than well-child visits (70 percent), but children with a baseline preventive dental visit at a younger age had more visits with shorter intervals. Caregivers reporting greater numbers of children and putting the child to bed with the bottle had more subsequent visits. Older age of child, male child, and caregiver education < or = 12 years were associated with fewer follow-up visits. CONCLUSIONS: Children with preventive dental services in medical offices have similar numbers of oral health and well-child visits, with both below recommended numbers. Strategies to increase these services may need to be tied to those aimed at increasing compliance with well-child visits, taking advantage of nonwell-child visits, and implementing Medicaid policies that allow for optimal timing of visits.

Evaluation of a word recognition instrument to test health literacy in dentistry: the REALD-99.

OBJECTIVE: This study aims to evaluate a dental health literacy word recognition instrument. METHODS: Based on a reading recognition test used in medicine, the Rapid Estimate of Adult Literacy in Medicine (REALM), we developed the Rapid Estimate of Adult Literacy in Dentistry (REALD-99). Parents of pediatric dental patients were recruited from local dental clinics and asked to read aloud words in both REALM and REALD-99. REALD-99 scores had a possible range of 0 (low literacy) to 99 (high literacy); REALM scores ranged from 0 to 66. Outcome measures included parents' perceived oral health for themselves and of their children, and oral health-related quality of life of the parent as measured by the short-form Oral Health Impact Profile (OHIP-14). To determine the validity, we tested bivariate correlations between REALM and REALD-99, REALM and perceived dental outcomes, and REALD-99 and perceived dental outcomes. We used ordinary least squares regression and logit models to further examine the relationship between REALD-99 and dental outcomes. We determined internal reliability using Cronbach's alpha. RESULTS: One hundred two parents of children were interviewed. The average REALD-99 and REALM-66 scores were high (84 and 62, respectively). REALD-99 was positively correlated with REALM (PCC = 0.80). REALM was not related to dental outcomes. REALD-99 was associated with parents' OHIP-14 score in multivariate analysis. REALD-99 had good reliability (Cronbach's alpha = 0.86). CONCLUSIONS: REALD-99 has promise for measuring dental health literacy because it demonstrated good reliability and is quick and easy to administer. Additional studies are needed to examine the validity of REALD-99 using objective clinical oral health measures and more proximal outcomes such as behavior and compliance to specific health instructions.

Development and testing of the Test of Functional Health Literacy in Dentistry (TOFHLiD).

OBJECTIVE: This study aims to evaluate the reliability and validity of the Test of Functional Health Literacy in Dentistry (TOFHLiD), a new instrument to measure functional oral health literacy. METHODS: TOFHLiD uses text passages and prompts related to fluoride use and access to care to assess reading comprehension and numerical ability. Parents of pediatric dental patients (n = 102) were administered TOFHLiD, a medical literacy comprehension test (TOFHLA), and two word recognition tests [Rapid Estimate of Adult Literacy in Dentistry (REALD), Rapid Estimate of Adult Literacy in Medicine (REALM)]. This design provided assessments of dental and medical health literacy by all subjects, both measured with two different methods (reading/numeracy ability and word recognition). Construct validity of TOFHLiD was assessed by entering the correlation coefficients for all pairwise comparisons of literacy instruments into a multitrait-multimethod matrix. Internal reliability of TOFHLiD was assessed with Cronbach's alpha. Criterion-related predictive validity was tested by associations between the TOFHLiD scores and the three measures of oral health in multivariate regression analyses. RESULTS: The correlation coefficient for TOFHLiD and REALD-99 scores (monotrait-heteromethod) was high (r = 0.82, P < 0.05). Coefficients between TOFHLiD and TOFHLA (heterotrait-monomethod: r = 0.52) and REALM (heterotrait-heteromethod: r = 0.53) were smaller than coefficients for convergent validity Cronbach's alpha for TOFHLiD was 0.63. TOFHLiD was positively correlated with OHIP-14 (P < 0.05), but not with parent or child oral health. TOFHLA was not related to dental outcomes. CONCLUSIONS: TOFHLiD demonstrates good convergent validity but only moderate ability to discriminate between dental and medical health literacy. Its predictive validity is only partially established, and internal consistency just meets the threshold for acceptability. Results provide solid support for more research, but not widespread use in clinical or public health practice.