Eliminating Medicaid dental benefits and early-stage oral cancer diagnoses.

BACKGROUND: Despite the importance of regular dental visits for detecting oral cancer, millions of low-income adults lack access to dental services. In July 2009, California eliminated adult Medicaid dental benefits. We tested if this impacted oral cancer detection for Medicaid enrollees. METHODS: We analyzed Surveillance, Epidemiology, and End Results-Medicaid data, which contains verified Medicaid enrollment status, to estimate a difference-in-differences model. Our design compares the change in early-stage (Stages 0-II) diagnoses before and after dropping dental benefits in California with the change in early-stage diagnoses among eight states that did not change Medicaid dental benefits. Patients were grouped by oropharyngeal cancer (OPC) and non-OPC (oral cavity cancer), type, and the length of Medicaid enrollment. We also assessed if the effect of dropping dental benefits varied by the number of dentists per capita. RESULTS: Dropping Medicaid dental benefits was associated with a 6.5%-point decline in early-stage diagnoses of non-OPC (95% CI = -14.5, -3.2, p = 0.008). This represented a 20% relative reduction from baseline rates. The effect was highest among beneficiaries with 3 months of continuous Medicaid enrollment prior to diagnosis who resided in counties with more dentists per capita. Specifically, dropping dental coverage was associated with a 1.25%-point decline in the probability of early-stage non-OPC diagnoses for every additional dentist per 5000 population (p = 0.006). CONCLUSIONS: Eliminating Medicaid dental benefits negatively impacted early detection of cancers of the oral cavity. Continued volatility of Medicaid dental coverage and provider shortages may be further delaying oral cancer diagnoses. Alternative approaches are needed to prevent advanced stage OPC.

Perceived social status, socioeconomic status, and preventive dental utilization among a low-income Medicaid adult population.

OBJECTIVES: Perceived Social Status (PSS) is a measure of cumulative socioeconomic circumstances that takes perceived self-control into account. It is hypothesized to better capture social class compared to socioeconomic status (SES) measures (i.e., education, occupation, and income). This study examined the association between PSS and dental utilization, comparing the strength of associations between dental utilization and PSS and SES measures among a low-income adult Medicaid population. METHODS: A cross-sectional survey was administered to a random sample of low-income adults in Iowa, United States with Medicaid dental insurance (N = 18,000) in the spring of 2018. Respondents were asked about PSS, dental utilization, and demographics. A set of multivariable logistic regression models examined the relative effects of PSS and SES measures on dental utilization, controlling for age, sex, health literacy, whether the respondent was aware they had dental insurance, transportation, and perceived need of dental care. RESULTS: The adjusted response rate was 25%, with a final sample size of 2252. Mean PSS (range 1-10) was 5.3 (SD 1.9). PSS was significantly associated with dental utilization (OR = 1.11; CI = 1.05, 1.18) when adjusting for control variables, whereas other SES measures-education, employment, and income-were not. CONCLUSIONS: PSS demonstrated a small positive association with dental utilization. Results support the relative importance of PSS, in addition to SES measures, as PSS may capture aspects of social class that SES measures do not. Results suggest the need for future research to consider the effects of PSS on oral health outcomes and behaviors.

Association of Medicaid expansion with dental emergency department visits overall and by states' Medicaid dental benefits provision.

BACKGROUND: Evidence on the association of Medicaid expansion with dental emergency department (ED) utilization is limited, while even less is known on policy-related changes in dental ED visits by Medicaid programs' dental benefits generosity. The objective of this study was to estimate the association of Medicaid expansion with changes in dental ED visits overall and by states' benefits generosity. METHODS: We used the Healthcare Cost and Utilization Project's Fast Stats Database from 2010 to 2015 for non-elderly adults (19 to 64 years of age) across 23 States, 11 of which expanded Medicaid in January 2014 while 12 did not. Difference-in-differences regression models were used to estimate changes in dental-related ED visits overall and further stratified by states' dental benefit coverage in Medicaid between expansion and non-expansion States. RESULTS: After 2014, dental ED visits declined by 10.9 [95% confidence intervals (CI): -18.5 to -3.4] visits per 100,000 population quarterly in states that expanded Medicaid compared to non-expansion states. However, the overall decline was concentrated in Medicaid expansion states with dental benefits. In particular, among expansion states, dental ED visits per 100,000 population declined by 11.4 visits (95% CI: -17.9 to -4.9) quarterly in states with dental benefits in Medicaid compared to states with emergency-only or no dental benefits. Significant differences between non-expansion states by Medicaid's dental benefits generosity were not observed [6.3 visits (95% CI: -22.3 to 34.9)]. CONCLUSIONS: Our findings suggest the need to strengthen public health insurance programs with more generous dental benefits to curtail costly dental ED visits.

Dentist-reported differences in services provided to patients with public vs. private dental insurance.

INTRODUCTION: Variation in dentists' provision of types of dental services based on patients' insurance may impact population access to comprehensive care. The aim of this study was to describe differences in the types of services provided to adult patients with Medicaid versus private insurance among private practice general dentists. METHODS: The data source was a 2019 survey of private practice dentists in Iowa, and the study sample included general dentists with current or recent participation in Iowa's Medicaid program for adults (n = 264). Bivariate analyses were used to compare differences in the types of services provided to privately insured and publicly insured patients. RESULTS: Dentists reported the greatest differences in services provided to patients with public versus private insurance for prosthodontic procedures, including complete dentures, removable partial dentures, and crown and bridge services. Endodontic services were the least frequently provided category of services provided by dentists for both patient groups. Patterns were generally similar among both urban and rural providers. CONCLUSION: Access to dental care for Medicaid members should be evaluated not only on the proportion of dentists who see new Medicaid patients but also on the types of services dentists provide to this population.

Motivations and experiences among dentists in rural private practice: A qualitative study.

OBJECTIVES: Despite the critical importance of access to dental care for rural residents and concerns about a shrinking rural dentist workforce, few studies have examined rural dentist motivations to practice in rural areas. The aim of this study was to explore practicing rural dentists' motivations and experiences qualitatively through semi-structured interviews to help inform and guide recruitment and retention efforts in rural areas. METHODS: Dentists were included in the sample frame if they were general dentists in private practice and had a primary practice located in a rural Iowa county. Rural dentists with publicly available email addresses were contacted by email to participate. Semi-structured interviews were administered to 16 private practice general dentists. All interviews were audio recorded, transcribed, and coded using pre-set and emergent codes. RESULTS: Participants were most commonly male (75%), under age 35 (44%), white (88%), and practiced in a partnership arrangement (44%). The main codes regarding dentists' experiences and motivations to practice in a rural area included familiarity with a rural area, community, financial factors, and clinical care delivery. Having been raised in a rural area was a major influence in most dentists' decisions about where to locate. CONCLUSIONS: The importance of rural upbringing in this study underscores the need to consider rural upbringing in dental student admissions. Additional findings, such as financial benefits of a rural practice and other practice-related factors can be used to inform recruitment efforts.

Access to dental insurance and oral health inequities in the United States.

While the oral health status of the United States (U.S.) population has improved over the years, racial/ethnic inequities are pervasive with Black Americans carrying a greater burden of oral diseases in most measured outcomes. Access to dental care is a major structural and societal determinant of oral health inequities rooted in structural racism. From post-Civil War-era to present day, this essay presents a series of examples of racist policies that have shaped access to dental insurance for Black Americans both directly and indirectly. Additionally, this essay explains the unique challenges of Medicare and Medicaid highlighting the specific disparities that these public insurance programs face, and proposes policy recommendations aimed to reduce racial/ethnic inequities in dental coverage and access to advance the nation's oral health with comprehensive dental benefits in public insurance programs.

Molecular Mechanisms of Winter Survival.

Winter provides many challenges for insects, including direct injury to tissues and energy drain due to low food availability. As a result, the geographic distribution of many species is tightly coupled to their ability to survive winter. In this review, we summarize molecular processes associated with winter survival, with a particular focus on coping with cold injury and energetic challenges. Anticipatory processes such as cold acclimation and diapause cause wholesale transcriptional reorganization that increases cold resistance and promotes cryoprotectant production and energy storage. Molecular responses to low temperature are also dynamic and include signaling events during and after a cold stressor to prevent and repair cold injury. In addition, we highlight mechanisms that are subject to selection as insects evolve to variable winter conditions. Based on current knowledge, despite common threads, molecular mechanisms of winter survival vary considerably across species, and taxonomic biases must be addressed to fully appreciate the mechanistic basis of winter survival across the insect phylogeny.

Dentist attitudes toward an annual benefit maximum in Iowa's adult Medicaid program.

OBJECTIVES: The Dental Wellness Plan (DWP) provides dental coverage for adult Medicaid enrollees in Iowa. In September 2018, a $1000 annual benefit maximum (ABM) was implemented in the DWP program. The aim of this study was to explore private dentists' attitudes toward ABMs and factors associated with ABM attitudes. METHODS: The data source was a mailed survey administered in spring 2019 to all private practice dentists in Iowa. The two dependent variables were (1) attitude toward the $1000 ABM and (2) attitude toward any ABM generally. Independent variables included demographic and practice-related factors, and participation in and attitudes toward the DWP. Descriptive, bivariate, and multivariable analyses were conducted. RESULTS: While over half (56%) of providers reported a positive attitude toward "Any ABM," less than half (40%) reported a positive attitude toward the "$1000 ABM." Attitudes toward both "$1000 ABM" and "Any ABM" were significantly and positively associated with attitudes toward DWP overall and toward DWP structure. Independent variables that were significantly associated with both the "$1000 ABM" and "Any ABM" included overall attitude toward the DWP, attitude toward DWP structure, and practice busyness. CONCLUSIONS: Utilizing an ABM, particularly one set at $1000 for a Medicaid program, elicits mixed attitudes among dentists. Future research should evaluate the impact of Medicaid ABMs on long term dentist participation and patient's ability to receive needed care.

The impact of clinical simulation on the development of advanced practice skills.

This article considers the findings of a qualitative research study into the impact of simulation on the development of advanced clinical practitioners' skills and knowledge. STUDY AIM: To explore simulated learning through the eyes of trainee and trained advanced clinical practitioners (ACPs) and consider its potential in supporting their development. METHOD: This qualitative research study explored the experiences of trained and trainee ACP volunteers undertaking a structured simulated event provided by a local acute hospital trust simulation team. A questionnaire (n=10) and a focus group (n=4) acted as the data gathering tools. RESULTS: Although simulation can be daunting for the participants, the overwhelming outcome was positive. Participants stated that they gained confidence and suggested that simulation offered a safe place to practise the challenging scenarios that occur in the clinical environment. Additionally, they emphasised that simulation provided a place to network and receive constructive feedback that was non-judgemental, and which helped them to develop clinical knowledge and appreciate their limitations. CONCLUSION: Simulation is a valuable addition to the education and development of ACPs. It should be considered for inclusion within the educational curriculum as a supplement to theoretical knowledge and to the structured clinical supervision provided within the clinical environment.

Postsecondary Faculty Attitudes and Beliefs about Writing-Based Pedagogies in the STEM Classroom.

Writing is an important skill for communicating knowledge in science, technology, engineering, and mathematics (STEM) and an aid to developing students' communication skills, content knowledge, and disciplinary thinking. Despite the importance of writing, its incorporation into the undergraduate STEM curriculum is uneven. Research indicates that understanding faculty beliefs is important when trying to propagate evidence-based instructional practices, yet faculty beliefs about writing pedagogies are not yet broadly characterized for STEM teaching at the undergraduate level. Based on a nationwide cross-disciplinary survey at research-intensive institutions, this work aims to understand the extent to which writing is assigned in undergraduate STEM courses and the factors that influence faculty members' beliefs about, and reported use of, writing-based pedagogies. Faculty attitudes about the effectiveness of writing practices did not differ between faculty who assign and do not assign writing; rather, beliefs about the influence of social factors and contextually imposed instructional constraints informed their decisions to use or not use writing. Our findings indicate that strategies to increase the use of writing need to specifically target the factors that influence faculty decisions to assign or not assign writing. It is not faculty beliefs about effectiveness, but rather faculty beliefs about behavioral control and constraints at the departmental level that need to be targeted.

Enhanced Degradation of Juvenile Hormone Promotes Reproductive Diapause in the Predatory Ladybeetle Coccinella Septempunctata.

Improved knowledge on the regulation of reproductive diapause in Coccinella septempunctata, an important predator of aphids, is crucial for improving shelf-life and mass production of the ladybeetles. In many insects, the absence of juvenile hormone (JH) is a central regulator of reproductive diapause. JH is principally degraded by JH esterase (JHE) and JH epoxide hydrolase (JHEH). Previous studies have shown that genes encoding these enzymes were upregulated in early diapause of C. septempunctata, but whether increased JH degradation contributes to the reduction of JH levels and facilitates reproductive diapause remains unknown. Here, we investigate the role of JH and JH degradation genes during reproductive diapause in C. septempunctata females. Applying methoprene, a JH analogue, to the diapause preparation females clearly elevated JH signaling and reversed diapause program, suggesting that a lower level of JH is critical for the induction of reproductive diapause in the ladybeetle. Full-length cDNA sequences of JHE and JHEH were cloned and characterized, and their deduced proteins contain all the conserved active domains and typical motifs as identified in other insects. The expressions of JHE and JHEH were both significantly increased in diapause preparation and remained at a high level for a period throughout diapause, and then decreased after the termination of diapause. Knocking down these JH degradation genes clearly increased the expression levels of JH-inducible genes Krüppel-homolog 1 (Kr-h1) and vitellogenin (Vg), indicating an elevated JH level. Simultaneously, silencing JH degradation genes distinctly reduced diapause-related features and promotes reproduction, indicated by accelerated ovary growth, yolk deposition, and suppressed lipid accumulation. These results indicate that the enhanced JH degradation plays a critical role in regulating reproductive diapause of C. septempunctata.

Randomized experiment on the effect of incentives and mailing strategy on response rates in a mail survey of dentists.

OBJECTIVES: Response rates for mail surveys of dentists and other health care providers have declined appreciably over the past several decades. The objective of this study was to update evidence about the impact use of incentives and different mail strategies on response rates in a mail survey of dentists. METHODS: We randomized private practice dentists in Iowa (N = 1267) into six study groups to test the effects of incentives and mail strategy on response rate. Survey incentives included either a $2 bill or a customized pen/stylus; a control group with no incentive was included. Mail strategies included bulk mail or first-class stamps. RESULTS: The overall survey response rate was 43%. A $2 bill incentive was associated with significantly higher likelihood of returning a survey compared to the control group with no incentive (48% response rate vs. 40%, respectively). A non-monetary incentive was not significantly associated with likelihood of response. Use of first-class stamps compared to bulk mail did not significantly affect response rate. CONCLUSIONS: This study demonstrated the effectiveness of a $2 incentive to increase response rate in a mail survey of dentists. Given the background trend of declining survey participation rates, researchers should consider use of monetary incentives and explore new strategies to increase participation among dentists and other health care providers.

Teaching Tool for Teledentistry Modeled with Pediatric Dentistry Residents.

Purpose: To present a patient interaction teaching tool for synchronous teledentistry visits following concepts in critical thinking and report on the viability, assessment and implementation of the tool in an academic pediatric dentistry clinic.
Methods: A teaching tool was derived from interviews with pediatric dental residents and clinicians. The tool contained six main sections and 26 steps. The main sections included: greeting, medical, dental and behavioral histories; airway assessment; treatment recommendations; behavioral modalities of treatment; and follow-up. A faculty member assigned each interviewer dichotomous values of yes and no for implementation of each step of the teaching tool.
Results: Six pediatric dentistry residents participated in a tool use demonstration with 21 patients. The purpose of each interview was to gain information for procedural treatment at the first onsite visit. All pediatric dental residents completed over 90 percent of the steps in each section. The interview duration ranged from eight to 29 minutes (median: equals 18 minutes). Eighteen of the 21 patients were scheduled for follow-up visits.
Conclusions: The emulation model for provisional treatment planning is viable for teledentistry. Pilot results showed students consistently completed over 90 percent of skillset steps and that this teaching tool serves as a framework for teledentistry appointments.

Patient centered dental home: Building a framework for dental quality measurement and improvement.

INTRODUCTION: This article presents results of the second phase of a project to develop a patient-centered dental home (PCDH) model. Aims of PCDH model development include broadening the scope of prior dental home definitions to include populations across the lifespan, developing a quality measurement framework to facilitate quality assessment and improvement, and promoting opportunities for medical-dental integration through alignment with existing PCMH models. This phase determined the components, or conceptual subdivisions, associated with a previously developed PCDH definition and characteristics. METHODS: We used a modified Delphi process to obtain structured feedback and gain consensus among the project national advisory committee (NAC). The process included a web-based survey that asked NAC members to rank the importance of each potential component on a scale of 1-9. Criteria for consensus on component inclusion/exclusion combined a median rating and measure of disagreement. Respondents were also encouraged to provide open-ended feedback regarding rationale for component ratings and additional suggested components. RESULTS: A total of 47 out of 51 members completed the survey. All 34 components met the quantitative criteria for inclusion in the PCDH model. Changes were made to components based on open-ended feedback. CONCLUSIONS: This project phase further developed a PCDH measurement framework that aims to guide practice transformation, quality measurement and improvement in dental care delivery, as well as integration between medicine and dentistry. Using a Delphi approach with a broad group of stakeholders ensured that components had face validity and were conceptually aligned with the PCDH definition and characteristics.

Dental Hygienists' Attitudes and Experiences with Public Health Supervision in Iowa.

Purpose: Iowa is one of 42 states with a direct access dental hygiene workforce model. Public health supervision (PHS) in Iowa allows dental hygienists (DH) to provide services in community settings without a prior examination from a dentist. The purpose of this study was to assess the current PHS workforce in Iowa and add to the body of evidence on direct access DH care.Methods: A 40-item mixed-mode survey was administered to all DH working under PHS in Iowa (n=126). Consent letters were mailed with directions to an online survey. Follow-up letters were sent to non-responders with an enclosed paper copy of the survey. Univariate analyses were performed to analyze the data.Results: The response rate was 52% (n=62), with 69% (n=42) of participants currently providing services under PHS. The most common employer categories were local public health agencies (59%), community health centers (CHCs) (20%), and nonprofit clinics (10%). The most common types of services provided under PHS were dental screenings (95%), fluoride varnish (91%), and sealants (50%). The majority of supervising dentists worked in private practice (61%) and CHCs (27%). Most supervising dentists (71%) accepted some referrals; however, a majority of PHS participants (71%) reported that it was somewhat or very difficult to find dentists to accept patient referrals.Conclusion: Most PHS DHs were employed by government agencies, however the majority of supervising dentists worked in private settings. Although most supervising dentists accepted at least some patient referrals, PHS DHs still experienced a high degree of difficulty referring patients for care.

From expert to advanced clinical practitioner and beyond.

This article considers the potential development of advanced clinical practitioners (ACPs) and consultant practitioners, beyond the 'expert' status as defined by Pat Benner in 1984. The suggested Derby Model: 7 Levels of Practice Advancement, adapted from Benner's From Novice to Expert, recognises Health Education England's four pillars of advanced practice and how they can be implemented and enhanced within these senior roles, and what that means in a 21st century healthcare system.