Midface Growth in Patients With Unilateral Cleft Lip and Palate Treated With a Nasoalveolar Molding Protocol.

This retrospective cohort study aimed to determine the impact of a nasoalveolar molding (NAM) protocol on midface growth in school-aged children with non-syndromic unilateral cleft lip and palate (UCLP). Data from 56 consecutively treated, NAM-prepared, Caucasian patients with non-syndromic UCLP from a single US cleft palate center were compared to pooled center data based on 56 patients with non-syndromic UCLP treated at 2 Eurocleft centers that did not use presurgical infant orthopedics (non-PSIO). Lateral cephalograms were obtained and 28 landmarks were identified. Published cephalometric measurements from Eurocleft centers were used for comparison. Seven cephalometric measurements (SNA, SNB, ANB, A'N'B', G'-Sn'-Pg', Sn-CT-LS, ANS-Me/N-Me%), available or derivable for both centers, were analyzed. Means and standard deviations for the 7 measurements were calculated for the NAM center. Student's t-tests were used to compare group means for 6 of the measures and a test of proportion was used for ANS-Me/N-Me%. No significant differences were found between the NAM protocol-prepared group and the Eurocleft non-PSIO centers on any of the 7 analyzed cephalometric relationships after accounting for false discovery rate. The NAM treatment protocol does not appear to impact skeletal or soft tissue facial growth in school-aged children with non-syndromic UCLP.

Comparative Analysis of Three-Dimensional Nasal Shape of Casts from Patients With Unilateral Cleft Lip and Palate Treated at Two Institutions Following Rotation Advancement Only (Iowa) or Nasoalveolar Molding and Rotation Advancement in Conjunction With Primary Rhinoplasty (New York).

OBJECTIVES: To compare 3-dimensional nasal symmetry in patients with UCLP who had either rotation advancement alone or nasoalveolar molding (NAM) followed by rotation advancement in conjunction with primary nasal repair. DESIGN: Pilot retrospective cohort study. MATERIALS AND METHODS: Nasal casts of 23 patients with UCLP from 2 institutions were analyzed; 12 in the rotation advancement only group (Iowa) and 11 in the NAM, rotation advancement with primary nasal repair group (New York). Casts from patients aged 6 to 18 years were scanned using the 3Shape scanner and 3-dimensional analysis of nasal symmetry performed using 3dMD Vultus software, Version 2507, 3dMD, Atlanta, GA. Cleft and noncleft side columellar height, nasal dome height, alar base width, and nasal projection were linearly measured. Inter- and intragroup analyses were performed using t tests and paired t tests as appropriate. RESULTS: A statistically significant difference in mean-scaled 3-dimensional asymmetry index was found between groups with group 1 having a larger measure of asymmetry (4.69 cm3) than group 2 (2.56 cm3; P = .02). Intergroup analysis performed on the most sensitive linear measure, alar base width, revealed significantly less asymmetry on average in group 2 than in group 1 ( P = .013). CONCLUSION: This study suggests the NAM followed by rotation advancement in conjunction with primary nasal repair approach may result in less nasal asymmetry compared to rotation advancement alone.

A Social History of Disease: Contextualizing the Rise and Fall of Social Inequalities in Cause-Specific Mortality.

Fundamental cause theory posits that social inequalities in health arise because of unequal access to flexible resources, including knowledge, money, power, prestige, and beneficial social connections, which allow people to avoid risk factors and adopt protective factors relevant in a particular place. In this study, we posit that diseases should also be put into temporal context. We characterize diseases as transitioning through four stages at a given time: (1) natural mortality, characterized by no knowledge about risk factors, preventions, or treatments for a disease in a population; (2) producing inequalities, characterized by unequal diffusion of innovations; (3) reducing inequalities, characterized by increased access to health knowledge; and (4) reduced mortality/disease elimination, characterized by widely available prevention and effective treatment. For illustration, we pair an ideal-types analysis with mortality data to explore hypothesized incidence rates of diseases. Although social inequalities exist in incidence rates of many diseases, the cause, extent, and direction of inequalities change systematically in relation to human intervention. This article highlights opportunities for further development, specifically highlighting the role of stage duration in maintaining social inequalities in cause-specific mortality.

Basal View Reference Photographs for Nasolabial Appearance Rating in Unilateral Cleft Lip and Palate.

The Asher-McDade system is a 5-point ordinal scale frequently used to rate the components of nasolabial appearance, including nasal form and nasal symmetry, in unilateral cleft lip and palate. Although reference photographs illustrating this scale have been identified for the frontal and right profile view, no reference photographs exist for the basal view. The aim of this study was to identify reference photographs for nasal form and nasal symmetry from the basal view to illustrate this scale and facilitate its use. Four raters assessed nasolabial appearance (form and symmetry) on basal view photographs of 50 children (average age 8 years) with a repaired cleft lip. Intraclass correlation coefficients show fair to moderate inter-rater reliability. Cronbach α indicated strong agreement between raters (0.77 nasal form; 0.78 nasal symmetry; 0.80 overall), along with low duplicate measurement error and strong internal consistency between the measures. The photographs with the highest agreement among raters were selected to illustrate each point on the 5-point scale for nasal form and for nasal symmetry, resulting in the selection of 10 reference photographs. The basal view reference photograph set developed from this study may complement existing reference photograph sets for other views and facilitate rating tasks.

Assessment of presurgical clefts and predicted surgical outcome in patients treated with and without nasoalveolar molding.

Obtaining an esthetic and functional primary surgical repair in patients with complete cleft lip and palate (CLP) can be challenging because of tissue deficiencies and alveolar ridge displacement. This study aimed to describe surgeons' assessments of presurgical deformity and predicted surgical outcomes in patients with complete unilateral and bilateral CLP (UCLP and BCLP, respectively) treated with and without nasoalveolar molding (NAM). Cleft surgeon members of the American Cleft Palate-Craniofacial Association completed online surveys to evaluate 20 presurgical photograph sets (frontal and basal views) of patients with UCLP (n = 10) and BCLP (n = 10) for severity of cleft deformity, quality of predicted surgical outcome, and likelihood of early surgical revision. Five patients in each group (UCLP and BCLP) received NAM, and 5 patients did not receive NAM. Surgeons were masked to patient group. Twenty-four percent (176/731) of surgeons with valid e-mail addresses responded to the survey. For patients with UCLP, surgeons reported that, for NAM-prepared patients, 53.3% had minimum severity clefts, 58.9% were anticipated to be among their best surgical outcomes, and 82.9% were unlikely to need revision surgery. For patients with BCLP, these percentages were 29.8%, 38.6%, and 59.9%, respectively. Comparing NAM-prepared with non-NAM-prepared patients showed statistically significant differences (P < 0.001), favoring NAM-prepared patients. This study suggests that cleft surgeons assess NAM-prepared patients as more likely to have less severe clefts, to be among the best of their surgical outcomes, and to be less likely to need revision surgery when compared with patients not prepared with NAM.

Endogenous cell therapy improves bone healing.

BACKGROUND: Although bone repair is often a relatively rapid and efficient process, many bone defects do not heal. Because an adequate blood supply is essential for new bone formation, we hypothesized that augmenting new blood vessel formation by increasing the number of circulating vasculogenic progenitor cells (PCs) with AMD3100 and enhancing their trafficking to the site of injury with recombinant human parathyroid hormone (rhPTH) will improve healing. METHODS: Critical-sized 3-mm cranial defects were trephined into the right parietal bone of C57BLKS/J 6 mice (N = 120). The mice were divided into 4 equal groups (n = 30 for each). The first group received daily subcutaneous injections of AMD3100 (5 mg/kg). The second group received daily subcutaneous injections of rhPTH (5 mg/kg). The third group received both AMD3100 and rhPTH. The fourth group received subcutaneous injections of saline. Circulating vasculogenic PC numbers, new blood vessel formation, and bony regeneration were assessed. Progenitor cell adhesion, migration, and tubule formation were assessed in the presence of rhPTH and AMD3100. RESULTS: Flow cytometry demonstrated that combination therapy significantly increased the number of circulating PCs compared with all other groups. In vitro, AMD3100-treated PCs had significantly increased adhesion migration, and tubule formation was assessed in the presence of rhPTH. Combination therapy significantly improved new blood vessel formation in those with cranial defect compared with all other groups. Finally, bony regeneration was significantly increased in the combination therapy group compared with all other groups. CONCLUSIONS: The combination of a PC-mobilizing and traffic-enhancing agent improved bony regeneration of calvarial defects in mice.

Comparative Study of Early Secondary Nasal Revisions and Costs in Patients With Clefts Treated With and Without Nasoalveolar Molding.

The present study aims to determine the risk of early secondary nasal revisions in patients with complete unilateral and bilateral cleft lip and palate (U/BCLP) treated with and without nasoalveolar molding (NAM) and examine the associated costs of care. A retrospective cohort study from 1990 to 1999 was performed comparing the risk of early secondary nasal revision surgery in patients with a CLP treated with NAM and surgery (cleft lip repair and primary surgical nasal reconstruction) versus surgery alone in a private practice and tertiary level clinic. The NAM treatment group consisted of 172 patients with UCLP and 71 patients with BCLP, whereas the non-NAM-prepared group consisted of 28 patients with UCLP and 5 with BCLP. The risk of secondary nasal revision for patients with UCLP was 3% in the NAM group and 21% in the non-NAM group. The risk of secondary nasal revision for patients with BCLP was 7% in the NAM group compared with 40% in the non-NAM group. Using multicenter averages, the non-NAM revision rates were calculated at 37.8% and 48.5% for U/BCLP, respectively. Applying these risks of revision, NAM treatment led to an estimated savings of between $491 and $4893 depending on the type of cleft. In conclusion, NAM can reduce the number of early secondary nasal revision surgeries and, therefore, reduce the overall cost of care.

Social inequalities in suicide: the role of selective serotonin reuptake inhibitors.

We aimed to examine the relationship between socioeconomic status (SES) and suicide associated with the introduction and diffusion of selective serotonin reuptake inhibitors (SSRIs). Negative binomial regression was used to estimate county-level suicide rates among persons aged 25 years or older using death certificate data collated by the National Center for Health Statistics from 1968 to 2009; SES was measured using the decennial US Census. The National Health and Nutrition Examination Survey and the Medical Expenditure Panel Survey were used to measure SSRI use. Once SSRIs became available in 1988, a 1% increase in SSRI usage was associated with a 0.5% lower suicide rate. Prior to the introduction of SSRIs, SES was not related to suicide. However, with each 1% increase in SSRI use, a 1-standard deviation (SD) higher SES was associated with a 0.6% lower suicide rate. In 2009, persons living in counties with SES 1 SD above the national average were 13.6% less likely to commit suicide than those living in counties with SES 1 SD below the national average--a difference of 1.9/100,000 adults aged ≥25 years. Higher SSRI use was associated with lower suicide rates among US residents aged ≥25 years; however, SES inequalities modified the association between SSRI use and suicide.

Innovative state oral health initiatives: A qualitative analysis of Centers for Medicare & Medicaid Services demonstrations.

BACKGROUND: US health care delivery and financing arrangements are changing rapidly as payers and providers seek greater efficiency, effectiveness, and safety. The Centers for Medicare & Medicaid Services uses grants and technical assistance to drive such development through innovative demonstration programs, including for oral health care. The authors reviewed these dental demonstrations to identify common themes and identify barriers to and facilitators of implementation. METHODS: The authors compared 12 identified demonstrations across 6 domains: grant and technical assistance, stakeholders, inner care settings, outer contextual settings, interventions, and outcomes. They developed program summaries for each demonstration and interviewed key informants using a semistructured guide to review, correct, clarify, and expand on program summaries. RESULTS: Common across all programs were engagement of nontraditional providers, care in nontraditional settings, payment as a critical externality for program adoption, interventions that integrate medical and oral health care, use of alternative payment models, and tracking process measures. Adoption facilitators included an engaged oral health champion and obtaining mission support and alignment among stakeholders. Common barriers included unanticipated organizational disruptions, poor information technology infrastructure, cultural resistance to nontraditional care models, and lack of providers in high-need areas. CONCLUSIONS: Descriptive findings suggest that oral health care may evolve as a more accountable, integrated, and accessible health service with an expanded workforce; collaboration between providers and payers will remain key to creating innovative, sustainable models of oral health care. PRACTICAL IMPLICATIONS: The Centers for Medicare & Medicaid Services' efforts to advance health equity, expand coverage, and improve health outcomes will continue to drive similar initiatives in oral health care.

A scoping review of the economic impact of family oral health: Implications for public health, research, and policy.

OBJECTIVES: To summarize evidence on the impact of oral health on individual and family economic outcomes, describe trends in the literature, and identify areas for additional research to inform public health research and practice. METHODS: Searches were conducted within PubMed, CINAHL, EconLit, Cochrane Library, PsycInfo, and Web of Science databases. Article review, selection, abstraction, and reporting processes were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. RESULTS: Of 2758 unduplicated records identified, 52 met inclusion criteria. Study outcomes included indicators of employment/employability (n = 9), earnings/earnings potential (n = 26), parent missed work and family financial impacts of child oral health (n = 19), and financial loss (n = 3). Dental caries-related variables were the most common predictors of poorer economic outcomes. Other oral health problems, such as poorer dental functioning or poorer self-reported oral health status, also were associated with adverse economic outcomes. Significant associations with employment were found among studies that assessed interventions designed to improve oral health. Only one study estimated the impact of oral health on earnings. One-third of studies conducted multivariable analyses, and 14% incorporated race and ethnicity variables. CONCLUSIONS: Although existing evidence suggests associations between oral health problems and poorer economic outcomes, there is a substantial need for more rigorous research to better understand the extent of economic impact of oral health problems and which populations are most affected. Additional high-quality research is needed to inform which interventions are most likely to improve oral health, reduce adverse economic impacts, and promote health and economic equity.

Change in parental knowledge and beliefs about early childhood dental caries following a pragmatic community-based trial.

OBJECTIVES: To evaluate parent knowledge and belief changes following the MySmileBuddy (MSB) early childhood caries (ECC) intervention. METHODS: Pre- and post-intervention surveys were completed by 669 parents of children with visually-evident ECC from among 977 participants in a 6-12-month pragmatic community-based caries management trial administered by community health workers (CHWs). Six domains of knowledge about caries and motivating and facilitating determinants were assessed via 26 survey items. Principal components analysis and reliability testing reduced dataset dimensionality. Parent and CHW characteristics were analyzed as potential moderators. Paired T-tests measured pre-to-post-intervention changes. Generalized estimating equations accounted for within-participant correlation with significance set at p < 0.05. RESULTS: Twenty items consolidated into five factors (saliva, hygiene, diet, seriousness/susceptibility, and outcome expectations). Six additional items were evaluated individually. Positive post-intervention changes (p < 0.0001) were observed across all factors and all but one individual item (tooth decay is very common). Greatest knowledge increases related to caries as a bacterial disease in two measures, the saliva factor and a single caries belief item tooth decay is an infectious disease (0.59 unit increase, 95% CI [0.55, 0.64] and 0.46 unit increase, 95% CI [0.4, 0.51], respectively), and in the value of fluoridated water over bottled (0.46 unit increase, 95% CI [0.39-0.53]). Most parents improved knowledge of ECC salivary (72%) and dietary risks (57%), and preventative hygiene behaviors (59%). CONCLUSIONS: MSB enhanced knowledge and beliefs about caries and confirmed hypothesized mediators of behavior change among parents of high-risk children. Engaging peer-like CHW interventionists may have moderated intervention effects, warranting further exploration.

The dynamic relationship between physical function and cognition in longitudinal aging cohorts.

On average, older people remember less and walk more slowly than do younger persons. Some researchers argue that this is due in part to a common biologic process underlying age-related declines in both physical and cognitive functioning. Only recently have longitudinal data become available for analyzing this claim. We conducted a systematic review of English-language research published between 2000 and 2011 to evaluate the relations between rates of change in physical and cognitive functioning in older cohorts. Physical functioning was assessed using objective measures: walking speed, grip strength, chair rise time, flamingo stand time, and summary measures of physical functioning. Cognition was measured using mental state examinations, fluid cognition, and diagnosis of impairment. Results depended on measurement type: Change in grip strength was more strongly correlated with mental state, while change in walking speed was more strongly correlated with change in fluid cognition. Examining physical and cognitive functioning can help clinicians and researchers to better identify individuals and groups that are aging differently and at different rates. In future research, investigators should consider the importance of identifying different patterns and rates of decline, examine relations between more diverse types of measures, and analyze the order in which age-related declines occur.

Fundamental causes of colorectal cancer mortality in the United States: understanding the importance of socioeconomic status in creating inequality in mortality.

OBJECTIVES: We used the fundamental cause hypothesis as a framework for understanding the creation of health disparities in colorectal cancer mortality in the United States from 1968 to 2005. METHODS: We used negative binomial regression to analyze trends in county-level gender-, race-, and age-adjusted colorectal cancer mortality rates among individuals aged 35 years or older. RESULTS: Prior to 1980, there was a stable gradient in colorectal cancer mortality, with people living in counties of higher socioeconomic status (SES) being at greater risk than people living in lower SES counties. Beginning in 1980, this gradient began to narrow and then reversed as people living in higher SES counties experienced greater reductions in colorectal cancer mortality than those in lower SES counties. CONCLUSIONS: Our findings support the fundamental cause hypothesis: once knowledge about prevention and treatment of colorectal cancer became available, social and economic resources became increasingly important in influencing mortality rates.

Fundamental causes of colorectal cancer mortality: the implications of informational diffusion.

CONTEXT: Colorectal cancer is a major cause of mortality in the United States, with 52,857 deaths estimated in 2012. To explore further the social inequalities in colorectal cancer mortality, we used fundamental cause theory to consider the role of societal diffusion of information and socioeconomic status. METHODS: We used the number of deaths from colorectal cancer in U.S. counties between 1968 and 2008. Through geographical mapping, we examined disparities in colorectal cancer mortality as a function of socioeconomic status and the rate of diffusion of information. In addition to providing year-specific trends in colorectal cancer mortality rates, we analyzed these data using negative binomial regression. FINDINGS: The impact of socioeconomic status (SES) on colorectal cancer mortality is substantial, and its protective impact increases over time. Equally important is the impact of informational diffusion on colorectal cancer mortality over time. However, while the impact of SES remains significant when concurrently considering the role of diffusion of information, the propensity for faster diffusion moderates its effect on colorectal cancer mortality. CONCLUSIONS: The faster diffusion of information reduces both colorectal cancer mortality and inequalities in colorectal cancer mortality, although it was not sufficient to eliminate SES inequalities. These findings have important long-term implications for policymakers looking to reduce social inequalities in colorectal cancer mortality and other, related, preventable diseases.

Parameters of care for craniosynostosis.

BACKGROUND: A multidisciplinary meeting was held from March 4 to 6, 2010, in Atlanta, Georgia, entitled "Craniosynostosis: Developing Parameters for Diagnosis, Treatment, and Management." The goal of this meeting was to create parameters of care for individuals with craniosynostosis. METHODS: Fifty-two conference attendees represented a broad range of expertise, including anesthesiology, craniofacial surgery, dentistry, genetics, hand surgery, neurosurgery, nursing, ophthalmology, oral and maxillofacial surgery, orthodontics, otolaryngology, pediatrics, psychology, public health, radiology, and speech-language pathology. These attendees also represented 16 professional societies and peer-reviewed journals. The current state of knowledge related to each discipline was reviewed. Based on areas of expertise, four breakout groups were created to reach a consensus and draft specialty-specific parameters of care based on the literature or, in the absence of literature, broad clinical experience. In an iterative manner, the specialty-specific draft recommendations were presented to all conference attendees. Participants discussed the recommendations in multidisciplinary groups to facilitate exchange and consensus across disciplines. After the conference, a pediatric intensivist and social worker reviewed the recommendations. RESULTS: Consensus was reached among the 52 conference attendees and two post hoc reviewers. Longitudinal parameters of care were developed for the diagnosis, treatment, and management of craniosynostosis in each of the 18 specialty areas of care from prenatal evaluation to adulthood. CONCLUSIONS: To our knowledge, this is the first multidisciplinary effort to develop parameters of care for craniosynostosis. These parameters were designed to help facilitate the development of educational programs for the patient, families, and health-care professionals; stimulate the creation of a national database and registry to promote research, especially in the area of outcome studies; improve credentialing of interdisciplinary craniofacial clinical teams; and improve the availability of health insurance coverage for all individuals with craniosynostosis.

Parameters of care for craniosynostosis: dental and orthodontic perspectives.

INTRODUCTION: A multidisciplinary conference was convened in March 2010 with the charge to develop parameters of care for patients with craniosynostosis. The 52 participants represented 16 medical specialties and 16 professional societies. Herein, we present the dental, orthodontic, and surgical care recommendations for those with craniosynostosis, with special emphasis on craniosynostosis syndromes. METHODS: Plenary and small-group iterative discussions were held to draft specialty-specific parameters of care. All participants reviewed and discussed each specialty-specific document. Special care was taken to ensure cross-discipline interactions, recognizing the importance of interdisciplinary team care. RESULTS: A unified document was produced delineating longitudinal care parameters from prenatal assessment and consultation to adulthood in all the represented specialty areas. The dental and orthodontic care parameters from infancy to adulthood are explained in terms of stages of development and coordinated with interdisciplinary assessments and interventions. CONCLUSIONS: The consensus document provides a detailed description of physical, functional, and cognitive development in persons with craniosynostosis and recommends staged team observations and interventions. The expectation is that the document will help to ensure state-of-the-art care for patients with craniosynostosis and provide a generally acceptable framework for collaborative studies.

Small-area socioeconomic status and children's oral health in a safety-net care delivery setting.

OBJECTIVES: To better understand the impact of small-area socioeconomic status (SES) on caries experience and sealant presence among children receiving services through a comprehensive community-based safety-net oral health program. METHODS: Census-tract level household data from the American Community Survey was utilized to construct an index that reflects the small-area socioeconomic environments in which children receive oral health services. This area SES index was entered into a logistic model with sociodemographic participant data collected by the community-based oral health program to consider its association with outcomes (caries and sealant experience) at first program visit, among children older and younger than 5 years. RESULTS: Among poor children older than 5 years of age, higher census-tract level SES was associated with lesser caries experience and greater sealant experience at presentation for care to a community-based oral health program. Each standard deviation increase in census-tract level SES index was associated with reduced odds of any caries experience (aOR = 0.92; 95 percent CI 0.85, 0.99; P = 0.021) and increased odds of sealants (aOR = 1.20; 95 percent CI 1.05, 1.37; P = 0.009). Among children 5 years and under, only grade was associated with both outcomes. CONCLUSIONS: Within an inner city area of poverty, the greater a census tract's socioeconomic risks to health, the greater the odds that children over age five experience caries and the lesser their odds of having dental sealants. While associations between SES and oral health outcomes across the full spectrum of SES have been recognized, this study suggests that within lower SES areas, SES-associated gradients exist in children's oral health.

Examination of inequalities in HIV/AIDS mortality in the United States from a fundamental cause perspective.

OBJECTIVES: We examined changes in socioeconomic status (SES) and Black to White inequalities in HIV/AIDS mortality in the United States before and after the introduction of highly active antiretroviral therapy (HAART). METHODS: Taking a fundamental cause perspective, we used negative binomial regression to analyze trends in county-level gender-, race-, and age-specific HIV/AIDS mortality rates among those aged 15 to 64 years during the period 1987-2005. RESULTS: Although HIV/AIDS mortality rates decreased once HAART became available, the declines were not uniformly distributed among population groups. The associations between SES and HIV/AIDS mortality and between race and HIV/AIDS mortality, although present in the pre-HAART period, were significantly greater in the peri- and post-HAART periods, with higher SES and White race associated with the greatest declines in mortality during the post-HAART period. CONCLUSIONS: Our findings support the fundamental cause hypothesis, as the introduction of a life-extending treatment exacerbated inequalities in HIV/AIDS mortality by SES and by race. In addition to a strong focus on factors that improve overall population health, more effective public health interventions and policies would facilitate an equitable distribution of health-enhancing innovations.

Children's dental service use reflects their parents' dental service experience and insurance.

BACKGROUND: Decisions about children's oral health care are made by parents. Parents' dental insurance, dental service use, and perceived affordability all influence their children's oral health care. METHODS: Using data from the 2016 National Health Interview Survey, the authors constructed a database of 4,396 nationally representative US children and their linked household adults. The authors assessed the relationship between children's and parents' use of dental services, private and public dental insurance, and deferral of oral health care owing to cost. To adjust for factors that may influence outcomes independently, the authors performed multivariate analyses to consider child, parent, and household characteristics. RESULTS: Children have 2 times the risk of lacking a dental visit in a year if the parent has none, 7 times the risk of reportedly lacking dental coverage if the parent has none, and nearly 10 times the risk of having care deferred owing to cost if the parent finds oral health care unaffordable. Affordability risk factors for children include older age and minority race, whereas protective factors include public insurance, parents with higher educational attainment, and female-led households. Increased oral health care use by children was associated with states that provide more extensive adult Medicaid dental benefits. CONCLUSIONS: Greater parental dental service use, dental coverage, and ability to afford care benefit their children's use of oral health care. PRACTICE IMPLICATIONS: Policies by employers and government that expand quality private and public coverage for adults hold strong promise to improve oral health care for both parents and their children.

Fundamental social causes of inequalities in colorectal cancer mortality: A study of behavioral and medical mechanisms.

BACKGROUND: Fundamental cause theory posits that social conditions strongly influence the risk of health risks. This study identifies risk mechanisms that social conditions associated with socioeconomic status (SES) and race/ethnicity shape in the production of colorectal cancer (CRC) mortality. METHODS: Two large datasets in the United States examining behavioral and medical preventive factors (N = 4.63-million people) were merged with population-level mortality data observing 761,100 CRC deaths among 3.31-billion person-years of observation to examine trends in CRC mortality from 1999-2012. Analyses examined the changing role of medical preventions and health behaviors in catalyzing SES and racial/ethnic inequalities in CRC mortality. RESULTS: Lower SES as well as Black, Hispanic, Asian/Pacific Islander, and Native American race/ethnicity were associated with decreased access to age-appropriate screening and/or increased prevalence of behavioral risk factors. Analyses further revealed that SES and racial/ethnic inequalities were partially determined by differences in engagement in two preventive factors: use of colonoscopy, and participation in physical activity. DISCUSSION: Social inequalities were not completely determined by behavioral risk factors. Nevertheless, a more equitable distribution of preventive medicines has the potential to reduce both the risk of, and social inequalities in, CRC mortality.