Associations between child abuse and neglect, and dento-alveolar injuries in a Children's hospital population.

BACKGROUND/AIM: The purpose of this study was to identify social variables common to children with dento-alveolar trauma (DAT) and child abuse and neglect (CAN) in a large children's hospital population. METHODS: Emergency department data from an urban trauma Level 1 children's hospital were queried between December 02, 2017 and September 30, 2022 to identify children with both DAT and CAN. Patients with DAT and CAN were compared to DAT-only children in a case-control study design. Descriptive statistics were used to report characteristics of children in case and control groups. Chi-Squared and Fisher's exact tests were used to compare cases and controls. The level of significance was set at p ≤ .05. RESULTS: In total, 14 children who had DAT and CAN reported simultaneously comprised the case group. A total of 42 children with DAT-only, age/sex matched with cases, comprised the control group. Mean (SD) age of cases was 10.4 (±4) and controls was 10.1 (±3.9) years-old. Eight cases (57.1%) and 24 controls (57.1%) were female. No statistical differences (p = .05) were present for language, race, insurance coverage, parental custody, legal guardianship, and type of residence for cases versus controls. Five (35.7%) cases had a special need versus 4 (9.5%) controls and was statistically different (p = .03). Nine (64.3%) cases had behavioral problems versus 13 (31%) controls (p = .05). Cases were more likely to have facial injuries than controls (74.3 vs. 31%), however no significant differences were present for total number of injured teeth, head injury or neck injury between cases and controls. In half of cases, the perpetrator reported was the sibling. CONCLUSIONS: Demographics did not predict CAN in children with dental injuries. Sibling violence should be considered in suspected CAN children.

The changing profile of infective endocarditis: A multi-year retrospective study for dentists.

BACKGROUND: Infective endocarditis (IE) has high morbidity and mortality and is often attributed to dental procedures. AIM: This study characterized variables related to paediatric IE in a paediatric hospital cohort. DESIGN: A retrospective review of medical records, from January 1, 2008, to January 1, 2020, to examine demographic, medical and dental history, and risk factors associated with children diagnosed with IE at Nationwide Children's Hospital. RESULTS: Of the 242 patients who were admitted with tentative IE diagnoses, 67 met the inclusion criteria: 46 (69%) had underlying cardiac conditions and 21 (31%) had not. One-third had an infection with S. aureus and viridans streptococci. Age was significantly associated with intracardiac devices in children with IE. Mean hospitalization was 25 days, and the mortality was 6 (9%); 41(61%) required surgery for causative defects, and 24 (32%) had dental consultation during admission. CONCLUSION: Although cardiac-related conditions were present in most cases, IE occurred in patients without cardiac factors.

Comparison of dmft and behavior rating scores between children with systemic disease and healthy children at the first dental visit.

PURPOSE: To evaluate and compare oral health and behavior scores at the first dental visit and dental treatment need using general anesthesia/sedation (GA/S) of children with systemic diseases (SD) and healthy children. METHODS: Data were obtained from healthy children (n = 87) and children with SD (n = 79), aged 4 to 6 years, presenting to a hospital dental clinic for a first dental examination. The total number of decayed, missing and filled teeth (dmft), dental behavior score using Frankl Scale, and dental treatment need using GA/S were recorded. Chi-square / Fisher's exact test and Mann-Whitney U tests were used for statistical analyses. RESULTS: The patients with SD were diagnosed with cardiac disease (61%), renal disease (9%), and pediatric cancers (30%). The median dmft values of the SD group (3.00) were significantly lower than those of healthy children (5.00) (p = 0.02) and healthy children exhibited significantly more positive behavior (90.8%) than children with SD (73.4%) (p = 0.002). The number of patients needing GA/S for dental treatment did not differ significantly between the two groups (p = 0.185). There was no relationship between dental treatment need with GA/S and dental behavior scores of the patients (p = 0.05). A statistically significant relationship was found between the patients' dmft scores and the need for dental treatment using GA/S; and the cut-off value was found to be dmft > 4 for the overall comparisons. CONCLUSION: The presence of chronic disease in children appeared to affect the cooperation negatively at the first dental visit compared to healthy controls, however, it did not affect the oral health negatively. Having a negative behavior score or SD did not necessitate the use of GA/S for dental treatment.

Acceptability of medical immobilization: Results from a pilot international survey.

BACKGROUND: Controversy exists on the acceptability of medical immobilization (MI). AIM: To identify regulations, professional conventions, and opinions on the acceptability of MI and to identify practice patterns through a pilot study of members of the International Association of Paediatric Dentistry (IAPD) and their colleagues. DESIGN: A 22-item questionnaire was developed and electronically distributed to 1191 members of the IAPD. RESULTS: Responses were received from 182 dentists in 45 countries. The majority (74.9%) of respondents use MI, and 29.1% use an immobilization device. MI with an immobilization device was reported as professionally acceptable (58.1%) and permitted by medicolegal regulations (70.8%) in their countries of practice. Dentists rated acceptability of MI higher than they perceived parents would overall and perceived MI to be more acceptable by parents for emergency situations and for children with special healthcare needs but 19.8% of respondents found it totally unacceptable in all scenarios. Use and opinions of acceptability varied by geographical location with respondents from North America being more accepting of MI. Most dentists felt that the use of an immobilization device could lead to lasting psychological trauma (72.3%) and violation of the rights of the child (55.4%) but that it improves access to care (58.5%). CONCLUSION: The acceptability of MI remains an area of controversy for paediatric dentists internationally.

A 3-Year retrospective study of traumatic dental Injuries to the primary dentition.

BACKGROUND/AIMS: Traumatic dental injuries (TDIs) in the primary dentition are a significant public health problem, which has been neglected worldwide. Despite its high prevalence, limited studies address this injury. The aim of this study was to determine the characteristics and treatment modalities of TDIs affecting primary teeth, along with accompanying medical co-morbidities and attendance at follow-up appointments. MATERIAL AND METHODS: This retrospective analysis included all TDIs affecting primary teeth from January 2014 to January 2017. Data abstraction included demographics, time lapse prior to arrival at hospital, trauma etiology, classification of TDIs, soft tissue and supporting bone injuries, medical co-morbidities, emergency treatment, follow-up appointments and prognosis. RESULTS: Records of 283 children with 536 traumatized primary teeth were reviewed. The median age was 2 years and the maxillary right central incisor (35.1%) was the most frequently injured tooth. Almost half the patients, 46.3%, sought treatment after 24 h. Periodontal tissue injuries (97.2%) predominated TDIs for which fall accidents (82.0%) were the most encountered cause. Most patients (177/283) had accompanying soft tissue/supporting bone injuries and 67.2% had multiple traumatized teeth. Seventy percent of the patients were examined only or were prescribed medication. Survival time following TDIs was unknown in 67.7% of traumatized teeth due to non-attendance at follow-up appointments. Most patients (55.1%) did not attend the follow-up appointments. CONCLUSIONS: TDIs occurred in the primary dentition with the predominance of periodontal tissue injuries. When TDI was the presenting problem to hospital, accompanying systemic injury was rare. Treatment modalities were mostly limited to examination or extraction. The follow-up appointments were poorly attended.

Absorbable Hemostatic Pack Effect After Primary Incisor Extraction: A Pilot Study and Introduction of a Novel Scale to Assess Post-Operative Bleeding.

OBJECTIVES: This pilot study compared hemostatic pack (HP) application with no intervention following extraction of maxillary primary incisors in healthy children for effect on bleeding time and influence of patient or tooth variables utilizing a novel scale for assessment of bleeding following extraction. STUDY DESIGN: A novel scale was created to assess bleeding after extraction. This scale was utilized in a randomized, split mouth study of healthy children ages 2-7 years old requiring extraction of at least 2 primary maxillary incisors under general anesthesia. One extraction site was randomly assigned to receive HP and the other had no hemostatic measures. Post-operative bleeding was rated at 2, 10, and 15 minutes post-extraction. Other variables recorded included age, sex, periapical radiolucency, presence of fistula, swelling, discoloration, intraoral stabilization device used, and vital signs at two time intervals. Pre-operative radiographs were reviewed for root resorption and periapical radiolucency. RESULTS AND CONCLUSIONS: Twenty-five patients provided 50 teeth. Hemostatic pack had a significant effect on reducing bleeding at each time point and that effect did not change over time. Age, sex, tooth pain, post-extraction heart rate, blood pressure, discoloration, amount of resorption, and presence of a periapical radiolucency had no significant effect on bleeding. The proposed bleeding scale had good intra-rater reliability and could be useful in future studies, once validated.

An Algorithm for Managing Emergent Dental Conditions for Children.

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

Safety and Efficacy of 3 Pediatric Midazolam Moderate Sedation Regimens.

Our aim was to characterize effectiveness and complications in children receiving oral midazolam alone, nasal midazolam alone, or oral midazolam with other sedatives. Children received oral midazolam alone, nasal midazolam, or oral midazolam in combination with other sedative medications. All subjects received a presedation history and physical examination and were sedated per protocol by any of 28 resident providers under attending supervision. Sedations were rated for success and complications by clinicians. Postoperative complications were assessed by trained staff up to 48 hours postoperatively. Seven hundred and one encounters, completed over 24 months, yielded 650 usable sedations. The majority of children were healthy (469; 68.2%) and 86% (532) weighed between 10 and 25 kg. Sedations were deemed successful in about 80% of cases. Planned treatment was completed in over 85% of encounters. Oral midazolam alone yielded the best behavior. Physical assessment factors of behavior and age were correlated (P = .035) with effectiveness. Hiccups and a positive medical history were significantly related (P = .049). Side effects of either nausea/vomiting, dysphoria, or hiccups occurred in less than 10% of cases. All 3 regimens were effective with minimal postoperative complications.

Do Early Dental Visits Reduce Treatment and Treatment Costs for Children?

PURPOSE: The purpose of this paper was to determine if number and cost of dental treatments in high caries-risk children differs in children with early dental intervention compared to children with later intervention. METHODS: Billing data from children age zero to seven years old, whose first dental visit was between January 1, 2004 and December 31, 2004, were collected from 20 corporate treatment centers serving children from lower socioeconomic status backgrounds. Data included age at first visit, dental treatment codes, and associated costs for eight years after the first dental visit. Treatment included restorations, crowns, pulpotomies, and extractions. First visit age was categorized into early starters (younger than four years old) and late starters (four years of age or older). Linear regression with cluster adjustment for clinic determined a difference in costs and dental treatments by early and late starters. RESULTS: Of 42,532 subjects, 17,040 (40 percent) were early starters and 25,492 (60 percent) were late starters. There were 3.58 more dental procedures per- formed on late starters, over eight years of follow-up, than on early starters (P < .001). Late starters spent $360 more over eight years of follow-up than early starters (P < .001). CONCLUSION: In this study, number of procedures per- formed were fewer and cost of treatment less for children seen earlier versus later.

Age of first dental visits: A benefit of the pediatric medical home.

OBJECTIVE: This retrospective cohort study compared differences in age one dental visit use and age at first dental visit according to fluoride varnish receipt at the pediatric medical home. METHODS: Enrollment and claims data were used from Partners For Kids, a pediatric accountable care organization covering Medicaid-enrolled children living in 47 of 88 counties in Ohio. The main outcomes were having an age one dental visit and the mean age at first dental visit. Descriptive statistics and bivariate comparisons were applied. RESULTS: Among 17,675 children, 2.8% had an age one dental visit. The mean age at first dental visit was 4.8 years. Children who received fluoride varnish from their medical home (12% of study population) were significantly younger at their first dental visit (4.1 vs. 4.9 years, p < 0.001). CONCLUSION: Despite longstanding recommendations for the age one dental visit, very few Medicaid-enrolled children in Ohio had one. The pediatric medical home lowered the age of first dental visit.

Evaluating the type of pediatric dental care use in the context of neighborhood opportunity.

BACKGROUND: Increasing evidence supports the influence of neighborhood factors on health care use and outcomes. This study measured the association between area-level social determinants of health (SDH) and type of dental care use among Ohio pediatric Medicaid beneficiaries. METHODS: A retrospective dental claims analysis was completed for children aged 1 through 5 years enrolled in Ohio Medicaid with a dental visit in 2017. Dental care use was measured from 2017 through 2021 as 1 of 4 visit types: (1) preventive, (2) caries treatment, (3) dental general anesthesia (GA), and (4) dental emergency department. The Ohio Children's Opportunity Index defined area-level SDH at the census tract level. Exploratory analysis included descriptive statistics of area-level SDH for each outcome. Poisson regression models were developed to examine the associations between the number of each dental care use outcome and Ohio Children's Opportunity Index quintiles. Visualizations were facilitated with geospatial mapping. RESULTS: Fifty-six percent of children (10,008/17,675) had caries treatment visits. Overall area-level SDH were positively associated with preventive (fifth vs first quintile incidence rate ratio [IRR], 1.09; 95% CI, 1.07 to 1.12), caries treatment (fifth vs first quintile IRR, 1.16; 95% CI, 1.08 to 1.24), and dental GA visits (fifth vs first quintile IRR, 2.13; 95% CI, 1.13 to 4.01). CONCLUSIONS: Children with preventive, caries treatment, and dental GA visits were more likely to live in neighborhoods with better SDH. Future efforts should investigate the mechanisms by which area-level factors influence dental access and use. PRACTICAL IMPLICATIONS: Neighborhood factors influence pediatric dental care use. Patient home addresses might add value to caries risk assessment tools and efforts by care networks to optimize efficient care use.

Ohio School Nurses´ Perceptions of School Absences for Dental Care.

Purpose: To evaluate the knowledge, practices and attitudes of Ohio school nurses regarding school absenteeism (SA) for dental treatment. Methods: A 40-item questionnaire was generated and distributed to 246 attendees at an annual conference for Ohio school nurses in December 2019. Results: The response rate was 65.9 percent (n=162 out of 246 attendees) and 136 surveys were eligible for inclusion. The sample was female (100 percent), worked at public schools (86.0 percent, n=117) and trained as registered nurses (83.8 percent, n=114). Nurses reported no change in concerns over children missing school for dental appointments in the last five years (69.9 percent, n=95) and most agreed that SA for dental visits "almost never" negatively impacted the educational needs of children. The medical history of the patient was the most common factor when determining the duration of a school excuse (81.6 percent, n=111) and the potential for pain was the most common dental consideration (93.4 percent, n=127). Nurses reported that they "sometimes" had problems with a child after a dental visit (44.9 percent, n=61) and pain was the most reported problem (83.8 percent, n=114). Conclusion: Nurses did not feel that SA for dental treatment negatively impacted the educational needs of children.

Dental Care Differences Among the Behavioral Health Population in an Accountable Care Organization: A Retrospective Cohort.

OBJECTIVE: To compare dental utilization and expenditures between children with and without behavioral health (BH) diagnoses in an accountable care organization. METHODS: This retrospective cohort study used enrollment and claims data of Medicaid-enrolled children in Ohio. Children with 7 years of continuous enrollment from 2013 to 2019 were included. We calculated 5 dental utilization outcomes: 1) Diagnostic only visits, 2) Preventive visits, 3) Treatment visits, 4) Treatment visits under general anesthesia (GA), and 5) Orthodontic visits. Total 7-year cumulative expenditures were calculated for each outcome. Multivariable logistic regression models were run for each outcome adjusting for demographics and medical comorbidities. RESULTS: Among 77,962 children, 23% had ≥1 BH diagnosis. No utilization differences were noted between children with and without BH for diagnostic only visits, treatment visits, and orthodontic visits. BH status modified the likelihood of having a preventive visit and dental GA visits based on medical comorbidity. For example, children with BH diagnoses had significantly lower odds of a preventive visit (eg, non-complex chronic comorbidity: odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.85-0.89), and significantly higher odds of a dental treatment under general anesthesia visit (eg, non-chronic comorbidity: OR = 3.69, 95% CI: 3.26-4.18). The total cumulative dental expenditures were $10.5M greater for children with BH. CONCLUSIONS: Children with BH diagnoses were significantly less likely to have preventive visits and more likely to have dental GA visits, which was expensive. Early identification and intervention could alter treatment approaches, improve care, reduce risk of harm, and achieve cost-savings within a pediatric accountable care organization.

Impact of Reduced Operating Room Access on Dental Departments in Children's Hospitals.

Purpose: Access to hospital operating rooms (HORs) for pediatric dental patients worsened with the COVID-19 pandemic. The purpose of this study was to assess the impact of hospital operating room denials for dental patients on service and teaching missions in selected US children's hospitals (CHs). Methods: A 12-question online survey was sent to administrative heads of 34 CH dental departments. Results: Twenty-two surveys were completed. All respondent CHs were engaged in pediatric dentistry training. The majority (68 percent) reported that access to HORs worsened since 2017, resulting in longer wait times for hospital dental service cases (82 percent), decreased ability to achieve and maintain oral health for special needs patients (64 percent), more caries-related emergency department visits (50 percent), and delays in medical surgery for children needing dental clearance (45 percent). A quarter (27 percent) reported HOR availability somewhat affected resident training. Conclusion: Lack of access to hospital operating rooms in training hospitals had a negative impact on the quality and timeliness of care and the quality of training.

Associations Between Oral Health Fatalism and Demographic Factors, Dental Practices, Fatalism, and Oral Health Self-Efficacy.

Purpose: To evaluate the relationship between demographics, dental beliefs and practices, fatalism, oral health self-efficacy, and oral health fatalism (OHF) among parent (guardian, caregivers). Methods: English-speaking parents of children presenting for dental care at a hospital dental clinic, a dental surgery center, and two private practices answered a 33-item questionnaire regarding demographics, general fatalistic views, and dental beliefs, practices, and history. Participants rated their agreement with the OHF statement: "Most children eventually develop dental cavities." Results: More than half (58.4 percent) of parent respondents (n equals 332) were Caucasian, and 44.6 percent had education beyond high school. Most were female (81.3 percent), with public (Medicaid) insurance (67.5 percent), and were raising three (average) children. Less than 30 percent endorsed the OHF statement, and 42.5 percent were neutral. Higher OHF was found in parents of children with Medicaid insurance (P=0.02), fair (P=0.01) or poor (P=0.03) dental health, previous caries history (P=0.02), and those attending their first dental visit (P=0.03). Higher OHF was found in parents whose children do not brush their teeth when asked (P=0.02) or who do not behave when a parent helps (P=0.02), as well as those who subscribe to general fatalism beliefs (P=0.002). Conclusions: Higher oral health fatalism was associated with general fatalism, low oral health self-efficacy, parents of children with Medicaid insurance, suboptimal dental health, and first dental visits. Future studies investigating whether OHF can change over time and the role providers play in OHF can help dental professionals understand parent health behaviors and plan for health promotion interventions.

Knowledge and Perceptions of Dental Care During Pregnancy: A Cross-Sectional Survey of Adolescents and Young Adults.

Purpose: To evaluate knowledge, perceptions and current practices regarding care-seeking behaviors and oral health in pregnant and non-pregnant adolescent and young adults, and to assess barriers to dental care during pregnancy.
Methods: An 18-question survey was distributed to patients in three tertiary hospital clinics in Columbus, Ohio, USA. Statistical analyses used chi-square and Fisher's exact tests, with significance at P <0.05.
Results: Of 227 respondents, 197 were female and about 30 percent were pregnant. The mean and median age was 17 years. Almost half were African American, 69 percent had public insurance and over 75 percent had one or two annual dental check-ups. Less than one percent indicated pregnant females should never go to the dentist, although 63 percent of pregnant respondents had not sought dental care while pregnant and less than five percent had been to the dentist in the six months prior to pregnancy. The most reported barrier to seek dental care was the patient being too busy.
Conclusions: Dental care among pregnant adolescents seems to be less utilized than their non-pregnant peers. The importance and safety of dental care during pregnancy are less understood among adolescents and young adults than in older, pregnant women. Most respondents, including males, stated that if a pregnant female has tooth pain, she should go to the dentist, but were unaware if materials used at the dentist were harmful to the baby. Interventions to improve knowledge and reduce barriers to dental care during pregnancy are needed for adolescents and young adults.

Comparison of Spanish-Speaking Parental Understanding Using Two Alternative Consent Pathways.

Purpose: The purpose of this study was to assess the understanding of Spanish-speaking caregivers consenting to dental care using general anesthesia (GA) utilizing two consent-delivery pathways. Methods: Seventy-eight parents of children who never had GA were randomly assigned to one of two groups: (1) interpreter; or (2) video; they completed a survey to evaluate comfort level with GA and comprehension of areas of informed consent. Results: Most parents in both groups understood the risks associated with GA (89 percent in the interpreter group and 90 percent in the video group). The majority of families had difficulty understanding indications for GA (64 percent in the interpreter group versus 60 percent in the video group). Overall, 97 percent of participants believed they sufficiently understood the information presented about GA. The mean score for comfort level with GA was 7.03 for the interpreter group and 6.82 for the video group. Conclusion: Consent pathways used in this study were not significantly different for risk understanding and acquisition of consent-related knowledge.

Oral health in America 2021: Making a case for curricular change.

BACKGROUND: The NIH Oral Health in America: Advances and Challenges report is the most recent evidence-based review of the status of oral health in North America since Oral Health in America: A Report of the Surgeon General, which was published in 2000. This article aims to synthesize and discuss information from the report pertinent to improving dental education to positively impact oral health. Calls for action and suggestions for implementation are presented. METHODS: The authors reviewed each section from the report and identified key messages relevant to dental education. These were then combined into a framework based on the NIH report's three main "call to action" items. A matrix for calls to action and implementation recommendations was developed using the findings from the 2021 NIH report and a previous 2018 report on Advancing Dental Education in the 21st Century. CONCLUSION: The information discussed in the report related to dental education has the potential to improve oral health, and educators, schools, professional organizations, state, and federal agencies are called to develop and/or implement action plans focused on curriculum, competencies, workshops, guidelines, and policies based on the summary framework presented in this study.

Safety Training in US Pediatric Dentistry Advanced Education Programs: A Survey of Program Directors.

Purpose: Incorporation of patient safety and quality improvement into the educational framework of all health care trainees, including those in dentistry, is growing. The purpose of this study was to characterize the current state of patient safety training and education in US pediatric dentistry residency programs. Methods: A 19-item web-based survey was emailed to all US pediatric dentistry residency program directors in 2021. The survey collected information regarding program background, safety education, safety protocol and experience, attitudes toward safety, and potential support for safety education. Data were analyzed using descriptive statistics and Fisher's exact test. Results: Seventy-two directors (76 percent response rate) completed the survey. The majority felt safety education was somewhat (11 percent, N equals six) or extremely important (68 percent, N equals 49) for residents. Only six percent (N equals four) reported residents entered their program with an adequate understanding of safety science. Most (74 percent, N equals 53) taught safety science through both didactic seminars and clinical experience. Timeouts under general anesthesia (78 percent, N equals 56) and emergency simulations (72 percent, N equals 52) were more common modes of clinical safety training. Overall, a limited number of program directors had familiarity with many safety tools used to prevent adverse events. Program directors' experience with adverse events was not associated with opinions regarding the importance of safety education. The majority expressed interest in AAPD supporting safety education. Conclusions: Although program directors feel safety education is important, programs do not sufficiently address safety education and look for support to help integrate safety measures into education.