Domiciliary dentistry clinics: a multiple case study in the province of Quebec, Canada.

BACKGROUND: The demand for more flexible and person-centered models of oral healthcare delivery is increasing and while mobile and domiciliary dental services have the potential to increase access to oral healthcare among dependent elderly and people with disabilities; the uptake of this service model by dentists remains low. Therefore, the aim of this study was to understand how existing domiciliary dental services operate within a particular context. METHODS: We used a qualitative descriptive multiple case study design. We studied three independent domiciliary dentistry clinics in the province of Quebec, Canada. We completed observations of 27 domiciliary visits, four of which were in private homes and the remaining 23 in LTCFs. We also conducted semi-structured interviews with dental professionals, patients, and caregivers. We performed a qualitative content analysis using a deductive/inductive coding framework. RESULTS: We presented a detailed description of the physical and service features of the studied cases. Physical features included the set-up of the mobile clinics, the portable equipment used, and the domiciliary locations of visits. For service features, we described the roles, attitudes, and interactions among those involved on both the providers' and recipients' sides, as well as, the logistical and financial aspect of the domiciliary dental services. CONCLUSIONS: Despite variations in setup and years of practice, the three mobile clinics had similar physical and service features. They also faced common logistic challenges but were able to provide services and respond to the high demand for domiciliary dental services. Additional research in different contexts would further contribute to building evidence-based models to help increase the uptake of this type of practice by current and future dental professionals.

Physical Constraint in Pediatric Dentistry: The Lived Experience of Parents.

BACKGROUND: The use of physical constraint in pediatric dentistry is highly controversial. Papoose boards in particular, which envelop and immobilize children during treatment procedures, have been described as barbaric devices even though their goal is to protect the patient. In this debate, the voice of parents is important but still missing in the scientific literature. AIM: To understand how parents or caregivers experienced physical constraint and the use of the papoose board on their children during regular dental treatment. DESIGN: We conducted qualitative research rooted in interpretive phenomenology. Accordingly, we performed in-depth individual interviews with a purposive sample of 7 parents or caregivers. The interviews took place in Montréal, Canada, after the children had been treated with a papoose board for nonemergency dental treatments. The discussions were audio recorded, transcribed, and thematically analyzed. RESULTS: Two perspectives emerged among participants. Some explained that the papoose board calmed their children, helped the dentist to complete the procedures, and made their experience less stressful. For others, the papoose board was a horrible and traumatizing experience, leading to feelings of guilt toward their children. They expressed anger toward the dentists for not allowing them enough time to decide and for imposing use of the device. CONCLUSION: Our study raises serious ethical concerns about this practice. We believe that using a papoose board should remain an extraordinary measure and, more generally, that dental professionals should reflect on the place of children and their families in clinical encounters. KNOWLEDGE TRANSFER STATEMENT: The findings of this study should encourage policy makers, dental professionals and ethicists to consider the following points: 1) the traumatizing experiences described by parents raise serious ethical concerns about the use of papoose boards; 2) the dental profession should reflect on the place of children and their families in the clinical encounter and grapple with the importance of consent and how to ensure consent in encounters involving children and their parents.

Single-Implant Overdentures Retained by a Novel Attachment: A Mixed Methods Crossover Randomized Clinical Trial.

INTRODUCTION: Single-implant mandibular overdentures (SIMOs) are one of the least invasive implant treatments for edentulism. The new Novaloc attachment system can improve the clinical performance of implant-retained overdentures but has not been tested for SIMOs. OBJECTIVES: To compare Novaloc and a gold standard system (Locator) for SIMOs in an edentate elderly population in terms of patient-reported outcomes and device- and treatment-related complications. METHODS: In this single-center crossover randomized clinical trial (RCT), 10 edentulous participants received an implant in the lower midline and had their lower complete dentures converted to SIMOs. The participants received each attachment system for 3 mo in a randomized order, followed by measurement of patient satisfaction and oral health-related quality of life via the McGill Denture Satisfaction Questionnaire and the Oral Health Impact Profile for Edentulous People questionnaire, respectively. Complications were registered throughout the RCT. Patients were interviewed for their experiences with SIMOs and preference for one of the attachment systems. Quantitative analysis employed mixed linear models and chi-square tests (α = 0.05), whereas interview data underwent thematic analysis and, in turn, integration into quantitative data (mixed methods explanatory design). RESULTS: All 10 randomized participants completed the trial. Mean ± SD general satisfaction was 92% ± 8% with Novaloc versus 85% ± 13% with Locator (mean difference, 9%; 95% CI, 1% to 17%). For specific McGill Denture Satisfaction Questionnaire items, only denture stability was significantly increased for Novaloc. Seven participants preferred Novaloc over Locator at the end of the RCT (chi-square, P = 0.045). No difference was found between the attachments in terms of oral health-related quality of life based on the Oral Health Impact Profile for Edentulous People and complications. Thematic analysis revealed high patient satisfaction with SIMOs, with denture stability the main criterion for their satisfaction and attachment preference. CONCLUSION: Among elderly edentulous patients wearing SIMOs, Novaloc led to increased patient satisfaction and preference. Better patient-perceived denture stability may explain this result. The attachment systems exhibited similar short-term maintenance needs. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03126942 (first registered on April 13, 2017). Secondary identifiers: A03-M07-17A (McGill University, Institutional Review Board) and 2018-3873 (McGill University Health Centre, Research Ethics Board). KNOWLEDGE TRANSFER STATEMENT: The results of this mixed methods study can be used by clinicians when choosing which attachment system to use for SIMOs. Results suggest that edentulous patients prefer attachments with a better-defined seating position, such as that of the Novaloc system, as opposed to the nylon matrix on metallic abutment of the Locator system.

Dentists' experience with low-income patients benefiting from a public insurance program.

France has a system of public coverage that guarantees low-income earners full payment of basic dental health costs. In spite of this coverage and major needs for care, deprived populations have lower access to dental care. The aim of this qualitative study was to explore dentists' experience with low-income patients benefiting from the French universal healthcare coverage system. This study is based on 17 one-on-one semistructured interviews carried out with French private dentists. Dentists distinguished two categories of low-income patients: 'good patients', described as being regular attenders; and 'bad patients', whose main characteristic is irregular attendance. Dentists explained that they have difficulties in dealing with patients who do not keep their appointments. First, dentists feel that they fail in conducting their mission of being a care provider (therapeutic failure). The absence of the patient is also seen as a lack of recognition (relationship failure). Furthermore, dentists do not earn money when patients miss their appointments (financial failure). In this context, many dentists feel discouraged and powerless (personal failure). Moreover, dentists do not understand why patients renounce the dental-care opportunities offered under the system of public coverage (failure of the system). Dentists who repeatedly experience failures related to irregular attendance tend to adopt exclusion strategies.

Time to Develop Social Dentistry.

Knowledge Transfer Statement: We are calling researchers, educators, and dental professionals to be at the forefront of actions addressing social determinants of health. We indeed argue that 1) it is the dentists' and other oral health care professionals' role to tackle social determinants of health and 2) as researchers and educators, we need to help clinicians in this endeavor and lead the development of a "social dentistry" movement.

Social dentistry: an old heritage for a new professional approach.

If dental professionals want to improve the oral health of their patients, they need to address what makes them sick: the social determinants of health. In this article, we propose a model of 'social dentistry' that shows how dentists could tackle these fundamental causes of oral disease. Socially engaged dentists conduct actions at three levels. At the individual level, they provide patient-centred care and, when necessary, liaise with local resources to better address what makes their patients sick. At the community level, they adapt their practice to the needs of the most vulnerable groups and advocate for healthier local policies. At the societal level, they are engaged in upstream actions addressing the social determinants of health.

How can we provide person-centred dental care?

Patient- or person-centred care is the current paradigm in the health profession yet there is still no clear understanding of what it means or how it could be implemented in dentistry. Building on a previously proposed person-centred model in clinical dentistry, in this article a person-centred dental clinical approach is presented. The approach consists of three guiding principles - humility, hospitality and mindfulness - that influence the different processes of the dental clinical encounter: connecting, examining, sharing, and intervening. The presented approach provides a rich opportunity for dentists to fine tune their own clinical approach in order to keep up with the upcoming expectations of their patients.

Observed volatilization fluxes of S-metolachlor and benoxacor applied on soil with and without crop residues.

Volatilization may represent a major dissipation pathway for pesticides applied to soils or crops, and these losses may be modified by soil surface conditions or in the presence of plant residues. This paper investigates the effect of surface conditions on volatilization through experimental results. The two experiments consisted of volatilization flux measurements for 3 days after an application of S-metolachlor together with benoxacor: one with two wind tunnels to compare the effect of the presence of crop residues on the soil on volatilization losses and another one at the field scale from bare soil without crop residues. Volatilization fluxes were large immediately after application (between 77 and 223 ng m-2 s-1 for S-metolachlor depending on experimental conditions), decreasing down to a few nanograms per square meter per second on the last day. Volatilization fluxes followed a diurnal cycle driven by environmental conditions. The losses found for both compounds were in accordance with their physicochemical properties. The crop residue on the soil surface modified soil surface conditions-primarily the soil water content essentially, the degradation of S-metolachlor, and the dynamics of volatilization loss.

Measurement of trifluralin volatilization in the field: Relation to soil residue and effect of soil incorporation.

Volatilization may represent a major dissipation pathway for pesticides applied to soils or crops. A field experiment (September, 2002), consisted in volatilization fluxes measurements during 6 days, covering the periods before and after soil incorporation carried out 24 h after trifluralin spraying on bare soil. Evolution of concentration in soil was measured during 101 days, together with soil physical and meteorological variables. Volatilization fluxes were very high immediately after application (1900 ng m(-2) s(-1)), decreased down to 100 ng m(-2) s(-1) in the following 24 h. Soil incorporation strongly abated trifluralin concentration in the air. 99% of the total volatilization losses recorded over the 6 days following application occurred before incorporation. Volatilization fluxes evidenced a diurnal cycle driven by environmental conditions. Soil trifluralin residues could still be quantified 101 days after application. Our results highlight the caution required when using soil degradation half-life values in the field for volatile compounds.

Dental caries experience: a two-generation study.

The life-course framework stresses the importance of social, psychosocial, and biological factors in early life on the development of later disease. From this perspective, the association between edentulousness of mothers and their children's caries risk has not been studied. Therefore, a sample of 6303 mother-child pairs was randomly selected in Quebec (Canada). Mothers (6039 dentate and 264 edentulous) completed a self-administered questionnaire, and their children, aged 5 to 9 years, were clinically examined. Bivariate analyses and multiple logistic regressions showed that edentulous mothers' children are more likely to experience caries on both primary [OR=1.7 (1.3-2.3)] and permanent [OR=1.4 (1.0-2.0)] dentitions when compared with dentate mothers' children. These results are independent of socio-economic status, age, gender, and children's oral-health-related behaviors. Our study is the first to show that edentulous mothers' children constitute a group at risk of caries. It also highlights the need for a better understanding of the mother-child transmission of risk.

[Socioeconomic variables and the prevalence of dental caries in second and sixth grade Quebec children in 1989-90]. / Association des variables socio-economiques avec la prévalence de la carie dentaire chez les ecoliers québécois de deuxième et sixième année en 1989-1990.

OBJECTIVES: 1) To determine caries risk factors in second and sixth grade Quebec children; 2)To test multivariate models which identify children as belonging to a high prevalence group. METHODS: For the 1989-90 Santé Dentaire Québec survey, 2,291 second grade and 2,111 sixth grade school children responded to a questionnaire on their personal habits of hygiene and diet and underwent a clinical examination, while their parents answered a questionnaire regarding their family's socio-economic status. RESULTS: Statistics demonstrate a stronger link between socioeconomic variables and caries prevalence than demographic and sanitary factors. Children emerging from a high socioeconomic milieu have better dental health than children with low socioeconomic standing. The most effective model, However, registers a sensitivity of 65% and a specificity of 66%, revealing the inadequacy of statistical models to accurately identify children in the caries high prevalence group.

[Social inequalities in the demand for dental care]. / Inégalités sociales dans le recours aux soins dentaires.

BACKGROUND: Despite excellent general health indices, Quebec is in a difficult situation concerning oral health: tooth loss remains at a high level in adults and reveals important social inequalities. The objective of this research was to show that dental health inequalities reflect inequalities in the demand for dental care. METHODS: For the Dental Health Survey of Quebec 1998-1999, 9930 parents of children aged 5 to 8 years were randomly selected across Quebec and received a questionnaire at their home on the demand for dental care. Among them, 8430 adults completed and sent back the questionnaire (responses rate: 85%). After excluding edentulous persons, the sample was reduced to 6585 parents aged 30 to 44 years. RESULTS: The majority of respondents (76.4% of women and 72.8% of men) visit the dentist in a preventive manner rather than wait until dental problems occur. However, our study shows important disparities: the proportion of preventive attenders increases as income increases. A multiple logistic regression model suggests that there are financial as well as cultural barriers in dental care access. CONCLUSION: The proportion of preventive attenders is high in Quebec and allows practitioners to adopt a preventive management of dental caries. Social disparities are high however, and are associated with financial as well as cultural barriers that need to be reduced.

[Determinants of dental caries in Haitian schoolchildren and implications for public health]. / Déterminants de la carie dentaire parmi les écoliers haïtiens et implications pour la santé publique.

This work was carried out as part of a community development project in North-West Haiti. The aim was to determine the prevalence of dental caries among young Haitians and to identify the principal determinants and risk factors. A total of 322 schoolchildren, all aged 12 years, participated in the study in March and April 1996. Demographic characteristics, hygiene and dietary habits were recorded. In parallel, a dentist assessed the amount of debris present on the teeth and investigated the children's history of caries. Almost two thirds of the children examined were free of caries. The mean number of decayed missing and filled teeth (DMFT index) was 0.93, which is low. However, a high-risk group was identified with a mean DMFT index of 3.8. This group is a source of some concern, particularly as the region's health services are often inaccessible resulting in dental caries frequently remaining untreated until tooth extraction is required. Logistic regression analysis showed that dental hygiene and, to a lesser extent, sugar intake, were the principal risk factors for dental caries. Adolescents who consume more than three meals per day and who, presumably, have a higher intake of cariogenic food, present more caries than those who consume less. These schoolchildren meet the objectives of the WHO for dental caries for 2000, but two courses of action are nonetheless necessary: caries prevention and improved access to dental health care. To prevent caries, techniques for increasing the resistance of teeth could be recommended, as in industrialized countries. However, such strategies would be difficult to implement in the rural context of a developing country. The addition of fluoride to drinking water, for example, is not practical as most of the inhabitants of rural areas do not have access to running water. The use of sealing agents, which protect against decay affecting the occlusal surfaces of molars, is also impractical, for financial reasons. Thus, basic measures involving the improvement of dental hygiene and reducing the intake of cariogenic foods remain the principal means of preventing caries. Increasing the accessibility of dental care, like prevention, involves a number of problems. Increasing the number of health centers, or renovating existing clinics requires resources, and possibly infrastructure, that the Haitian state may not be in a position to provide. The recently developed ART (Atraumatic Restoration Treatment) overcomes this problem. This method involves manually cleaning cavities and sealing then with glass ionomer. This product is highly adhesive, which frees dentists from the constraints of having to use rotating electrical equipment. Caries can therefore now be treated in remote areas with a minimum of dental equipment. However, although encouraging results were obtained in a three-year trial in Thailand, the mechanical quality of glass ionomer and its ability to block caries development are unclear. In conclusion, a lack of financial resources limits the possibilities of intervention in developing countries, drawing attention to the important question of the financing of health programs. Funding remains the key to any program and has been shown to be an essential issue in epidemiological studies.

Comparison of three pesticide fate models with respect to the leaching of two herbicides under field conditions in an irrigated maize cropping system.

The ability of three models (PEARL, MACRO and PRZM) to describe the water transfer and leaching of the herbicides S-metolachlor and mesotrione as observed in an irrigated maize monoculture system in Toulouse area (France) was compared. The models were parameterized with field, laboratory and literature data, and pedotransfer functions using equivalent parameterization to better compare the results and the performance of the models. The models were evaluated and compared from soil water pressure, water content and temperature data monitored at 0.2, 0.5 and 1 m depth, together with water percolates and herbicide concentrations measured in a tension plate lysimeter at 1 m depth. Some hydraulic (n, θ(s)) parameters and mesotrione DT50 needed calibration. After calibration, the comparison of the results obtained by the three models indicated that PRZM was not able to simulate properly the water dynamic in the soil profile. On the contrary, PEARL and MACRO simulated generally quite well the observed water pressure head and volumetric water content at the three different depths during wetting periods (e.g. irrigated cropping period) while a poorest performance was obtained for drying periods (fallow period with bare soil and beginning of crop period). Similar water flow dynamics were simulated by PEARL and MACRO in the soil profile although in general, and due to a higher evapotranspiration in MACRO, PEARL simulated a wetter soil than MACRO. For the whole simulated period, the performance of all models to simulate water leaching at 1m depth was poor, with an overestimation of the total water volume measured in the lysimeter (ranging from 2.2 to 6.6 times). By contrast, soil temperature was properly reproduced by the three models. The models were able to simulate the leaching of herbicides at 1m depth in similar appearance time and order of magnitude as field observations. Cumulative observed and simulated mesotrione losses by leaching were consistently higher than the observed and simulated losses of the less mobile herbicide, S-metolachlor. In general, PRZM predicted the highest concentrations for both herbicides in the leachates while PEARL simulated the observed herbicide concentrations better than MACRO and PRZM.

Socio-economic inequalities and oral health in Canada and the United States.

This paper describes and compares the magnitude of socio-economic inequalities in oral health among adults in Canada and the US over the past 35 years. We analyzed data from nationally representative examination surveys in Canada and the US: Nutrition Canada National Survey (1970-1972, N = 11,546), Canadian Health Measures Survey (2007-2009, N = 3,508), The First National Health and Nutrition Examination Survey (1971-1974, N = 13,131), and National Health and Nutrition Examination Survey (2007-2008, N = 5,707). Oral health outcomes examined were prevalence of edentulism, proportion of individuals having at least 1 untreated decayed tooth, and proportion of individuals having at least 1 filled tooth. Sociodemographic indicators included in our analysis were place of birth, education, and income. Data were age-adjusted, and survey weights were used to account for the complex survey design in making population inferences. Our findings demonstrate that oral health outcomes have improved for adults in both countries. In the 1970s, Canada had a higher prevalence of edentulism and dental decay and lower prevalence of filled teeth. This was also combined with a more pronounced social inequality gradient among place of birth, education, and income groups. Over time, both countries demonstrated a decline in absolute socio-economic inequalities in oral health.

Assessing the ability of mechanistic volatilization models to simulate soil surface conditions: a study with the Volt'Air model.

Ammonia and pesticide volatilization in the field is a surface phenomenon involving physical and chemical processes that depend on the soil surface temperature and water content. The water transfer, heat transfer and energy budget sub models of volatilization models are adapted from the most commonly accepted formalisms and parameterizations. They are less detailed than the dedicated models describing water and heat transfers and surface status. The aim of this work was to assess the ability of one of the available mechanistic volatilization models, Volt'Air, to accurately describe the pedo-climatic conditions of a soil surface at the required time and space resolution. The assessment involves: (i) a sensitivity analysis, (ii) an evaluation of Volt'Air outputs in the light of outputs from a reference Soil-Vegetation-Atmosphere Transfer model (SiSPAT) and three experimental datasets, and (iii) the study of three tests based on modifications of SiSPAT to establish the potential impact of the simplifying assumptions used in Volt'Air. The analysis confirmed that a 5 mm surface layer was well suited, and that Volt'Air surface temperature correlated well with the experimental measurements as well as with SiSPAT outputs. In terms of liquid water transfers, Volt'Air was overall consistent with SiSPAT, with discrepancies only during major rainfall events and dry weather conditions. The tests enabled us to identify the main source of the discrepancies between Volt'Air and SiSPAT: the lack of gaseous water transfer description in Volt'Air. They also helped to explain why neither Volt'Air nor SiSPAT was able to represent lower values of surface water content: current classical water retention and hydraulic conductivity models are not yet adapted to cases of very dry conditions. Given the outcomes of this study, we discuss to what extent the volatilization models can be improved and the questions they pose for current research in water transfer modeling and parameterization.

Providing humanistic care: dentists' experiences in deprived areas.

Communication barriers severely reduce the effectiveness of oral health care provision to people living in poverty. Our objective was to identify specific approaches and skills developed by dentists for more effective treatment of people living in poverty and addressing their needs. We conducted qualitative research based on in-depth interviews with eight dentists practicing in disadvantaged communities of Montreal, Canada. Analyses consisted of interview debriefing, transcript coding, and data interpretation. Results revealed that, over years of practice, these dentists had developed a five-faceted socio-humanistic approach that involved: (1) understanding patients' social context; (2) taking time and showing empathy; (3) avoiding moralistic attitudes; (4) overcoming social distances; and (5) favoring direct contact with patients. This approach is original, and, even though participants found it successful, it should be evaluated in terms of its impact for access to services and patients' experience of care.

How people on social assistance perceive, experience, and improve oral health.

Oral diseases are highly prevalent among people on social assistance. Despite benefiting from public dental coverage in North America, these people rarely consult the dentist. One possible reason is rooted in their perception of oral health and the means to improve it. To respond to this question, largely unexplored, we conducted qualitative research through 8 focus groups and 15 individual interviews in Montreal (Canada). Thematic analysis revealed that people on social assistance: (a) define oral health in a social manner, placing tremendous value on dental appearance; (b) complain about the decline of their dental appearance and its devastating impact on self-esteem, social interaction, and employability; and (c) feel powerless to improve their oral health and therefore contemplate extractions and complete dentures. Our research demonstrates that perception of oral health strongly influences treatment preference and explains low and selective use of dental services in this disadvantaged population.